Mental health services research is a new field of inquiry that can be helpful to clinicians and policymakers.

Overview of Mental Health Services Research Bentson H . McFarland

Mental health services research may be broadly defined as the field of in- quiry that examines characteristics of mental health consumers and pro- viders while also studying the actual services delivered. An important goal of mental health services research is to provide a rational framework for policy formation.

For present purposes a mental health service may be operationally defined as a product that is labeled as such by a consumer (that is, a patient or client), a provider, or a third party (for example, a payor). It is generally profitable to subdivide the field into studies of services used primarily by persons with mental or emotional disorders, mental retarda- tion or developmental disabilities, or alcohol or drug dependence. In this chapter I will concentrate on mental health services research pertaining to persons with mental or emotional disorders. There is particular interest among policymakers in individuals with severe or chronic mental condi- tions such as schizophrenia or bipolar disorder.

Examples of mental health services research include: follow-up studies of individuals using services of particular segments of the mental health care delivery system (for example, involuntarily committed persons or offenders found not guilty by reason of insanity); investigations into the economic impact of capitated financing systems for mental health ser-

J. D. Bloom (ed.). SI5&-University Collabomf~on: The Oregon Expcnence. New Directions for Mental Health Services. no. 44. San Francisco: Jossey-Bass, Winter 1989. 55

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vices; examinations of the actual delivery of mental health services (for example, the way psychotropic medications are used by practicing clini- cians); and analyses of the relationship between mental disorder and the utilization of general medical care.

Types of Research

Clinical mental health services research is that portion of the field that examines the impact of mental health treatments on the consumer. Questions pertaining to the value of short- versus long-stay psychiatric hospitalization, studies of inpatient versus outpatient treatment for per- sons with mental disorders, or demonstration projects designed to mini- mize hospitalization can all be subsumed under the rubric of clinical mental health services research.

The relationship between psychopharmacology and the use of mental health services is an increasingly fruitful area for clinically oriented work in this field. One example is the effect of psychotropic medication refusal by committed inpatients on length of stay, safety, and clinical outcome. Another example is the relationship between diagnostic methods and prescribing practices of clinical psychiatrists. The impact on consumers and service delivery systems of monitoring for medication side effects (such as tardive dyskinesia) remains to be examined. Introduction of newer medications (for example, anticonvulsants for bipolar disorder or clozapine for schizophrenia) could well alter the usage of inpatient and outpatient mental health services in ways that have yet to be determined. While randomized trials have been designed to address the clinical impact of these drugs, the programmatic and fiscal effects still need to be investigated.

Economic issues form a large portion of mental health services research. The traditional economic questions (who is paying how much for what product?) are often included in the researcher’s agenda, particu- larly studies on the effects of different payment mechanisms in either the public or the private sector.

Less well-established but potentially quite important aspects of mental health services research include the testing of strategies designed to pre- vent or minimize the impact of mental illness, and the evaluation of different types of training for mental health care providers.

Historical Background

Mental health services research has only emerged as a distinct field of inquiry within the last five to ten years. Seminal studies include Stein and Test’s (1980) randomized trial of inpatient versus community treat- ment for the chronically mentally ill, and the Rand Corporation’s work

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on the relationship between insurance coverage and the use of mental health services (Wells, Manning, and Benjamin, 1986).

Not surprisingly, mental health services research represents a segmen- tation of the larger field-namely, health services research. Health services research itself is only some twenty-five years old. Starfield (1973) provided a useful model of health services research. She pointed out that health status is determined by the patient’s (that is, the consumer’s) genetic makeup and behavior, by the nature of medical practice, and by the environment. In turn, medical practice (in today’s terminology the appro- priate phrase would be health service delivery system) has several compo- nents, including structural features (for example, personnel, facilities, organization, and financing) as well as functional aspects (such as prob- lem recognition, diagnosis, and treatment). Starfield described the “pro- cess of care” as the interaction between the delivery system’s functional aspects and the behavior of consumers. Health services research, then, is the study of: (a) structural aspects of health care systems (personnel, facilities, organization, financing, and so on); (b) the process of health care delivery (problem recognition, management, utilization of services by consumers, compliance with treatment, and so on); and (c) the out- comes of the interaction between the health care delivery system and the consumer (for example, longevity, level of activity, and quality of life). These concepts are, of course, pertinent to the mental health care system.

It is also interesting to note the change in terminology over the fifteen years since Starfield’s paper appeared. Reflecting, perhaps, the increas- ingly commercial nature of health care, the patient is now known as a consumer (or, especially in the public sector, a client). Health profession- als, health care entrepreneurs, and health care delivery facilities are now known collectively as providers. Health services research has played a significant role in altering the vocabulary used to describe the health care system.

In contrast to Starfield, Lewis (1977) questioned the utility of the health services research field. He reported the results of a survey in which members of the Institute of Medicine were asked to list “important” health services innovations and researchers. The survey showed that (at least in 1977) there was considerable difficulty in identifying noteworthy innovations. Few “important” researchers received more than two or three votes. Lewis concluded that health services research was unlikely to produce major alterations in the health care delivery system. In hindsight this prediction was clearly erroneous.

Within the last ten years, the impact of health services research on national health policy and clinical practice has become increasingly obvious. The 1970s brought the “new health professionals” (nurse prac- titioners and physician assistants), whose utility and cost-effectiveness (especially in health maintenance organizations) were well documented

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by health services researchers (Hooker, 1986). The early 1980s saw the introduction of Diagnosis-Related Groups and the Prospective Payment System-both of which flowed from prior health services research (Fetter and others, 1980). Accompanying these dramatic changes in the health care system were the completion of the Rand Corporation’s Health Insurance Experiment (which demonstrated the cost-effectiveness of health maintenance organizations) and the subsequent rise in the number of managed care systems (Manning and others, 1984). The late 1980s have witnessed the conclusion of the long-term care “channeling” exper- iment, which showed the limited value of intensive community services designed to minimize nursing home utilization (Kane, 1988). As the dec- ade ends, health services researchers will be deeply involved in setting payment rates for physicians and in determining a relative value scale for physician fees (Hsiao, Braun, Dunn, and Becker, 1988).

One might imagine that in the 1990s mental health services research will begin to have significant impact on policy formation. Indeed, the National Institute of Mental Health has recently funded five Centers for Research on the Organization and Financing of Care for the Severely Mentally Ill. These centers (one of which is the Western Mental Health Research Center in Portland, Oregon) will undoubtedly stimulate inves- tigation into many aspects of the mental health delivery system. Research of this nature is vital for policymakers wishing to obtain the best return on limited mental health dollars. Several examples of mental health services research in Oregon follow.

Research in Oregon

Surveys. Survey research has played an important part in Oregon’s mental health services projects. One example is a 1986 survey of civil commitment investigators and judges. This work was commissioned by a state task force whose mission was to evaluate Oregon’s involuntary treat- ment system and to recommend improvements. The task force raised several questions-for example, the utility of devising special civil com- mitment criteria for outpatient commitment-which in turn were posed in the survey instruments. The survey outcomes were then reported to the task force. The surveys complemented oral or written testimony of individuals and enabled large numbers of professionals to share their views with the task force. The detailed outcomes of these surveys are reported elsewhere (McFarland and others, 1989a).

Analogous surveys were conducted among family members of men- tally ill persons and among clients of Oregon’s community mental health system. The results of the family member survey have been presented in detail (McFarland and others, 1989b; McFarland and others, forthcom- ing). Here, I briefly describe the client survey.

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The survey of consumers was requested (as something of an after- thought) by a task force member who sought some barometer of clients’ views on commitment. Owing to limitations imposed by considerations of confidentiality and funding, the client questionnaire was distributed nonrandomly during 1986 to mentally ill persons attending Oregon com- munity mental health programs. Often the client found the questionnaire too difficult and required assistance from a case manager. Some forty-two questionnaires were returned. The typical respondent was a 44-year-old single woman with a diagnosis of schizophrenia. On average, the clients had been admitted on seven occasions to a psychiatric hospital (with five admissions being to a state mental hospital). The typical client had been admitted to a psychiatric hospital twice in the last year. The overwhelm- ing majority had been involved with civil commitment-in fact, the average client had been committed three times.

Interestingly, when asked about their experiences at the last commit- ment, a third of the clients reported that they had had no problems. However, some 15 to 20 percent expressed concern about being shackled by the police and having their opinions neglected. A third of the clients felt that mental health center staff or a local doctor had been helpful at the last commitment, while 20 percent indicated that the whole experi- ence was a problem for them.

When asked to recommend changes in civil commitment, a majority of clients requested more education about mental illness and a better explanation of the involuntary treatment process. A third felt no changes were needed. A vast majority of clients supported the concept of out- patient commitment. Clients also endorsed the notion of a trial visit, in which the patient might be required to participate in ambulatory care following discharge from a state hospital.

A fascinating aspect of the survey pertained to clients’ opinions about the utility of their last commitment. A clear majority (26 of 42, or 62 percent) stated that they needed treatment the last time they were com- mitted, while only 14 percent replied in the negative. Similarly, 55 percent indicated that their last commitment was justified, while 19 percent said it was not justified. Not surprisingly, given the method of recruiting subjects, 64 percent said they would now agree to accept treatment vol- untarily, while 7 percent declined voluntary therapy.

While the survey is certainly flawed methodologically, i t is presented here as an illustration of clinical issues that can usefully be addressed by mental health services researchers. It is worthwhile to know that at least some clients feel involuntary treatment is justified. This result is consis- tent with previous findings (Bradford, McCann, and Merskey, 1986).

Systems EvuZuation. Other mental health services research in Oregon has revolved around detailed examinations of the civil commitment sys- tem. Theoretical work has shown the value of dividing the commitment

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process into three steps: screening, investigation, and hearing (Faulkner, Bloom, McFarland, and Stern, 1985; Faulkner, McFarland, Bloom, and Stern, 1986a, 1986b, 1987; McFarland, Faulkner, and Bloom, 1987). Research has been conducted into each step in the process.

Work done in a rural area examined the effects of changes in screen- ing (step one) on the flow of clients through the commitment system (Faulkner, Bloom, McFarland, and Stern, 1985). This project began when Oregon Mental Health Division staff noted that state hospital commit- ments from a southern Oregon county had dramatically increased. Local mental health officials felt that the election of a new judge was an impor- tant factor in explaining the rise in the commitment rate. A detailed investigation of the country’s involuntary treatment system and its clien- tele suggested otherwise. Mental health services researchers reviewed the records of persons in involuntary treatment before and after the sudden rise in the county’s commitment rate. Particular attention was paid to each of the three steps in the commitment process. It soon became appar- ent that while the new judge was committing greater numbers of patients to the state hospital he was in fact committing the same percentage of the clients brought before him as his predecessor had. Chart reviews indicated that clients who were in the involuntary treatment system prior to the rise in the commitment rate were similar, demographically and diagnos- tically, to those participating in the process during the time when the commitments increased. The increase in commitments could best be explained by a rise in the number of hearings held rather than by a change in clientele or judicial practice.

Looking at earlier steps in the involuntary treatment system showed that changes in the local hospital emergency room could account for much of the rise in the commitment rate. Budget cutbacks had made local community mental health professionals unable to offer consultation to emergency room physicians. Consequently, the physicians initiated involuntary treatment proceedings on clients who earlier might have been placed in the community. The result was a rise in the number of persons flowing through the commitment system.

An important aspect of this research is the follow-up. When commu- nity mental health funds were restored and service was again provided to the emergency room, the county’s commitment rate went back down to its baseline. We are currently following a sample of the clients involved in this county’s civil commitment system to determine the long-range impact (if any) of these changes.

There are clear policy implications in this type of study. Removing mental health consultation from a hospital emergency room may well result in the use of more expensive (and more restrictive) involuntary services by clients who could have been managed in the community.

Private Sector Studies. Community management of the severely men-

tally ill is an important area for mental health services research in Ore- gon. One interesting question is the role of the private sector in providing services to this population. Preliminary studies have been conducted at the Kaiser Permanente Health Plan in Portland. This 350,000-member health maintenance organization enrolls some 25 percent of the greater Portland metropolitan area population. Researchers have been able to use the health plan's automated pharmacy system to identify and describe users of antipsychotic medications. Preliminary work suggests that some severely mentally ill persons do receive treatment within the health main- tenance organization. It will be of interest to characterize the extent and nature of the mental health services delivered to these individuals within the managed care sector.

Evaluation of Tyfm of Services. A last example of mental health services research done in Oregon pertains to the value of local versus state hospital involuntary treatment (Faulkner, McFarland, and Bloom, 1989). In this instance, researchers took advantage of a "natural experi- ment" in which an Oregon county had received for one year sufficient funding to operate its own involuntary treatment facility. Before and after that year the county sent its involuntary clients to the state hospital. During the year that the local facility was open, only clients who were court committed for six months of treatment would require state hospital admission. Clients who were detained pending a court hearing could be treated locally.

While the details of this study have been presented elsewhere (Faulkner, McFarland, and Bloom, 1989), i t is worth noting that in fact none of the locally treated clients even required a court hearing. All were released after only a few days of involuntary treatment. In contrast, before the local facility opened and after it closed, clients involuntarily treated at the state hospital were frequently committed at judicial hearings. The state hospital clients' length of stay was about ten times greater than that of the persons treated locally (McFarland and others, forthcoming). De- tailed chart reviews showed that the two groups of clients were otherwise quite similar (Faulkner, McFarland, and Bloom, 1989). From the policy- making perspective, this line of research might be used to support argu- ments for altering the role of state mental hospitals (Goldman and Taube, 1985). Again, longitudinal follow-up of the clients will be important in determining the ultimate value of local versus state hospital involuntary treatment.

Conclusion

Mental health services research is a new but important area of inquiry. Directed at clinical, economic, and administrative issues, this research can have considerable impact on policy formation. Equally significant is

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the interchange among consumers, family members, clinicians, adminis- trators, and investigators that takes place during the conduct of this research. This process can lead to the development of useful and answer- able research questions. In the next chapter we shall see an example of this process at work-namely, in the construction and use of mathemati- cal models in the mental health field.

References

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Faulkner, L. R., McFarland, B. H., and Bloom, J. D. “An Empirical Investiga- tion of Emergency Commitment.” American Journal of Psychiatry, 1989, 146,

Faulkner, L. R., McFarland, B. H., Bloom, J. D., and Stern, T. 0. “A Method for Quantifying and Comparing Civil Commitment Processes.” American Journal of Psychiatry, 1986a, 143, 744-749.

Faulkner, L. R., McFarland, B. H., Bloom, J. D., and Stern, T. 0. “Methodology for Predicting the Effects of Changes in Civil Commitment Decision Making.” Bulletin of the American Academy of Psychiatry and the Law, 198613, 14, 71-80.

Faulkner, L. R., McFarland, B. H., Bloom, J. D., and Stern, T. 0. “Methodology for the Analysis of Civil Commitment Detention Times and Costs.” Bulletin of the American Academy of Psychiatry and the Law, 1987,15, 359-370.

Fetter, R. B., Shin, Y., Freeman, J. L., Averill, R. F., and Thompson, J. D. “Case Mix Definition by Diagnosis-Related Groups.” Medical Care, 1980, 18 (supple- ment no. 2).

Goldman, H. H., and Taube, C. A. “Mental Health Financing and the Future of the State Mental Hospital.” American Journal of Social Psychiatry, 1985,5, 26-30.

Hooker, R. S. “Medical Care Utilization: MD-PA/NP Comparisons in an HMO.” In S. F. Zarbock and K. Harbert (eds.), Physician Assistants-Present and Future Models of Utilization. New York: Praeger, 1986.

Hsiao, W. C., Braun, P., Dunn, D., and Becker, E. R. “Resource-Based Relative Values: An Overview.” Journal of the American Medical Association, 1988, 260,

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McFarland, B. H., Faulkner, L. R., and Bloom, J. D. “Quantitative Analysis of a State Civil Commitment System.” Proceedings of the American Statistical Asso- ciation, Social Statistics Section, 1987, pp. 352-357.

McFarland, B. H., Faulkner, L. R., Bloom, J. D., Hallaux, R., and Bray, J. D. “Investigators’ and Judges’ Opinions About Civil Commitment.” Bulletin of the American Academy of Psychiatry and the Law, 1989a, 17, 15-25.

McFarland, B. H., Faulkner, L. R., Bloom, J. D., Hallaux, R., and Bray, J. D. “Chronic Mental Illness and the Criminal Justice System.” Hospital and Com- munity Psychiatry, 1989b, 40, 718-723.

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McFarland, B. H., Faulkner, L. R., Bloom, J. D., Hallaux, R., and Bray, J. D. “Family Members’ Opinions About Civil Commitment.” Forthcoming.

Manning, W. G., Leibowitz, A., Goldberg, G. A., Rogers, W. H., and Newhouse, J. P. “A Controlled Trial of the Effect of a Prepaid Group Practice on Use of Services.” New England Journal of Medicine, 1984, 310, 1505-1510.

Starfield, B. “Health Services Research: A Working Model.” New England Journal of Medicine, 1973, 289, 132-136.

Stein, L. I., and Test, M. A. “Alternative to Mental Hospital Treatment: I. Con- ceptual Model, Treatment Program, and Clinical Evaluation.” Archives of General Psychiatry, 1980,37, 392-397.

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Bentson H . McFarland is assistant professor and director of the Western Mental Health Research Center in the Department of Psychiatry, Oregon Health Sciences University. He is also an investigator at the Kaiser Permanente Center for Health Research in Portland.