CLINICAL HANDBOOK OF SCHIZOPHRENIA

52. Evidence-Based Practices 543• Supported employment services, which help the 70–80% of clients whose goal iscompetitive employment.• Family psychoeducation services, which enable families and their member withmental illness to acquire knowledge, coping skills, and supports.• Integrated dual-disorder services, which help the 50% of clients who have cooccurringsubstance use disorders to achieve abstinence.• Assertive community treatment services, which provide intensive in-community interventionsto the 15–20% of clients who have difficulty maintaining housing andavoiding hospitalizations and homelessness.Other mental health practices have research support as well, but the aforementionedpractices have been the focus of several large-scale studies of implementation.Although these evidence-based practices could improve many lives, they are not routinelyavailable to people in mental health settings. In the most extensive demonstrationof this issue, the Schizophrenia Patient Outcome Research Team (PORT; Lehman,Steinwachs, & Survey Coinvestigators of the PORT Project, 1998) showed that peoplewith a diagnosis of schizophrenia in two state mental health systems were highly unlikelyto receive effective services. Even simple medication practices only met standards of effectivenessabout half or less than half of the time. Only 10% or fewer people receivedpsychosocial interventions supported by effectiveness research.IMPLEMENTATION PROJECTSResearch on implementation is accumulating rapidly as a result of several large, multisiteprojects. Key examples are the Johnson & Johnson–Dartmouth Community MentalHealth Program, the National Evidence-Based Practices Project, the Texas MedicationAlgorithm Project, and the Social Security Administration’s Mental Health TreatmentProject. In each of these projects, one or more of the evidence-based practices we mentionedhave been implemented in multiple sites with careful monitoring and evaluation.We next outline several lessons from these large implementation studies.Starting with “Early Adopters”One common strategy for large-scale systems change involves comprehensive top-downchange. Frequently, this has been accomplished in single-payer systems, such as thoseused in European countries or by the federal Veterans Administration health system inthe United States. These systems are characterized by centralized control of policies andprocedures. Comprehensive change is sometimes feasible in such systems. For example,every health practitioner in Veterans Administration hospitals is required to use the samemedical record, so that specific decision supports and requirements can be inserted intothe medical record within this system. There are also many examples within single-payersystems of resistance to top-down change efforts, especially when the interventions arecomplex and not easily enforced or monitored by electronic medical records.Efforts at comprehensive change have generally failed in state mental health systems,where there is much less centralized authority. For example, state mental health programsthat have attempted to implement a new practice, such as integrated dual-disorders treatment,on a uniform and simultaneous statewide basis have not been successful.An alternative strategy is to start with early adopters and plan for the gradualspread of a new practice. This approach recognizes that some states, organizations, and