An Overview of Evidence-Based Mental Health

Can J Psychiatry. 2011;56(9):511-513. The preceding articles by Dr Rob Whitley and colleagues' and by Dr Eric A Latimer and colleagues2 review 2 critical aspects of evidence-based mental health (EBMH): incorporating recovery ideology and cultural diversity into research-supported practices. Striving for more effective mental health care will entail addressing these and other challenges. As the US Institute of Medicine3 described the situation, gap between what can and should be and what exists is so large that ... it constitutes a chasm.p 30 In this editorial, we identify 4 other contextual aspects of offering EBMH: practice implementation, decision making, program management, and systems oversight. For each, we describe the issue, the current state of mental health services, and possible future directions. Evidence-Based Practice Implementation Clinicians and program leaders want to support the recovery of their clients by offering practices that consistently promote the outcomes their clients seek. However, even for motivated implementers, the process of establishing a new evidence-based service is complex.4 Important facets of implementation outcome include practice acceptability, appropriateness, fidelity, affordability, and penetration.5 Current approaches to implementation encompass a combination of manuals, fidelity reviews, learning collaboratives, and regional technical assistance centres.6 Technical assistance centres are at the heart of efforts in most regions. Consultants in these centres provide local programs with administrative guidelines and advice, training of new clinicians, ongoing supervision by telephone, and regular visits to monitor progress and suggest further strategies.7,8 This approach has been moderately successful9 and has qualitative research support.7,10,11 However, the science of implementation is very young - the field needs rigorous evidence regarding implementation strategies.12 Emerging strategies for getting evidence-based practices (EBPs) to those who need them emphasize information technology, such as distance learning, telemedicine, computerized self-treatment, and electronic decision supports.13 In theory, electronic systems can incorporate evidence-based guidelines, individual tailoring (now called personalized medicine), and training for clinicians while they are providing services.14,15 Further, electronic records permit direct measurement of aspects of implementation, such as screening and practice penetration (the per cent of people who get a needed screening or service). Evidence-Based Decision Making High-quality health care decisions integrate patient preference, clinical judgment, and the constantly expanding corpus of scientific knowledge.3 Nevertheless, today most decisions rely on clinician judgment alone. Few practice sites routinely ask patients about their preferences.16 The scientific knowledge base is accessible, but using it requires a systematic approach to framing the clinical question, finding the current research, evaluating the quality of the research, deciding if the research applies to the current patient and situation, and using the research in a process of shared decision making.17 Mental health practitioners can master the techniques of evidence-based decision making,'8 but several common barriers reduce their use in everyday practice; for example, time constraints and lack of computer access. The fundamental challenge is to get patient preference, health status (symptoms, function, and side effects), and the relevant scientific evidence to the patient and the clinician in understandable formats at the time when a decision needs to be made.'9 To have direct impact on routine care, the clinician and the patient would need to be able to enter the patient's personal data, specify the question, and access the relevant evidence immediately. This kind of access to patient-relevant, up-to-date science is impossible now because current methods for asking and answering the questions are too complex and time-consuming for most real-world settings. …

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