Mental health care often ineffective

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Reprinted from an opinion article by Leonard Bickman, PhD, in the Tennessean on February 11, 2013

bickmanIn the wake of the Newtown tragedy, which has shaken our nation to its core, we have identified problems and offered solutions in our desperate need and hope to minimize the potential of a repeated tragedy like Newtown. There has been widespread but diffuse discussion about the importance of improving access to mental health services. After Newtown, President Obama said we needed to make “access to mental health care at least as easy as access to guns.”

Too often, this assertion on “improving access” has been the answer to resolving mental health problems in our country. Limited access is part of the conspicuous crises in mental health along with continual decreases in funding of services. But ineffective treatment is a quieter and unacknowledged crisis that is more pervasive and insidious than insufficient access. Increasing access to poor quality services would simply be a waste of resources because current research indicates mental health care for children does not work very well.

The lead article in the January special issue of the journal I edit, Administration and Policy in Mental Health and Mental Health Services Research, synthesizes research on the effectiveness of psychotherapeutic mental health services for children and adolescents as delivered in mental health clinics. The authors conclude that typical outpatient mental health care for children is mostly ineffective. The article notes that several large-scale studies show (at best) less than half the children improve. Studies using comparison groups of children who do not receive mental health services tend to report both groups improve but to a similar degree.

I solicited eight commentaries on this article from experts. One commentator, Dr. William Reay, a director of a large statewide mental health agency, said: “These problems have been widely known to both the provider and research communities for years, and have been largely ignored by policymakers and funding sources of children’s mental health services. How these problems have persisted in the face of this overwhelming evidence is perplexing. More confusing is the general lack of outrage at this multilevel failure.”

The research does not suggest that all mental health services are ineffective. However, the evidence reveals that we can no longer just assume psychotherapeutic services are successful, including those delivered by experienced licensed therapists who have earned graduate degrees from accredited educational institutions. Moreover, current measures of quality are outdated given new technology that enables us to monitor the effectiveness of services as they are delivered.

The good news is that treatment has been shown to be very effective under the right conditions. We have evidence about what we need to do to enhance and improve mental health services. These actions include:

  • Monitoring the quality of services to ensure they are working.
  • Holding service providers accountable for well-implemented evidence-based treatments that show positive outcomes.
  • Integrating mental health and primary medical care following a public health model.
  • Eliminating widespread practices and regulations that do not benefit clients and that hamper the best efforts of underfunded agencies.
  • Improving client and family engagement to lower the high client dropout rate in treatment.
  • Providing improved education and training so the workforce is more capable of adopting modern technological approaches.
  • Providing financial incentives to agencies for delivering effective services.

Without significant policy reform, mental health agencies will remain subject to ever deeper funding cuts. With the growing awareness of the quiet crises of ineffective services and the pressure to increase access, current resources will not be able to accomplish both goals. Technology is beginning to improve mental health services, which will allow us to deliver better services at lower costs, but in the short run it will increase costs.

This is not a plea for just more funding, but a redirection of funding to incentivize creative and practical solutions. There are a handful of bold and innovative leaders in government, agencies and the research community who are demonstrating that it is feasible to monitor quality and to improve client outcomes. However, there are still major gaps in our knowledge that need to be filled by research, but regrettably improving effectiveness in the “real world” is not a federal research priority.

Kristen Woodlock, the acting commissioner for the New York State Office of Mental Health, commented in the special issue of the journal, “A winning action plan would gather visionaries in our community … to pioneer a trail that others can follow. ... (to) reduce suffering and improve the lives of children and their families.”

We know, however, that such meetings and action plans alone are not sufficient to effect change in our complex and fragmented mental health system. The problems and solutions have been identified. Now we need the commitment and cooperation of funders, researchers, providers and consumers to produce meaningful action. Obtaining such commitment is the heart of the issue.

Leonard Bickman, Ph.D., is professor of psychology, psychiatry and public policy at Vanderbilt University. He is editor-in-chief of Administration and Policy in Mental Health and Mental Health Services Research.

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