The role of mental health service research in promoting effective treatment for adults with schizophrenia*

BACKGROUND: Significant gaps exist between scientific knowledge about the efficacy of treatments for mental disorders and the availability of efficacious treatments in routine practice. Mental health service research can help bridge this gap between basic clinical research and the usual care afforded adults with mental disorders. AIMS: To illustrate this potential, data on the efficacy of treatment for schizophrenia are reviewed. METHODS: The treatments reviewed include pharmacotherapies, psychological interventions, family interventions, vocational rehabilitation and assertive community treatment and case management. Using treatment recommendations based upon outcome data about these treatments and the results of a large survey of usual care for schizophrenia from the Schizophrenia Patient Outcomes Research Team (PORT) project, examples of current deficiencies in the usual treatment of adult mental disorders and relevant questions that need to be addressed by mental health services research are identified. RESULTS: Major deficiencies in treatment that were identified include inappropriate dosing with antipsychotic agents, underutilization of adjunctive antidepressant therapy, very low rates of prescription of psychosocial interventions and lack of continuity between inpatient and outpatient settings. DISCUSSION: These findings raise serious concerns about access to care and the appropriateness and quality of care that is offered. IMPLICATIONS: This knowledge about what treatments work for schizophrenia and the patterns of current care suggest the following major questions be addressed by mental health services research: What is the nature of care currently being offered adults with mental disorders? To what degree does this care measure up to scientifically derived quality of care and treatment standards? What is the effectiveness of new technologies under usual practice conditions? For which patients are they cost-effective and under what conditions? How should financial incentives be structured within systems of care to promote the most cost-effective use of new technologies? How should service systems themselves be organized to promote appropriate access and utilization? What educational, organizational and financing interventions promote adoption of effective interventions? Do we have valid methods for assessing quality of care? What strategies (interventions) are effective at improving the quality of care? In addition, we need to develop strategies that transfer mental health services research technologies into practice. These include: (i) development of outcome measures that meet scientific standards and that are practical for general application in service systems to facilitate "outcome management"; (ii) development of quality of care assessment methodologies that are practical and scientifically sound and (iii) cost-effectiveness methodologies. Mental health services research can facilitate the translation of knowledge developed from basic clinical research into more effective systems of care. The tools used by health services research to this end include examination of patterns of usual care in relation to scientifically established standards of efficacious care, interventions to improve the effectiveness of care and examination of the impacts of the organization and financing of services on outcomes and costs. In short, mental health service research holds high on its agenda the translation of basic and clinical research into practice. All of us must face the challenges posed by our rapidly changing mental health care system, changes driven not only by managed care and cost containment, but by exciting new developments in the treatment of mental disorders. We take on these challenges as researchers, clinicians, administrators, patients, families and taxpayers. Here I seek to provide a perspective on what we know about the treatment of adults with mental disorders and to discuss the implications of this knowledge for the work of mental health service research. Each of us has a particular window on this scene; mine is primarily that of a clinical mental health services researcher who studies schizophrenia. I will briefly summarize current knowledge about the efficacy of treatments for schizophrenia and the services research questions that this knowledge raises in its translation to clinical practice. The lessons from this examination readily generalize to the treatment of other adult mental disorders.