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Implementation of evidence-based care for serious mental illnesses such as bipolar disorder has been suboptimal. Improving and sustaining concordance with clinical practice guidelines has been a cornerstone of efforts to enhance evidence-based care and improve outcomes. For bipolar disorder, however, there has been only one regional controlled trial reporting guideline concordance, and no data are available for time periods longer than 1 year. In a multiregion effectiveness trial in veterans with bipolar disorder, the authors assessed the effects of a collaborative care model for this disorder on guideline concordance in care over a 3-year period.A total of 306 participants with bipolar disorder were randomly assigned at hospital discharge to 3 years of follow-up treatment with a collaborative care model or to usual care. The collaborative care model included provider support through simplified practice guidelines, patient skills management enhancement through group psychoeducation, and facilitated access and continuity via nurse care management. Concordance with guideline-recommended antimanic pharmacotherapy was assessed at baseline and prospectively over six 6-month epochs. Group differences were assessed with generalized estimating equations that controlled for relevant covariates.The collaborative care model achieved significantly higher rates of guideline-concordant antimanic treatment than usual care over the entire follow-up period. Baseline guideline concordance, but not patient age or bipolar type, was associated with higher concordance.Multicomponent collaborative care models, which include not only provider support for guideline implementation but also patient self-management skill enhancement and facilitated treatment access and continuity, can improve guideline concordance over the long term, even in severely impaired patients.

The authors examined the disruption of ongoing treatments among individuals with preexisting mental disorders and the failure to initiate treatment among individuals with new-onset mental disorders in the aftermath of Hurricane Katrina.English-speaking adult Katrina survivors (N=1,043) responded to a telephone survey administered between January and March of 2006. The survey assessed posthurricane treatment of emotional problems and barriers to treatment among respondents with preexisting mental disorders as well as those with new-onset disorders posthurricane.Among respondents with preexisting mental disorders who reported using mental health services in the year before the hurricane, 22.9% experienced reduction in or termination of treatment after Katrina. Among those respondents without preexisting mental disorders who developed new-onset disorders after the hurricane, 18.5% received some form of treatment for emotional problems. Reasons for failing to continue treatment among preexisting cases primarily involved structural barriers to treatment, while reasons for failing to seek treatment among new-onset cases primarily involved low perceived need for treatment. The majority (64.5%) of respondents receiving treatment post-Katrina were treated by general medical providers and received medication but no psychotherapy. Treatment of new-onset cases was positively related to age and income, while continued treatment of preexisting cases was positively related to race/ethnicity (non-Hispanic whites) and having health insurance.Many Hurricane Katrina survivors with mental disorders experienced unmet treatment needs, including frequent disruptions of existing care and widespread failure to initiate treatment for new-onset disorders. Future disaster management plans should anticipate both types of treatment needs.

The purpose of this study was to assess the effectiveness of assertive community treatment in the rehabilitation of homeless persons with severe mental illness using a meta-analysis.A structured literature search identified studies for review. Inclusion criteria were the use of an assertive community treatment-based rehabilitation treatment in an experimental or quasi-experimental model, exclusive treatment of homeless subjects, and follow-up of housing and psychiatric outcomes. Two reviewers independently abstracted data on methodology and outcomes from included studies. The authors calculated effect differences, summary effects and confidence intervals (CIs) for housing, and hospitalization and symptom severity outcomes.Of the 52 abstracts identified, 10 (19%) met inclusion criteria. Of these, six were randomized controlled trials, and four were observational studies, totaling 5,775 subjects. In randomized trials, assertive community treatment subjects demonstrated a 37% (95% CI=18%-55%) greater reduction in homelessness and a 26% (95% CI=7%-44%) greater improvement in psychiatric symptom severity compared with standard case management treatments. Hospitalization outcomes were not significantly different between the two groups. In observational studies, assertive community treatment subjects experienced a 104% (95% CI=67%-141%) further reduction in homelessness and a 62% (95% CI=0%-124%) further reduction in symptom severity compared with pretreatment comparison subjects.Assertive community treatment offers significant advantages over standard case management models in reducing homelessness and symptom severity in homeless persons with severe mental illness.

Costs of treating child psychiatric disorders fall on educational, primary care, juvenile justice, and social service agencies as well as on psychiatric services. The authors estimated multiagency mental health costs by integrating service unit costs with utilization rates in an 11-county area. Using psychiatric diagnoses made independently of service use records, the authors calculated costs across agencies as well as the extent of unmet need for psychiatric care.Annual parent and child reports were used to measure mental health care needs and units of service across 21 types of settings for the population-based Great Smoky Mountain Study sample of 1,420 adolescents from ages 13 to 16. Unit costs for services were generated from information from service providers and records. The authors calculated costs overall, costs by type of service, and costs by diagnosis.Average annual costs per adolescent treated were $3,146. Juvenile justice and inpatient/residential facilities accounted for well over half of the total costs. Costs for youths with two or more diagnoses were twice as much as costs of those with a single disorder. Among adolescents with service needs, 66.9% received no services. Public health insurance was associated with higher rates of specialty mental health care than either private insurance or no insurance.Annual costs across all services were three to four times greater than recent health insurance estimates alone. Many costs for adolescents with mental health problems were borne by agencies not designed primarily to provide psychiatric or psychological services. Only one in three adolescents needing psychiatric care received any mental health services.

This article explores the link between violence and the practice of legally mandating treatment in the community or leveraging benefits from the social welfare system, such as subsidized housing and disability income support, to ensure adherence to treatment.Data are presented from a survey of 1,011 persons with psychiatric disorders receiving treatment in public mental health service systems in five U.S. cities. Multinomial logit analysis was used to examine the association between physically assaultive behavior and experience of social welfare leverage, legal leverage, or both types of leverage, with the analyses controlling for demographic and clinical characteristics.Across study sites, 18% to 21% of participants reported having committed violent acts in the past 6 months; 3% to 9% reported having used or made threats with a lethal weapon, committed sexual assault, or caused injury. About three-quarters of subjects who reported such serious violence also reported having experienced some form of leveraged treatment, compared with about one-half of subjects who did not report serious violence. Demographic and clinical factors that were independently associated with the likelihood of experiencing both types of leverage included younger age, male gender, poorer clinical functioning, more years in treatment, more frequent hospitalizations, higher frequency of outpatient visits, and negative attitudes toward medication adherence. Among participants who did not voluntarily take psychotropic medication, even minor assaultiveness was associated with having experienced legal leverage.A combination of concerns about safety and treatment nonadherence may influence decisions by clinicians and judges to apply legal leverage.

The authors explored the effects of an escalation of terrorism on the help-seeking behavior of the general population in Jerusalem, a city that offers an adequate supply of medical and psychiatric services.Time-series analyses were applied to examine the utilization of health services (primary medical care and ambulance calls) and mental health services (clinics, hospitals, and telephone hotlines) by Jerusalem residents before and during part of the current intifada. The authors assessed seasonality, general linear trends (from factors such as health education and increased access), short-term intifada impact (reflecting reactions that peaked at the third month and ended 1 year thereafter), and long-term impact (starting at the intifada outbreak and reflecting a more stable population behavior).Adult psychiatric outpatient visits did not change except for the elderly in ongoing care who had both short- and long-term increases. The proportion of recorded ICD-10 diagnoses reflecting intifada-related reactions remained generally stable. Short-term effects included an increase in psychiatric readmissions. First contacts to substance abuse clinics remained unchanged. While long-term effects included a decrease in new psychiatric hospitalizations, the rate of monthly general practitioner visitors and the number of monthly ambulance and hotline calls increased.Except for the elderly and previously hospitalized persons, Jerusalem residents did not increase their use of psychiatric services but did increase their use of some other health services. These results suggest that this terrorism-affected population did not perceive their mental and social suffering as requiring specialized intervention.

Objective: Time-limited manualized dynamic psychotherapy was compared with community-delivered psychodynamic therapy for outpatients with personality disorders. Method: In a stratified randomized clinical trial, 156 patients with any personality disorder diagnosis were randomly assigned either to 40 sessions of supportiveexpressive psychotherapy (N=80) or to community-delivered psychodynamic therapy (N=76). Assessments were made at intake and 1 and 2 years after intake. Patients were recruited consecutively from two community mental health centers (CMHCs), assessed with the Structural Clinical Interview for DSM-IV Axis II Personality Disorders, and included if they had a diagnosis of any DSM-IV personality disorder. The outcome measures included the presence of a personality disorder diagnosis, personality disorder severity index, level of psychiatric symptoms (SCL-90), Global Assessment of Functioning Scale score, and number of therapy sessions. General mixed-model analysis of variance was used to assess group and time effects. Results: In both treatment conditions, the global level of functioning improved while there were decreases in the prevalence of patients fulfilling criteria for a personality disorder diagnosis, personality disorder severity, and psychiatric symptoms. There was no difference in effect between treatments. During the follow-up period, patients who received supportive-expressive psychotherapy made significantly fewer visits to the CMHCs than the patients who received community-delivered psychodynamic therapy. Conclusions: Manualized supportive-expressive psychotherapy was as effective as nonmanualized community-delivered psychodynamic therapy conducted by experienced dynamic clinicians.

The purpose of the study was to examine the inpatient and outpatient service use and 4-year outcomes of newly admitted psychotic patients during a period of rapid change in the provision of psychiatric services in a well-defined catchment area in New York State in the 1990s.Subjects were 573 participants of the Suffolk County Mental Health Project. This group comprised patients with psychotic disorders first admitted between September 1989 and August 1995 to 12 inpatient facilities across Suffolk County, N.Y., and followed for up to 48 months. The subjects' service use, course of illness, symptomatic outcomes, suicide risk, homelessness risk, and satisfaction with care were compared across admission years.The length of inpatient stays decreased significantly across the years. However, the number of outpatient visits and therapy sessions did not vary. Although the patients admitted in later years were more symptomatic at admission to their first hospitalization, their course and outcomes over the follow-up period were not worse and they were not less satisfied with their care, compared with the patients admitted in earlier years.The clinical characteristics of patients and the role of inpatient care in the management of patients with psychotic disorders gradually changed during the 1990s. These changes, however, were not associated with changes in the use of outpatient services or outcomes. Nevertheless, shorter hospital stays and the presence of more severely ill patients highlight the need for more attention to linkage to aftercare and enhancement of support networks in the community.

Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled.Participants were 1,256 youths ages 6-18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strain, and parental depression.Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled. Race/ethnicity did not exert a significant effect on the use of informal or 24-hour-care services.Racial/ethnic disparities in service use remain a public health problem.

The inability to blind research participants to their experimental conditions is the Achilles' heel of mental health services research. When one experimental condition receives more disappointed participants, or more satisfied participants, research findings can be biased in spite of random assignment. The authors explored the potential for research participants' preference for one experimental program over another to compromise the generalizability and validity of randomized controlled service evaluations as well as cross-study comparisons.Three Cox regression analyses measured the impact of applicants' service assignment preference on research project enrollment, engagement in assigned services, and a service-related outcome, competitive employment.A stated service preference, referral by an agency with a low level of continuity in outpatient care, and willingness to switch from current services were significant positive predictors of research enrollment. Match to service assignment preference was a significant positive predictor of service engagement, and mismatch to assignment preference was a significant negative predictor of both service engagement and employment outcome.Referral source type and service assignment preference should be routinely measured and statistically controlled for in all studies of mental health service effectiveness to provide a sound empirical base for evidence-based practice.

The authors examined the prevalence of and risk factors for homelessness among all patients treated for serious mental illnesses in a large public mental health system in a 1-year period. The use of public mental health services among homeless persons was also examined.The study included 10,340 persons treated for schizophrenia, bipolar disorder, or major depression in the San Diego County Adult Mental Health Services over a 1-year period (1999-2000). Analytic methods that adjusted for potentially confounding variables were used. Multivariate logistic regression analyses were used to calculate odds ratios for the factors associated with homelessness, including age, gender, ethnicity, substance use disorder, Medicaid insurance, psychiatric diagnosis, and level of functioning. Similarly, odds ratios were computed for utilization of mental health services by homeless versus not-homeless patients.The prevalence of homelessness was 15%. Homelessness was associated with male gender, African American ethnicity, presence of a substance use disorder, lack of Medicaid, a diagnosis of schizophrenia or bipolar disorder, and poorer functioning. Latinos and Asian Americans were less likely to be homeless. Homeless patients used more inpatient and emergency-type services and fewer outpatient-type services.Homelessness is a serious problem among patients with severe mental illness. Interventions focusing on potentially modifiable factors such as substance use disorders and a lack of Medicaid need to be studied in this population.

Objective: The validity of the distinctions between dysthymic disorder, chronic major depressive disorder, and episodic major depressive disorder was examined in a family study of a large community sample of young adults. Method: First-degree relatives (N=2,615) of 30 probands with dysthymic disorder, 65 probands with chronic major depressive disorder, 313 probands with episodic major depressive disorder, and 392 probands with no history of mood disorder were assessed by using direct interviews and informant reports. Results: The rates of major depressive disorder were significantly greater among the relatives of probands with dysthymic disorder and chronic major depressive disorder than among the relatives of probands with episodic major depressive disorder, who in turn exhibited a higher rate of major depressive disorder than the relatives of probands with no history of mood disorder. The relatives of probands with dysthymic disorder had a significantly higher rate of dysthymic disorder than the relatives of probands with no history of mood disorder, and the relatives of probands with chronic major depressive disorder had a significantly higher rate of chronic major depressive disorder than the relatives of probands with no history of mood disorder. However, the relatives of the three groups of probands with depression did not differ on rates of dysthymic disorder and chronic major depressive disorder. Conclusions: Chronic depression is distinguished from episodic depression by a more severe familial liability. This familial liability may contribute to the more pernicious course of chronic depression.

Community surveys have demonstrated significant psychological distress since the terrorist attacks of Sept. 11, 2001. Since people with posttraumatic stress disorder (PTSD) and other mental illnesses are especially vulnerable to stressful events, the authors examined the use of PTSD treatment services and other mental health services at Department of Veterans Affairs (VA) medical centers in New York City and elsewhere after the attacks.Analysis of variance was used to compare changes in average daily service use in the 6 months before and the 6 months after September 11, with changes in service use across the same months in the 2 previous years. Chi-square tests were used to examine differences from previous years in the proportion of new patients (i.e., who had not received treatment in the previous 6 months) entering treatment after September 11.There was no significant increase in the use of VA services for the treatment of PTSD or other mental disorders or in visits to psychiatric or nonpsychiatric clinics in New York City after September 11 and no significant change in the pattern of service use from previous years. Nor was there a significant increase in PTSD treatment in the greater New York area, Washington, D.C., or Oklahoma City or in the proportion of new patients.No increase was observed in the use of mental health services among VA patients with PTSD or other mental illnesses in response to the terrorist attacks of September 11.

Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice.Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized.Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services.Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

Objective: This study presents data on the use of complementary and alternative therapies to treat anxiety and depression in the United States. Method: The data came from a nationally representative survey of 2,055 respondents (1997–1998) that obtained information on the use of 24 complementary and alternative therapies for the treatment of specific chronic conditions. Results: A total of 9.4% of the respondents reported suffering from “anxiety attacks” in the past 12 months; 7.2% reported “severe depression.” A total of 56.7% of those with anxiety attacks and 53.6% of those with severe depression reported using complementary and alternative therapies to treat these conditions during the past 12 months. Only 20.0% of those with anxiety attacks and 19.3% of those with severe depression visited a complementary or alternative therapist. A total of 65.9% of the respondents seen by a conventional provider for anxiety attacks and 66.7% of those seen by a conventional provider for severe depression also used complementary and alternative therapies to treat these conditions. The perceived helpfulness of these therapies in treating anxiety and depression was similar to that of conventional therapies. Conclusions: Complementary and alternative therapies are used more than conventional therapies by people with selfdefined anxiety attacks and severe depression. Most patients visiting conventional mental health providers for these problems also use complementary and alternative therapies. Use of these therapies will likely increase as insurance coverage expands. Asking patients about their use could prevent adverse effects and maximize the usefulness of therapies subsequently proven to be effective.

Objective: About one-quarter of homeless Americans have serious mental illnesses. This review synthesizes research findings on the cost-effectiveness of services for this population and their relevance for policy and practice. Method: Service interventions for seriously mentally ill homeless people were grouped into three overlapping categories: 1) outreach, 2) case management, and 3) housing placement and transition to mainstream services. Data were reviewed both from experimental studies with high internal validity and from observational studies, which better reflect typical community practice. Results: In most studies, specialized interventions are associated with significantly improved outcomes, most consistently in the housing domain, but also in mental health status and quality of life. These programs are also associated with increased use of many types of health service and housing assistance, resulting in increased costs in most cases. The value of these programs to the public thus depends on whether their greater effectiveness is deemed to be worth their additional cost. Conclusions: Innovative programs for seriously mentally ill homeless people are effective and are also likely to increase costs in many cases. Their value ultimately depends on the moral and political value society places on caring for its least-well-off members.

This study examined the mental health service utilization and costs of 321 discharged state hospital patients during a 3-year follow-up period compared with costs if the patients had remained in the hospital.The study subjects were long-stay patients discharged from Philadelphia State Hospital after 1988. A longitudinal integrated database on all mental health and medical services reimbursed by Medicaid and Medicare as well as state- and county-funded services was used to construct service utilization and unit cost measures.During the 3-year period after discharge, 20%-30% of the patients required rehospitalization an average of 76-91 days per year. The percentage of rehospitalized patients decreased over time, but the number of hospital days increased. All of the discharged patients received case management services, and a majority also received outpatient mental health care (66%-70%) and residential services (75%) throughout the follow-up period. The total treatment cost per person was approximately $60,000 a year after controlling for inflation, with costs rising slightly over the 3-year period. The estimated cost of state hospitalization, with the use of 1992 estimates, would have been $130,000 per year if the patients had remained institutionalized.This analysis suggests that most former long-stay patients are able to live in residential settings while receiving community outpatient treatment and intensive case management services at a reduced cost. There is no indication of cost shifting from the psychiatric to the health care sector; however, some cost shifting from the state mental health agency to the Medicaid program has occurred, since most psychiatric hospital care now takes place in community hospitals.

Although many geriatric patients with schizophrenia have been referred to nursing home care, little is known about their characteristics. Across nursing home and chronic hospital settings, the authors directly assessed poor outcome geriatric patients with schizophrenia and contrasted their cognitive, symptomatic, and adaptive functioning to that of acutely admitted patients with a better outcome over the lifetime course of the illness.The subjects were 97 chronically hospitalized patients with schizophrenia, 37 patients with chronic schizophrenia who lived in nursing homes, and 31 acutely admitted geriatric patients with schizophrenia. These patients were rated with the Positive and Negative Syndrome Scale, tested with a neuropsychological battery, evaluated with the Mini-Mental State examination, and rated on a scale of social and adaptive deficits, the Social Adaptive Functioning Evaluation scale.Each group of patients proved discriminable from the other two: nursing home patients displayed the most severe adaptive deficits, and acutely admitted patients were the least cognitively impaired. Cognitive impairment was the strongest predictor of adaptive deficits for all three groups, and negative symptom differences among the groups were smaller than differences in cognitive impairment. Nursing home patients had the least severe positive symptoms, and the acutely ill and chronic hospital patients did not differ on positive symptoms.Cognitive impairment is a predictor of both overall outcome and specific adaptive deficits. These data suggest that interventions aimed at cognitive impairment may have an impact on overall functional status. In comparison, positive symptom severity is less strongly correlated with overall adaptive outcome and is uncorrelated with specific deficits in adaptive skills.

In 1989, Philadelphia began a bold experiment involving the total shutdown of a 500-bed state hospital. This study examines the service utilization and cost of treating individuals with serious mental illness in a community-based care system in which the state hospital was replaced with 60 extended acute care beds in general hospitals and 583 residential beds.A pre-post study design was used to determine the utilization and cost differences before and after the state hospital closed for individuals with a diagnosis of schizophrenia who required extended psychiatric hospitalization following an acute care crisis episode in a general hospital. The number and cost of days spent in general and in extended hospital and residential treatment were compared on an episode and an annual basis.The results of this analysis showed that after the state hospital closed, the direct treatment cost of an episode of care increased from $68,446 to $78,929, and the average annual cost of care per patient increased from $48,631 to $66,794 because of an increase in acute care hospitalization.This study suggests that an "admission" cohort of seriously mentally ill patients requires an optimal mix of acute care, extended care, and residential beds, as well as ambulatory services, in order for cost-efficient care to be delivered during a crisis period. Determining the appropriate allocation and supply of beds in different settings is essential if community mental health systems are to manage the care of individuals with serious mental illness outside of institutional settings.

OBJECTIVE: The authors examined different ways of measuring unit costs and how methodological assumptions can affect the magnitude of cost estimates and the ratio of treatment costs in comparative studies of mental health interventions. Four methodological choices may bias cost estimates: study perspective, definition of the opportunity cost of resources, cost allocation rules, and measurement of service units. METHOD: Unit costs for outpatient services, individual therapy, and group therapy were calculated under different assumptions for a single community mental health center (CMHC). Using hypothetical service utilization profiles, the authors used the unit costs to calculate the costs of mental health treatments provided by two programs of the CMHC. RESULTS: The unit costs for an hour of outpatient services ranged from $108 to $538. The unit costs for an hour of therapy varied by 156%; unit costs were lowest if the management perspective was assumed and highest if the economist perspective was assumed. The ratio of the outpatient costs in the two treatment programs ranged from 0.6 to 1.8. CONCLUSIONS: The potential errors introduced by methodological choices can bias cost-effectiveness findings based on randomized control trials. These errors go undetected because crucial methodological information is not reported.

Objective: The authors sought to evaluate how the services required by the Italian Psychiatric Reform of 1978 were implemented in Emilia-Romagna, a region of 4 million inhabitants in Northern Italy. Method: All psychiatric facilities were monitored from 1978 to 1994 to determine the number and rates of admissions, average duration of stay, average intake, and percent of beds occupied at inpatient facilities as well as the number of patients residing in former mental hospitals and the number and rates of first contacts with mental health community centers. Results: Three mental hospitals out of nine were closed during the period, and the number of patients who resided in mental hospitals declined from 4,798 to 655. By 1994, there were 145 community centers, 48 day treatment centers, 12 general hospital psychiatric wards, three university psychiatric clinics, seven private psychiatric clinics, 24 psychiatric residences, and 123 supervised apartments that were operating as alternatives to asylums. The overall rate of inpatient admissions remained stable, but compulsory admissions gradually decreased by 35% throughout the period. First contacts at outpatient centers increased by 17.9% from 1984 to 1991. Conclusions: The shift from a hospital-based to a communitybased psychiatric system of care, as foreseen by the Italian psychiatric reform, seems feasible. Some general political, administrative, and social backup conditions appear crucial to ensure the good outcome of this process. (Am J Psychiatry 1997; 154:94‐98)

Objective: The purpose of this study was to evaluate the policy of closing psychiatric hospitals and replacing their functions with community-based services. Method: All long-stay nondemented patients in two U.K. hospitals scheduled for closure were assessed with a series ofschedules. All patients in one hospital and a proportion of those in the other hospital were reassessed 1 year after discharge to community facilities. Results: Of the 73 7 patients discharged from the two hospitals, 24 died before follow-up, two by suicide. Follow-up was successful for 94.6% of the survivors. Only seven patients were lost to follow-up and are presumed to have become homeless. Only two patients went to prison, one briefly. There was very little change in patients’ psychiatric symptoms or social behavior problems. The community homes provided a much less restrictive environment than the hospital wards. Discharged patients were very appreciative of their increased freedom, and over 80% wished to stay in their community homes. There was an increase in the proportion ofpatients with incontinence and immobility. The patients ‘ social lives were enriched by an increase in friends, and some made contact with neighbors and others in the community. However, there was a decrease in contact with relatives following discharge. Conclusions: When the capital and revenue resources ofa psychiatric hospital are reinvested in community services, based on staffed houses, there are few problems with crime or homeless;iess. With such well-resourced services, the benefits greatly outweigh the disadvantages for both old and new long-stay patients. (Am JPsychiatry1996; 153:1318-1 324)

Objective: The authors compared service utilization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program. Method: The patients (N=1 97) were randomly assigned to one of the two programs and followed for I 0 months after discharge. Both programs were provided by a community mental health center (CMHC) in a poor urban community. Data were collected for developing service utilization profiles and estimates ofper-unit costs ofthe inpatient, day hospital, and outpatient services provided by the CMHC. Results: On average, the day hospital/crisis respite program cost less than inpatient hospitalization. The average saving per patient was $7, 1 00, or roughly 20% ofthe total direct costs. There were no significant differences between programs in service utilization or cost during the follow-up phase. Cost savings accrued in the index episode because per-unit costs were lower for day hospital/crisis respite and the average stay was shorter. Significant differences in cost were found among patient groups with psychosis, affective disorders, and dual diagnoses; psychotic patients had the highest costs in both programs. The two programs had roughly equal direct service staffand capital costs but significant!)’ different operating costs (day hospital/crisis respite operating costs were 51 % of inpatient hospital costs). Conclusions: The programs were equally effective, but day hospital/crisis respite treatment was less expensive for some patients. Potential cost savings are higher for nonpsychotic patients. Cost differences between the programs are driven by the hospital’s relatively higher overhead costs. The roughly equal expenditures for direct service staff costs in the two programs may be an important clue for understanding why these programs provided equally effective acute care. (AmJ Psychiatry 1996; 153:1074-1083)

Objective: This study investigated the stability of behavioral and emotional problems from adolescence into young adulthood. Method: Subjects from the general population (N=459), aged 13-1 6 years, were evaluated initially with the Child Behavior Checklist (completed by parents) and 8 years later with the Young Adult Self-Report. The scoring format and factor structure of the two assessment instruments are similar; syndromes constructed from the two instruments are based on parents’, teachers’, and self-report information derived from large clinical samples. Signs of maladjustment also were assessed at follow-up through interviews. Results: Ofthe individuals with totaiproblem scores in the deviant range on the Child Behavior Checklist, 27.3% had totalproblem scores in the deviant range on the Young Adult Self-Report at follow-up. The probability ofhaving a total problem score in the deviant range at follow-up was raised 7.4-fold by having deviant-range scores on the Child Behavior Checklist somatic complaints and anxious/depressed syndromes (simultaneously) at the initial assessment. Ref erral to mental health services was predicted by deviant-range scores on the anxious/depressed syndrome, while suicide attempts were predicted by deviance on the withdrawn syndrome. Conclusions: Adolescent problems tended to persist into young adulthood to a moderate degree. High rates ofwithdrawal from social contacts, anxiety or depression, somatic complaints without known medical origin, social problems, attention problems, delinquent behavior, and aggressive behavior during adolescence were risk factors for specific types of psychopathology and maladjustment at 8-year follow-up. The presence of psychopathology in adolescence should not be regarded as normative. (Am J Psychiatry 1995; 152:1586-1594)

Objective : The authors tested the efficacy of individual psychotherapy in the rehabilitation counseling of psychiatrically symptomatic opiate-dependent patients during methadone maintenance treatment in community programs. Method : Volunteers in three community programs were randomly assigned to 24 weeks of counseling plus supplemental drug counseling or to counseling plus supportive-expressive psychotherapy. Follow-ups were done 1 and 6 months after treatment ended. A total of 84 subjects were evaluated at both follow-up points. Results : During the study the patients receiving supportive-expressive psychotherapy and those receiving drug counseling had similar proportions of opiate-positive urine samples, but the patients receiving supportive-expressive psychotherapy had fewer cocaine-positive urine samples and required lower doses of methadone. One month after the extra therapy ended both groups had made significant gains, but there were no significant differences between groups. By 6-month follow-up many of the gains made by the drug counseling patients had diminished, whereas most of the gains made by the patients who received supportive-expressive psychotherapy remained or were still evident ; many significant differences emerged, all favoring supportive-expressive psychotherapy. Conclusions : Psychotherapy can be delivered to psychiatrically impaired patients in community methadone programs. Additional counseling is associated with early benefits comparable to those from psychotherapy, but these gains are not sustained. The gains associated with psychotherapy persist and in some cases strengthen for at least 6 months after the end of therapy.

Objective: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations. Method: The authors reviewed the published controlled clinical trials ofassertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems. Results: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use ofan ecological model ofbehavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan. Conclusions: As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions. (AmJ Psychiatry 1995; 152:1111-1123)

Objective This study explored the effect of veterans' race and of the pairing of veterans' and clinicians' race on the process and outcome of treatment for war-related posttraumatic stress disorder (PTSD). Method As part of the national evaluation of the PTSD Clinical Teams program of the Department of Veterans Affairs, data on assessment of 4,726 white and black male veterans at admission to the program and on the race and other characteristics of their 315 primary clinicians were obtained. Measures of service delivery and treatment emphasis were obtained 2, 4, 8, and 12 months after program entry, along with clinicians' ratings of improvement. Results After control for sociodemographic characteristics, clinical status, and clinicians' characteristics, multivariate analysis showed that black veterans had significantly lower program participation ratings than white veterans on 10 of 24 measures, but no differences in clinicians' improvement ratings were noted. Additional analyses showed that pairing of white clinicians with black veterans was associated with lower program participation on four of the 24 measures and with lower improvement ratings on one of 15 measures. When treated by either black or white clinicians, black veterans had poorer attendance than white veterans, seemed less committed to treatment, received more treatment for substance abuse, were less likely to be prescribed antidepressant medications, and showed less improvement in control of violent behavior. Conclusions Although no differences were noted on most measures, the pairing of black veterans with white clinicians was associated with receiving fewer services. According to some other measures, black veterans received less intensive services regardless of the clinician's race.

The authors assessed health care costs associated with psychoanalytically oriented partial hospital treatment for borderline personality disorder compared with treatment as usual within general psychiatric services.Health care utilization of all borderline personality disorder patients who participated in a previous trial of partial hospital treatment compared with treatment as usual was assessed by using information from case notes and service providers. Costs were compared for the 6 months before treatment, 18 months of treatment, and an 18-month follow-up period.There were no cost differences between the groups during pretreatment or treatment. Costs of partial hospital treatment were offset by less psychiatric inpatient care and reduced emergency room treatment. The trend for costs to decrease in the partial hospitalization group during the follow-up period was not apparent in the treatment-as-usual group.Specialist partial hospital treatment for borderline personality disorder is no more expensive than treatment as usual and shows considerable cost savings after treatment.

Objective: The authors sought to determine whether 20 years ofcultural change have altered the clinical lore and earlier findings that Mexican-Americans are more resistant to psychotherapy than other ethnic groups and less likely to be referred for it. Method: All charts of patients seen on a university hospital psychotherapy service since its inception in 1979 were reviewed in three separate studies. The charts of all cases closed as of I 984, the charts of all active patients during 1 985, and the charts ofallpatients screened for therapy in I 986 were included. Ethnic background, age, sex, education, income, treatment modality recommended, duration of therapy, and outcome (interrupted versus completed therapy) were recorded for each patient. Results: There were minor significant differences between the Mexican-American patients and the Anglo-American patients in age and education. No other significant differences were found. Conclusions: Because of cultural change, altered psychiatric perspectives, and/or the effects ofsocioeconomic status as a confounding variable in previous studies, the accepted clinical lore and earlier findings about psychotherapy with Mexican-Americans may no longer apply. (Am J Psychiatry 1992; 149:626-630)

OBJECTIVE The purpose of this study was to examine the relationship of racial/ethnic identity to the amount and type of psychiatric treatment received by white, black, Latino, and Asian patients in the Los Angeles County mental health system. METHOD The patients studied (N = 19,400) consisted of all adult inpatients and outpatients seen in all county mental health facilities between January 1983 and August 1988. Multiple regression analysis was used to test the relationship between race/ethnicity and four measures of treatment received: number of treatment sessions, treatment modality, treatment setting, and therapist's discipline. The covariates included in the analyses were age, sex, socioeconomic status, primary language, diagnosis, and measures of treatment when these were logical predictors and were not acting as dependent variables. RESULTS Race/ethnicity did not have a consistent significant relationship to the treatment variables studied. However, diagnosis had a consistent and highly significant relationship to all four measures of treatment. A psychotic diagnosis was related to receiving more treatment sessions, greater use of medication, greater use of inpatient treatment, and less treatment by a professional therapist. Socioeconomic status and primary language also had consistent and significant relationships to three of the treatment variables. CONCLUSIONS In considering modifications to the service delivery system, clinicians must evaluate whether the type of treatment provided to psychotic patients is the treatment of choice in terms of effectiveness and efficiency or whether it involves bias in service delivery. Similarly, the issue of bias in treatment of lower socioeconomic patients must be addressed.

OBJECTIVE Preliminary studies suggest that during the 1980s, spending for community mental retardation services in the United States may have grown much more rapidly than spending for community mental health. The primary objective of this study was to test empirically the validity of this thesis on a national basis. An additional objective was to determine why such a distinction in community spending patterns might have evolved nationally. METHOD The study used states as the units of analysis and employed a five-factor hierarchical regression to predict variance in mental health and mental retardation spending. Factors were state size, state wealth, degree of federal assistance, state civil rights activity, and strength of consumer advocacy groups. Strong roles for the civil rights and consumer advocacy factors were hypothesized. A collateral opinion survey in the 10 states exhibiting the greatest within-state difference in community mental health and mental retardation spending was also completed. RESULTS Community mental retardation spending grew nearly four times more rapidly than community mental health spending in the 1980s. The consumer advocacy and civil rights factors were strongly associated with spending for community mental retardation services in the states, but these factors did not predict spending for community mental health services. CONCLUSIONS Study recommendations included strengthening mental health family and consumer advocacy groups in the states and promoting systematic exchange between the mental health and mental retardation fields through joint state planning initiatives, studies, and conferences. The need for Medicaid reform is a unifying theme in both the mental health and mental retardation fields.

Objective : The purpose of this study was to extend previous findings on the relationship of V code conditions to use of psychiatric services and treatment outcome. Method : The group under study involved 2,542 outpatients from three community mental health centers in Nova Scotia, Canada. From this group three subgroups of patients were compared : 1) patients with V code conditions, 2) patients with DSM-III-R mental disorders, and 3) patients with both V code conditions and mental disorders. Results : The majority of patients (61.8%) were diagnosed with V code conditions, and a substantial minority (19.6%) had V code conditions as the sole diagnoses. Patients with V code conditions without mental disorders were similar to patients with mental disorders in consumption of treatment resources and treatment outcome. Conclusions : Strategies for improving the efficiency of mental health services to patients with V code conditions need to be developed.