Mental health policy and practice across Europe: an overview

104 Mental health policy and practice
Is the EBM movement applicable to evidence-informed
mental health policy?
In short, the answer is yes, but not in isolation. To link EBM to evidenceinformed
policy-making it is essential to take into account a myriad of factors
including local context, needs, existing structures and human resources, as well
as flexibility for system change. The use of evidence from quantitative research
methods, such as the RCT on its own, is unlikely to be sufficient to answer many
of the questions that policy-makers have to contend with. Policy-makers need
more information than the evidence from an RCT on whether symptoms get
better with drug A or drug B, and perhaps at what cost. For instance, they need
to know the context in which a study was undertaken, the potential for replicability
in their own setting, and the perspectives of service users and health care
professionals on the merits of these drugs. Complementary qualitative research
methods can help to broaden this information to better inform policy-makers
on the context in which individual interventions have been shown to work.
However, this is only one additional element of the information required for
evidence-informed policy-making.
The key questions and contextual issues for policy-making are much broader
than simply what works best, and also, must operate at the macro level as well
as the individual level. For instance, while access to new medications and the
balance between community and institutional-based care may be the predominant
preoccupation in some of the relatively rich countries of western
Europe, in other parts of the continent access even to basic older medicines may
still be restricted. Moreover, there may be little desire or flexibility within the
mental health system to invest in community-based services.
Key policy issues in some countries thus may revolve around ensuring that
the medicines used are adequate in terms of their availability and that staff have
basic training and continuing professional education on their use, management
of side-effects and recognition of early symptoms of relapse. They may also need
information on the necessary resources for, and the most effective ways of,
delivering new services such as community-based care, rehabilitation, supported
employment and risk management. These are but a few of the issues that
need to be considered in formulating national mental health policies ( Jenkins
et al. 2002; World Health Organization 2004).
Another key constraint in both the formulation and implementation of
policy is the availability of resources. Highly cost-effective interventions that
may be included within a mental health policy may be cost-increasing. This
can have significant consequences for the health budget; if investing in new
cost-effective approaches requires a greater share of the existing health budget,
then the number of people that may be treated or the nation’s ability to maintain
other services or ensure that adequate training is provided may be reduced.
Policy solutions need to be tailored to match available resources within countries
(see Chapter 4).
Evidence-informed policy thus will not be achieved simply by referring to the
disparate elements of effectiveness and cost-effectiveness studies. A number of
years ago, a senior figure in the EBM movement stated that since the only RCT
on mental health in primary care we had (at that time) was on the benefit of