MacArthur Foundation Network on
Mental Health Policy Research
—Robert Drake, Jonathan Skinner, and
W H Y S O S L O W T O A D O P T C E R T A I N
P R O V E N T R E A T M E N T S ? G A I N I N G A
B E T T E R U N D E R S T A N D I N G O F H O W
A D V A N C E M E N T S I N M E N T A L H E A L T H
C A R E A R E D I S S E M I N A T E D
The past twenty years have seen strong advances in use and treatment as a fi rst step in better in the treatment of mental illness. However, unlike understanding these barriers. other health care treatments, providers have been slow to adopt proven treatments and medications. What Prevents Widespread AdoptionFor example, fewer than percent of schizophrenia of New Treatments and Medications? outpatients receiving care in two large public mental Despite strong empirical evidence about the health systems in the late s were prescribed an effectiveness of a particular drug or intervention, antipsychotic medication within the recommended such treatments do not always reach everyone dose range. Another study found that only one- who could benefi t from them. Professionals and third of treatments for mental illness met minimal patients may lack information on the treatment, standards of adequacy.
treatment may be too expensive, or wide profi t margins may create incentives for distributors to
Unlike new medications, where the marketing of push certain interventions over others. new practices is supported and encouraged by patents, psychosocial treatments are not patented Informational barriers are a fi rst potential barrier to and therefore lack the economic incentives to more widespread use. Because research on regional promote them widely. Because it is diffi cult to variation in mental health treatment diffusion is market, doctors are less exposed to best practice limited, Drake, Skinner, and Goldman explore strategies and consumers are often unaware of such barriers in treatments for heart disease and other strategies for treatment.
alcoholism. Despite widespread clinical evidence, for example, on the effectiveness of beta blockers
In their paper “Why So Slow to Adopt Certain in treating acute myocardial infarction, physician Proven Treatments?” for the Fundamental
Policy and other professionals’ opinions about the value – Spotlight on Mental Health Conference, Robert of drugs affected diffusion and subsequent use of Drake, Jonathan Skinner, and Howard Goldman the drug. argue that research must better understand the barriers to wider dissemination and adoption of Research shows that a primary reason for low use improved treatments and medications for mental among both patients and physicians of naltrexone illness. They identify informational, fi nancial, and in treating alcoholism is lack of information about profi tability barriers to widespread adoption and the drug. Other reasons cited for low naltrexone use call for studies that document regional variation included unfounded fears of addictive potential,
confusion about indications, and limited patient health care as a first step in better understanding demand and access to physicians. Also, within the these barriers. Because there are significant “culture of abstinence” in the fi eld of substance distinctions by state or locality in adoption abuse treatment, some providers object to the use of new technologies, researchers can use these of medications.
distinction to uncover potential reasons for the wide disparities in adoption. Understanding
Financial barriers may also affect diffusion. Even why some communities may incorporate interventions that have shown great promise, such treatment strategies more than others may draw as multi–systemic therapy (mst) for youth and out effective diffusion practices and potentially the impact model to treat geriatric depression, identify which strategies work best for given have been slow to spread because of high costs populations of consumers. Researchers could of training and fi nancing the intervention.
use national databases1 to develop population–based measures of resource use and drug
Finally, profi tability incentives may drive diffusion. treatments stratified by disease type, which For example, “second generation drugs” for would limit research costs. schizophrenia, which advertised greater effi cacy and fewer side effects than fi rst–generation A more costly alternative would test the medications, were aggressively marketed in the effectiveness of methods to speed the diffusion early s. Prices for these medications were of an effective drug (e.g., naltrexone) in general ten times those of the fi rst–generation drugs—a mental health practice. While we know a great key reason behind more aggressive marketing deal about implementing effective treatments, less and sales. Consequently, expenditures for these is known about systematic regional differences second–generation medications in the United stemming from region–specifi c factors such as States rose to . billion in , accounting social capital. for percent of users and percent of total expenditures for antipsychotics. Notably, longer– The ultimate goal of these and other research term, well controlled studies found that the new questions is to better understand and overcome second–generation antipsychotic medications are barriers that prevent all citizens from attaining no more effective than the older antipsychotics.
Research AgendaDrake, Skinner, and Goldman propose a new research agenda to better understand what curtails the diffusion of improved mental health
Examples are databases maintained by the
treatments. They suggest measuring regional
U.S. Department of Veteran’s Affairs, or
variations in the provision of effective mental
Disability Insurance (SSDI) program.
Robert Drake, MD,
Howard Goldman, MD, PhD,
The MacArthur Foundation Network on Mental
Health Policy Research has worked to develop a
knowledge base linking mental health policies,
financing, and organization to their effects on
Jonathan Skinner, PhD,
access to quality care. www.macfound.org
in the preparation of this material.
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Walking Between the Worlds: Links between Psi, Psychdelics, Shamanism and Psychosis An Overview of the LIterature In folk lore there is a belief that many people who have an acute psychotic breakdown exhibit signs of psychic ability. Research into this folk lore is virtually non-existent, but some interesting work by Neppe (1980) and Persinger (Persinger & Makarec, 1987) psi sugge