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Public sector managed behavioral care is changing faster than researchers can evaluateits effects. This chapter presents a format for managed behavioral health evaluations which is less expensive and easier to implement than methods which require prospective data collection. A framework is presented for evaluating managed care interventions based on two criteria: (1) access to care, defined as first contact with a behavioral health clinician; and (2) changes in utilization patterns. These issues can be addressed using three pre-existing electronic administrative data sources: Medic-aid paid claims and enrollment rosters; state substance abuse datasets; and state or county mental health treatment datasets. Various linkage strategies are presented, as well as statistical methods that handle multiple repeated time elements, such as policy periods, changing insurance status, and episodes of care. Potential controls and comparisons are also discussed. Finally, the human subjects implications of these designs will be addressed.

Depression is a major public health problem. The distress and functional and social disability it causes are costly to individuals and families, the health care system, and society. The majority of depressed patients are treated by primary care clinicians. Understanding is limited about the factors that affect the pathway to outpatient care for depression in HMO settings. This study describes, among members of a large U.S. health maintenance organization (HMO), the predictors of outcomes that represent progress on the pathway to care for depression, focusing in particular on the relative contribution of depressive symptom levels, gender, age, and other medical and nonmedical factors. The study population is an age/sex stratified sample of HMO members aged 25+ (N=7,844). Data sources include member survey questionnaires, medical charts, and automated utilization databases. Data were collected during a baseline year prior to the members' survey response date (1990–1992) and a follow-up year after that date. The study outcomes measured during the followup year were; study subjects' use of primary medical care; chart notations by a primary care clinician of depression diagnoses, antidepressant prescriptions, and referrals to specialty mental health care; and use of specialty mental health care. Predictor variables included age, gender, level of depressive symptoms, social role functioning, mental health care history, general health status, baseline health care utilization, sociodemographic characteristics, and relation to a personal primary care clinician (and the specialty of that clinician).

This paper examines the effects on families of a broad range of intervention programs designed to assist family caregivers of persons with mental illness. In so doing, the paper critically discusses the intervention designs utilized, similarities and differences in intervention modalities, the characteristics of study subjects, and the effects of these intervention programs on a variety of caregiver outcomes. The paper addresses the degree to which particular interventions are more effective than others, and assesses the strengths, weaknesses, and limitations of these intervention studies. Implications for future practice, policy, and research are presented.

The purpose of this study was to identify contextual factors that affect the ability of caregivers to provide necessary supports to mentally ill individuals. Context was defined here as the socially patterned arrangements of peoples' everyday lives and the social and cultural meanings attached to them. Three contextual areas of caregiver burden were explored: race, role responsibility, and relationship between caregiver and the mentally ill individual. Using a stress process model as a guide for our analysis we examined the role of contextual factors, primary stressors and social supports as predictors of several dimensions of caregiver burden: objective financial burden, subjective financial burden, and household disruptions. Analyses were based on interviews with 219 caregivers of persons with severe persistent mental illness who were part of randomized clinical trial of outpatient commitment (OPC) combined with community based treatment. The findings provide evidence of the importance of environmental context in structuring different aspects of caregiver burden, in particular the influence of race and relationship with the client. Parents and spouses experienced more financial burden and household disruptions than other relationships and African American caregivers reported more subjective financial burden than whites. African American caregivers also were more tolerant of client behaviors than whites. Instrumental social support and help with the client were predictors of caregiver burden. The latter was interpreted as evidence of a support mobilization effect.

This paper explores the relationship between social integration and mental health.We extend the notions of relational costs and relational rewards (Levinger and Huesmann 1980), and we introduce the concepts of binding and nonbinding social integration. Binding social ties include obligatory relations, such as those with family or at work; nonbinding integration represents more voluntary relationships, such as those with friends, neighbors, or membership in various organizations. We argue (1) that the direct effects of social integration on psychological distress arise out of the more proximate effects of relational costs and rewards, and (2) that costs are more associated with binding integration, while rewards are more associated with nonbinding integration. We test these hypotheses using a two wave panel study of individuals from the Indianapolis area (N = 486) and find some support for our claims. Most clearly we find that the binding nature of relationships seems to effect mental health outcomes. Because of inherent limitations regarding how costs and rewards of relationships have been measured—both traditionally and in our data—support for our ideas about relational costs and rewards is more tenuous and will require further investigation. We conclude that the main effect of social integration may fruitfully be addressed by considering the binding or nonbinding nature of social ties as the source of relational costs and rewards which directly affect mental health.

Prior research indicates that homeless consumers of mental health services have a marked preference for independent living, while clinicians tend to recommend staffed, group housing. In order to understand this divergence and identify its consequences for mental health policy, we test influences on housing preferences suggested by rational choice and social structural perspectives. We use a randomized field trial of independent and group housing to identify the consequences for subsequent housing loss and consumer functioning of consumer- and clinician-determined housing placements. We find that consumer preference at baseline for independent living indicates greater vulnerability to housing loss, but the bases of preferences change after consumers gained experience with stable housing. We interpret the results as indicating the contingent rationality of preferences and the susceptibility of preferences to change with experience.

The effects of distress and social networks on psychiatric help seeking were examined in an adult sample from a community survey of 3,481 adults in Baltimore, Maryland. Data were derived from the Johns Hopkins University site of the NIMH Epidemiologic Catchment Area program. Statistical adjustment for the independent effects of social (age, education, marital status, race, household composition, and sex), economic (employment, income, and insurance), and physical health factors were controlled for in estimating the relative odds of mental health service utilization. Subjects who were young, without full-time employment, or who reported one or more chronic medical problems were more likely to utilize mental health professionals. Married persons and the aging were less likely to seek psychiatric treatment. Social support and psychological distress interact to affect the use of mental health care. Persons with weak family ties were five times more likely to seek professional help than those with strong family ties, while persons with confiding social support were over four times as likely to use mental health services as those lacking confiding relationships. Interventions and other treatment efforts to encourage use of mental health services are recommended.