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Special Report
Preventive Interventions
Under Managed Care: Mental Health
and Substance Abuse Services
Quality of the Evidence
The Clinician’s Handbook of Preventive Services, 2nd Edition,
U.S. Preventive Services Task Force (1998), contains recommendations
regarding clinical preventive services, including
some related to mental health and substance abuse. In a rigorous review of
the knowledge base, the Task Force categorized the strength of the
research based upon the quality of scientific evidence as follows:
I: Evidence obtained from at least
one properly designed randomized
controlled trial.
II-1: Evidence obtained from well-designed
controlled trials without
randomization.
II-2: Evidence obtained from well-designed
cohort or case-control
analytic studies, preferably from
more than one center or research
group.
II-3: Evidence obtained from multiple
time series with or without the
intervention, or dramatic results in
uncontrolled experiments.
III: Opinions of respected authorities,
based on clinical experience,
descriptive studies, or reports of
expert committees.
(U.S. Department of Health and
Human Services, 1998)
While the Task Force concluded that evidence
was insufficient to support universal
screening for behavioral health problems, its
report cited indications for targeted screening
of at-risk populations (CSAP, 1996).
The extensive review of the state of the
knowledge base that underpins the 1994
IOM report, Reducing Risks for Mental
Disorders: Frontiers for Prevention Intervention
Research, also found convincing
evidence of prevention effectiveness.,
According to that report:
There have now been sufficient
advances in knowledge to warrant the
prompt mounting of intensive interventions
designed to prevent mental disorders,
so long as these programs are rigorously
evaluated; for other conditions
there is still the need for development
of an adequate knowledge base before
sound theoretically-based interventions
are warranted.
(Mrazek & Haggerty, 1994, p. vi)
Mental health reimbursement from
existing health insurance should be
provided for preventive interventions
that have proved effective under rigorous
research standards
(Mrazek & Haggerty, 1994, p. xiii)
In its deliberations, the Institute of Medicine’s
Committee on Quality Assurance and
Accreditation Guidelines for Managed Behavioral
Health Care used an evidence-based
approach. In doing so, the Committee concluded
that the research base in behavioral
health care is far less advanced than in other
areas of health care (Edmunds et al., 1997).
The National Institute on Drug Abuse
(NIDA) recently observed that "empirical
data gathered through rigorous scientific
methods are being demanded by the field so
that policy making can be improved by the
adoption and implementation of science-based
drug abuse prevention programs that
actually work in the real world" (NIDA,
1998, p. 1). Some prevention research is
insufficiently rigorous to add to the evidence
base. Experimental designs (pretest-posttest
control group design; posttest-only control
group design; delayed treatment design) are
the most rigorous. However, the complexities
of prevention research sometimes rely on
quasi-experimental designs (nonequivalent
comparison group, time-series, time-series
with comparison group) or nonexperimental
designs. NIDA (1998) has noted that
methodological flaws are common in prevention
program evaluations. Examples of these
methodological problems include small samples,
participant attrition, and insufficient
long-term followup (Heller, 1996).
Among the hindrances to more rapid
knowledge advances is the extent to which
research efforts are dispersed in this multidisciplinary
arena. The 1994 IOM report noted
that research related to the prevention of
mental health problems emanates from many
fields, including neurosciences, genetics, epidemiology,
psychiatry, psychology, behavioral
sciences (including developmental psychopathology),
and risk research (Mrazek &
Haggerty, 1994). Research support comes
from diverse sources; investigators represent
a wide variety of disciplines; and results are
disseminated through a vast array of journals
and conferences, making it difficult to track
and integrate new knowledge. The report
called for a national commitment to rigorous
research and for cooperation among Federal,
State, and local agencies; universities; foundations;
researchers; and communities to
expand the evidence base.
According to the American College of
Mental Health Administration (ACMHA):
There are empirically validated studies
which demonstrate the efficacy, cost-offset
and improved outcomes for a
variety of mental health and medical
problems through psychosocial interventions.
It is now possible—and prudent—
to incorporate preventive services
for behaviorally related problems into
general health and mental health and
substance abuse systems of care.
(ACMHA, 1997, p. 27)
The National Mental Health Association’s
publication Preventing Mental Health and
Substance Abuse Problems in Managed
Health Care Settings concludes:
Evidence-based, effective preventive
interventions will increasingly be in
demand as a realistic tool for managing
the need for health care services. As
treatment services are curtailed as much
as purchasers, consumers, and politicians
will tolerate, prevention of initial
offset may become more valued, especially
as prevention before disorder
proves to be more cost effective than
treatment after disorder.
(Mrazek, 1998, p. 21)
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