Entering the new frontier of managed mental health care: Gold mines and land mines

The integrated behavioral health service delivery system model

Costs and effective management of health care in general, and behavioral health care in particular, have been of primary importance and concern to federal, state, and local governments. With the passage of Health Care Reform (HCR) these concerns will only escalate. Thus, the necessity for the development of innovative, successful, and integrated cost-effective treatments and procedures is evident. The behavioral health care model presented here is proposed to address these needs. The model centers on the composition of effective psychosocial treatment and provides a cost analysis of social work and its services. By defining the problems that need to be addressed in health care management and cost containment, and applying findings of evidence-based studies, this article provides an effective model for health care organizations. It also presents a profile of the behavioral health social worker, defining the requisite abilities for effectiveness in the role and looking at the key impact areas for a behavioral health model. This comprehensive guide will prepare new social workers entering health care organizations as well as provide a valuable reference for existing social workers, academics, and practitioners of behavioral health care.

A computer-assisted depression intervention in primary care

BACKGROUND

The clinical benefit for depression of an interactive computer-assisted cognitive-behavioral program on CD-ROM, the Wellness Workshop (WW), was evaluated in a randomized controlled trial.

METHOD

A total of 191 individuals referred by primary-care physicians were randomly assigned to a control group, where physician-directed treatment as usual (TAU) was provided, or to a treatment group, where TAU was supplemented with the WW CD-ROM, delivered by mail (WW+TAU). Data were collected at baseline, at 6 weeks' post-intervention, and at a 6-month follow-up assessment. Participants were given a strong incentive by a reimbursement of $75 for completion of each assessment. Measures included symptom ratings obtained via structured clinical diagnostic interviews, as well as a battery of self-report questionnaires on symptoms specifically targeted by the intervention.

RESULTS

Analysis of results demonstrated evidence for skill acquisition for improving dysfunctional thinking and reducing anxiety. Among those who met diagnostic criteria for depression, WW+TAU participants were three times more likely to remit at 6 weeks' post-test than TAU participants.

CONCLUSIONS

The evidence supports the conclusion that the WW intervention added benefit to traditional care for depression. No placebo comparison group was included and the WW+TAU participants received slightly more attention (a supportive telephone contact, ≤ 5 min from a psychologist 2 weeks after receiving the program). Overall, the findings add support to the accumulating evidence for the potential clinical benefit of computer-assisted behavioral health interventions.

Engaging suffering: towards a mindful re-visioning of family therapy practice

The myth of problem-free living is easily identifiable in Western culture through its childhood fairy tales and modern love stories. Even if inadvertently, the field of mental health perpetuates this myth with the very concept of "mental health," which implies a state without suffering. Using mindfulness, Buddhists assume an alternative stance towards suffering: rather than eliminate it, they compassionately engage it. This article explores the potentials of mindfulness as an alternative approach to suffering within the context of marriage and family therapy. Family therapists can integrate mindfulness principles into their work to help clients shift how they relate to the unique forms of suffering that one encounters in intimate relationships, such as abuse, divorce, rejection, and loss.

Integrating clinical psychology into primary care settings

The primary care setting offers a mostly new and exciting opportunity for clinical psychology. Historically, psychology has been relegated to the "back forty," distant and far removed from mainstream medicine in most major hospitals. The primary care integration possibilities for clinical psychology are many. The present article will highlight these opportunities as well as provide the reader with an understanding as to why this conceptual paradigm and practical shift is needed as well as how to integrate clinical psychology services into the primary care setting.

Practicing psychology in the era of managed care. Implications for practice and training

Beginning with the HMO Act of 1973, managed care, a system for controlling health care costs, rapidly expanded and gained influence as the main vehicle for health care delivery in the United States. Implementation of managed care principles in the mental health arena has generated much debate, particularly with respect to issues of quality of care. The authors briefly trace the development of managed care and evaluate its impact on the practice of psychology. The extant literature is reviewed with specific attention to issues of quality of care, confidentiality of patient information, and shifting practice patterns of clinicians. Finally, the future of professional psychology within the context of managed care is examined, and the implications of newly created mental health roles for practitioners, training programs, and organized psychology are discussed.

Evaluating mental health outcomes in an inpatient setting: convergent and divergent validity of the OQ-45 and BASIS-32

The evolution of managed behavioral health care has led to an increased emphasis on reliable and valid assessment of outcomes in clinical practice. The present study evaluated the convergent, divergent, and concurrent validity and sensitivity to change of two widely used measures: Behavior and Symptom Identification Scale (BASIS-32) and Outcome Questionnaire (OQ-45). Comparisons of the two measures revealed that both were sensitive to change over a relatively short inpatient stay. Both measures also showed evidence of convergent and divergent validity of specific subscales, although the total scores of each measure also were highly correlated. Evidence of concurrent validity was suggested by differences between diagnostic groups on specific subscale scores. Together with previous research, these results suggest that the BASIS-32 and OQ-45 can be useful measures for tracking patient functioning over a range of treatment contexts.

Training the scientist-practitioner for the 21st century: putting the bloom back on the rose

The field of clinical psychology has been characterized over the past five decades as shaped by social, economic, and political forces outside of it. Even before the Boulder Conference, meetings and writings evidenced the underpinnings of the scientist-practitioner model that was to be developed in a welcoming climate (Dosier, 1947; Kubie, 1949; Luchins, 1949). Difficulties in implementation, however, produced a schism between the scientist and practitioner aspects. Our thesis is that the current environment dictated by managed care necessitates a reaffirmation of the scientist-practitioner model. We believe that clinical psychologists are in an unparalleled position to intercede among forces in the current climate because of their sensitivity to clinical and research issues, and we offer suggestions for how clinicians, researchers, and training programs can close the gap between research and practice.