The term ‘evidence-based medicine’ keeps cropping up as the health-care debate continues. But many questions still swirl: What really makes a treatment “the best”? Whose research counts? Is this just a back-door way to ration care? In the field of mental health, the terrain is even trickier.
Evidence-based medicine. The term keeps cropping up as the health-care debate continues. It sounds simple: Make sure doctors use the treatments proven to work best. But many questions still swirl: What really makes a treatment “the best”? Whose research counts? Is this just a back-door way to ration care? In the field of mental health, the terrain is even trickier.
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The ideal of evidence based-treatments is the same in mental health as it is in physical health, says psychiatrist Bernard Arons. He is director of medical affairs at St. Elisabeth’s Hospital in Washington, D.C.
Arons: Proven, documented, scientifically evaluated practices, interventions, medications that work for different conditions.
Such well-researched, efficient treatments for mental illness exist. But the good news ends here.
Lehman: Even though there is evidence a wide variety of treatments may be helpful, patient access to many of these mental health treatments is not very good, particularly in certain areas of the country.
That’s Anthony Lehman, a psychiatrist with the University of Maryland.
He says Multiple barriers block stand between behavioral health patients and the most effective treatments. Among them: lack of insurance coverage, too few dollars for research, stigma – and a big gap between research and practice:
Lehman: So a lot of practitioners in the community have learned older kinds of treatments, and have not kept pace with the newer kinds of treatments.
Doctor’s orders can vary widely, depending on where a person goes for treatment. Bernard Arons:
Arons: The same individual, same depression, same history might go to one person, and have recommended interpersonal dynamic therapy, another might suggest couples’ therapy, someone else might start with medication, some combined.
The federal government would like to bridge the gap between research and practice. Drexel University psychologist Michael Lowe received a grant from the National Institute of Mental Health to take one successful intervention from the lab to the real world. This was a treatment for eating disorders based on cognitive behavioral therapy – which changes behavior by pinpointing the thoughts that trigger the behavior. Lowe took this approach to the Renfrew Center – a well-known clinic for eating disorders in Northwest Philadelphia. But creating a link between the lab and practice proved tricky.
Lowe: We had VERY different world views and therefore, it was extremely challenging to do that!
Lowe’s approach focuses on changing specific eating behaviors – dieting, purging, binging. He says the therapists at Renfrew focus on their patients’ overall well-being, trying to get to root causes. Other factors complicated the collaboration: Research settings are more controlled and stable than what therapists encounter in the real world, and researchers lack the kind of interpersonal experience therapists gain in working with patients.
Lowe: We turn to scales and numbers and statistics, whereas in the clinical setting – what treatment to use and how well it’s working is more subjective.
The Renfrew team says the scientists didn’t consider lack of patient motivation, either. They have incorporated some of Lowe’s work into their practice – and say the experiment was still valuable.
Michael Lowe agrees:
Lowe: It was a very important first step for all of us to appreciate the difficulty. It’s one thing to say, we have to take these research studies that have been done in this setting, and export them to this setting. But that itself is a science.
So, in the meantime, what’s a consumer to do? Take charge, says Edie Mannion of the Mental Health Association for Southeastern Pennsylvania:
Mannion: Try to really think about what it is you think you have, and research it, and ask around! Don’t just go through lists that your insurance company sends you, ask around, have you ever seen a good therapist for depression or bi-polar disorder. Self help groups can be a great resource for information.
Mental health experts agree on one thing – in this tough economy, the field has a choice – get better at bringing best practices to consumers – or cut services.