Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type

There is widespread acceptance of the notion that patients do better when evidence-based health care practices are used, but positive outcomes associated with evidence-based policy making are less widely acknowledged (1). In both health care practice and policy, an evidence-based approach relies on the best available science from a wide variety of methodologies to make decisions and recommendations. To clarify the difference between these two levels of evidence-based approaches, it is necessary to clarify how practices differ from policies.

Evidence-based health care practices incorporate the current best evidence from clinical research into the management and care of individual patients (2). For example, evidence-based health care practices provide guidance around identifying what medication or intervention is most likely to be effective and sufficiently safe for the average patient and important subpopulations. In contrast to evidence-based health care practices, evidence-based policy making addresses the use of current best evidence to inform health policies, which have an impact on the care of populations of patients. Policies are defined as “formal statement[s] or action plan[s] developed by a government agency or statutory body in response to an identified problem” (3). Health policies encompass the legislative, regulatory, and financial levers enacted at the federal, state, or local level that, among other objectives, promote or hinder the uptake of evidence-based clinical services. Policy makers include legislators, regulators, accreditors, licensing boards, officials at state and local mental health agencies, provider organizations, purchasers, insurance companies, and patient and family advocacy groups.

Evidence-Based Policy Making

Research in Mental Health Policy

Evidence-based policy research focuses on producing knowledge and the best evidence regarding health policies that are most likely to improve the quality of health care and create conditions for effective, safe, equitable, efficient, timely, and patient-centered care. Evidence-based policy research can examine approaches to enhance policy adoption, identify effective policy elements, or study systemwide outcomes of policies once they are implemented (4). These types of research can inform how laws and regulations affect the delivery of evidence-based practices and how policies can either counteract or perpetuate structural racism and health disparities, including disparities in health care.

A relatively small number of empirical studies have attempted to develop evidence-based policy making in the fields of mental health and substance use (described here as “mental health policy”) (5). These studies, including the RAND Health Insurance Experiment, the Substance Abuse and Mental Health Services Administration (SAMHSA) national demonstration projects, and New York State’s assisted outpatient treatment program (6), have had an outsized impact on care delivery and organization, highlighting the value of this type of research (7). Nonetheless, the fragmented funding and service delivery service sectors in the United States have created challenges in implementing these studies and moving their findings into practice. This decentralization makes it difficult to implement findings from this research uniformly, necessitating buy-in from numerous provider organizations and states. Outcomes of this type of work are difficult to measure, measurements often rely on administrative data, and, in the absence of randomized designs or rigorous implementation science techniques, outcomes are difficult to ascribe to particular policy interventions.

Several strategies applied at different phases of research can be effective approaches to informing and improving mental health policy, such as developing research questions, selecting methods and outcomes to be considered, and planning how to disseminate findings (8). For example, researchers could partner with policy makers, advocacy groups, and community members to identify salient questions and help disseminate findings (9). Researchers could develop designs to examine unique aspects of mental health policy that stem from the historical separation between general medical care and mental health care in the United States and the disproportionate burden of stigma and disadvantage affecting many people with mental illness. Mental health policy areas in need of study include the impacts of carved-out payment mechanisms, the roles of a multidisciplinary workforce in team-based care, the strengths and weaknesses of stand-alone public-sector services, the implications for mental health care of an employer-based health insurance system, and intersections with other social services and the criminal justice system.

To maximize the impact of scientific findings, researchers may endeavor to align the methods and aims of a study with priorities of particular policy makers and other stakeholders (10). They may also focus on key policy outcomes, especially economic impacts, given scarce resources and entrenched health care disparities that have led policy makers to pay more attention to cost-effectiveness (or value) of health care and distributional effects of policies. Researchers could further enhance the influence of their findings by using state and local data that correspond to the jurisdiction of the policy maker and by aligning rigorous research efforts with program evaluation and quality improvement and reporting activities overseen by policy makers. Implementation of supported employment offers an example of an evidence-based policy that whenever adapted in a particular state context should be evaluated in that same context (11). Other examples include New York’s implementation of assisted outpatient treatment or the potential effects of this program on racial disparities (6, 12), factors that might affect the diffusion of assertive community treatment (13), and ways in which payment schemes affect health care integration (14). Dissemination materials that use individual stories and qualitative data to frame and complement quantitative data can increase communication and bring findings to life for stakeholders. Such materials should also be concise and to the point (8).

Policy Efforts Informed by Mental Health Research

Recent legislation, regulatory efforts, and technological developments have supported the more widespread use of evidence in policy making. The Foundations for Evidence-Based Policymaking Act of 2018 incorporates recommendations of the U.S. Commission on Evidence-Based Policymaking (2017) to improve the use of evidence and data to generate policies and inform programs in the federal government (15, 16). This law requires agencies to implement a learning agenda that aligns evaluation efforts with key policy questions and to designate chief evaluation officers for managing data and overseeing the generation of evidence. SAMHSA’s Evidence-Based Practices Resource Center, launched in 2018, provides communities, clinicians, and policy makers with essential information on evidence-based practices that can be incorporated into a range of settings (17). Research evidence has been used to inform financing of evidence-based services, such as new billing codes that enable reimbursement for collaborative care services (18). New data sources, such as large electronic health record databases, are increasingly making it possible to use real-time data to promote the development of learning health systems that both facilitate quality improvement and produce generalizable findings that can be applied more broadly (19).

The Policy Review Article Type

To help fill the need for high-quality evidence to inform mental health policies, Psychiatric Services has recently launched a new article type: the Policy Review. These reviews define a specific policy-relevant issue affecting behavioral health systems, describe current knowledge and limitations, and provide an in-depth discussion of policy implications. Reviews can focus on mental health policies or address how other health or social policies affect people with mental illness or substance use disorders. Submissions can review existing policies, discuss potential benefits and drawbacks of future policy alternatives, or provide historical reviews of lessons learned from past policies. They can focus on the United States or describe how other countries deliver mental health care. Reviews should address the expected impacts of particular policies across different stakeholder groups. We encourage collaborations between researchers and policy makers to help identify the most important and pressing issues and to facilitate dissemination and implementation of the findings.

Many best practices that have been demonstrated to be effective in communicating with policy makers are also applicable to writing effective policy reviews. Such reviews should be succinct and should focus on policy-relevant outcomes; they may also combine quantitative findings with case examples to help highlight the effects of policies on individual patients, clinicians, and health systems. Particularly for policies that have had limited coverage in the peer-reviewed literature, it is important that authors also review gray literature, including white papers, unpublished evaluations, committee reports, and media stories (20). Finally, these reviews should propose specific actionable steps, as well as trade-offs among alternative strategies, for policy makers and other key stakeholders to consider.

In contrast to systematic reviews of clinical interventions, which typically focus on whether an intervention is effective, policy reviews place a greater emphasis on context, addressing for whom, in what circumstances, in what respects, and how a particular policy works (21). Because policies often have uneven effects across different populations, it is important to examine their impact on vulnerable populations, including implications for historically disadvantaged groups.

The evidence-based policy-making process is likely not immune to political cross-currents. For example, recent interest in “red flag laws” or various types of gun removal orders as an approach to reducing gun violence and suicide risk faces opposition from Second Amendment advocates. Such opposition would likely affect acceptance and implementation of such policy initiatives. Commentary on the political context of evidence-based policy making is clearly within the scope of these reviews. The problem raised by these politically charged policies is, in part, that evidence on the practice itself is bitterly contested, and thus the “true evidence” is difficult to fairly interpret.

Conclusions

The increasing availability of high-quality and timely data and a growing receptivity of policy makers to utilizing research findings have created a unique opportunity to increase use of evidence-based policy making in mental health. We look forward to working with Psychiatric Services’ authors and readers and with the broader mental health community to help advance that goal.