Psychosocial Interventions for Mental and Substance Use Disorders A Framework for Establishing Evidence-Based Standards (2015) / Chapter Skim
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Addressing this quality chasm in mental health and substance use care is par ticularly critical given the recent passage of the Patient Protection and Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act, which are changing the delivery of care and access to treatments for mental health and substance use disorders.
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Mental health and substance use disorders affect approximately 20 percent of Americans and are associated with significant morbidity and mortality. Although the current evidence base for the effects of psychosocial interventions is sizable, subsequent steps in the process of bringing a psychosocial intervention into routine clinical care are less well defined.
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convened an ad hoc committee to create a framework for establishing the evidence base for psychosocial interventions, and to describe the elements of effective interventions and the characteristics of effective service delivery systems. STUDY CHARGE AND APPROACH The American Psychiatric Association, American Psychological Association, Association for Behavioral Health and Wellness, National Association of Social Workers, National Institutes of Health, the Office of the Assistant Secretary for Planning and Evaluation within the U.S.
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Specifically, the committee will: • haracterize the types of scientific evidence and processes needed to C establish the effectiveness of psychosocial interventions. – Define levels of scientific evidence based on their rigor.
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In addition, interventions can address psychosocial problems that negatively impact adherence to medical treatments or can deal with the interpersonal and social challenges present during recovery from a mental health or substance use problem. Sometimes multiple psychosocial interventions are employed.
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Evidence-based psychosocial interventions often are not taught in programs training mental health and substance use providers and often are not available as part of routine clinical care for mental health and substance use disorders. This gap between what is known to be effective and the actual delivery of care is due to problems of access, insurance coverage, and fragmentation of care (different systems of providers, separation of primary and specialty care, different entities sponsoring and paying for care, and poor coordination of care, as well as variability in the training of numerous types of providers and the lack of requirements that evidence-based interventions be taught in training programs)
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A Proposed Framework for Improving the Quality and Delivery of Psychosocial Interventions Figure S-1 depicts the committee's framework, which identifies the key steps in successfully bringing an evidence-based psychosocial intervention into clinical practice. This framework highlights the need to • support research to strengthen the evidence base on the efficacy and effectiveness of psychosocial interventions; • based on this evidence, identify the key elements that drive the ef fects of an intervention; • conduct systematic reviews to inform clinical guidelines that incor porate these key elements; • using the findings of these systematic reviews, develop quality measures -- measures of the structure, process, and outcomes of interventions; and • establish methods for successfully implementing and sustaining these interventions in regular practice.
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Importantly, the committee intends for the framework to be an iterative one, with the results of the process being fed back into the evidence base and the cycle beginning anew. Much has been done to establish the current evidence base for psychosocial interventions, but much more needs to be done to improve the quality of that evidence base; create new evidencebased interventions; engage consumers in this process; train the providers of psychosocial interventions; and ultimately streamline the process of developing, testing, implementing, and disseminating interventions that address the psychosocial needs of those with mental health and substance use problems.
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Steps in this iterative process should focus on • strengthening the evidence base for interventions, • identifying key elements of interventions, • conducting independent systematic reviews to inform clinical guidelines, • developing quality measures for interventions, and • implementing interventions and improving outcomes. This is a complex process, and the framework is intended to be used to guide a continuous progression.
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Finally, there is a need to develop and test new interventions that are more effective and address currently unmet needs. Identify Key Elements of Interventions Once the evidence base for psychosocial interventions has been expanded, the next step is to identify the key elements that drive the effects of the interventions.
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In the future, an elements framework could advance training in and implementation of evidence-based psychosocial interventions, as practitioners would learn strategies and techniques that can be applied across target problems, disorders, or contexts. Conduct Independent Systematic Reviews to Inform Clinical Guidelines No national, standardized, and coordinated process exists in the United States for compiling, conducting, and disseminating systematic reviews, guidelines, and implementation materials for use by providers and by those formulating guidance for implementation and for insurance coverage.
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A potential direction is for the U.S. Department of Health and Human Services, in partnership with professional and consumer organizations, to develop a coordinated process for conducting systematic reviews of the evidence for psychosocial interventions and creating guidelines and implementation materials in accordance with the IOM
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The U.S. Department of Health and Human Services, in partnership with professional and consumer organizations, should expand and enhance existing efforts to support a coordinated process for conducting systematic reviews of psychosocial interventions and their elements based on the Institute of Medicine's recommendations for conducting high-quality systematic reviews.
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To guide the consideration of opportunities to develop quality measures for psychosocial interventions, the committee built on prior work to offer an approach for the development of quality measures -- structure, process, and outcome measures -- for psychosocial interventions. Structure measures are necessary to ensure that key elements of care can actually be implemented in a way that conforms to the evidence base linking those elements to key outcomes.
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The committee drew the following conclusion about quality measurement for psychosocial interventions: Approaches applied in other areas of health care can be applied in care for mental health and substance use disorders to develop reliable, valid, and feasible quality measures for both improvement and accountability purposes. Recommendation 5-2.
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Stakeholders in each of these areas can manipulate various levers that can shape the quality of the psychosocial interventions delivered to patients. Stakeholders and examples of levers as their disposal include • consumers -- meaningful participation in governance, in organiza tional leadership positions, and as board members; • providers -- quality measurement and reporting, such as tracking outcomes for practices and for populations served; • provider organizations -- electronic data systems with which to share medical records across disciplines and sites of service; • health plans and purchasers -- benefit design, such as pay-for performance systems; and
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Support quality improvement at multiple lev els using multiple levers. Purchasers, health care insurers, providers, consumers, and professional organizations should pursue strategies de signed to support the implementation and continuous quality improve ment of evidence-based psychosocial interventions at the provider, clinical organization, and health system levels.
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A Research Agenda Additional research is needed to expand the evidence base on the effectiveness of psychosocial interventions, validate strategies for applying elements approaches, develop and test quality measures, and design and evaluate implementation strategies and policies. The committee offers the following recommendations as a research agenda to further progress in each phase of the framework.
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Recommendation 5-1. Conduct research to contribute to the develop ment, validation, and application of quality measures.
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The gap between what interventions are known to be effective and the care that is delivered, together with the changing landscape in health care, demands fundamental changes in processes used to ensure the availability and delivery of high-quality evidence-based psychosocial interventions. Determining the best ways to strengthen the evidence base, identify elements that underpin interventions, conduct systematic reviews to inform clinical guidelines, develop quality measures to track the effectiveness of interventions, and implement quality interventions to improve patient outcomes has been remarkably challenging for the field of mental health.
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