Spring 1996 Volume 5, Number 2
Commentary
MENTAL DISORDERS:
Translating Science Into Clinical Care
BY MILES F. SHORE, M.D.
Mental health care has been the quintessential "non-system," dedicated individual providers working largely alone in private offices, isolated from one another except for referrals and consultations, offering psychotherapy as the predominant form of treatment for a wide range of troubling disorders. This care has been repeatedly demonstrated to be effective, with one important exception: Most major mental illnesses--schizophrenia, manic depression and depressive disorders--do not yield to psychotherapy alone. With few definitive treatments and needing expensive long-term care, these patients have long fallen back on public care, a system itself largely abandoned by the public.
Now, converging revolutions in neuroscience and health care economics have the potential to change the situation dramatically. Striking advances in research have strengthened the validity and reliability of definitions of various mental disorders. A host of new biological treatments have come from research --clozapine for treatment-resistant schizophrenia, new medications for obsessive compulsive disorder, and new, highly effective treatments for depression. An explosion of basic research on the causes and treatment of mental illness utilizing molecular biology, molecular genetics, imaging studies and neuropsychology has also ocurred. Services research has led to innovative alternatives to inpatient care and new methods of rehabilitation. Variants of psychotherapy --cognitive/behavioral, interpersonal, and others --based on controlled studies of efficacy and effectiveness offer focused treatment. And extensive research on measures of performance and outcome is providing increasingly useful benchmarks for quality.
These advances are exciting, but they must be translated into practice to benefit patients. This is easier to say than to do, especially in office-based treatment by individual practitioners who cherish their autonomy and the personal nature of the care they provide. It has been said that it took ten years for the average obstetrician to act on the research finding that women did not need to restrict their weight gain during pregnancy, and these were practitioners who worked in hospitals, constantly exposed to colleagues and to the intensive scrutiny of accrediting agencies. How much more difficult is the translation task in a field where, until recently, there has been very little science-based knowledge to guide day to day practice and where practitioners tend to work in isolation.
Surprisingly, the advent of managed care may offer some help to practitioners in adopting scientific advances. Managed care, by definition, creates links between providers and demands accountability within external guidelines. It also links providers with larger, centralized systems on a national basis. The managed behavioral health care (MBHC) industry is now responsible for some 111 million "covered lives" --employed individuals and their dependents. Some 3 to 5 percent of these individuals seek behavioral health treatment each year. Highly successful, because it offers employers cost savings and some measures of quality and value, the MBHC industry is also intensely controversial, because it creates incentives to limit care and intrudes into the therapist-patient relationship.
But MBHC also opens the door to quality in mental health care by creating organized systems. While these systems are designed to support cost reductions, they also seek to assure quality by measuring process and outcome. They rely on sophisticated electronic links between providers and central case managers and in some cases between provider and provider. Information technology transmits data about eligibility, clinical state, treatment interventions and clinical progress. It can easily be adapted to provide clinical algorithms --electronic consultation systems --to furnish information about disorders that may be complex or unfamiliar to individual providers. These systems can provide ongoing consultation and education about the steps to follow in working with depressions that do not respond to treatment with standard antidepressants, or schizophrenic conditions that do not improve with first-line anti-psychotic medications.
Such practice aids also can include recommendations for psychotherapeutic interventions. This will be more important as drugs get better. For example, clozapine, a biological miracle for some individuals with schizophrenia, opened up a new field of psychotherapy --so-called Rip Van Winkle treatment to help patients catch up on years of psychological development lost during the schizophrenic episode.
In discussing medical errors, Lucien Leape, of the Harvard School of Public Health, contrasted health care with the airline industry. He noted that, in health care, error prevention relies on practitioners to practice with perfection, error-free. In contrast, the airline industry, similar in that life and death depend on the reliability of technology, assumes that human errors will occur, and creates backup systems to compensate. Leape suggests that health care follow suit, using technology to support practitioners in reducing errors and enhancing the quality of care.
His endorsement of technological supports for practice could be extended to include interactive systems available at the site of behavioral treatment. The fledgling efforts to systematize care --the by-product of managed behavioral health care --are ripe for adaptation to this expanded use. With appropriate financial and professional support, office-based practitioners can utilize technology to treat more seriously ill patients, make use of the latest advances in the science base of practice, consult with colleagues, and assure themselves and the public that the treatment of behavioral disorders is at the forefront of medical practice. *