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Why So Slow to Adopt Certain Proven Treatments? Gaining a Better Understanding of How Advancements in Mental Health Care are Disseminated

By Robert Drake, Jonathan Skinner, and Howard Goldman

The past twenty years have seen strong advances in the treatment of mental illness. However, unlike other health care treatments, providers have been slow to adopt proven treatments and medications. For example, fewer than 30 percent of schizophrenia outpatients receiving care in two large public mental health systems in the late 1990s were prescribed an antipsychotic medication within the recommended dose range. Another study found that only one-third of treatments for mental illness met minimal standards of adequacy.

Unlike new medications, where the marketing of new practices is supported and encouraged by patents, psychosocial treatments are not patented and therefore lack the economic incentives to promote them widely. Because it is difficult to market, doctors are less exposed to best practice strategies and consumers are often unaware of other strategies for treatment.

In their paper "Why So Slow to Adopt Certain Proven Treatments?" for the Fundamental Policy – Spotlight on Mental Health Conference, Robert Drake, Jonathan Skinner, and Howard Goldman argue that research must better understand the barriers to wider dissemination and adoption of improved treatments and medications for mental illness. They identify informational, financial, and profitability barriers to widespread adoption and call for studies that document regional variation in use and treatment as a first step in better understanding these barriers.

What Prevents Widespread Adoption of New Treatments and Medications?

Despite strong empirical evidence about the effectiveness of a particular drug or intervention, such treatments do not always reach everyone who could benefit from them. Professionals and patients may lack information on the treatment, treatment may be too expensive, or wide profit margins may create incentives for distributors to push certain interventions over others.

Informational barriers are a first potential barrier to more widespread use. Because research on regional variation in mental health treatment diffusion is limited, Drake, Skinner, and Goldman explore such barriers in treatments for heart disease and alcoholism. Despite widespread clinical evidence, for example, on the effectiveness of beta blockers in treating acute myocardial infarction, physician and other professionals’ opinions about the value of drugs affected diffusion and subsequent use of the drug.

Research shows that a primary reason for low use among both patients and physicians of naltrexone in treating alcoholism is lack of information about the drug. Other reasons cited for low naltrexone use included unfounded fears of addictive potential, confusion about indications, and limited patient demand and access to physicians. Also, within the “culture of abstinence” in the field of substance abuse treatment, some providers object to the use of medications.

Financial barriers may also affect diffusion. Even interventions that have shown great promise, such as multi-systemic therapy (MST) for youth and the IMPACT model to treat geriatric depression, have been slow to spread because of high costs of training and financing the intervention.

Finally, profitability incentives may drive diffusion. For example, “second generation drugs” for schizophrenia, which advertised greater efficacy and fewer side effects than first-generation medications, were aggressively marketed in the early 2000s.  Prices for these medications were ten times those of the first-generation drugs—a key reason behind more aggressive marketing and sales. Consequently, expenditures for these second-generation medications in the United States rose to $2.6 billion in 2003, accounting for 71 percent of users and 93 percent of total expenditures for antipsychotics. Notably, longer-term, well controlled studies found that the new second-generation antipsychotic medications are no more effective than the older antipsychotics.

Research Agenda

Drake, Skinner, and Goldman propose a new research agenda to better understand what curtails the diffusion of improved mental health treatments. They suggest measuring regional variations in the provision of effective mental health care as a first step in better understanding these barriers. Because there are significant distinctions by state or locality in adoption of new technologies, researchers can use these distinction to uncover potential reasons for the wide disparities in adoption. Understanding why some communities may incorporate treatment strategies more than others may draw out effective diffusion practices and potentially identify which strategies work best for given populations of consumers. Researchers could use national databases to develop population-based measures of resource use and drug treatments stratified by disease type, which would limit research costs.

A more costly alternative would test the effectiveness of methods to speed the diffusion of an effective drug (e.g., naltrexone) in general mental health practice.  While we know a great deal about implementing effective treatments, less is known about systematic regional differences stemming from region-specific factors such as social capital.

The ultimate goal of these and other research questions is to better understand and overcome barriers that prevent all citizens from attaining the highest quality health care.

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Robert Drake, MD, Psychiatric Research Center, Dartmouth Medical School

Jonathan Skinner, PhD, Center for Evaluative Clinical Sciences, Dartmouth Medical School

Howard Goldman, MD, PhD, Division of Services Research, Department of Psychiatry, University of Maryland-Baltimore

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The authors acknowledge the support of the Robert Wood Johnson Foundation in the preparation of this material.