Cochrane, Early Intervention, and Mental Health Reform
Among the noncommunicable diseases, mental ill-health represents the major threat to social and economic progress because it impacts so powerfully on the most critical decades of life. Consequently, mental health reform is increasingly recognized as an urgent priority worldwide. This brings into sharp focus the role of evidence, and more specifically the Cochrane paradigm, in influencing decisions about health system reform. Cochrane clearly still has great value, especially in evidence-based medicine, where the focus is the evaluation of individual treatments. However, it cannot be allowed to be a dominant influence in evidence-based health care (EBHC) policy decisions for health system reform, unless it is modernized or complemented. Health services reform should definitely be as evidence-based as possible; however, the jury should consider its verdict on key reform proposals based on the balance of probabilities and informed by the best "available" evidence from all sources, not only randomized clinical trials, which in many domains may be never be feasible. This is particularly the case when reform is urgent, and the status quo has manifestly failed. So on the one hand, the evidence-based paradigm must not be misused to stifle or paralyze urgent reform. Alternatively, there is a real risk that, if we do not improve the sophistication of EBHC, the whole paradigm will be sidelined and reform will remain reactive, impulsive, and desultory. The recent Cochrane review on early intervention in psychosis provides an opportunity to consider these issues and their wider significance.
Mental health reform is one of the grand challenges of the 21st century. In every country, even in the wealthiest societies, people suffering from mental ill-health have considerably worse access to care than those with physical ill-health and that care is of much lower quality. This lop-sided and self-defeating allocation of the health dollar continues despite the fact that 75% of mental ill-health emerges before the age of 25 years, and its disabling and life shortening impact blights the prime productive years of life, causes untold misery, and weakens and diminishes society socially and economically. The recent report on noncommunicable diseases from the World Economic Forum graphically illustrates this in calculating that mental illness will, using 3 different forms of analysis, be the major contributor to the erosion of gross domestic product over the next 20 years. We urgently need much more research in prevention and better and safer treatments. However, the most immediate problem is the gap between what we know works and actually delivering this in the most cost-effective manner in a way that consumers find acceptable. This problem has a solution very much within reach. Even with existing knowledge, we could achieve a very substantial reduction in the burden of mental ill-health. There is absolutely no doubt that this should be carried out informed by the best available evidence. The publication of the recent Cochrane review on early intervention in psychosis (EIP) provides an opportunity to discuss how this should occur and the appropriate role of the Cochrane approach in the reform of mental health services.
Abstract and Introduction
Abstract
Among the noncommunicable diseases, mental ill-health represents the major threat to social and economic progress because it impacts so powerfully on the most critical decades of life. Consequently, mental health reform is increasingly recognized as an urgent priority worldwide. This brings into sharp focus the role of evidence, and more specifically the Cochrane paradigm, in influencing decisions about health system reform. Cochrane clearly still has great value, especially in evidence-based medicine, where the focus is the evaluation of individual treatments. However, it cannot be allowed to be a dominant influence in evidence-based health care (EBHC) policy decisions for health system reform, unless it is modernized or complemented. Health services reform should definitely be as evidence-based as possible; however, the jury should consider its verdict on key reform proposals based on the balance of probabilities and informed by the best "available" evidence from all sources, not only randomized clinical trials, which in many domains may be never be feasible. This is particularly the case when reform is urgent, and the status quo has manifestly failed. So on the one hand, the evidence-based paradigm must not be misused to stifle or paralyze urgent reform. Alternatively, there is a real risk that, if we do not improve the sophistication of EBHC, the whole paradigm will be sidelined and reform will remain reactive, impulsive, and desultory. The recent Cochrane review on early intervention in psychosis provides an opportunity to consider these issues and their wider significance.
Introduction
Mental health reform is one of the grand challenges of the 21st century. In every country, even in the wealthiest societies, people suffering from mental ill-health have considerably worse access to care than those with physical ill-health and that care is of much lower quality. This lop-sided and self-defeating allocation of the health dollar continues despite the fact that 75% of mental ill-health emerges before the age of 25 years, and its disabling and life shortening impact blights the prime productive years of life, causes untold misery, and weakens and diminishes society socially and economically. The recent report on noncommunicable diseases from the World Economic Forum graphically illustrates this in calculating that mental illness will, using 3 different forms of analysis, be the major contributor to the erosion of gross domestic product over the next 20 years. We urgently need much more research in prevention and better and safer treatments. However, the most immediate problem is the gap between what we know works and actually delivering this in the most cost-effective manner in a way that consumers find acceptable. This problem has a solution very much within reach. Even with existing knowledge, we could achieve a very substantial reduction in the burden of mental ill-health. There is absolutely no doubt that this should be carried out informed by the best available evidence. The publication of the recent Cochrane review on early intervention in psychosis (EIP) provides an opportunity to discuss how this should occur and the appropriate role of the Cochrane approach in the reform of mental health services.
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