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.
Policy & Service Delivery Issues
Current goals of community service delivery (eg, treatment in the least restrictive environment, continuity of care, provision of a continuum of care) tend to be inconsistent with current financing and reimbursement practices. Third-party payers have been resistant to reimbursement for ambulatory services and often have placed arbitrary limits on outpatient reimbursement. Attention to the deficiencies in current research, including a scarcity of community-based effectiveness studies, may help to bring parity in resources to mental health services and research. Financing and reimbursement, however, are only part of the dilemma. Implementing systems of care requires strong leadership and increased interagency communication and coordination.
In light of figures indicating substantial unmet needs, limited access to mental health services, and the need to control costs while maintaining quality of care, the use of paraprofessionals and nonprofessionals in service delivery has received renewed attention. Interventions offering promise of effectiveness, such as assertive community treatment and multisystemic therapy, are typically delivered by nondoctoral-level mental health providers. Even as the states are assuming a more prominent role in the financing of CMHCs and mental health care in general, the employment and patient-care responsibility of psychiatrists in CMHCs has decreased. The recruitment and training of additional service providers for innovative service delivery, with psychiatrists and psychologists serving as expert consultants, directors, or supervisors, may be an effective method of addressing unmet mental health needs. Although most research has revealed bias in the views of some professionals in their opinions of self-help groups or service delivery by nonprofessionals, there is growing emphasis and involvement of consumers and family members in service delivery and in service evaluation efforts. For instance, family members are more often being employed in care coordination and patient advocacy roles at provider sites. Further, evaluators are more often hiring consumers and family members to collect patient data or to cofacilitate focus groups.
The process of defining current policies in health and mental health is largely political, reflecting the agglomerations of advocacy strength and professional coordination; thus more emphasis should be placed on building a strong constituency across professions and interests as well as with consumer and family advocacy groups. This is particularly true in the new age of managed health care that is driven in large part by profit.
Because mental health services remain primarily supported by categorical funding streams, interagency coordination continues to be a system-level problem with potential negative consequences at the patient and family levels. States and local governments need to incorporate, into managed care contracts, incentives for interagency coordination, and agencies need to forge interagency agreements.
Services Research Issues
Several factors limit evaluation and thus its contributions to service delivery and effective policy. First, there is a paucity of longitudinal funding that allows sufficient start-up time for the development, implementation, and stabilization of the interventions, services, and systems being studied. Research agencies, among others, often underestimate the amount of time needed to realize significant improvement in outcome; thus research projects may be of insufficient duration.
Second, although the array of funding mechanisms is broadening, fundamental biases exist in the way proposals for extramural funding are reviewed. For example, with the current shift to results-based accountability, there are pressures to avoid efforts that pose measurement difficulties and do not promise quick results. Also, research agencies often prefer traditional scientific research methods, emphasizing, for example, strong internal validity and low risk of false-positive errors, contrary to the views of Cronbach et al discussed earlier in this chapter. The result is cookie-cutter evaluations with little innovative or informative value.
Third, partly because of some of these pressures, researchers falter and fail to conduct research informed by the problems of applied research documented in the literature. Too often, warnings described in the scientific literature are overlooked because funding allows too little time or too few resources. In order to further the field, researchers must be innovative and creative by drawing from a broader range of methodologies and increasing stakeholder involvement in the research process in order to overcome the problems discussed in this chapter and elsewhere.
The construction of a solid base of knowledge regarding the effectiveness of interventions provided in the community will promote parity in economic resource allocations for mental health services. It is incumbent on the mental health field to support outcome evaluations that examine what works best for whom and under what circumstances. For instance, researchers must establish the conditions under which patients need and can benefit from longer-term interventions. In order to overcome the shortcomings of traditional mental health services, clinicians and researchers must collaborate to develop interventions and services that address the multidimensional nature of mental illness within patients’ natural environments. Research is needed to inform public policy regarding alternative modes of treatment, the training of alternative service providers and paraprofessionals, the relative effectiveness of various treatment modalities (and combinations of treatment), and the impact of social helping networks. Research synthesis methods (eg, meta-analyses) have grown since the late 1980s or so and provide a critical tool for assessing the effectiveness of psychological interventions. Unfortunately, funding for such efforts often is inadequate.
Micro-level examinations of interventions (eg, RCTs) must be united with macro-level (or service system) research drawing on a systems framework that addresses how the separate components of the service system fit together most effectively. Some researchers have pointed to the lack of research on traditional clinical interventions and have advocated for the use of RCTs in order to investigate the effectiveness of services. Research on specific interventions is needed to address potential interaction effects and to broaden the picture of which specific components within the “black box” are related to outcome. However, the establishment of intervention efficacy, as we have already seen, is no guarantee of its effectiveness in community-based settings or within the context of a system of care. Thus controlled studies of interventions in natural settings are critically needed. Real-world contexts often involve barriers to access and treatment, such as a politicized environment, competition between professionals, poor communication, and professional ignorance. In order to accomplish these goals, there must be better cooperation among researchers, practitioners, and managed care companies. Managed care companies should take responsibility for supporting research and development rather than the federal government being solely responsible for funding research in this field.
Some evaluators have referred to many micro-level efforts as self-defeating and have emphasized the need to test the impact of the entire system. Such research is consistent with systems thinking, according to which the service system will have a synergy of its own, not defined or understood by the parts taken alone. Chelimsky has questioned how we can expect such findings to have a large impact on public policy when the fundamental link between an intervention and its putative effect has not been established. Rather than arguing the relative merits of research focusing on different levels of services, the limitations of each type of research should be acknowledged. Micro-level studies can inform authorities in the development and implementation of programs and system-reform efforts, and macro-level systems research can address the effectiveness of system-level reform.