Front Matter

Robert E. Drake, M.D., Ph.D., and Howard H. Goldman, M.D., Ph.D.

Robert E. Drake, M.D., Ph.D., Howard H. Goldman, M.D., Ph.D., H. Stephen Leff,Ph.D., Anthony ELehman, M.D., M.P.H., Lisa Dixon, M.D., M.P.H., Kim T.Mueser, Ph.D., and William C. Torrey, M.D.

WiUiam C. Torrey, M.D., Robert E. Drake, M.D., Ph.D., Lisa Dixon, M.D., M.P.H., Barbara J. Bums, Ph.D., Laurie Flynn, A.John Rush, M.D, Robin E. Clark, Ph.D., and Dale Klatzker, Ph.D.

Patrick WCorrigan, Psy.D, Leigh Steiner, Ph.D., Stanley G. McCracken, Ph.D., Barbara Blaser, R.N., and Michael Barr, Ph.D.

Frederick J.Frese III, Ph.D., Jonathan Stanley, J.D., Ken Kress, J.D., Ph.D., and Suzanne Vogel-Scibilia, M.D.

Gary R Bond, Ph.D., Deborah R Becker, M.Ed., Robert E. Drake, M.D., Ph.D., Charles A. Rapp, Ph.D., NeilMeisler, M.S.W, Anthony F.Lehman, M.D., M.S.P.H., Morris D.Bell, Ph.D., and CrystalR.Blyler, Ph.D.

Robert E. Drake, M.D, Ph.D., Susan M. Essock, Ph.D., Andrew Shaner, M.D., Kate B. Carey, Ph.D., Kenneth Minkoff, M.D., Lenore Kola, Ph.D., David Lynde, MS. W, Fred C. Osher, M.D, Robin E. Clark, Ph.D., and Lawrence Rickards, Ph.D.

Susan D.Phillips, M.S.W, Barbara J. Burns, Ph.D., Elizabeth R Edgar, M.S.S.W, Kim T.Mueser, Ph.D., Karen W Linkins, Ph.D., Robert A. Rosenheck, M.D, Robert E. Drake, M.D, Ph.D., and Elizabeth C. McDonel Herr, Ph.D.

Lisa Dixon, M.D, M.P.H., WiUiam R McFarlane, M.D, Harriet Lefley, Ph.D., Alicia Lucksted, Ph.D., Michael Cohen, M.A., Ian FaUoon, M.D, Kim Mueser, Ph.D., David Miklowitz, Ph.D., Phyllis Solomon, Ph.D., and Diane Sondheimer, M.S., M.P.H.

Thomas A Mellman, M.D, Alexander L Miller, M.D, Ellen M. Weissman, M.D, M. Lynn Crismon, Pharm.D., Susan M. Essock, Ph.D., and Stephen R. Marder, M.D.

Stanley D. Rosenberg, Ph.D., Kim T.Mueser, Ph.D., Matthew J. Friedman, M.D., Ph.D., Paul G. Gorman, Ed.D., Robert E. Drake, M.D., Ph.D., Robert M. Vidaver, M.D., William C. Torrey, M.D., and Mary KJankowski,Ph.D.

Kimberly Hoagwood, Ph.D., Barbara J. Burns, Ph.D., Laurel Kiser, Ph.D., Heather Ringeisen, Ph.D., and Sonja K. Schoenwald, Ph.D.

Stephen J. Bartels, M.D., Aricca R. Dums, B.A, Thomas R Oxman, M.D., Lon S. Schneider, M.D., Patricia A. Aredn, Ph.D., George S.Alexopoulos, M.D., and Dilip VJeste, M.D.

The evidence-based-practices movement has become a catalyst for reform in the public mental health system. National organizations and state mental health systems alike have embraced the concept that they have an ethical obligation to provide treatments that work.

One question that arises is, Why now? The U.S. health care system has been committed to scientifically based treatment for the past century, and the movement to adopt a set of specific techniques in general medicine, which is termed evidence-based medicine, is now more than a decade old (1). A confluence of several developments may have created the impetus for change. The evidence base regarding effective treatments for persons with severe mental illness who are living in the community in the postdeinstitutionalization era has been steadily building for nearly 50 years. The Schizophrenia Patient Outcomes Research Team project (2) was seminal in clarifying that we know a considerable amount about treatments that work and that these treatments are not widely available and used. The Surgeon General’s first report on mental illness clarified these points for the public (3).

With the crisis in health care funding and the movement toward managed care, the demand for accountability has been pervasive. The courts have ruled repeatedly that mental health care providers have a legal obligation to provide the best available treatments. The National Alliance for the Mentally Ill, the National Association for State Mental Health Program Directors, the Robert Wood Johnson Foundation, the MacArthur Foundation, the West Foundation, and other national organizations and advocacy groups in one way or another have provided support and leadership in the movement toward effective treatment. The National Institute of Mental Health has shifted its research emphasis to study treatments that work in routine practice settings rather than primarily in university settings. The Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration has led the effort to identify and disseminate effective treatments. Remarkably, all this has happened in the context of even more limited mental health care dollars (4).

John A. Talbott, M.D., the editor of Psychiatric Services, has been a leader in mental health care reform for decades. When we approached him about publishing a series on this topic for the journal, he immediately recognized the timeliness and significance of the issue. The papers in this volume were originally published in Psychiatric Services during 2001 and 2002. They are remarkable in representing a broad-based attempt to synthesize the available information on the effectiveness of community-based mental health practices. Several papers address general issues in the field: What do we know about reviewing the evidence transparently, about implementing practices in routine mental health settings, and about the policy implications of this movement? Other papers address specific practices for which substantial evidence exists, including practices for particular populations.

The field of evidence-based mental health practices is in its infancy. These initial attempts to summarize the knowledge and issues are ungainly in many ways. The common criticisms of evidence-based practices— for example, that they conflict with recovery and other ideological commitments—highlight the inadequate job we have done to inform all stakeholders about the philosophy of evidence-based medicine and developments in the mental health field. The basic tenets of evidence-based medicine have not been articulated and discussed in public forums. We have not clarified several issues. For example, we need to demonstrate how scientific evidence can be used to improve the quality of services and the quality of life of service recipients as well as how a hierarchy of evidence is constructed and used in decision making. We also need to clarify how other important issues, such as individual client characteristics, client preferences for treatment and outcomes, and client autonomy, are valued in evidence-based practices (5).

Consumers and families have expressed fears that they will be displaced from their roles in delivering services and supports, that their service options and choices will be reduced, and that services will be less individualized. All these fears are in fact antithetical to the basic tenets of evidence-based practices. Practitioners have expressed concerns about the credibility of the evidence base, the difficulty of learning new techniques and taking on new responsibilities without training and time, and the lack of inclusion of their favorite interventions in the initial attempts to identify evidence-based practices. Administrators and policy makers have also expressed concerns, often related to the difficulties of financing, organizing, implementing, and sustaining new practices. Vested-interest groups feel a new pressure to show that what they do is effective.

All these concerns should be discussed publicly. Without public debate, evidence-based practices, as has been the case with some other attempts at reform, could be transmogrified into unintended representations and conclusions that might further restrict access to effective and needed care. Thus we consider these articles to be a starting point. It has been our privilege to bring these papers together. It is our hope that they will stimulate helpful discussion. ♦