10 - Meeting unmet needs: can evidence-based approaches help?

Summary

In this chapter, we will discuss our attempt to develop evidence-based systems for defining, guiding, and monitoring aspects of psychiatric care in the USA; some of the limitations in these approaches (i.e., we should not get too overconfident about our capacities); and finally provide some recommendations about how to deal with some of these limitations – and particularly the role of a practice-based research network.

Basically, the problem put before contributors to this volume can be framed as four questions. Who gets treatment? What treatments are or should be provided? How are treatments provided – by whom, how much, and for how long? (and this ultimately translates into the economics). And, on what basis do we determine the above ‘who’, ‘what’, and ‘how’ – do we base it on tradition, on market values, or on evidence?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) introduction is clear in defining mental disorders as a grouping of symptoms plus either clinically significant distress or impairment in major role functioning [American Psychiatric Association (APA), 1994a]. The challenges are to determine which treatments are effective for whom, and to make sure that the people most in need get those treatments. It is important to define how we develop systems that encourage incentives for ensuring that the people in need of treatment receive the most appropriate medical care. In the USA there has been enormous growth in ‘managed care’ as a general approach for making these determinations. Our group has developed a model (Figure 10.1) of how managed care affects patient care, which can be applied to evaluating the processes of any health plan (Pincus, Zarin & West, 1996).