Evidence-based practice in mental health: practical weaknesses meet political strengths

RATIONALE, AIMS, AND OBJECTIVES: Evidence-based medicine (EBM) has given rise to evidence-based practice (EBP) in the field of mental health. EBP too is predicated on an evidence hierarchy and has the goal of using the "best evidence" (usually randomized controlled trials) to improve practice. EBP is increasingly influential in mental health care in the U.S. Growing numbers of researchers and public officials endorse its claims and pursue its benefits. The rationale for this paper is to examine the potential of EBP for the field of mental health-and public mental health care specifically. Is it likely to contribute to improved lives for mentally ill people? If so, how?

This qualitative study relies on archival, and to a much lesser extent, informant interview data. Informants were mostly public mental health officials because they are in a position to implement EBP on a large scale and their policies are a matter of public record. Interviews were semi-structured, held in person and on the telephone, and lasted one to two hours. Archival research included the substantial literature on EBM and EBP plus studies and articles on the practice and policy of U.S. public mental health care.

The results of this study were that there exists an extensive, coherent literature critical of EBM and of EBP specifically. Attempts to implement EBP will falter on epistemological and organizational barriers. Still, as a public idea--that more science will bring about better mental health practice--EBP may well serve political purposes, especially in the U.S. public mental health system, where more overtly ideological policies have been inadequate in the past. EBP, as a public idea, has the advantage of ambiguity, accountability, quantifiability, etc.

This paper concludes that EBP is growing more influential in public mental health care in the U.S. Its practical strengths, i.e., its improvement of mental health practice, may turn out to be less than its strengths as a public idea in the formulation and dissemination of mental health policy.