Forty years of progress in community mental health: the role of evidence-based practices.
Explore the source record for details and available documents.
Community Mental Health Services↗
Biomedical subjects
Howard H Goldman
Publications and source records attributed to Howard H Goldman.
"Usual care" for major depression in the 1990s: characteristics and expert-estimated outcomes.
OBJECTIVE: Motivated by the public health importance of major depression and calls to study the effectiveness of treatments frequently used in routine practice, the authors characterized the usual outpatient care of acute-phase major depression in a privately insured population as well as the effectiveness of this care. METHOD: Upon identifying frequent antidepressant interventions from a large administrative database spanning the years 1991-1996, and after completing an exhaustive review of published efficacy evidence, the authors undertook a two-stage elicitation process. A panel of 10 experts estimated probabilities of symptom-based outcomes for 120 combinations of treatment, provider type, and patient characteristics seen in 9,054 depressive episodes. The 10 most frequent treatments, utilized in 90% of the episodes, are reported here. RESULTS: A short course of psychotherapy delivered by specialists to healthy premenopausal women was the most frequent pattern of care. Only two prevalent treatments had adequate evidence. On the basis of expert-estimated rates of remission (Hamilton Depression Rating Scale score <8), response (score <13), and no change (score >/=18), three of the 10 most frequent treatments were highly effective, two were moderately effective, and five were minimally effective. CONCLUSIONS: Although experts gave high marks to three commonly used treatments, the expert-estimated effectiveness for this particular system of care was quite modest. More research is needed on the outcomes associated with specific usual care practices as well as the contributors to ineffective care.
Adolescent↗
Introduction to the special section on the President's New Freedom Commission report.
Explore the source record for details and available documents.
Advisory Committees↗
Overview of the ACCESS Program. Access to Community Care and Effective Services and Supports.
The authors provide an overview of the ACCESS program (Access to Community Care and Effective Services and Supports), which evaluated the integration of service systems and its impact on outcomes for homeless persons with severe mental illness. The ACCESS program provided funds and technical assistance to nine community sites to implement strategies for system change that would promote systems integration. These experimental sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment for 100 clients a year for four years at each site. Data on the implementation of system change strategies were collected from 1994 to 1998 during annual visits to the sites. Data on changes in systems integration were obtained from interviews with key informants from relevant organizations in each community. Client outcome data were obtained at program entry and three and 12 months later from 7,055 program participants across the four annual client cohorts at all sites. Detailed findings from the ACCESS evaluation are presented in two accompanying articles, and overall conclusions are offered in a fourth article.
Community Mental Health Services↗
Lessons from the evaluation of the ACCESS program. Access to Community Care and Effective Services.
The authors summarize the main findings of the ACCESS (Access to Community Care and Effective Services) program and offer lessons for policy makers. Data from studies at the site level and the client level, which were presented in the two previous articles in this issue of Psychiatric Services, are summarized and synthesized with the authors' collective experience with the ACCESS program. The results of the evaluation suggest that although service systems integration can be improved, targeted efforts to implement strategies for integration do not produce better client outcomes. Efforts to integrate service systems can be supported by their effects on some organizational relationships within the mental health service system but not by their widespread effects across human services or their direct effects on clients.
Community Mental Health Services↗
Perspectives: parity--prelude to a fifth cycle of reform.
BACKGROUND: Based on 2000 Carl Taube Lecture at the NIMH Mental Health Economics Meeting. AIMS OF THE STUDY: This perspective article examines the relationship between a policy of parity in financing mental health services and the future of reform in service delivery. METHODS: Applying theories of static and dynamic efficiency to an understanding of parity and the evolution of mental health services, drawing upon Burton Weisbrod s concept of the health care quadrilemma . RESULTS: Each of four cycles of reform in mental health services have contended with issues of static and dynamic efficiency. Each cycle was associated with static efficiency in the management and financing of services, and each was associated with a set of new treatment technologies intended to improve dynamic efficiency. Each reform proved ultimately unsuccessful primarily because of the failure of the treatment technologies to prevent future patient chronicity or to achieve sustained recovery. Recent advances in treatment technology and management of care can permit an unprecedented level of efficiency consistent with a policy of improved access to mainstream health and social welfare resources, including insurance coverage. This policy of so-called financing parity can improve current mental health service delivery, but it may also portend a future fifth cycle of reform. If new technologies continue to advance as full technologies - simple to deliver and producing true recovery - and mainstream resources are made available, then the specialty mental health services may contract dramatically in favor of effective care and treatment of mental illness in primary care and other mainstream settings. DISCUSSION: Predicting the future of health care is speculative, but it may be easier using the Weisbrod formulation to understand the process of mental health reform. Over-reliance on administrative techniques for building static efficiency and false optimism about dynamic efficiency from new technology have stymied previous reforms. All the same, a fifth cycle of reform could succeed, if the right conditions are met and mainstream resources are available.
Community Mental Health Services↗
Medicaid and mental health: be careful what you ask for.
Medicaid has had an enormous impact on the shape and impact of public mental health care. Medicaid mental health policy has expanded access, fostered consumerism, and created incentives for expansion of community-based providers. It also has dramatically changed the economic rules governing public mental health care, leading state governments to alter their behavior. The result has been a tilting of public mental health care toward Medicaid-covered people and services.
Cost Allocation↗
'How do you pay your rent?' Social policies and the President's Mental Health Commission.
Mental health policy involves broad social policies related to housing, education, work disability and rehabilitation, welfare, and criminal justice. The modern era of community care has moved patients, clinicians, and policymakers from closed institutions into the mainstream of society and its health and human service systems. The importance of knowing about the broad array of human services and their policies is reflected in the deliberations and policy recommendations of the President's New Freedom Commission on Mental Health. It is hoped that these recommendations will provide a roadmap for further change to enable people affected by severe mental illness "to live, learn, work, and participate fully in their communities."
Advisory Committees↗
Defining 'mental illness' in mental health policy.
Mental health policy is shaped fundamentally by the definition of mental illness associated with the policy. Changing policies reflect changing definitions. At various times, the definition may be narrow or broad with respect to the scope of conditions covered by a specific policy. The priority accorded to impairment severity is the most crucial and enduring policy issue related to the definition of mental illness and the scope of that definition. This paper explores the role of definitions in framing mental health policy, using examples from the history of policy making over the past half-century.
Advisory Committees↗