Health care experts frequently lament the gap between what is known about
good medical treatment and what is practiced.
A group of Michigan mental health care practitioners and advocates has come
up with a plan that tackles an important aspect of that problem in a project
called the Michigan Mental Health Evidence-Based Practice Initiative.
With support from the Ethel and James Flinn Foundation, they have produced
a comprehensive, multiphase approach to encourage and assist physicians to
adopt best practice or evidence-based practice (EBP) in the prescription and
monitoring of drugs for people with major depression, bipolar disorder, and
schizophrenia. (The terms "best practice" and"
evidence-based" practice are used synonymously in their
Thomas Carli, M.D., chair of the panel, told Psychiatric News that
the effort came about after a study by Blue Cross/Blue Shield of Michigan
found "unexplained variations in prescription patterns in
Michigan." Carli is a clinical associate professor of psychiatry at the
University of Michigan.
He said, "We know that certain treatments for people who have
depression, schizophrenia, and bipolar disorder work better than others.
Unfortunately, guidelines [promoting effective treatment] are not used
frequently enough. For example, only a minority of primary care patients with
major depression received recommended dosages and duration of antidepressant
At the national level, the Institute of Medicine and President Bush's New
Freedom Commission on Mental Health had emphasized the importance of finding
ways to implement what medical researchers have discovered about effective
Panel members noted how difficult it is for physicians to keep up with and
assess which treatments are best for their patients in light of the amount of
information on treatment options.
The 25-member Michigan panel considered various guidelines and algorithms
and recommended that the Texas Implementation of Medication Algorithms (TIMA)
be modified for use in Michigan.
Carli said that the guidelines and alogorithms the panel considered"
don't differ a great deal" from each other. TIMA has the
advantage of including provisions for the education and support of patients
and families and could be adopted for use in a variety of settings.
Michael Engel, D.O., a member of the panel and immediate past president of
the Michigan Psychiatric Society, pointed out that TIMA is frequently updated."
It was important to find guidelines that will correspond with changes
in thinking and knowledge."
Both physicians commented on the challenges of implementation.
Carli said, "We know that dissemination of practice guidelines alone
will reach too few doctors."
The Michigan practice initiative differs from efforts to change prescribing
practices in other states, such as Missouri and Massachusetts, in its
It aims to use multiple strategies to influence practice in a wide variety
of settings and to educate a broad range of stakeholders. The panel members
wrote, "For the EBP project to succeed, there must be buy-in from
stakeholders—practitioners, patients, advocacy groups, payers, and
academic researchers on both the broad state and local level."
Ultimately, the panel wants its recommendations to affect practice by
primary care physicians, as well as psychiatrists, and in both the public and
Panel members focused considerable attention on identifying barriers to
adoption of guidelines and factors that would promote their use.
They reviewed research results on how practice changes occur among
physicians and came up with four principles:
Mark Reinstein, Ph.D., president and CEO of Michigan's Mental Health
Association, told Psychiatric News that TIMA, as currently presented,
would be very difficult for a family member or patient to understand. Success
of the project for these individuals will require considerable redesign of how
TIMA is presented.
The first stage of the initiative was conducted concurrently with
deliberations of the Michigan Mental Health Commission. "We were able to
get strong support from the commission for evidence-based practice as a core
ingredient of system reform," Carli said.
The Flinn Foundation supported staff work of the Michigan Mental Health
Commission, as well as of the prescribing initiative.
The next step will be the issuance of a request for proposal for three to
five pilot projects that would run for approximately three years. The aim of
those projects is to identify "innovative and early adopting
champions" to implement and test the TIMA and other related EBPs, with
the expectation that success of the pilots will help promote use
Among the sites being considered are state hospitals, university consortia,
and private mental health practices with a university affiliation.
That stage will be funded by the Flinn Foundation and other sources yet to
"Closing the Quality Gap in Michigan: A Prescription for
Mental Health Care" is posted online at<www.mimentalhealthebp.net/action_plan.htm>.▪