level of the health care system—clinicians; health care organizations; health plans and payers; regulators, lawmakers, and other policy makers; accrediting organizations; educational institutions; and all those who shape the environment in which care is delivered. The preceding chapters present recommendations for all these parties organized according to the problems addressed. This chapter concludes by presenting those recommendations separately for each party. From this latter perspective, the recommendations form an agenda that can be pursued at each level of the health care system to improve the quality of M/SU health care.

KNOWLEDGE GAPS IN TREATMENT, CARE DELIVERY, AND QUALITY IMPROVEMENT

Previous chapters of this report have identified gaps in our knowledge about how best to treat certain mental and/or substance-use (M/SU) problems and illnesses; how best to treat these conditions when the patient’s and treating provider’s resources and environments do not match those of the researchers developing the treatment; and how to ensure that evidence-based practices identified through research are applied uniformly to all those patients for whom they are appropriate. Filling these knowledge gaps will require that the finite available research dollars be used strategically and coordinated across funders. Also necessary will be a thoughtful approach to the more rapid generation of valid and reliable evidence of practical use to treating clinicians in their usual settings of care.

Gaps in Treatment Knowledge

The numerous gaps in our knowledge about how to treat M/SU problems and illnesses encompass effective treatments, effective delivery of known treatments, and ways to improve care quality. A few examples of each of these knowledge gaps are discussed below.

Gaps in Knowledge About Effective Treatments

Treatment of multiple conditions Despite the high degree of comorbidity of mental and substance-use conditions, as described in Chapter 5, and the great strides made in understanding the relationship between co-occurring mental and substance-use problems and illnesses, little is known about the etiology and temporal ordering of these comorbidities (SAMHSA, undated). There also is a substantial lack of knowledge about effective treatment for individuals with certain complex comorbidities, such as schizophrenia and concurrent mood disorders (Kessler, 2004) and comorbid general health conditions (Kane et al., 2003).



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