Evidence Based Treatment and Psychology

As a psychologist trained 30 years ago in a Boulder-model scientist practitioner training program in clinical psychology, the ability to critically evaluate research and to determine its application to the treatment of my patients was an essential part of my practice and of my outlook on clinical psychology. That initial training fed my early interest in Cognitive Behavioral Therapy. I still have vivid recollection of attendance at my first two-day workshop conducted by Jeff Young (Jeffrey E. Young, Ph.D.) on Beck-style Cognitive Therapy of Depression, a workshop that had profound impact on the treatment I provided. Even my later identification as a Feminist Therapist and my questioning of programmed, patriarchal methods that elevated the therapist above the patient was always tempered by the need to use the scientific method in my practice and in my life. (I’ll credit George Kelly’s ‘man, the scientist’ and Franz Epting, Ph.D. for that.)

As I have mentioned previously, I have been retired from active practice since 1993. Imagine my surprise to learn this past November that clinical psychologists value their own experience and the guidance of their colleagues more than they do the dictates of science. In fact, according to the authors of Current Status and Future Prospects of Clinical Psychology: Toward a Scientifically Principled Approach to Mental and Behavioral Health Care by Timothy B. Baker, Richard M. McFall, and Varda Shoham, some clinical psychology training programs are downright anti-scientific. They believe the solution to this ‘problem’ is a new system of accreditation for training programs. NPR’s Science Friday aired an episode on this topic on December 4, 2009. The show, entitled The Science of Clinical Psychology, is a quick way to get a sense of the much longer paper.

This paper and the PR blitz surrounding it including an article in The Washington Post by the authors, has received strong reaction from practicing psychologists, directors of training programs in clinical psychology and divisions of the American Psychological Association (APA).

While some would describe the Baker, McFall, Shoham article as politically motivated and an attempt to wrest accreditation away from the APA, it seems to me that focusing in a defensive fashion on political motivations accomplishes little. Perpetuation of the ad hominem arguments used in the paper will not get us very far. Perhaps we should focus instead on the notion of scientific support for mental health and behavioral treatments, how clinical research might be encouraged, how evidence-based treatments (EBTs) might be most effectively promulgated, and whether psychologists are alone in their hesitance to adopt EBTs.

In his December editorial in Current Psychiatry Online, Henry A. Nasrallah, M.D. suggests that psychiatrists also could benefit from self-evaluation regarding their use of EBTs. Below is an excerpt from Dr. Nasrallah’s article:


 The Schizophrenia Patient Outcomes Research Team5 assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.

A study using data from the National Comorbidity Survey6 found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.

Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia7 showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.

It would appear that psychologists and psychiatrists all need a stronger push toward use of EBTs.

In the world of community behavioral health, Medicaid and Medicare are pushing providers of care to the chronically mentally ill toward use of EBTs. SAMHSA has an entire section of its web site dedicated to EBTs. SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) contains a searchable database of interventions for the prevention and treatment of mental and substance use disorders. The database currently contains 150 entries along with a method for submitting programs for review and inclusion in the database. The NREPP has the potential for becoming a clearinghouse for effective behavioral health treatment interventions.

How does your organization approach the issue of evidence-based treatments? What is your take on the current controversy in the field of clinical psychology? How do you imagine we ought to move forward in advancing scientifically-tested approaches to mental health treatment? Given the costs of health care, this seems like an extremely important issue for all providers of behavioral health services to address.

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Integrating Behavioral Health and Primary Care

The September 29, 2009 edition of NJAMHA Newswire reports on a trend appearing strongly in New Jersey and in many other states: attempts to provide primary care treatment at the behavioral health setting or alternatively, to integrate behavioral health treatment into the primary care setting. In fact, the National Council, the major membership organization of community behavioral health care providers, has introduced an online Resource Center for primary care and behavioral health collaboration on their web site. This center comes out of six years of work in this arena.

FierceHealthcare, a daily newsletter for health care executives, reported on this trend in its September 30, 2009 edition. The article mentions the research literature that documents the tendency of primary-care physicians to miss the signs of common mental health issues like depression. Overlooking the mental health issues can often complicate both behavioral health and physical health treatment. A diabetic who experiences some debilitating mental health issue may not be able to comply with their required diet and self-care, just as a pregnant woman taking lithium to manage her bipolar disorder faces consequences for her child from her medication. The behavioral health and physical issues are inextricably intertwined.

Behavioral Healthcare online edition of October 1, 2009 reported a SAMHSA-funded study that indicated that general practitioners, not psychiatrists, are the most frequent prescribers of psychotropic medications. This includes pediatricians among the GP category since they usually are the primary care physicians for children.

The FierceHealthcare article identifies the financial and health benefits of the integration of mental health screening and prescribing into primary health care settings. Making sure that mental illness is not overlooked is one way of assuring that patients get the most effective treatment for all of their illnesses.

Since mental health treatment has usually been considered specialist-level care, there is concern among behavioral health providers that such screening and treatment by GPs is not the appropriate care in the right setting. Given how busy primary care providers are, it is highly likely that medications will be prescribed without psychotherapy or other appropriate behavioral interventions.

Health care reform is focused on saving money and providing effective care as efficiently as possible. Some would argue that the primary care provider’s intervention in behavioral health issues is the appropriate, cost-effective way to assure proper diagnosis and treatment. Most mental health providers I know would disagree, perhaps arguing that screening and referral to specialists is the appropriate and most effective way to provide care.

What are your thoughts on this issue? Do you see the possible integration of behavioral health care and primary care as positive for you and your clients? How is this likely to impact the way you currently provide services? What about those of you who already work in primary care settings; is this the ideal way to provide care to all patients, to complicated patients, or to no one at all?

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E-prescribing and a Behavioral Health EHR: Where to from here?

For the past several years Synergistic Office Solutions, Inc. has had the privilege and pleasure of participating as a member of the Software and Technology Vendor Association (SATVA), a group of vendors of software and other technology for the Behavioral Health and Social Services community. Last Thursday, I returned from our semi-annual member meeting…charged up with information about what is happening in the behavioral health world and full of questions about how all of the current events will impact SOS and our customers.

Standards for Electronic Health Records (EHR) for Behavioral Health were our primary discussion topic at this meeting. The community mental health world has long known that they will need to use EHRs to maximize the efficiency of their services and document the effectiveness of their treatments. State reporting requirements alone make use of an EHR a worthwhile way to simplify the lives of clinicians and administrators. Psychologists and psychiatrists in the private practice community have been slower to embrace the idea that electronic clinical records will improve care. The cost of the product and the time it takes to learn and use such software has been an obstacle for many organizations. While our mental health clinical record software has been around since 1992, we have many fewer users of that product than of our billing software.

Some states and payers are rapidly moving toward mandates for implementation of aspects of an EHR. FierceHealthIT, a newsletter for those working in information technology for health care, reported last week that MA BCBS will be requiring e-prescribing by January 1, 2011 for physicians who participate in their incentives program. The Centers for Medicare and Medicaid Services (CMS) has developed an electronic prescribing incentive that will increase physician reimbursement by 4.5% by 2014 for those who use qualified electronic prescribing products. The National Governor’s Association (NGA) has provided a forum and support for states to move forward on Health Information Exchange (HIE), electronic prescribing and computerized physician order entry (CPOE) . At the federal level, a public-private partnership has been formed in the AHIC Successor, Inc. to move forward the process of developing a National Health Information Network (NHIN); and the Certification Commission for Healthcare Information Technology (CCHIT) has formed the necessary work group to certify a Behavioral Health EHR.

While the names and acronyms of these bodies may be new to many of you, they are working hard to assure that interoperable EHRs are widely implemented by 2014. Many in the industry consider this an unrealistic goal date for such comprehensive change, but many entities are dedicated to seeing successful adoption of this technology in the not very distant future.

How will the requirement for health care providers to utilize EHRs affect psychologists, psychiatrists and social workers in private practice? Will the expectations be different for private care providers than for behavioral health providers in a community setting? How do you expect these changes to affect your organization? Are you already using an EHR? Let’s talk about where you see this going in your world.