Review of Best Practices in Mental Health Reform

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• Summary of Section I
• Summary of Section II

EXECUTIVE SUMMARY 

The purpose of this literature review is to summarize the evidence that is most relevant to the reform of our mental health systems and to guide the reader to other reviews and resources.

The review has focused upon services and strategies for persons with serious mental illness at the program and system level. It has generally not included research into client-level treatment interventions. The question of interest is how to best organize programs and systems within which efficacious clinical interventions and treatments can be provided.

The nature of the evidence that is used to define 'best practice' is somewhat different when one moves from medical treatment research to the effectiveness of programs in community settings. In this review we have whenever possible reported the findings of randomized, controlled studies. But as will become clear, such evidence is not always available, especially with regard to newer service and support modalities. In its absence, the best recent data-based evaluations are described.

In the search for best practices we surveyed published and unpublished evidence-based knowledge about mental health reform initiatives. Articles and documents in French as well as English were appraised for this review. A computer assisted search of PsychLit and MEDLINE databases was conducted. This was supplemented by citations in the literature and by checking our search results with the Psychiatric Rehabilitation Journal and Current Psychiatric Opinion, both of which publish reviews of recent literature on similar topics of interest. In some instances we contacted experts in other jurisdictions for information about unpublished articles or documents.

This review has two parts. The first is concerned with the development of effective services and supports that are components of a comprehensive community support system. It compiles information about current evidence to inform decision making about the different elements of care that should be in place in each local community. Proven and promising approaches to providing individual supports, inpatient/outpatient care, housing, employment and self-help are described. The second part of the review shifts to macro-level or system-wide strategies that foster the widespread implementation of the effective services and supports identified in Section I. Facilitative policy, modified governance and funding mechanisms, evaluation and human resource strategies can all be tools for change. Evaluation of macro-level approaches to system change is difficult but there are some empirical studies that can guide the definition of best practice, as can descriptions of experience in other jurisdictions.

We have examined these two types of practice separately, but they should be applied together. For example, the system strategy of setting clear and measurable targets about shifting resources from hospital to community is successful only if it contributes to an increase in the availability of case management programs or consumer and family initiatives, which then improve the quality of life of their participants. There are not always immediate or visible connections between the two types of practice, but system practices are ineffective if they do not act through services and supports. At the same time, widespread dissemination of effective services and supports is dependent upon conducive system practices.

If best practices are considered to be activities and programs that are in keeping with the best possible evidence about what works, then the studies that are reviewed in this document provide a solid base for the definition of best practices related to mental health reform. There is stronger research evidence for some types of services and supports than others, and in some areas little can be said from this perspective. Still, the adage that we know far more than we do, clearly applies to the provision of community support for those who are severely mentally ill. 

The following descriptions of best practice are meant to influence and inform policy rather than dictate specifically what course should be taken. Descriptions of best practice in many ways resemble descriptions of ideal service delivery systems. In the real world it is rare for all the components to be achieved and usually attention is focussed upon selected aspects as targets for change. Incremental progress on multiple fronts is the most typical way in which systems are improved.