Scientific Areas Relevant to Modern Psychiatry
What Is Mental Health Services Research?
Although mental health services research is not easily defined, it “consists mainly of those studies examining the effectiveness of the health care system in the prevention, diagnosis, and treatment of individuals with or at risk of mental disorders” (Kelleher and Long 1994, p. 133). Effectiveness should be defined broadly, allowing examination of issues such as service access, utilization, cost, and quality in addition to issues of service impact (ie, outcome evaluation) but deemphasizing specific disorders or conditions. The classic delineation of areas within services research distinguishes between clinical (or process) and systems (or structural) research. Clinical health services research is relatively more narrow in focus and includes, for example, investigation of the outcome of specific interventions and the relationship between clinicians and patients. Systems research is typically broader, encompassing organizational and financial factors that affect the delivery or quality of health care.
Functions of Mental Health Services Research
The ultimate goal of mental health services research is to influence policy and programmatic decision-making in order to improve mental health services. The evaluation of programs, services, and systems provides a relatively objective means of choosing among alternative programs or services competing for limited resources and informing decisions that will affect public policy. Services research may provide information about the services that are being delivered as compared to those intended, how services are being utilized and by whom, the extent to which services are effective, and the costs of services. In addition, evaluation encourages accountability, cost-consciousness, and responsiveness to those in need of and utilizing services. Further, services research can synthesize what is already known, unearth false assumptions, debunk myths, develop new information, and explain the implications of this information for future decision-making. Moreover, it may be unethical to continue to provide untested, perhaps invalid, services to children and their families in the name of treatment.
Child versus Adult Research
Services research is often dichotomized into child versus adult mental health issues. This child-adult split has been characterized as just one of many categories in services research (eg, psychology versus psychiatry, community versus inpatient). Child mental health and adult mental health research offer qualitatively different challenges to researchers. Some researchers have asserted that mental health policy regarding children is arguably more important nationally than adult policy. However, research, theory, knowledge, and legislation in children’s mental health services has lagged far behind that in the adult field. In contrast, as the average age of the U.S. population continues to climb, issues facing the elderly will demand attention. The key is the realization that research in these areas is qualitatively different and that findings in one area may not generalize to another. However, as discussed in the “Implications for Future Research” section of this chapter, now is the time for researchers, clinicians, and advocates to develop mutual respect for one another and collaboratively advocate for parity in resources allocated to mental health issues.
History of Services Research
Mental health services research has been slow to evolve; however, much of the current thinking in the field has stemmed from ideas formed decades ago. Mental health services, since the beginning of the 20th century, have been influenced more by federal initiatives than by individuals. From the 1930s through the 1960s, the mental health field did not focus on its relationship with other agencies (eg, schools, juvenile courts), nor did it seem to be concerned with social problems influenced by poverty. In essence, mental health services were isolated from other agencies dealing with those in need.
Relevance to Psychiatry
As psychiatry develops a more biomedical emphasis, it will be important to retain a comprehensive perspective in the treatment of mental disorders while concurrently researching the biological etiology of such disorders. There has been a shift away from simplistic causal theories to multidimensional causality across all types of psychiatric research. The interplay among genetic predisposition, brain processes, and psychosocial events has been represented in complex conceptions of etiology and perpetuation of various disorders.
Current Issues & Findings in Mental Health Services Research
Although not an exhaustive review of current issues, this section discusses some of the salient issues in mental health services research. Current issues include management, use, accessibility, cost, effectiveness, and quality of mental health services.
Implications for Future Research
Mental health services research is still in its infancy. Much work is yet to be done, particularly in light of health care reforms expected to have a substantial effect on many of the issues discussed in this chapter.
Mental health services research is a new and growing area in mental health. Services research addresses questions that are significant to all stakeholders, including patients, clinicians, and policy makers: What are the best ways to assure access to services? How can we best describe the treatments that patients receive? Which treatments are most effective with which types of patients? What are the best ways to affect clinician practices? These are all questions posed by services researchers. In this chapter we have noted that we do not know the answers to these questions. We have also described the political and methodologic difficulties encountered in trying to answer them. If we are to achieve any real progress in serving those who need services, then we need to answer these and similar questions with well-designed research.
Family studies provide evidence that some anxiety disorders may be transmitted separately from one another. This is best established for panic disorder and least so for generalized anxiety disorder (GAD). Observations on the increased familial risk for anxiety disorders have been recorded in the literature for over 100 years. Family studies of panic disorder are often complicated by comorbidity with social phobia and GAD. One family study of pure panic disorder probands found a significantly higher risk for panic among first-degree relatives compared to relatives of controls. There was also a fivefold increase in risk for any anxiety disorder. Similarly, an increased risk for agoraphobia (11.6%) has been reported for the relatives of agoraphobic probands, compared to 1.9% for relatives of panic disorder probands and 1.5% for relatives of control probands. A study of simple phobia found an increased risk for simple phobia (31%) among relatives of probands with that diagnosis (but no other anxiety disorder) compared to relatives of control probands (11%). A family history study of social phobia demonstrated that relatives of phobic probands were at increased risk for this disorder (6.6%), compared to relatives of panic disorder probands (0.4%) or relatives of control probands (2.2%).
The risk of eating disorders in relatives of anorexic patients is higher than that found in control subjects (Table 6-6). Affective illness is also increased in relatives. Even if probands without a major affective illness are considered as a separate group, an excess of affective illness is observed in relatives compared to relatives of control subjects. In one study, 40 bulimic probands were compared to 24 control subjects. Relatives of bulimic probands had a 27.9% risk of major affective illness compared to 8.8% in relatives of control subjects. In comparison, the risk of major affective illness in relatives of bulimic probands without major affective illness was lower (19.1%), but this risk is still higher than for relatives of controls. The same study found that 11.8% of relatives of bulimic probands had an eating disorder, compared to 3.5% of relatives of controls. In the study of bulimia, relatives of probands also showed an excess of alcoholism and ASPD in comparison to relatives of controls.
The pooled frequency of autistic disorder in siblings of autistic probands is about 3%, which is 50–100 times the frequency in the general population. A twin study reported an MZ concordance of 36% and a DZ concordance of 0%. When the phenotype was extended to include language and cognitive abnormalities, concordance rates rose to 82% and 10%. This sample of twins, though carefully selected, was small (N = 21), but the essential conclusions regarding heritability were borne out in later studies.
Antisocial Personality Disorder
According to one family study of 223 male criminals, 80% were found to have a diagnosis of antisocial personality disorder (ASPD). Of the first-degree male relatives who were interviewed, 16% also received this diagnosis, whereas only 2% of female relatives were so diagnosed. In comparison, 3% of male control subjects and 1% of female control subjects had ASPD. Increased rates of alcoholism and drug abuse were also found among the relatives in this study.
A review of 39 studies on families of 6251 alcoholic subjects and 4083 nonalcoholic subjects reported a 27.0% prevalence of alcoholism in fathers of alcoholic subjects and a 4.9% prevalence in mothers; 30.8% of the alcoholic subjects had at least one alcoholic parent. The same preponderance of alcoholism was not seen in the parents of comparison groups of patients with other psychiatric disorders. The nonpsychiatric control subjects included in the same review showed a 5.2% prevalence of alcoholism in fathers and a 1.2% prevalence in mothers. A recent multicenter study confirmed familial aggregation of alcoholism, with more severe forms showing greater familiality.
Empirical data for genetic counseling are summarized in Table 6-10. Some illnesses have fairly narrow age-at-onset distributions in the general population. For example, first episodes of bipolar illness almost always occur before age 50. Fully 50% of bipolar individuals develop an initial episode (either depressive or manic) before age 25. Age at onset should be considered in a general way when assessing risk. For example, an unaffected 40-year-old son of a parent with bipolar disorder has already passed through most of the age at risk; thus his risk of developing bipolar disorder is substantially less than 9%. An estimate of approximately 2% would be more accurate in this case.
A family history study evaluated first-degree relatives of 49 probands with degree relatives of probands with other somatoform disorders and affective disorder. The risk for a complicated medical history was 8.0% in the first-degree relatives of the somatization disorder probands, compared to 2.3% and 2.5% in the control groups (P < .01).