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Taking Issue   |    
Changing the Oil While Driving the Car
Lloyd I. Sederer, M.D.
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.5.575
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A remarkable yet underappreciated fact is that efficacy studies have shown that mental health treatments are as effective as other medical interventions. Maybe mental health treatments are so unappreciated because we do such a poor job of using them. Robert Drake demonstrated in his research on co-occurring serious mental illness and substance use disorders that half get no treatment, over 40% get poor treatment, and a fortunate single-digit percent get evidence-based practices—which work! Former Surgeon General Dr. David Satcher described this sorry state as the gap between what we know and what we do; a huge gap indeed.

I envy the dissemination process that Resnick and Rosenheck describe in this issue for supported employment: what great resources they had—$16 million, time, technical assistance, fidelity assessment, and the Department of Veterans Affairs closed system of care itself. How do we mental health professionals improve our performance? Demonstration projects and pilots that implement evidence-based practices work only as long as their funds flow, then they stop working. We know what works, such as supported employment and integrated treatment for co-occurring serious mental illness and substance use disorders, so why conduct more demonstrations? We need wholesale transformation—systemwide implementation of what works.

What we are doing in New York State for co-occurring disorders in over 1,200 statewide mental health and chemical dependency clinics has foundation and state money for technical assistance, training, and clinical distance learning. But what do you do if you are a state that is small, poor, and short staffed?

Let not the perfect be the enemy of the good. Clinical training programs can ensure that their graduates can competently use evidence-based therapies. State mental health authorities can set quality standards and import tools and training from other states, federal agencies, or academic centers; they can reduce administrative burden and show what can be done, not harp on what cannot. Providers can pursue quality improvement efforts for practices that work and proudly show the results. Payers can stop buying ineffective care and pay for what works. This will take leadership, courage, and commitment. Because no one can stop services to fix them, it will take changing the oil while driving the car.

The greatest public mental health improvements we will see in the next five to ten years will be from closing the gap between what we know and what we do. Imagine if half of those who do not come for care started to come and if half of those who now get poor care received evidence-based practices. Imagine the benefits for consumers, families, and communities. Imagine the pride clinicians would feel. That is what we need to keep in mind when trying to do what can seem like the impossible. As has been said, fortune favors the bold.

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