ity in diagnosing mental problems and illnesses relative to general health conditions, (4) a less-well-developed infrastructure for measuring and reporting the quality of M/SU health care, and (5) inadequate adoption of quality improvement practices at the locus of M/SU care delivery. The following sections of this chapter present evidence on these issues and describe actions that can be taken to address them, specifically by:

  • Improving the production of evidence.

  • Improving diagnosis and assessment.

  • Using evidence-based practices and untapped resources to better disseminate the evidence.

  • Strengthening the quality measurement and reporting infrastructure.

  • Applying quality improvement methods at the locus of care.

Related issues of improved care coordination, use of information technology, implications of a more diverse workforce, and creation of incentives in the marketplace to support this five-part strategy are addressed in succeeding chapters.

IMPROVING THE PRODUCTION OF EVIDENCE

Gaps in the Evidence Base

Efficacious Treatments

Over the past two decades, there has been an impressive increase in the number and quality of studies on M/SU problems, illnesses, and therapies for both children (Burns and Hoagwood, 2004, 2005; Pappadopulos et al., 2004; Weisz, 2004) and adults (IOM, 1997; Johnson et al., 2000). Nonetheless, gaps remain in our knowledge of how to treat some M/SU conditions, how to care simultaneously for multiple comorbidities, how to care for some population subgroups, and which evidence-based therapies are better than others or best of all (see Box 4-1).

Such gaps in knowledge mean that evidence-based clinical practice guidelines are unavailable for many M/SU problems and illnesses.

The Efficacy–Effectiveness Gap

In addition to the above gaps in knowledge of efficacious therapies, there has been more research on the efficacy of specific treatments than on the effectiveness of these treatments when delivered in usual settings of care; in the presence of comorbid conditions, social stressors, and varying degrees of social support; and when administered by service providers with-



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