Examining the research base for child mental health services and policy

This article reviews the existing research base for child mental health services and policy. It emphasizes the importance of research that looks at the overall community-based system of care as the unit of analysis, and stresses the need to maintain a systems perspective, even when research is focused on components of the overall system. The review concludes that there is a need for a considerable increase in child mental health services research but also indicates that there has been a recent increase in research that has the potential of building a base to change policy. In particular, a need is identified for well-controlled studies that assess both clinical and cost outcomes and for studies that examine the mega issues of the organization and financing of systems of care.     

Hemispheric specialisation, spatial activity experience, and sex differences on tests of mental rotation ability

A sex difference in mental rotation ability is well established. Among the explanations offered for this difference are that males are more frequently right hemisphere specialised for spatial processing and that they receive more spatial processing experience because of the sex stereotyping of activities involving spatial ability that exists in Western societies. Several studies have shown that males do report more spatial activity experiences on the Spatial Activity Questionnaire of Newcombe, Bandura, and Taylor (1983) and that such experience does correlate with performances on tests of mental rotation. However, two prior lateralised tachistoscopic studies failed to show right hemisphere superiority for spatial task performance or that it was positively associated with better performances on the Vandenberg Mental Rotation Test. The tachistoscopic tasks used in these studies can be criticised on methodological grounds. The present study employed a new tachistoscopic task that showed that males were significantly more right hemisphere specialised (left visual-field superior) for the tachistoscopic task than females. Magnitudes of right hemisphere specialisation on the tachistoscopic task were positively and significantly related to mental rotation ability. Spatial activity experiences were also more common in males. Covariance and partial correlation analyses indicated that the sex difference in spatial ability was primarily due to sex differences in right hemisphere specialisation for mental rotation, while sex differences in spatial activity experiences were only secondarily involved.     

Hemispheric specialisation,spatial activity experience,and sex differences on tests of mental rotation ability

A sex difference in mental rotation ability is well established. Among the explanations offered for this difference are that males are more frequently right hemisphere specialised for spatial processing and that they receive more spatial processing experience because of the sex stereotyping of activities involving spatial ability that exists in Western societies. Several studies have shown that males do report more spatial activity experiences on the Spatial Activity Questionnaire of Newcombe, Bandura, and Taylor (1983) and that such experience does correlate with performances on tests of mental rotation. However, two prior lateralised tachistoscopic studies failed to show right hemisphere superiority for spatial task performance or that it was positively associated with better performances on the Vandenberg Mental Rotation Test. The tachistoscopic tasks used in these studies can be criticised on methodological grounds. The present study employed a new tachistoscopic task that showed that males were significantly more right hemisphere specialised (left visual-field superior) for the tachistoscopic task than females. Magnitudes of right hemisphere specialisation on the tachistoscopic task were positively and significantly related to mental rotation ability. Spatial activity experiences were also more common in males. Covariance and partial correlation analyses indicated that the sex difference in spatial ability was primarily due to sex differences in right hemisphere specialisation for mental rotation, while sex differences in spatial activity experiences were only secondarily involved.     

Alternatives to drgs: Research issues

Legislative mandates for the development of prospective payment methodologies for reimbursing inpatient care have spurred the psychiatric community into its own independent effort, applying both clinical and service research, to develop schemes which are fair to psychiatric patients, their providers and payers. Many of the issues involved in the development of an equitable prospective payment system (PPS) for psychiatric care are not new to the field, namely, problems of limited diagnostic accuracy, a limited knowledge of the outcomes of clearly defined treatment protocols, and a lack of integration, efficiency and efficacy in a highly differentiated service system. The research community needs to respond to these problems in the context of cost containment with an awareness that its response will influence care for psychiatric patients for the remainder of this century.In this paper, we will describe the background issues that have brought the psychiatric community to the present point in its response to PPS, and discuss some of the research problems posed by the need for a PPS with the right incentives for clinical effectiveness and efficiency.     

Public health context of women's mental health research.

As more attention is directed to the mental health care of women, sex and gender differences in research design and in regulatory policies have interfaced with clinical care and public policy. An emphasis on women's mental health issues in the provision of treatment and care as well as the design of large-scale screening strategies to identify and treat women with mental disorders promises to be effective public health approaches to reducing the burden of mental illness in women. The past decade has seen increased emphasis on women's mental health and sex/gender differences in the federal sector and in the research community. Federal regulations (summarized in the NIH Outreach Notebook) call for the inclusion of women and minorities in NIH-funded clinical research. The regulations also place emphasis on gender analysis of the results of clinical trials, in particular phase III trials, the findings of which are likely to influence practice. There has been substantial progress toward the goal of including women in research, but more remains to be done. A 2000 GAO report titled "Women's Health: NIH Has Increased Its Efforts to Include Women in Research" commended NIH for tracking the number of women in clinical research but the report also noted that relatively few NIH-funded studies, including major clinical trials, had reported findings by gender of study participants. This was seen as an impediment to progress in developing gender-based effective treatments. In the past decade, the women's health field has moved beyond an exclusive emphasis on women's reproductive function to one that defines health as a scientific enterprise to identify clinically important sex and gender differences in prevalence, etiology, course, and treatment of illnesses affecting men and women in the population as well as conditions specific to women. Nonetheless, for mental disorders, women's reproductive function and its impact on mental health conditions is still understudied. Based on the epidemiology of mental disorders, the course of mental disorders in women in relation to reproductive transitions remains an important issue for the mental health field because the burden of mental disorders, such as depression and anxiety, fall disproportionately on women of childbearing and childrearing age. The public health emphasis on women's mental health does not lessen the basic scientific opportunities to be had by a focus on gender and sex differences. A 2001 report of the Institute of Medicine titled "Exploring the Biological Contributions to Health: Does Sex Matter?" underscores the benefit to health care of looking for sex differences at the biological level. Basic and clinical neuroscience research is rapidly accruing a knowledge base that will provide information at the level of genes and cells of the influences of biological sex on mental health outcomes in both women and men. A focus on women's mental health and gender/sex differences research promises to yield improvement in treatments and services and thereby to improve the public health as well as to increase fundamental knowledge about the etiology and neurophysiology of mental disorders.     

Reliability in multi‐site psychiatric studies

Multi‐site psychiatric studies need to take account of cultural and sometimes also linguistic differences and the reliability of the instruments used may need to be re‐established. The analysis of reliability data in these circumstances presents special problems, arising from the requirements to make the best use of all the available data and to compare reliability coefficients across sites, interpreting any differences found in terms of measurement errors and/or sample heterogeneity. Focusing on statistical issues, this paper discusses some topics that should ideally be considered when planning, conducting and analysing such studies. A number of practical examples using data from a recent European study involving the translation and cultural adaptation of five instruments used in mental health service research (the EPSILON Study) are used to illustrate the issues. Copyright © 2001 Whurr Publishers Ltd.     

The experience of schizophrenia: what's gender got to do with it? A critical review of the current status of research on schizophrenia

The role of gender in schizophrenia is explored, and literature on gender and schizophrenia is critically reviewed. The importance of investigating gender differences in schizophrenia is underscored by the lack of sufficient research in this area to date and the comparative neglect of sociocultural issues during the "decade of the brain." The importance of incorporating gender factors into research analysis is demonstrated via an interdisciplinary discussion that involves psychiatric, anthropological, and sociological theory. Methodological and measurement issues in gender-based research are considered. Selected directions for future research initiatives that expand beyond a dichotomous comparison of "male" and "female" sex differences to examine the role of gender along a continuum as a sociocultural influence on schizophrenia onset, illness presentation, and treatment are presented.     

Sex and gender in psychoneuroimmunology research: Past,present and future

To date, research suggests that sex and gender impact pathways central to the foci of psychoneuroimmunology (PNI). This review provides a historical perspective on the evolution of sex and gender in psychoneuroimmunology research. Gender and sexually dimorphic pathways may have synergistic effects on health differences in men and women. We provide an overview of the literature of sex and gender differences in brain structure and function, sex steroids, gender role identification, hypothalamic–pituitary–adrenal axis function, genetics, immunology and cytokine response. Specific examples shed light on the importance of attending to sex and gender methodology in PNI research and recommendations are provided.     

Administrative Issues in Child Psychiatry

Administrative issues related to operating child and adolescent psychiatry programs or child mental health centers are substantially different than their adult counterpart programs. The increasing demands from managed care and other regulatory agencies make these programs difficult to operate. The smaller scale of these programs and the fewer existing programs make managing access to care more complicated. The administrators and clinicians in these programs have to be vigilant of legal responsibilities and reporting mandates that child practitioners and agencies that treat children need to abide by. In order to continue thriving, programs need to be efficient and fiscally viable. Issues such as building the continuum of care and finding the qualified personnel to staff these services are discussed in this article.     

Criminal Engagement and Australian Culturally and Linguistically Diverse Populations: Challenges and Implications for Forensic Risk Assessment

There is a growing need for effective cross-cultural forensic health service delivery as Australia's population becomes increasingly diverse. The fastest growing migrant populations are of Culturally and Linguistically Diverse (CALD) origin and many refugees resettle in Australia through humanitarian intake programmes. As such it is important to ascertain whether there are cultural differences across factors that may directly or indirectly increase engagement in criminal behaviour. Similarly the applicability of violence risk instruments to Australian CALD populations is heavily under-researched and requires attention. This review addresses both key issues in an Australian context. Key risk items that may impact upon the criminal involvement of Australian CALD populations are identified and a review of violence risk studies with CALD populations is performed. Findings are discussed in view of a growing need for systemic cultural competence in the forensic health sector.     

Taking evidence-based practices to school: using expert opinion to develop a brief,evidence-informed school-based mental health intervention

School-based mental health services offer unparalleled opportunities for providing accessible care to children and adolescents. Research indicates that services available in schools are rarely based on evidence of effectiveness and are typically disconnected from the larger school context. To address these issues, the current paper presents initial studies to inform the development of a brief, evidence-based, flexible mental health intervention that fits the school context while maintaining clear structure. Results from two qualitative research studies – key informant interviews with school mental health experts and a nominal group decision-making process with stakeholders – are presented, both of which were aimed at informing intervention development and testing assumptions about how best to design an effective, context-specific mental health intervention that can be flexibly applied in educational settings. An explicit focus on educational outcomes within the context of mental health service delivery was identified as a key component of this integration. The paper concludes with a discussion of how this research has influenced the ongoing development of the intervention protocol, exemplifying a collaborative and iterative approach to developing school-based programmes.     

Cultural diversity in the integration of disaster mental health and public health: a case study in response to bioterrorism

Disaster leads to severe disruptions of the coping capacities of the community. Terrorism, and in particular bioterrorism, has tremendous impact on the community that is affected Cultural groups present unique issues that need to be appreciated for the effective integration of disaster mental health services with public health. The following paper identifies unique issues and challenges of cultural groups in disaster. It highlights issues such as language, cultural interpretation and expression of grief, and help-seeking behavior, as well as inherent cultural resources that can promote resilience. The implications of these cultural issues are illustrated in a potential bioterrorist event, addressing the areas of surge capacity, mass quarantine, and risk communication. Next steps are identified in promoting greater cultural competency in the integration of disaster mental health and public health, thus building greater community resilience.     

Model underpinning treatment for sex offenders with mild intellectual disability: current theories of sex offending

Although many writers have provided a theoretical framework for treatment of mainstream sex offenders, this research has not been extended to sex offenders with mild intellectual disability. My purpose here is to bring together several research strands to provide a theoretical model for working in this field, including theories of sex offending, developmental theories for offending, and work on quality of life. In addition to dealing with issues of sex offending, researchers should also investigate developmental and societal issues crucial in the genesis of sex offending and offending in general. Because societal issues are also important for treatment, engagement and identification with society are suggested. Quality of life and issues directly related to sex offending are of central importance.     

Consumers' perceptions of the fairness and effectiveness of mandated community treatment and related pressures

OBJECTIVE: Little research has been conducted on the attitudes of persons with psychiatric disorders toward the potentially adverse or beneficial effects of involuntary outpatient commitment and other forms of mandated community treatment. This study examined mental health consumers' appraisals of the fairness and effectiveness of mandated community treatment and related pressures to promote treatment adherence. METHODS: A total of 104 consumers who had been in treatment for schizophrenia or related disorders were interviewed in person to assess their perceptions of mandated community treatment and other legal pressures. RESULTS: Approximately 62 percent of the consumers regarded mandates as effective, and 55 percent regarded them as fair. Perceptions of the effectiveness and fairness of mandates were highly correlated. Consumers who regarded schizophrenia as a biopsychosocial disorder and who viewed themselves as ill and in need of treatment also tended to endorse the fairness and effectiveness of mandates. Those who rejected mandates as ineffective and unfair were more symptomatic and rejected a view of themselves as being ill. CONCLUSION:S: Consumers with schizophrenia who adopt a biopsychosocial view of their own illness, who are less symptomatic, and who have better insight also tend to believe that they benefit from a range of formal and informal sanctions to adhere to treatment and believe that they are imposed in the consumers' best interests and out of concern for their well-being. In contrast, consumers who reject treatment mandates tend to have more psychotic symptoms yet are less likely to perceive themselves as ill.     

Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950-2000: a review

OBJECTIVE: The authors reviewed the literature on mental health education for primary care physicians and made recommendations for the design of educational programs and research. METHOD: They searched the MEDLINE and PsycLIT databases from 1950 to 2000 by using a variety of key words and subjects. RESULTS: More than 400 articles were identified, ranging from empirical studies to philosophical articles. Many identified a perceptual gap between primary care and psychiatry as the basis for problems of contextual relevance in psychiatric education for primary care practitioners. There were few empirical studies; most reported only results of satisfaction surveys or simple tests of knowledge. Long-term outcomes were less positive; there were important negative findings. CONCLUSIONS: An extensive literature published over five decades identified a strong need for ongoing mental health training for primary care physicians. Helpful recommendations exist related to objectives, methods, and evaluation. However, there are organizational and attitudinal issues that may be equally or more important for educators to consider than the selection of educational methods.     

Dynamic representations and generative models of brain function

The main point made in this article is that the representational capacity and inherent function of any neuron, neuronal population or cortical area is dynamic and context-sensitive. This adaptive and contextual specialisation is mediated by functional integration or interactions among brain systems with a special emphasis on backwards or top-down connections. The critical notion is that neuronal responses, in any given cortical area, can represent different things at different times. Our argument is developed under the perspective of generative models of functional brain architectures, where higher-level systems provide a prediction of the inputs to lower-level regions. Conflict between the two is resolved by changes in the higher-level representations, driven by the resulting error in lower regions, until the mismatch is 'cancelled'. In this model the specialisation of any region is determined both by bottom-up driving inputs and by top-down predictions. Specialisation is therefore not an intrinsic property of any region but depends on both forward and backward connections with other areas. Because these other areas have access to the context in which the inputs are generated they are in a position to modulate the selectivity or specialisation of lower areas. The implications for 'classical' models (e.g., classical receptive fields in electrophysiology, classical specialisation in neuroimaging and connectionism in cognitive models) are severe and suggest these models provide incomplete accounts of real brain architectures. Generative models represent a far more plausible framework for understanding selective neurophysiological responses and how representations are constructed in the brain.     

Perceptions of teacher preparation and attitudes regarding students' mental health in Kenya

This study was conducted to identify whether high school teachers in Kenya perceive themselves as well prepared to effectively work with students who present with mental health concerns. The study also assessed teachers' attitudes toward the importance of mental health training as it relates to teaching success in the classroom. Gender and teaching experience differences on teachers' perception and attitudes were assessed as well as areas of need. Data were collected from 121 secondary school teachers in Kenya. Results of statistical analyses indicated that while the majority of teachers in Kenya rate their preparation positively, there are differences between male and female teachers, and teachers at different levels of teaching experience. The findings highlight the need for strengthening pre-service and in-service training for teachers in Kenya to increase teachers' ability to identify and manage mental health issues in schools.     

Assessing the quality of psychiatric care: research methods and application in clinical practice

The drive to contain the costs of health care in the United States is focusing attention on how quality of care is affected. This article discusses research methods for assessing the quality of psychiatric care and reviews findings from some major studies evaluating care. These findings are mixed, highlighting areas in which quality of care is less than optimal, as well as the importance of continued research and the need to develop better research methods. Evidence-based criteria and more-sensitive risk-adjustment techniques must be employed if data on quality are to yield fair comparisons among health plans. The challenge is to refine the methods now in use at both the research and clinical levels, so that better-quality assessments can be made for policy formulation, physician education, and consumer choice.     

The insula (Island of Reil) and its role in auditory processing: Literature review

The insular cortex is a complex structure which contains areas that subserve visceral sensory, motor, vestibular, and somatosensory functions. The role of the insular cortex in auditory processing was poorly understood until recently. However, recent case studies indicate that bilateral damage to the insulae may result in total auditory agnosia. Functional imaging studies demonstrate that the insulae participate in several key auditory processes, such as allocating auditory attention and tuning in to novel auditory stimuli, temporal processing, phonological processing and visual–auditory integration. These studies do not clarify the issue of further specialisation within the insular cortex, e.g. whether the posterior insulae are primarily sensory areas, while the anterior insulae serve mainly as integration/association auditory areas, two hypotheses that would be compatible with the cytoarchitectonic structure and connectivity of the insulae. The functional characterisation of the insulae remains incomplete, underlining the need for further studies.