Association for Public Policy Analysis & Management

This research analyzes the spread of evidence-based practices (EBPs) in public mental health services at the state level across the United States. The focus is on how system and environmental characteristics may influence the diffusion and implementation of such practices. The use of treatments with demonstrated clinical effectiveness is a stated priority in mental health policy with the goal of connecting knowledge to practice. Yet, an enduring gap remains between the frontier of clinical effectiveness knowledge and the state of available services. This research seeks to understand the conditions for programmatic change and the diffusion of practices across the United States. The research draws on policy diffusion and implementation science for its theoretical base.

Method:

The research design centers on a quantitative approach with panel data and cross-sectional analyses of the factors theorized to influence the implementation of EBPs in public mental health services. The unit of analysis is the state mental health system (rather than the clinic or organization) and the data are drawn from national reporting systems, surveys of organizations, and other sources covering all 50 states since around 2000. This quantitative approach covering the entire country is distinct from the existing body of research that has mainly used qualitative methods or considered only individual states or instances of EBP implementation. The compilation of multiple public sources into a novel dataset was an important step in this research and will allow for additional research avenues. Background interviews with policy experts provide valuable context for the quantitative findings and allow for comment on the underlying processes of implementation.

Findings:

The quantitative findings are not supportive of EBP implementation following a generalized diffusion path while the qualitative findings lend some support for EBP implementation theories that emphasize the importance of organizational settings. These findings imply for policymakers that systemic and environmental characteristics are not necessarily the most significant barriers and greater attention should be paid to the local conditions for innovation and opportunities for EBP promotion.

Implications:

This research is relevant to both the policy diffusion and implementation literatures by testing theoretical predictions as well as the validity of consensus opinions about EBP implementation. In practice, this research is helpful to illuminate the conditions and processes of effective EBP implementation for policymakers and professionals engaged in public mental health services. While this research is limited by the generalizations necessary for a national scope as well as the availability of uniform data over time and across states, it points a way forward. Future efforts can extend this research by refining the measures of system characteristics, exploring the effects of state Medicaid program differences, and examining the role of leadership and knowledge networks.