Reinventing Evidence-Based Interventions?

In Reply: Professor Hogarty takes issue with the approach we presented in our article describing the VA South Central MIRECC Clinical Partnership Program. We certainly agree that if our proposal results in "consigning [the mentally ill] to the whimsy of idiosyncratic experimentation," this would be dangerous indeed.

However, Professor Hogarty has misunderstood our main point—namely, that a balance between top-down and bottom-up approaches will enhance the success of evidence-based medicine. We are not advocating for discontinuation of the time-honored approach of researchers' generating evidence. Researchers should continue to expand this evidence base, and effective treatments should be disseminated and utilized in everyday care. The introduction of the bottom-up approach is meant to help expand this evidence base by bringing in frontline clinicians as partners.

Although research has produced a repertoire of efficacious treatments rooted in evidence, a majority of persons who have mental disorders do not enter treatment (1), and those who do are unlikely to receive care that is based on evidence (2). Quality improvement interventions have been reasonably successful in implementing evidence-based practices and demonstrating reduced costs, yet they have usually not been sustained or disseminated (3). One of many reasons for their less than optimal success is that clinicians sometimes resist them, often feeling that the interventions are imposed upon them.

As services researchers have struggled to devise ways to improve uptake and sustainability of evidence-based interventions, we have turned to other disciplines, such as marketing and organizational psychology, for new ideas. The partnership program drew primarily from the bottom-up models put forth by Dr. Duan (4) and community-participatory research (5). By drawing from these models, we do not seek to replace the traditional way of generating evidence but, rather, to identify new approaches that might prove useful. Community-participatory research has shown that involvement of multiple stakeholders often results in a higher likelihood of sustainability. Providers are key stakeholders and critical partners in the diffusion of new practices. We disagree with Professor Hogarty's statement that "clinicians in public mental health facilities have had little or no influence." Although clinicians' hands might be tied by formularies and other factors, they do exercise an important influence over the care that is provided and its delivery. It has been our experience in the VA that if local providers advocate for a practice it is far more likely to be sustained than if they do not.

In emphasizing the distinction between top-down and bottom-up approaches we may have inadvertently created a false dichotomy. We meant to portray the two approaches as complementary. As Professor Hogarty notes, all interventions, whether initiated by researchers or by clinicians, begin from the bottom up. Like any other research project, each of the interventions in our program arose from clinical experience and out of the desire to improve patient care, and each is being evaluated in terms of outcomes.

An important outcome of this project is that we have formed partnerships with clinicians. Researchers in academic centers often do not appreciate the tensions that exist between clinicians and researchers in usual care settings. We view the development of trust and understanding between clinicians and researchers as a major accomplishment that will serve us well in future efforts to improve the quality of care.