Evidence-based psychiatric practice? Long live the (individual) difference

Mental health services in Israel are about to undergo a major, and quite controversial, reform. Yet both those advocating these reforms and those opposing themrefrain from resorting to empirical science in arguing their respective cases. In the present article, we present findings concerning the central role of patients' individual differences in the outcome of mental health services. Data is presented from three research projects: 1. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP), in particular recent publications by Blatt, Zuroff, Shahar and their collaborators, 2. The Partnership Project in severemental illness, and 3. The Menninger Psychotherapy Research Project (MPRP). Findings from these three projects, largely predicted by Blatt's theory of interpersonal relatedness and self-definition, suggest that an effective, evidence-based mental health practice is contingent upon practitioners' sensitivity to pretreatment patient characteristics. Clinical and policy implications of this conclusion are discussed.     

Book Reviews

Book reviewed in this article: The Brain in Unclassified Mental Retardation . Edited by D. B. Cavanagh. Assessment for Learning in the Mentally Handicapped . Editor: Peter Mittler. Social Competence and Mental Handicap (2nd Edition) . Editor: H. C. Gunzburg. Mental Retardation and Behavioural Research . Institute for Research into Mental Retardation, Study Group No. 4. Edited by A. D. B. Clarke and A. M. Clarke.     

Community based treatment of the chronic psychotic

Community based treatment of the chronic psychotic offers promise as an approach for reducing the high recidivism rate and enhancing the poor community adjustment of this population. The program described is based upon social influence theory and principles of residential social treatment. An essential aspect of the program involves the utilization of indigenous community members who are trained by professional staff to supervise and instruct patients in social and instrumental behavior. A research design is presented to evaluate this program, and preliminary results indicate it is more effective than residential social treatment or traditional hospital programs.The data for this paper derive from a project conducted at the Philadelphia State Hospital. This project is supported by a National Institute of Mental Health, Hospital Improvement Grant (15155), Daniel Blain, M.D. Project Director, and a companion Research Grant (15008).     

Successful urban-to-rural professional role transition

Mental health professionals who move from urban to rural environments to seek changes in lifestyle frequently experience stress in making personal and professional role transitions. Difficulty in making role transitions is a factor that adversely affects the rate of professional retention in the rural mental health field. This article reviews the sociological variables known to affect the ease of transition into new roles utilizing typical rural situations and practice examples to highlight the application of role transition theory to rural practice. The article concludes with recommendations to rural MHC administrators on ways to improve screening procedures for urban job applicants and ways to facilitate the urban professional's transition to rural life.Robert S. Miller is a practicum instructor for the Rural Community Mental Health Training Project for MSW students. (The Project is sponsored jointly by the School of Social Work and the Department of Psychiatry and Behavioral Sciences. It is funded by the National Institute on Mental Health, Grant # 5 T01 MH15262).     

Goal attainment scaling: A general method for evaluating comprehensive community mental health programs

A mental health enterprise may be described by either (a) rather general philosophical total mental health goals, or (b) highly diverse and individualized patient-therapist goals. Goals a. have not provided a workable framework for program evaluation. This paper proposes that evaluation be done in the framework of goals b. by setting up, before treatment, a measurable scale for each patient-therapist goal, and specifying, for each patient, a transformation of his overall goal attainment into a standardized T-score. This method, together with random assignment of patients to treatment modes, was devised to permit comparison of treatment modes within a program, but it also provides a good basis for a judgmental evaluation of the total program.The authors would like to express appreciation to William W. Jepson, M.D., Program Director of the Hennepin County Mental Health Center, for his considerable contribution to the earlier formulation of the method reported here.     

Book Reviews

Book Reviews in this article: Clinics in Developmental Medicine 35/36. Spastics International Medical Publication in association with Heinemann Medical Books, London and J. B. Lippincott, Philadelphia. Mental Retardation and Social Action: A Study of the Associations for Retarded Children as a Force for Social Change. By ROBERT M. SEGAL. Springfield, Illinois Biochemical Screening in Relation to Mental Retardation. Ed. by D. C. CUSWORTH. Institute for Research into Mental Retardation Symposium No. 3. Oxford     

Managed care in the public mental health system

The movement towards managed care in the public mental health system has surpassed efforts to develop a systematic literature concerning its theory, practice, and outcome. In particular little has been written about potential challenges and difficulties in translating managed care systems from their origins in the private sector to the delivery of public sector mental health services. This paper provides an overview of managed care definitions, organizational arrangements, administrative techniques, and roles and responsibilities using a theoretical framework adopted from economics referred to as principal-agent theory. Consistent with this theory, we assert that the primary function of the managed care organization is to act as agent for the payor and to manage the relationships between payors, providers, and consumers. From this perspective, managed care organizations in the public mental health system will be forced to manage an extremely complex set of relationships between multiple government payors, communities, mental health providers, and consumers. In each relationship, we have identified many challenges for managed care including the complexity of public financing, the vulnerable nature of the population served, and the importance of synchronization between managed care performance and community expectations for the public mental health system. In our view, policy regarding the role of managed care in the public mental health system must evolve from an understanding of the dynamics of government-community-provider-consumer agency relationships.Mary Masland, M.S.P.H., is Research Associate, Institute for Mental Health Services Research.Giorgio Piccagli, Ph.D., is Affiliated Investigator, Institute for Mental Health Service Research.This work was supported by the National Institute of Mental Health funded Center for Research on the Organization and Financing of Care for the Severely Mentally Ill (P50-MH43694).     

The emotional health of children in the family setting

As a basis for planning services for children, the Mental Health Association of Westchester County initiated a project for estimating the emotional health or impairment of children, 3 to 18 years of age, in the general population. Mothers were interviewed in their homes by trained interviewers. The information obtained, supplemented by data from school records, was evaluated by child psychiatrists, who rated the emotional health of each child on a five-point scale from well to severely impaired, family functioning was also rated. Principal findings regarding impairment are summarized. The relationship of impairment to a number of demographic, familial, and behavioral variables is discussed.Olga R. Lurie, a psychologist, is Director of the research project on childhood emotional health, sponsored by the Mental Health Association of Westchester County, White Plains, N.Y. The project has been supported by a grant (M.H. 14792) from the National Institute of Mental Health. This report is adapted from a paper presented at the Eastern Psychological Assn. in Philadelphia on April 12, 1969. The author acknowledges the contribution of Esther D. Mallach, C.S.W., Director of the Mental Health Association; Laura Jensen, M.A., Research Assistant; and Thomas S. Langner, Ph.D.; Melvin Schwartz, M.D.; and Patricia Waly, Ph.D., Consultants.     

On the factors predicting rehospitalization among two state mental hospital patient populations

This study takes a new look at an old issue. It examines the background and performance characteristics of discharged patients from two mental hospitals in Florida in an effort to distinguish those who were readmitted from those still in the community at 6 months. Readmissions were best distinguished from those still in the community on the basis of continued use of outpatient aftercare, low leisure time activity levels, depression, and sensitivity to social stigma. They were also likely to be living alone or with nonrelatives in a living situation with which they were uncomfortable.Elane Nuehring, Ph.D., is affiliated with the Barry College School of Social Work, Miami Shores, Florida, 33161. Joel Thayer, Ph.D., is with the Department of Sociology, Francis Marion College, Florence, South Carolina, 29501. Robert A. Ladner, Ph.D., is the director of the Behavioral Science Research Institute, Coral Gables, Florida, 33134.Data for this study were provided by the Aftercare Project, Florida Department of Health and Rehabilitative Services, Mental Health Program Office. Robert J. Constantine, Ph.D., was the Aftercare project director and is thanked for his ongoing input into this work. The present computer analysis was cosponsored by the Barry College Professional Development Committee and Behavioral Science Research Institute, Coral Gables, Florida.     

Book Reviews

Book reviewed in this article:
The Brain in Unclassified Mental Retardation . Edited by J. B. C avanagh .
Mental Retardation: Occasional Papers 2, 3 & 4 (Institute for Research into Mental Retardation) . By K. S. H olt , S heila H ewett and E lspeth S tephens and J ean R obertson .
Organic Acidurias . Edited by J. S tern and C. T oothill .
Learning, Speech and Thought in the Mentally Retarded . Edited by A. D. B. C larke and M. M. L ewis .
The Genetics of Mental Disorders . By E liot S later and V alerie C owie .
Clubs for Mentally Handicapped Young People . A report on a survey made in 1967. By W. C. W ynne -W oodhouse .     

HIV risk factors for persons with serious mental illness

HIV risk factors were assessed among 120 persons in treatment for serious mental illness. Although subjects had good general knowledge regarding HIV, many engaged in high risk behaviors. Condom use was infrequent among those who had multiple sexual partners, and sharing needles was common for those who used IV drugs. Clearly, factual knowledge about HIV was not sufficient to prevent risky behavior. Nearly half of the sample was categorized as at medium to high risk, and almost half of the participants, especially those at medium risk, underestimated their own level of risk. The results suggest that education and intervention strategies should focus on increasing the accuracy of the individual's risk assessment as well as changing attitudes towards condoms and improving skills in using condoms. Assessing personal risk and adopting risk-reduction strategies are the keys to successful AIDS prevention for persons with serious mental illness.Michael D. Knox is Professor and Chair of the Department of Community Mental Health at the University of South Florida's Florida Mental Health Institute. He also serves as Director of the USF Center for HIV Education and Research. Timothy L. Boaz is Associate Professor in the Department of Community Mental Health. Martha A. Friedrich is Assistant Professor in the Department of Community Mental Health and Associate Director of the USF Center for HIV Education and Research. Michael G. Dow is Associate Professor and Director of Research in the Department of Community Mental Health.This research was funded in part through contract #91MF57230401D with the National Institute of Mental Health. The support and guidance of Armand Checker and Juan Ramos, National Institute of Mental Health, is appreciated.     

Organization development in mental health services

The term organization development encompasses a number of techniques developed largely in private industry to facilitate communication and collaborative problem solving in work groups. OD approaches now are being introduced into mental health organizations, so administrators need information related to making good decisions about whether an OD program might be beneficial in their settings. This discussion focuses on defining OD, describing its current use in mental health and other human service organizations, and assessing the potential payoffs and disadvantages of implementing an OD program in a mental health setting.Edward M. Glaser, Ph.D., is the president of the Human Interaction Research Institute, Los Angeles, and the managing associate of Edward Glaser & Associates, consulting psychologists to management, Los Angeles.Thomas E. Backer, Ph.D., is a senior staff associate of the Human Interaction Research Institute, Los Angeles, and consulting psychologist of Edward Glaser & Associates, Los Angeles.This article was prepared under the support of the National Institute of Mental Health, Mental Health Services Development Branch, Grant No. R12 MH27566-01.The authors are indebted to the following persons for their perceptive critiques of several draft versions of this article: Dr. John Bell, V. A. Hospital, Palo Alto; Dr. Leonard Goodstein, University of Arizona; Mr. Jim Kouzes, San Jose State University; and Mr. Marvin Weisbord, Organization Research & Development. Inputs from our editorial consultant, Ms. Molly Lewin, also were most helpful.     

A study of paraprofessionals in mental health

This article summarizes data gathered on 15 paraprofessional training programs sponsored by the National Institute of Mental Health (NIMH). Data on the backgrounds of trainees working as paraprofessionals are presented along with a breakdown of the kinds of tasks in which they are employed, as well as characteristics linked with ratings of success and retention in the programs. Trainees tended to be employed in a wide variety of tasks, often at rather sophisticated levels. Analysis of the tasks indicates that projects are fulfilling the NIMH New Careers goal of contributing to greater community impact in mental health. Results corroborate earlier findings that paraprofessionals have been accepted both by professionals and clients.The work upon which this publication is based was performed pursuant to Contract No. HSM-42-72-143 with the National Institute of Mental Health; Alcohol, Drug Abuse, and Mental Health Administration.     

Treatment dropouts from a community mental health center

Among 928 discharges from the Fort Logan Mental Health Center, 34% had left treatment without staff approval. These treatment dropouts differed significantly from a comparison group on 39 demographic, mental status, and social history variables. A cluster analysis of those variables yielded eight oblique clusters, characterizing dropouts as more impaired psychologically, more angry, and with a greater tendency to act out. Analyses by sex indicated that male anger was associated with acting out against others, female anger with anxiety and other neurotic symptoms. Dropouts were also younger and less likely to need custodial care. Findings suggest that dropouts are in need of treatment and constitute a problem for community mental health.Both authors were formerly in the Research Department, Fort Logan Mental Health Center, Denver, Colorado. This study was based on data supplied by the Fort Logan Record System Project, Dr. Paul Binner, Director. The Record System is supported in part by Public Health Service Grant No. 5-R11-MH-00931-07 from the National Institute of Mental Health.     

Global mental health: from science to action

This article charts the historical development of the discipline of global mental health, whose goal is to improve access to mental health care and reduce inequalities in mental health outcomes between and within nations. The article begins with an overview of the contribution of four scientific foundations toward the discipline's core agenda: to scale up services for people with mental disorders and to promote their human rights. Next, the article highlights four recent, key events that are indicative of the actions shaping the discipline: the Mental Health Gap Action Programme to synthesize evidence on what treatments are effective for a range of mental disorders; the evidence on task shifting to nonspecialist health workers to deliver these treatments; the Movement for Global Mental Health's efforts to build a common platform for professionals and civil society to advocate for their shared goal; and the Grand Challenges in Global Mental Health, which has identified the research priorities that, within the next decade, can lead to substantial improvements in the lives of people living with mental disorders. The article ends by examining the major challenges for the field, and the opportunities for addressing them in the future.     

Building Bridges to Evidence-based Practice: The MacArthur Foundation Child System and Treatment Enhancement Projects (Child STEPs)

The papers in this special issue describe research undertaken by the MacArthur Foundation-funded Research Network on Youth Mental Health. The project is designed to understand the challenges of implementing evidence-based treatments in community-based mental health practices. This Introduction and the following articles describe the impetus and conceptual framework underlying one cluster of the Network's activity-i.e., the Clinic Systems Project (CSP). The CSP studies examined the organizational and service system environments in a large national sample of community mental health and affiliated organizations that provide services to children. The main goal is to identify leverage points for, and barriers to, the adoption and implementation of evidence-based practices for children.     

Future issues in mental health administration: A report

This article describes highlights and findings of the 1977 National Conference in Mental Health Administration sponsored by The Staff College, National Institute of Mental Health. Over 100 invited experts from the mental health field were assembled to identify changes, trends and developments most likely to influence the administration of mental health services in the future. Conferees also itemized the skills administrators should possess to anticipate and successfully cope with these emerging issues.Noel Mazade, Ph.D. is Director, Advanced Training Program in Community Mental Health Administration, The Staff College, National Institute of Mental Health. The author wishes to thank the following Conference group leaders and recorders whose work forms the basis of this article: Dr. Joseph Aponte; Ms. Carolyn Cherington; Dr. Laurel Files; Ms. Lynn Gunn; Mr. Ronald Metzger; Dr. Joseph Morrissey; Mr. Larry Nikkel; Ms. Joan Offutt; Mr. John Sheets; Dr. Richard Surles; and Ms. Ann Thompson.     

Federally funded CMHCs: The effects of period of initial funding and hospital affiliation

Previous research on federally funded community mental health centers has largely failed to recognize fundamental differences among different types of centers. Here we show that such basic factors as the arrangement for providing inpatient services and the period of initial federal funding have large effects on the development and organization of a center. Although the centers joining the federal program from 1965–1970 are the largest, those facilities funded between 1971–1975 are generally smaller than those funded later. The arrangement for providing inpatient services has an important effect on staffing. This work suggests the national norms may not be the most useful data for evaluating past performance or planning the future of a specific center.Rosalyn D. Bass is with the Division of Biometry and Epidemiology, National Institute of Mental Health.An earlier version of this paper was presented at the Eastern Evaluation Research Society Meeting, held in Philadelphia, Pennsylvania, April 1984. Research on this project was supported in part by grants MH15783 and MH37864 from the National Institute of Mental Health.     

The NIMH blueprint for change report: research priorities in child and adolescent mental health

The National Institute of Mental Health established a special subgroup of its National Advisory Mental Health Council to review major research findings on child and adolescent psychiatric disorders over the past decade and to recommend research priorities for the next decade. This Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment published its report, titled Blueprint for Change: Research on Child and Adolescent Mental Health, in August 2001, and several new research announcements reflecting these new directions have been issued since that time. This article summarizes the rationale for and background to the report, its major conclusions, and the reasons why interdisciplinary and translational approaches to research questions in child and adolescent mental health will help to maximize scientific advances.     

Observations on the nature of human relatedness

The concept of human relatedness was reexamined in the context of a standardized evaluation of 55 boys and 13 girls referred with a diagnosis of childhood psychosis. Human relatedness was hypothesized to be a multidimensional complex construct which could be analyzed in terms of simpler, more basic functions. All children were evaluated on a 14-point diagnostic scale. Analysis of diagnostic data generated three factors, one of which comprised a cluster of variables representing a measure of human relatedness and various perceptual functions. The hypothesis was supported by factor loadings. Also, a multiple regression analysis indicated that most of the variance in human relatedness could be accounted for by perceptual variables. It is suggested that impairment of human relatedness is largely due to impaired perceptual functions, and that much inappropriate maternal behavior is in response to such functions.Supported in part by the National Institute of Mental Health Grant MH 15539. We gratefully acknowledge the statistical consultation of John Hawley, Psychometric Laboratory, University of North Carolina. Edwina Bentz and Laura Viernstein, Research Assistants in the Child Research Project, assisted in the collection and analysis of the data.