Effective Mental Health Services Research Articles

Practical geriatrics: psychiatric consultation to nursing homes.

Patients seen in psychiatric practice in nursing homes, or skilled nursing facilities, differ from those seen in mainstream psychiatry in several ways. First, the practitioner sees patients who have medical as well as psychiatric problems. Second, after the initial diagnostic evaluation, patients generally have infrequent visits with the practitioner. Third, patients are more likely to have impaired judgment and impaired communication skills. Finally, patients have experienced relocation from their personal residence.

Intra-Household Allocation and the Mental Health of Children: Structural Estimation Analysis

This paper estimates the structural parameters of a dynamic model where parents with one child periodically decide whether or not their child uses various mental health services. In this model, mental health services improve a child's mental health (which parents care about), however, mental health services may be costly to the parents both in terms of utility and household consumption. Using a panel data set collected as part of the Fort Bragg Mental Health Demonstration, we estimate the model with a maximum likelihood procedure that accounts for unobservable differences in mental health endowments of children and population heterogeneity in parental preferences and in the effectiveness of mental health services. We estimate that parents experience relatively high disutility when a child uses mental health services, implying parents enroll their children in mental health services only if these services have multi-period effects on their child's mental health. Correspondingly, we find that outpatient and inpatient mental health services have permanent effects on a child's mental health. We conclude that the improvement over time of the mental health of the children in our data is, in a large part, the outcome of forward looking parents choosing to increase their child's mental health.

Earnings changes for depressed individuals treated by mental health specialists.

It is unclear whether the additional benefits of receiving depression treatment from mental health specialists in routine care pays for the additional costs, compared with treatment delivered by general medical providers. This study examines the difference in lost earnings and the difference in treatment costs experienced by depressed individuals treated in these two sectors. Representative community residents with depression were recruited and interviewed at baseline and at 6-month and 12-month follow-ups. Lost earnings were measured by lost workdays multiplied by subjects' wage rates. Treatment costs were approximated by charges abstracted from provider and insurance records. After controlling for sociodemographic variables, baseline severity, and baseline comorbidity, the authors found a net mean annual economic savings of $877 associated with depression treatment delivered in the mental health sector compared with the general medical sector. Sensitivity analyses in alternative scenarios indicated similar savings. Although it is the trend for primary care providers to provide mental health services, these analyses indicate a net economic savings if depression treatment is provided by mental health specialists, probably as a result of patients' greater functional improvement. As gatekeepers, especially in managed care, primary care providers have a unique responsibility to identify and detect patients with mental health problems. In the current structure, however, they may lack the necessary time to provide effective mental health services. Therefore, mental health specialists play a crucial role, with primary care providers' cooperation (i.e., detection, consultation, and referral), in providing the most cost-effective mental health services.

School-based health centers in the context of education reform.

The rapid proliferation of school-based health centers is taking place at the same time that school systems are seeking to improve their educational practices. Many different school reform models are being promulgated with modest success. Absence of connections between school reorganization and the provision of human services may lead to failure. The emerging community school model integrates quality education with effective health, mental health, and social services in "one stop" school centers that become student, parent, and community hubs.

Psychiatric Consultation in the Nursing Home: A Survey of Six States

The authors examined availability, characteristics, and perceived adequacy of psychiatric consultation in nursing homes, as reported by directors of nursing, who returned 899 questionnaires. Thirty-eight percent of nursing home residents were judged to need a psychiatric evaluation; current frequency of consultation was rated as adequate by half of nursing directors. Nearly two-thirds reported that psychiatrists adequately provided diagnostic and medication recommendations; however, advice on nonpharmacologic management techniques, staff support, and dealing with staff stress and family conflicts was largely viewed as inadequate. Findings suggest that perceived need for psychiatric services is far greater than the level actually provided. Overall, more attention must be directed to identifying incentives for psychiatrists to practice in nursing homes, determining clinical effectiveness of mental health services, and examining effects of alternative payment mechanisms on level of care.

Treating Multi-Problem, High Stress Families: Suggested Strategies for Practitioners

It's Monday morning. Jan, a therapist at the Community Mental Health Center, is running late and rushing to make the 9:00 a.m. staff meeting. As she bursts through the conference room door, she sees her five colleagues beginning to sift through referral sheets. Jan recomposes herself and calmly takes a seat at the table as Sam begins to read the first referral: Jeremy K. is a 4-year-old boy who is exhibiting extreme behavior problems at preschool and at home like hitting and scratching other children. He is HIV-positive and was recently expelled from Head Start for biting other children. His parents report that he is unmanageable and Child Protective Services has referred him to our clinic. I'm sure you all remember this family. They have five other child:ren and have been in services with us two or three times before. Jerry, another therapist, interjects, remember them. I had this family last year. They started out pretty motivated, but after a few weeks they began missing appointments. I finally had to close the case after three no-shows. I would prefer to pass on this one. Sam's question, Any other volunteers for this one? . is met with silence. Okay, well let's try another one. As Sam continues on, a sigh of relief comes from the other therapists. Sam says, have a referral from the local homeless shelter. One of the shelter workers is seeking some parent trainiNg for a mother with three children. This mom came to the shelter after leaving an abusive relationship for the fourth time. The shelter worker called because two of the kids are running rampant all over the shelter and the other one seems to be depressed. The mother also has some symptoms of depression and is due to be checked out from the shelter this morning. She has no forwarding address or telephone number, but the shelter worker says she drops by occasionally and can give her messages. Jan, like the other therapists, rolls her eyes skeptically and begins mentioning all of the reasons why she can not take this case. Clearly the therapists in this scenario are not eager to work with either of these families, but why? What is it about these cases that turns the therapists off? The referrals described are not unlike the families that we, as clinicians, encounter each day. There are certain features about these families that make practitioners cringe: lack of adequate financial resources, previous failed therapy attempts, no phone, no transportation, and multiple problems. We cringe because these features are associated with more global issues that we know will pervasively interfere with treatment. Our clinical experience and intuition tells us that the most difficult families to treat are those with multiple problems, limited finances, and high stress. Research supports our intuition. Two of the articles in this issue of Family Relations highlight these issues. Fisher, Fagot, and Leve (1998) as well as Lindsey (1998) note two major concerns that interfere with treatment: financial limitations and high stress levels. Fisher, Fagot, and Leve suggest that socioeconomic status has an impact on family functioning in terms of parents' psychological well-being and the discipline strategies parents employ. These authors discuss the direct and indirect effects of stress on a high risk family system, including ways that antisocial behavior can develop in children. Direct effects of stress include irritability, whereas indirect effects include the disruption of parenting practice and positive family interactions. Lindsey reports that lack of adequate financial resources, like in the case of homelessness, can significantly impact the relationship between mothers and their children. Articles like these heighten our awareness of the impact that these concerns have on our therapy. We would like to expand on the issues raised by these articles by discussing some of the strategies we have been using in our own practice to try to provide more effective mental health services to high stress, multi-problem families. …

Implementing and evaluating outcome indicators of performance for mental health agencies.

Regulation-based processes for evaluating the performance of mental health agencies are gradually changing to focus on measuring the effectiveness of mental health services in obtaining the best possible outcomes. The decreased availability of resources for serving people with mental health problems has led to an emphasis on effectiveness, which is often expressed in terms of accountability. Thus, a singular reliance on compliance with practice standards has shifted to the need to be able to demonstrate that funds appropriated for mental health services are being used in ways that result in valued outcomes. In Colorado, this shift has led to the development of performance indicators that provide information reflecting stakeholder values about the performance outcomes of the mental health system. This article describes these performance indicators and presents the data that led to a decision to award monetary incentives to two community agencies. Potential benefits and pitfalls of Colorado's performance indicator process are also discussed.

Evaluations of Organiztional Effectiveness in Mental Health Programs

We present a conceptual framework derived from organizational theory for understanding the evaluation of the effectiveness of mental health services. We postulate that organizations are deemed "successful" by their constituents when they conform to institutional demands and expectations that are both internally and externally generated. We empirically assess institutional conformity by examining evaluations of effectiveness by 269 mental health providers in 29 different mental health programs. Specialist programs responded to institutional demands by targeting services to those considered most in need: clients with severe mental illnesses. The formal structure and program philosophy of these programs clearly reflected this emphasis; consequently, levels of goal incongruence were low and evaluations of effectiveness were high. Generalist programs continued to provide care to diverse client groups, had more professionals, offered traditional services (such as psychotherapy), and exhibited higher levels of goal incongruence; these factors resulted in lower evaluations of effectiveness. This research is important because it demonstrates that organizational processes of institutional conformity (program objectives meet the demands of external constituents) and goal congruence (program objectives meet with expectations of internal constituents) are critical to positive evaluations of effectiveness. With the current institutional demand for effective, efficient services, it is critical that researchers have a conceptual framework for analyzing those factors which influence evaluations of effectiveness.

Improving mental health services for urban First Nations: policy issues relevant to health care reform.

This paper discusses issues related to the development of plans to improve the effectiveness of mental health services for urban First Nations people. The discussion focuses on emerging issues related to health care reform and regionalization. While it is impossible to make specific recommendations without reference to local conditions, developing an awareness of the general issues involved will help in the process of identifying the principles and approaches needed to frame local solutions.

New ethical challenges to mental health services research in the era of community-based care.

Research on the use and effectiveness of mental health services conducted across a wide variety of settings, under new and diverse state-based legal statutes, and requiring the linking of a variety of existing and proposed data sources raises a number of ethical considerations. These new conditions are reviewed in the context of federal regulations for the protection of human subjects and, in particular, informed consent. Illustrations, suggestions, and resources are offered from recent experiences in a longitudinal, multisource study of the impact of a hospital closing on individual consumers, families, workers, and system costs.

Developing partnerships in mental health: honourable intentions, bad timing

The new Green Paper on developing effective mental health services helpfully offers a four option choice for bringing together the providers of mental health services from the health and social care authorities.

Effects of mental health services reform on clinical practice in the United Kingdom.

In the last few years, the British National Health Service, local government social services departments, the welfare benefits system, and the organization of primary health care in the United Kingdom have undergone major reforms that have had significant effects on mental health services. Local social service departments were given the lead role in purchasing and coordinating community supports for persons with mental illness, but were not given enough funds to arrange adequate services. In the National Health Service, an internal-market approach, in which local health authorities could contract with any provider or group of providers, was introduced. This purchaser-provider split has created a climate of competition in a traditionally collaborative environment and has reduced staff morale. Similar but separate case management models were introduced in both the health service and the social service departments, which has led to inefficiency in planning care for individual patients. Opportunities were created for general practitioners to use capitated funds to purchase specialty care directly from providers. This arrangement resulted in an initial emphasis on care for less severely mentally ill patients, although some general practitioners are beginning to explore new approaches for supporting severely ill patients in the community. On the positive side, the reforms have led to greater involvement of patients and their families in planning service delivery. However, the authors suggest that policy makers in the U.K. seem to be repeating many of the mistakes made by American mental health systems in the 1960s and 1970s.

Assessing the needs of the severely mentally ill: cultural and professional differences.

International interest is currently focused on the effectiveness of mental health services in helping the severely mentally ill. An important outcome measure is change in the level of individual need. Little research has been done into how mental health professionals prioritise needs. This question was addressed by undertaking a survey of mental health professionals in cities in India, Australia and England. Similar priorities were found in all survey sites, and across hospital and community staff, though differences were found due to professional background. This suggests that there is some cross-cultural consistency in prioritising needs, but the choice of profession to assess need may influence the way in which needs are assessed.

The question of cultural bias in assessment and diagnosis of ethnic minority clients: Let's reject the null hypothesis.

Cultural bias in the mental health assessment and psychiatric diagnosis of ethnic minorities has been asserted and challenged on the basis of clinical impression and a variety of psychometric criteria. The lack of a definitive empirical basis to resolve issues of assessment and diagnostic bias means that the null hypothesis (no bias or cross-cultural uniformity) prevails. This article argues that the traditional hypothesis to be nullified should be challenged. The consequences associated with its incorrect retention (Type II error = disservice to minority clients) may be more serious than its incorrect rejection (Type I error = misdirection to the mental health service system). If a clientcentered error is judged more serious than a service system error, then a statement of bias or crosscultural variance should be the null hypothesis until such time as empirical data suggest otherwise. The presumptions of valid measurement of psychological symptomatology and accurate diagnosis of psychiatric disorders are fundamental to the integrity of mental health research and to the delivery of effective mental health services. The fourth edition of the American Psychiatric Associations^ Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; 1994) reflects an increasing recognition of the importance of considering the cultural diversity of clients in rendering psychiatric diagnoses. Yet limited empirical data and even sparser theoretical preconceptions hinder researchers, professional practitioners, and policymakers in deciding whether or not—and, if so, how—a culturally informed mental health assessment ought to take place (Lopez, 1988; Lopez & Hernandez, 1987; Malgady, 1994). This issue is of special concern because effective psychopharmacological and psychotherapeutic treatment planning and continuity of care are predicated, in part, on accurate evaluation of symptom severity and diagnosis.

Research on Mental Health Services for Hispanics: Targets of Convergence.

In reaching to serve the mental health needs of new catchment neighborhoods, the 1963 federally funded Community Mental Health Center (CMHC) program stimulated culturally oriented research on the effectiveness of mental health services for Hispanics. The research, at first scattered and diffuse, has converged on a number of targets. This article examines four of the targets of research and how they can be brought into a unified perspective if they are viewed in temporal order as sequenced disadvantages Hispanics confront in using mental health services. The targets can be arrayed longitudinally: reasons for Hispanics' underutilization of professional mental health services, difficulties in retaining Hispanics in such services, errors in evaluating their mental health, and the problems of adapting treatment modalities to their needs.

Critical issues in reforming rural mental health service delivery.

Critical issues in reforming rural mental health service delivery systems under health care reform are outlined. It is argued that the exclusive focus on health care financing reform fails to include obstacles to effective mental health service delivery in rural area, which should focus on issues of availability, accessibility, and acceptability, as well as financing and accountability. Characteristics of rural areas are delineated and three assumptions about the structure of rural communities which are shaping the dialogue on rural health and mental health service delivery are examined. These assumptions include the notion that rural communities are more closely knit than urban ones, that rural services can be effectively delivered through urban hubs, and that rural dwellers represent a low risk population which can be effectively served through existing facilities and by extending existing services.

The State of the Art of Social Work Research: Implications for Mental Health

A summary is presented of the findings of a study of the social work research literature conducted for the National Institute of Mental Health (NIMH) Task Force on Social Work Research. Implications of those findings are drawn for building social work knowledge in the area of mental health. Arguments are made that building social work knowledge for effective mental health services and policies requires a focus on traditional areas of practice, research that includes higher level systems, an interdisciplinary knowledge base, and a commitment by the profession to improving the quality of its research.

The multiconstitutency approach to organizational performance assessment: A Canadian mental health system application

This papers applies a multiconstituency approach to assessing organizational performance in Canadian general hospital psychiatric units and provincial psychiatric hospitals. In the absence of reliable and valid outcome measures, researchers and administrators have increasingly considered the views of external constituencies as a means of both defining the criteria for effective performance and actually assessing organizational performance. Key constituencies included psychiatric unit staff, psychiatric hospital administrators, and directors of community agencies providing mental health and related services. Opinions about organizational roles were found to exist among constituencies and among professional groups. Perceptions of organizational performance were highest for primary roles and substantially lowest for roles of secondary importance to the constituency. Future analyses of this type could help to validate the use of both constituency measures and more traditional performance measures. While constituency views may be seen as subjective, they are nevertheless key to building effective mental health service delivery systems.

Enhancing the Delivery of Effective Mental Health Services to Children

An increasing number of children and adolescents are in need of mental health services, although few children receive the treatment they need. Although progress in understanding and treating children's mental disorders is limited, a great deal more is known today about how to prevent mental disorders, what treatments are effective, and the importance of providing multiple services. This article presents current knowledge on assessment, treatment, and service delivery to help social workers improve the effectiveness of services for children.

The Role and Tasks of Community Mental Handicap Teams. Edited by S. Brown and G. Wistow. (Pp. 226; illustrated.) Avebury: Aldershot. 1990. - Effective Community Mental Health Services. By P. Huxley. (Pp. 130; illustrated.) Avebury: Aldershot. 1990.

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