Strangers in the night: research and managed mental health care.

Abstract

Like strangers in the night, dimly aware of each other’s presence, health services researchers and managed mental health organizations have been exchanging glances but not much more. As a result, research findings have had only a negligible effect on managed mental health care. This is not to suggest that clinical practice—what clinicians actually do when they work with patients—has been unaffected by new knowledge, some of which does stem from research. The development of psychoactive drugs, the National Institute of Mental Health (NIMH)‐funded studies on the treatment of depression, and, more recently, the research-based practice guidelines, are three such examples. However, the dominant changes in the way mental health services are provided and paid for that developed in the latter half of the twentieth century (community mental health care and managed care) were not the products of or particularly influenced by research findings. Rather, they came about much more as the result of economic and social factors in the larger society of which mental health services are a part. When, for example, the idea of community mental health centers was gaining momentum in the early 1960s, fostered by the plight of the state mental hospitals, serious consideration was given to first developing a pilot that would evaluate whether and to what extent such a program would work. Although rational and attractive, this idea was abandoned for what appeared to be compelling reasons: It would take too long and thus risk a change in the legislative and executive climate that at the time appeared highly favorable to the passage of major federal mental health legislation. There was also considerable doubt about the value of such research, about whether enough would be learned to make the delay worthwhile. Of course, health services research was much less well developed then than it is today. A great deal of evaluation research on community mental health centers was done, but much later and far removed from the initial policy-making process. By and large, the research results were used to help justify policy decisions already made, to sustain the program, and to meet the needs of the powerful advocacy groups that had coalesced around it. Similarly, but in the private sector, managed mental health care came into being with little, if any, research base (with the exception, perhaps, of what had been done in managed medical care). It was an attempt to fix what appeared to be a major and rapidly growing problem: the escalating costs and questionable quality of mental health services