The authors describe the rationale for implementing evidence-based practices in routine mental health service settings. Evidence-based practices are interventions for which there is scientific evidence consistently showing that they improve client outcomes. Despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research shows that routine mental health programs do not provide evidence-based practices to the great majority of their clients with these illnesses. The authors define the differences between evidence-based practices and related concepts, such as guidelines and algorithms. They discuss common concerns about the use of evidence-based practices, such as whether ethical values have a role in shaping such practices and how to deal with clinical situations for which no scientific evidence exists.

Extensive empirical research, summarized in several reviews and codified in practice guidelines, recommendations, and algorithms, demonstrates that several pharmacological and psychosocial interventions are effective in improving the lives of persons with severe mental illnesses. Yet the practices validated by research are not widely offered in routine mental health practice settings. As part of an effort to promote the implementation of evidence-based practice, the authors summarize perspectives on how best to change and sustain effective practice from the research literature and from the experiences of administrators, clinicians, family advocates, and services researchers. They describe an implementation plan for evidence-based practices based on the use of toolkits to promote the consistent delivery of such practices. The toolkits will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Special materials will address the concerns of mental health authorities (funders), administrators of provider organizations, clinicians, and consumers and their families.

In this study we sought to understand the relationship between obtaining competitive employment and changes in nonvocational domains of functioning (symptoms, substance abuse, hospitalizations, self-esteem, quality of life) in persons with severe mental illness. A group of 143 unemployed patients participating in a study of vocational rehabilitation programs were assessed in nonvocational areas of functioning at baseline and 6, 12, and 18 months later. Statistical analyses examined the relationship between work status at the follow-up assessments and nonvocational functioning, controlling for baseline levels of nonvocational variables. Patients who were working at follow-up tended to have lower symptoms (particularly thought disorder and affect on the Brief Psychiatric Rating Scale), higher Global Assessment Scores, better self-esteem, and more satisfaction with their finances and vocational services than unemployed patients. Employment is associated with better functioning in a range of different nonvocational domains, even after controlling for baseline levels of functioning.

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The behavioral health workforce remains in flux. High turnover most often had a negative impact on implementation, although some teams were able to use strategies to improve implementation through turnover. Implementation models must consider turbulent behavioral health workforce conditions.

Day treatment remains a core component in many community mental health programs for persons with severe mental disorders throughout the United States. Many other mental health centers are moving away from day treatment toward psychosocial and vocational rehabilitation programs. Empirical research directly comparing these two systems of organizing outpatient services is needed. In this study the authors compared a rehabilitative day treatment program in one small city with a similar program in a nearby city that changed from day treatment to a supported employment model. Clients who were enrolled in community support services during a baseline year prior to the change and during a follow-up year after the change (71 in the program that changed and 112 in the other) were evaluated during both intervals. In the program that changed, competitive employment improved from 25.4% to 39.4% for all clients, and from 33.3% to 55.6% for those clients who had been regular attenders of day treatment during the baseline. Hours worked and wages earned similarly improved after the program change. For all work variables, clients who had not worked during the baseline year accounted for the improvements in outcome. Meanwhile, employment remained stable in the day treatment program. No negative outcomes were detected. These results indicate that eliminating day treatment and replacing it with a supported employment program can improve integration into competitive jobs in the community.

The hypothesis that working leads to improved self-esteem for people with severe mental illness was not supported. For this population, self-esteem, as measured by the Rosenberg Self-Esteem Scale, appears to be a relatively stable trait that reflects general life satisfaction and affective symptoms rather than objective functional status.

Persons with severe mental illnesses (SMI) often lack access to effective treatments. The authors describe the Implementing Evidence-Based Practices (EBPs) Project, designed to increase access for people with SMI to empirically supported interventions. The EBP Project aims to improve access through development of standardized implementation packages, created in collaboration with different stakeholders, including clinicians, consumers, family members, clinical supervisors, program leaders, and mental health authorities. The background and philosophy of the EBP Project are described, including the six EBPs identified for initial package development: collaborative psychopharmacology, assertive community treatment, family psychoeducation, supported employment, illness management and recovery skills, and integrated dual disorders treatment. The components of the implementation packages are described as well as the planned phases of the project. Improving access to EBPs for consumers with SMI may enhance outcomes in a cost-effective manner, helping them pursue their personal recovery goals with the support of professionals, family, and friends.