Psychosocial Interventions for Mental and Substance Use Disorders A Framework for Establishing Evidence-Based Standards (2015) / Chapter Skim
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1 Introduction
1 Introduction
Pages 21-46
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A variety of research approaches are available for establishing a psychosocial intervention as evidence based. Yet the subsequent steps entailed in 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 1 Mental Health Parity and Addiction Equity Act (MHPAEA) , amending section 712 of the Employee Retirement Income Security Act of 1974, section 2705 of the Public Health Service Act, and section 9812 of the Internal Revenue Code of 1986, Division C of Public Law 110343, 110th Congress, 2nd session (October 3, 2008)
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Among those quality measures addressing mental health and substance use disorders, only two that focus on psychosocial interventions are NQF-endorsed.4 The ACA includes reforms with the potential to mitigate the division of mental health and substance use care between primary and specialty care. The act creates opportunities for large networks of providers to become accountable care organizations (ACOs)
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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. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and 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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Given the committee's statement of task, the focus of this report is on evidence-based care, but this emphasis is not intended to discount the fact that many interventions may be effective but have not yet been established as evidence based. The long-term goal is for all psychosocial interventions to be grounded in evidence, and the intent of this study is to advance that goal.
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Lastly, once an intervention becomes evidence based, it must be studied to determine how best to implement it in the real world, and to disseminate it to and ensure its quality implementation by providers. Such studies do not rely solely on the randomized controlled trial, as the question being addressed may best be answered using a different research method.
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The recommendations also target providers, professional societies, funding agencies, consumers, and researchers, all of whom have a stake in ensuring that evidence-based, high-quality care is provided to individuals receiving mental health and substance use services. OVERVIEW OF MENTAL HEALTH AND SUBSTANCE USE DISORDERS: PREVALENCE, DISABLING EFFECTS, AND COSTS Mental health disorders encompass a range of conditions, including, for example, neurodevelopmental, anxiety, trauma, depressive, eating, personality, and psychotic disorders.
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, bipolar disorder (7.0 percent) , pervasive developmental disorders (4.2 percent)
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5.5% (4.9-5.9) injuries NOTE: DALYs = disability-adjusted life-years; UI = uncertainty interval; YLDs = years lived with a disability; YLLs = years of life lost.
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. States bear a large proportion of the indirect costs of mental health and substance disorders through their disability, education, child welfare, social services, and criminal and juvenile justice systems.
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nonspecific elements that are common to all effective psychosocial interventions, such as the therapeutic alliance, therapist empathy, and the client's hopes and expectations; and (2) specific elements that are tied to a particular theoretical model or psychosocial approach (e.g., communication skills training, exposure tasks for anxiety)
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. Providers Providers who deliver psychosocial interventions include psychologists, psychiatrists, social workers, counselors/therapists, primary care and other nonpsychiatric physicians, nurses, physical and occupational therapists, religious leaders, lay and peer providers, paraprofessionals and caregiv
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, community-based treatment (e.g., assertive community treatment, first episode psychosis interventions) ; vocational rehabilitation, peer support services, and integrated care interventions.
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The core features of assertive community treatment are individualization and flexibility of services based on recovery goals; small caseloads; assertive outreach; ongoing treatment and support, including medica tion; and 24-hour availability with crisis readiness and a range of psychosocial interventions, such as family psychoeducation, supported employment, dual disorder substance abuse treatment, and motivational interviewing. Cognitive-behavioral therapy is used for a wide array of mental health and substance use disorders.
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. Overall, among patients with a wide array of physical and mental disorders, only 54.9 percent had received recommended care.
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The American Psychiatric Association now urges that evidence of competence in psychodynamic therapy, cognitive-behavioral therapy, brief treatment, and combined treatment with medication be collected in residency training. In its new accreditation standards, still in the public comment stage, the American Psychological Association calls on doctoral training programs to focus on "integration of empirical evidence and practice" (APA, 2015)
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Uncovering therapeutic elements that cut across existing interventions and address therapeutic targets across disorders and consumer populations may allow psychosocial interventions to become far more streamlined and easier to teach to clinicians, and potentially make it possible to provide rapid intervention for consumers. The committee also acknowledges the challenges associated with this approach.
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Finally, the process would need to be coordinated and organized so as to limit confusion about just what is evidence based. Currently, systematic reviews and guidelines are created by different organizations, using different review standards, and the result can be conflicting information.
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. Research to develop quality measures from electronic health records is one potential means of improving how quality is determined.
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• What Process and Criteria Should Be Used Define levels of scientific evidence based to Review Evidence? on their rigor.
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Conduct research implement treatment in a manner to expand the evidence base for the that is consistent with evidence-based effectiveness of psychosocial interventions. standards; Chapter 5: Quality Measurement • Measures that encourage continuity of • Definition of a Good Quality Measure treatment; • A Framework for the Development • Measures that assess whether of Quality Measures for Psychosocial providers have the structures and Interventions processes in place to support effective Chapter 6: Quality Improvement psychotherapy; • Recommendation 6-3.
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2011. The impact of national health care reform on adults with severe mental disorders.
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2013. Final rules under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
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2014. Comorbidity of common mental disorders with cancer and their treatment gap: Findings from the world mental health surveys.
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46 FRAMEWORK FOR PSYCHOSOCIAL INTERVENTIONS Wood, E., J
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