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‘Effective’ at What? On Effective Intervention in Serious Mental Illness

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Abstract

The term “effective,” on its own, is honorific but vague. Interventions against serious mental illness may be “effective” at goals as diverse as reducing “apparent sadness” or providing housing. Underexamined use of “effective” and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as “effective.” Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, “Effective at what? For whom? How effective? And why that goal?” Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified.

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Notes

  1. We use the definition of serious mental illness proposed by the National Institute of Mental Health (NIMH): “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities” [46].

  2. The document does sketch a range of questions that need addressing in research, such as “the efficacy and effectiveness of psychological treatments with children and youths at different developmental stages,” [2, p. 275]. It also notes the variability of interventions—for example, the report notes that “…psychological services are most likely to be effective when they are responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences” (p. 278). Even with such refinements, however, the criteria for effectiveness can be specified in multiple ways.

  3. Perhaps this blandness explains why the use of general success terms like “effectiveness” has not been much examined in the literature we surveyed. Sandra Tanenbaum’s work is a notable exception. Within the context of critique of evidence-based practice, Tanenbaum presents well the basic insight that the definition of “effective” is both unclear and contentious [62]. She points out that “effectiveness” is defined in objective terms in EBP, and that these measures to do not reflect treatment outcomes pursued by many. She also raises the critical issue of who is defining effectiveness, and she points out the potential coerciveness of implementing treatment or policy with “effectiveness” defined in certain ways. Our discussion is broader than Tanenbaum’s, notably in pointing out that the need to define effectiveness is critical for all involved in SMI intervention, not just those doing EBP. In addition, while Tanenbaum points out that “what works” has moral connotations, she doesn’t enlarge on this or explain the moral connotations of other approaches, nor does she demand specification of goals. Cartwright and Stegenga are another exception; they consider the term in discussing criteria and methods for translating scientific efficacy to policy effectiveness [10].

  4. A third conceptual issue concerns the complexities of translating scientifically demonstrated efficacy or clinically demonstrated need to effective policy; on this issue we offer a pragmatist-oriented direction, but details are beyond the scope of this paper.

  5. With respect to psychological research, Paul independently developed a similar statement of the problem in 1967 [51].

  6. Some “non-clients” are people experiencing SMI who cannot access care. Others are non-clients because they prefer to avoid intervention, tend to their own care, or work with peer interventions; their perspectives are represented in this section and elsewhere.

  7. The term “effectiveness” implies an endpoint, while “process” and “relationship” do not necessarily. Nevertheless, processes and relationships can be better or worse (i.e., more effective) at achieving other goals, and more or less satisfying in the present (hence, more effective at an overall goal of a life well lived). Attempts to assess the quality of processes and relationships are therefore common in research and practice.

  8. Additionally, a few bioethicists argue that effective treatment goals are not appropriate for all clients with SMI. For example, Wijsbek argues that euthanasia may be appropriate for intractably depressed patients [65], and Draper suggests that treatment refusal, rather than forced feeding [18], should be allowed for some patients who suffer from severe and prolonged anorexia nervosa. It is not as clear that providers endorse such positions.

  9. Drug companies have in recent years decreased their spending on psychiatric drug development. This is not necessarily a good thing, given that improved medications, with fewer side effects, could be useful.

  10. The knowledge base on interventions for serious mental illness is weak even taken according to commonly accepted “rules”; that is, accepting DSM categories and the standards of evidence-based medicine. For example, the 2005-2015 Cochrane database entries for bipolar disorder and schizophrenia find “strong” evidence that antipsychotic medications relieve positive symptoms of these disorders in the short term. But that is the only strong evidence found among hundreds of articles that review dozens of medication types, psychosocial interventions, and endpoints.[Unpublished analysis by one of the authors, SCH] Morlino et al. [44] undertook a study of systematic reviews of interventions for schizophrenia in more databases, including the Ovid and Pubmed databases as well as Cochrane. They determined that only 25% of the reviews produced definitive conclusions. In addition to these concerns, Leucht et al. also point out that the entire Cochrane database (comprising meta-analyses including 13,542 articles, by their count) concerns only “first pass” efficacy—that is, the articles consider the effectiveness of initial interventions, but don’t provide guidance on the clinically crucial question of what to do if the approach fails [39]. Turning to the literature, the group found only 10 articles that addressed switching antipsychotics, and found that none of these gave conclusive information.

  11. The Montgomery-Asberg Depression Rating Scale (MADRS) is scored on a 60-point scale. The items examined include apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts. For example, the “apparent sadness” section assesses “despondency, gloom, and despair (more than just ordinary transient low spirits) reflected in speech, posture, facial expression, and posture.” The rater is instructed to “rate by depth and inability to brighten up” with the following scale: 0 points for “No sadness”; 2 points for “Looks dispirited but does brighten up without difficulty”; 4 points for “Appears sad and unhappy most of the time”; and 6 points for “Looks miserable all the time. Extremely despondent.”

  12. Thank you to an anonymous reviewer for making this point.

  13. Relative to high-quality quantitative research, qualitative research has less control and generalizability. Both qualitative and quantitative research embed biases; interpretive methodologies make qualitative research especially prone to observer biases.

  14. Establishing ways to evaluate how scientific efficacy translates to clinical or policy effectiveness is a very active area of discussion in the philosophies of science and medicine [10, 16]. The details are beyond the scope of this article.

  15. Given the likely connection of these “lifestyle” variations to mental illness, drug side effects, or both, the term “lifestyle,” suggesting full agency and responsibility, is likely misleading here. Still, well-targeted interventions might enhance quality or duration of life for people experiencing schizophrenia.

  16. According to a recent meta-analysis, effect sizes are mostly modest and acceptability is lower relative to placebo [12].

  17. Debates over the rationality of goals expressed by individuals with some forms of SMI, or by individuals at some stages of illness, introduce complex issues involving judgments of goal rationality and whether goals need to be rational. We will not debate that issue here, but we point out that it applies to a minority of people with SMI.

  18. We say “at least partially inconsistent” because complications of up-front versus net costs, among other factors, make costs difficult to determine.

  19. Tanenbaum makes a similar point in the context of EBP “…whenever EBP researchers state their outcome measures, [T]hey should say why they have chosen those measures and whose interests they represent (p. 171).” [62] Our point is that it is not just EBP researchers that need to do this, but all researchers, and providers and policy-makers as well.

  20. Other questions might also point to values. For example, asking “Effective at what?” and “For whom?” jointly might point toward effectiveness standards that benefit caregivers or investors more than patients.

  21. See also Footnote 7.

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  1. Philosophy Department, St. Catherine University, 2004 Randolph Ave, St. Paul, MN, 55105, USA

    Susan C.C. Hawthorne

  2. Psychology Department, St. Catherine University, 2004 Randolph Ave, St. Paul, MN, 55105, USA

    Anne Williams-Wengerd

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Hawthorne, S., Williams-Wengerd, A. ‘Effective’ at What? On Effective Intervention in Serious Mental Illness. Health Care Anal 27, 289–308 (2019). https://doi.org/10.1007/s10728-019-00367-9

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