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One overwhelming, regrettable, and disheartening fact about the treatment of schizophrenia in the United States is that few people with this disorder receive well-recognized and highly effective treatments. This reality is known as the science-to-service gap: Intervention science has demonstrated with rigorous research methods that a number of interventions are effective, yet services research shows indisputably that people with this serious mental disorder are likely to receive few if any of these effective interventions. In this special theme issue, the authors review 3 aspects of this problem: first, the evidence for lack of effective services at the epidemiological and clinical levels; second, difficulties of clinical engagement and retention in services; and third, the widespread failure to implement and sustain effective interventions in routine practice settings.
Ramin Mojtabai and his colleagues review the epidemiology. They conclude that nearly half of persons with schizophrenia receive no mental health interventions, another large proportion receives less-than-effective interventions, and only a minority receives effective interventions. The deficiencies are worse for outpatients than for inpatients, and compared with effective medication strategies, effective psychosocial interventions are rarely used. Most alarming, the situation appears to be worsening rather than improving, especially in regard to the availability of evidence-based psychosocial interventions.
Not having access to effective, acceptable treatment services clearly is a major problem for people with a serious illness like schizophrenia. Julie Kreyenbuhl and her colleagues review the evidence regarding lack of engagement in mental health services and dropping out of services. Because of stigma, dissatisfaction with previous services, unawareness of benefits achievable with appropriate treatment, and other factors, the majority of people with schizophrenia, especially young adults and those from minority backgrounds, essentially opt out of mental health treatment. The details of these studies suggest greater use of skilled outreach workers and clinical care management. Several modifications to current mental health service approaches, such as shared decision making, are also potentially helpful, but we are not yet certain what impact they might have on the problem of service providers engaging only a fraction of individuals who would benefit from evidence-based services.
When people are engaged with the mental health system, the major service issue is failure to provide effective services. Robert Drake and colleagues review major efforts aimed at ameliorating this problem. Multilevel interventions—at the federal, state, local, clinical, and advocacy levels—to promote effective services are underway. Such initiatives could benefit from substantial changes in financing, information technology infrastructure, workforce training and tenure, treatment philosophy, and organizational commitment.
Implications of these reviews might be addressed in terms of systems, clinical services, workforce issues, and future research. At the system level, the conclusion that in most parts of the country we have no real system, but rather a fragmented set of disconnected and largely ineffective services that are rejected by a majority of persons with schizophrenia, seems inescapable. As described by the Institute of Medicine1 and the President's New Freedom Commission,2 constructing a genuine system will require aligning finances with effective treatments, putting clients with mental illness at the center of decisions about clinical care, using modern information technology, integrating mental health care with primary medical care and rehabilitation, and training and maintaining a workforce that can coordinate these components. We have a long, challenging, and vitally important path ahead to insure that service offerings are such that persons with schizophrenia are engaged in effective services.
At the clinical level, a system should support 3 essential elements of quality improvement: attention to each client's informed preferences, use of evidence-based practices and treatment guidelines, and clinical experience. Shared decision making represents the current paradigm for integrating these elements.3 Most psychiatric decisions involve complex trade-offs rather than a clear best choice; an informed patient and an experienced clinician must consider the available evidence together at each decision point and develop a decision and an action plan that they believe is optimal. To make shared decision making a functional, credible, everyday reality in schizophrenia treatment, we need to develop a workforce that understands and embraces this paradigm, to activate and inform persons with schizophrenia to participate meaningfully, and to build information infrastructure that will facilitate rather than impede the process.
Such changes have huge implications for the mental health workforce. We need to take seriously educating and continually retraining mental health professionals for a modern health care system that is team oriented, integrated, evidence based, outcome driven, and client centered. This will require new forms of preprofessional, professional, and postprofessional training based on current knowledge about how practitioners learn. It will also require paying mental health professionals on the front line a higher wage to increase job tenure.
The findings reviewed in this issue require careful thought about service system design and funding mechanisms by mental health services researchers. Presently, substantial resources are devoted to developing more effective treatments for the small minority of persons with schizophrenia who currently receive evidence-based care. The impact of this incremental improvement in effectiveness may pale in comparison to the impact of developing new ways to engage in evidence-based treatments those individuals who currently receive none. An emphasis on implementing effective services for the majority of persons with schizophrenia who do not currently receive such therapeutics would have a dramatic impact. Major advances with novel therapeutic methods are needed, but research must also address the approximately 95% of people with schizophrenia who are not currently receiving an appropriate array of evidence-based services.