This issue introduces a series of reviews updating the evidence base for several evidence-based practices. In 1989, when the Robert Wood Johnson Foundation asked Howard Goldman and me to address implementation of evidence-based practices, the concept was controversial, criteria for systematic reviews were just emerging, and the evidence for many common practices was lacking. Much has changed, and remarkable progress will be clear from reviews in the Assessing the Evidence Base Series to be published over the next several months.
Nonetheless, challenges are legion and vexing. Common problems include the limits of efficacy research, failure to identify ineffective and harmful practices, lack of standards for assessing emerging practices, neglect of implementation science, absence of end-users’ perspectives, a dearth of studies of technology, and persistent misalignment between evidence-based practices and financing. Many efficacious practices do not transfer to routine settings because they are too complicated, do not attract the target population, cannot be maintained at high fidelity, cannot be supported by data systems, do not fit into the current care structure, and so on. We have not identified and eliminated deleterious practices, which are often maintained by interest groups well beyond their usefulness. No clear pathway exists for developing and testing emerging practices; yet practices of uncertain validity are often adopted and financed.
For practices that deserve implementation, programs and systems do not follow basic knowledge regarding implementation science. We have not prioritized testing and implementation of the practices of greatest interest and usefulness to people with mental disorders and their families. How many randomized controlled trials of consumer support services exist relative to studies of cognitive-behavioral therapies? Guilds and profit centers continue to dictate availability and financing. Effective and needed practices lose out to every new medication of unproven benefit and potential harm. Everyone agrees that behavioral health technologies could expand reach, and the related research is strong. But where are these technologies used outside research settings?
Getting effective interventions to those who need them, when they need them, and where they want to access them—and in a fair and equitable manner—is fundamentally an issue of productivity. Thus we need to emphasize the well-known components of productivity: infrastructure, human capital, and new technology. But where is the investment in infrastructure? Are we building communications and delivery systems for the next decade? Where is the human capital? Are we educating clinicians to be adept with new technologies? And are we developing new technologies to extend effective services to the growing numbers of people around the world who will need them? Perhaps we should expand our thinking about evidence-based practices.
