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c h a p t e r 3 The Evolving Technology of Mental Health Care The past fifty years have been filled with technological innovations in health care. From the polio vaccine to water fluoridation, from new pharmaceuticals to joint replacement, the benefits of new technologies over the past half century have been staggering. The economist William Nordhaus estimates that during these years the value of improved health from new technologies was roughly equal to the growth in the U.S. gross domestic product (Nordhaus, 2003). Improvements in treatment technologies are likely to be a particularly significant contributor to well-being for people with any disabling condition, including mental illness. For some diseases, technological innovation has been nothing short of revolutionary . Smallpox, polio, and measles have been eradicated in the wealthiest nations through the development and administration of vaccines. Consider, as well, the near elimination of Hansen’s disease (also known as leprosy), a chronic, disabling condition that, like mental illness, had its own dedicated provider systems in 1950. Mental illness has not been as fortunate. Most of its treatments remain “halfway technologies ” that manage symptoms but do not alter the underlying disease (Thomas, 1974). For the most part, we have not improved our ability to cure or prevent these diseases over the past half century. Yet there have been substantial improvements in relieving symptoms of mental illness, and they have contributed importantly to the well-being of people with mental illness. This chapter examines technological developments in the treatment of mental health problems over the past fifty years. We compared “then” (the 1950s and 1960s) to “now” by looking closely at the best available treatment technologies at each point in time—the technological frontier.1 We did this by comparing today’s practice guidelines with the scientific literature of the past and two prominent psychiatric textbooks from earlier eras: the American Handbook of Psychiatry (1959), by Silvano Arieti, and the Comprehensive Textbook of Psychiatry (1967), by Alfred Freedman, Harold Kaplan, and Helen The Evolving Technology of Mental Health Care 27 Kaplan. To analyze the nature of treatment advances, we have also drawn on FDA records, comparative clinical trials,2 and histories of psychiatric treatments. Our focus is on schizophrenia, depression, anxiety disorders, and ADHD, which collectively account for most mental illness. Technological changes may extend the technological frontier by providing new treatments or by improving knowledge about existing treatments. Improved knowledge about existing treatments may lead to exnovation (removal from practice) of existing technologies that turn out to be harmful or to new uses for existing technologies.3 These too serve to extend the “best practice” frontier. Some important innovations, however, do not advance the technological frontier. Rather, they enhance the ability of providers and consumers to reach the existing frontier. In our discussion below, we group innovations into three categories. Efficacy advance—a new treatment dominates the best treatments in the earlier era because of its superiority in reducing target symptoms and advances the technological frontier. Exnovation—an old treatment that was ineffective or harmful is no longer, or less frequently, offered as a result of new knowledge, which likewise advances the frontier. Practice advance—a new treatment is no more efficacious than the old one, and so it does not extend the frontier; yet is safer, more tolerable, or easier to prescribe or use. Most assessments of technology focus on the state of the technological frontier . Innovations that extend the frontier are very important, but the study of technological advance suggests that the effect of a technology also depends on the ease with which it can be diffused. The long history of inventions that were “before their time”—consider Leonardo da Vinci’s helicopter in the 1500s or Charles Babbage’s computer in the 1800s—demonstrates the central importance of diffusion . A recent survey of technological change noted that “it is diffusion rather than invention or innovation that ultimately determines the pace of economic growth and the rate of change of productivity” (Hall and Khan, 2003). Advances in practice facilitate this diffusion. In medicine the importance of different types of innovation is likely to depend on the policy context. In a system dominated by a small number of specialist providers, where consumers have few choices over care, efficacy advances and exnovation are likely to be most important because the care delivered depends critically on the state of knowledge. By contrast, in a fragmented and pluralistic 28 Better But Not Well system...


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