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Research on patient-centered care supports use of patient/consumer self-report measures in monitoring health outcomes. This study examined the incremental value of self-report mental health measures relative to a clinician-rated measure in predicting functional outcomes among mental health service recipients. Participants (n = 446) completed the Behavior and Symptom Identification Scale, the Brief Symptom Inventory, and the Veterans/Rand Short Form-36 at enrollment in the study (T1) and 3 months later (T2). Global Assessment of Functioning (GAF) ratings, mental health service utilization, and psychiatric diagnoses were obtained from administrative data files. Controlling for demographic and clinical variables, results indicated that improvement based on the self-report measures significantly predicted one or more functional outcomes (i.e., decreased likelihood of post-enrollment psychiatric hospitalization and increased likelihood of paid employment), above and beyond the predictive value of the GAF. Inclusion of self-report measures may be a useful addition to performance measurement efforts.

In this commentary, we review recent research suggesting that (a) second-generation antipsychotics (SGAs) may be no more effective than first-generation antipsychotics (FGAs), (b) the reduced risk of EPS and tardive dyskinesia with SGAs is more weakly supported by the research literature than has been appreciated, and (c) benefits may be offset by greater metabolic risks of some SGAs and their substantially greater cost. Bearing in mind, as well, that risperidone, currently the least expensive SGA, will soon be available as an even less expensive generic drug, we propose a new algorithm for maintenance antipsychotic therapy. We further outline a cautious implementation procedure that relies on standardized documentation and feedback, without a restrictive formulary that would limit physician choice. The algorithm outlined here and the process for its implementation are intended as a stimulus for discussion of potential policy responses, not as a finalized proposition.

In 1986, our hospitals were selected by a large Massachusetts independent practice HMO to administer a capitated program for psychiatric inpatients residing in Boston and in neighboring northern cities and towns. Administering this program necessitated designing new systems of accounting, utilization review, physician reimbursement, staff education, orientation, and management control as well as contracting with other hospitals for locked psychiatric beds. It also included developing day treatment, crisis intervention, and visiting nurse services. Psychiatrists had to adapt to a new reimbursement system which paid by the admission or which withheld 30% of payment until program performance was evaluated. Those who valued intrapsychic change found it hard to value crisis intervention and symptom reduction to the same degree. Although there was considerable variation in each hospital's performance, there was over a 25% decrease in patient days and an overall reduction in readmission rate during the first year of the program.

The authors compared the records of 59 psychiatric patients involutarily committed to a Veterans Administration hospital on an emergency basis with those of a control group of 59 psychiatric patients with respect to the number of assaults noted during the first 45 days of hospitalization. The committed group had a .41 probability and the control group a .08 probability of committing an assault. The difference between the two groups was mainly accounted for by assaults that occurred during the first 10 days of hospitalization. The occurrence of an actual act of battery before admission did not predict assault in the hospital to a greater degree than did a verbal threat. The authors conclude that short-term clinical predictions of dangerousness predict assaultiveness in the hospital to a significant degree.