Dr. Robert Drake, a national leader in the move toward evidence-based practices, characterizes evidence-based practices as standardized treatments and services subjected to controlled research involving objective outcome measures and more than one research group. Evidence-based practices are built on scientific principles, and while they are supported by certain values and assumptions they are not themselves values; rather, they are specific interventions and treatment models that have been shown to improve client functioning and the course of severe mental illness. ^[1]  

Among the evidence-based practices experts believe should be available in the public mental health system are: appropriate use of all available psychotropic medications; assertive community treatment; supported employment; family psychoeducation; illness self-management; and integrated treatment for co-occurring mental illness and substance abuse disorders. This is by no means an immutable list. In fact, it is expected that these currently identified practices represent just the leading edge of a much larger body of evidence-based practices that will result in more reliable standards for mental health services. Promising practices exist in a variety of areas, including rehabilitative services, supported housing, and case management, among others. Properly implemented, existing evidence-based practices have been shown to improve outcomes for both the client and the system. There is every reason to believe that if they were implemented more broadly, fewer people with mental illness would become involved in the criminal justice system.

 Studies show, for example, that people who are prescribed the newer, "atypical" antipsychotic medications experience fewer debilitating side effects than do clients taking the older classes of medications, with the result that they are more likely to adhere to their treatment regimens and thus to see the course of their illness improve. Yet the schizophrenia PORT study shows that the newer medications are seriously underutilized, especially in African-American and other minority populations, resulting in higher noncompliance with treatment and the familiar consequences of untreated mental illness. ^[2]   The evidence shows that mental health service providers should make the newer medications routinely available to those who would benefit from them.

The Assertive Community Treatment (ACT) model (also known as Program of Assertive Community Treatment, or PACT) has been the subject of more than a quarter century of research showing its effectiveness with clients who do not respond to less comprehensive approaches. Since its inception in Madison, Wisconsin, in the 1970s, the ACT model has demonstrated that a mobile, multidisciplinary team approach, with services available twenty-four hours a day, significantly improves outcomes for persons with hard-to-treat mental illnesses. In some sites, persons with histories of criminal justice involvement or deemed to be at risk of criminal justice involvement have been identified as priority clients of ACT programs.

Despite the abundance of research that demonstrates ACT's effectiveness, providers and systems have until recently been reluctant to make the changes necessary to implement the program. Research is less clear on the factors that may have impeded implementation of ACT, but many providers note that it is difficult to change staff habits, program configurations, and patterns for state funding and federal reimbursement. In this way, the story of ACT is illustrative of some of the hurdles to be overcome by all evidence-based practices. So, too, is the recent upturn in ACT implementation, which stems from increased advocacy for the program at both the federal and grassroots levels, as well as clarification of reimbursement rules under Medicaid and other funding streams.

It is important to note that evidence-based practices are not all treatment interventions. Supported employment, family psychoeducation, and illness self-management are better seen as support techniques that ultimately allow a client to develop his or her self-reliance and personal strengths. Each in its own way can be a critical element in a person's recovery and ability to function, but none of these practices can be seen as direct treatment.

The U.S. Surgeon General and others have made efforts to gather and disseminate information about evidence-based practices, but it is apparent that a huge gap remains between knowledge and practice, between what is known through research and what is actually implemented in many public mental health systems across the country. A particular challenge for public mental health stakeholders is to ensure that evidence-based practices become more broadly available and more seamlessly integrated into existing systems of care.

The Surgeon General's 1999 report on mental health makes this challenge particularly clear. "Exciting new research-based advances are emerging that will enhance the delivery of treatments and services in areas crucial to consumers and families - employment, housing, and diversion of people with mental disorders out of the criminal justice systems. Yet a gap persists in the broad introduction and application of these advances in services delivery to local communities, and many people with mental illness are being denied the most up-to-date and advanced forms of treatment." ^[3]