James A. Ciarlo

Gender, Social Roles, and Mental Health: An Epidemiological Perspective

The social roles men and women occupy may account for gender differences in rates of psychiatric disorder. Women are thought to have poorer experiences within any given role (role strain theory), have more conflicts among their different roles (role-configuration theory), or have fewer role opportunities available to them (role accumulation hypothesis) compared to men. These theories are examined in a community sample (n = 4,745, 52% females and 48% males; Caucasian [84.2%], Hispanics [10.0%], African Americans [3.8%], Native American [1.4%], Asian [0.6%], and Pacific Islander [0.1%]). No gender differences in the overall rate of DSM, psychiatric disorders were found; however, differences were found for specific disorders. Although multiple roles were generally found to be associated with lower rates of disorders for both men and women, some role combinations were associated with a higher rate of disorders. The possibility that roles may be associated with both stressors and protective factors is discussed.

Overview of the Community Mental Health Centers Program from an evaluation perspective

The 18-year Community Mental Health Center (CMHC) Program of the National Institute of Mental Health (NIMH) was a complex and ambitious social experiment. This review identifies nine of the major goals of the program and examines available evaluative information on how well each was achieved. The most significant achievements of the program include increasing the quantity and range of public mental health services. Equality of access to services was also improved but all inequities were not removed. Problems continue to exist in funding services on the basis of need, in providing services to chronic clients, and in coordinating services. Prevention efforts suffered from uncertainties and perhaps overly optimistic expectations. The achievements of the program are currently threatened by third-party reimbursement mechanisms, the loss of federal leadership and oversight, and the loss of a community orientation in public mental health services. A great deal can be learned from the achievements and the shortfalls of the CMHC program that may be useful in state and federal mental health planning.

I. Validation of indirect methods to estimate need for mental health services: Concepts, strategy, and general conclusions

Abstract This first of six articles presents a summary and overview of a large-scale needs-assessment research project in Colorado. Its primary goal was to test empirically the validity of a number of statistical procedures or “models” currently available for indirectly estimating the need for alcohol, drug abuse, and mental health (ADM) services in an entire state or region and across its geographic subareas. The models examined included both “social-indicator” and “syntheticestimation” types, several of which are currently used by state public mental health systems as part of their mental health services planning and funding procedures. The validating criteria of need, against which predictions of the various models were tested, were provided by the Colorado Social Health Survey (CSHS), a household-based probability sample of 4,745 adults aged 18 and over. The survey used three different measures of need: (1) diagnosable disorders as assessed by the Diagnostic Interview Schedule, (2) project-developed scales for dysfunction in everyday living, and (3) “demoralization” as assessed with the Center for Epidemiologic Studies — Depression (CES-D) Scale. These assessments were intercorrelated only slightly, suggesting multiple types or components of need for ADM services and indicating an overall current prevalence rate of 26.5% for all categories of need for services. While few of the models as originally constructed performed well in predicting to different categories of need for services across the 48 Colorado subareas surveyed, most displayed considerable potential for improving the accuracy of needs estimation when compared to using a uniform or “flat” rate of need for services in all subareas. After model parameters were adjusted to provide the best possible fit with survey results, two existing models and two new models were selected as most promising for use by states and others interested in indirectly estimating need for ADM services. Use of such models for making the best available estimates of need is strongly recommended.

Awareness, use, and consequences of evaluation data in a community mental health center

A major aspect of the effort of the Mental Health Systems Evaluation Project of the Northwest Denver Community Health Centers has involved studying the utilization of program evaluation data by community mental health center managers and clinicians. The intent of this effort was twofold: to assess the impact of program evaluation feedback in the community mental health center per se; and to investigate factors that influenced this impact. The impact of such input was assessed initially at the level of “subjective utility.” Later attempts involved more extended or interactive forms of input and impact assessment. Basic findings to date suggest that program evaluation data are most likely to have impact when directed at the managers most closely involved with the service at issue, and when presented, preferably simply and personally, in ways that insure an understanding of the data and its implications by those receiving it.

VI. Implementing indirect needs-assessment models for planning state mental health and substance abuse services☆☆☆

Abstract This article addresses several services-planning issues necessary for successful implementation of an indirect needs-assessment model to estimate geographic differences in the prevalence of needs for alcohol, drug abuse, and mental health (ADM) services. These include: (1) definition and selection of appropriate ADM services need categories as “target groups”, (2) selection of a model that can validly estimate the prevalence of those need categories, and (3) understanding the data requirements, calculation procedures, and limitations on the generalizability of selected models. A strategy for making the best possible use of indirect needs-assessment models, additional research findings to buttress the validity of selected models, and procedures for model implementation in a state are also presented. A key to effective use of such procedures is clear identification of the target groups to be estimated, ranging from the broadest and most prevalent to highly specialized, low-prevalence need groups. Because predictive models are weaker with narrowly defined, low-prevalence need categories than with larger ones, and because of the importance of presenting a full picture of the ADM needs of a state, it is recommended that states employ a series of “nested” target groups that represent the full range of population needs. While the originally proposed models studied here would be useful with higher-prevalence need categories, only two newly developed models that involve the poverty social indicator could successfully predict to low-prevalence surveyed “chronic mental illness” in this study. Enough is now known about indirect needs-assessment models to warrant implementation by states of one of the better-performing models. The results presented strongly support the validity and potential utility of specific models for estimating varieties of need for ADM services at both state and subarea levels.

Assessing Mental Health Program Effectiveness

In order to assess the advantages and disadvantages of face-to-face interviews, telephone interviews, and mailed questionnaires, 1100 clients were randomly assigned to one of these follow-up methods. All participating clients were contacted approximately 180 days after intake using a well-documented treatment outcome measure. Response rates for the telephone interview and mailed questionnaire were approximately one-half as high as the face-to-face interview, yet for each method very few client background variables were related to whether or not clients responded. The mailed questionnaire was least affected by socially desirable responses, and also cost less to administer than either of the interview methods.

Evaluation in the community mental health centers program: A bold new reproach?

The Federal Community Mental Health Centers Program (CMHC)-from 1963 to 1981-was heralded as a revolution in mental health care. Championed by many, and severely criticized by others, the actual impact of the program on the nations mental health remains unclear. The authorization to evaluate the CMHC Program came originally from congressional legislation (PL 90-174), and later from the policies and regulations of NIMH under a series of Federal laws, notably PL 94-63. From 1976-1980, two dominant evaluation strategies were prevalent: funds expended by NIMH each year for studies of CMHC services or program-wide evaluations, and a much larger expenditure by CMHCs to conduct their own, independent evaluations following federal guidelines. As the Centers Program was turned over to the states in the form of block grants (PL 97-35), a group of professionals involved with setting and carrying out federal CMHC evaluation policy of both varieties met in public forum to debate the impact of these two evaluation approaches. While some participants cited gains in evaluation technology and impact upon local management of CMHCs, others found the lack of a coordinated and systematic approach to evaluating the CMHC Program to have been an opportunity missed. The impact of CMHC evaluation efforts are also discussed in terms of their major contribution to the field of evaluation research as a whole.

IV. Social-indicator models for indirectly assessing mental health service needs: Epidemiologic and statistical properties

Abstract In this fourth of a six-article series, six existing statistical procedures or “models” for indirectly estimating the prevalence of need for alcohol, drug abuse, and mental health (ADM) services in a large region or state and across its smaller subareas are described and critiqued in terms of their epidemiologic and statistical characteristics. These models capitalize upon demonstrated or assumed epidemiologic relationships between the predictor variables and different categories or components of need for ADM services, at least in clinical patient groups. Five of the six models reviewed produce quantitative estimates of general-population prevalence rates for ADM service needs in different subregions or subareas, while the sixth provides only a ranking of subareas with respect to need. This analytic review and critique indicated that several of the models were impressive with respect to their basic methodology and epidemiologic sophistication. However, they all displayed some shortcomings, ranging from minor problems such as reliance upon potentially outdated decennial census data to more serious ones involving the methodological core of the procedure and/or miscalibration of the models parameters. The least problematic model on an a priori basis appeared to be a Synthetic Estimation procedure, although several other models were felt to have greater potential for improvement in predictive accuracy. Specific advantages and disadvantages of each model are listed and summarized for consideration by ADM services planners, both to encourage implementation of such models for indirectly assessing need for ADM services across a number of regions or state subareas, and to facilitate selection by state or local planners of one or more models appropriate to their particular situation.

The Colorado homeless mentally ill: Users and nonusers of services: An empirical investigation of “difficult to treat” characteristics

This study examines the mental health problems of a selected case sample of homeless mentally ill (HMI) men and women in Colorado. The HMI sample was selected to compare those HMI who utilize mental health services (N = 46) with those who do not (N = 50) with respect to psychopathology and to characteristics related to being “difficult to treat.” Findings show that although the HMI current users are slightly more dysfunctional than the non-users, the rates of serious disorders are high among both HMI groups. HMI current users of mental health services, particularly voluntary users, were found to have fewer “difficult to treat” characteristics than the nonusers.

III. Determining "cases" of mental health-related dysfunction from continuous scales of everyday functioning

Abstract The Colorado Social Health Survey (CSHS) was designed to generate need prevalence rates for alcohol, drug abuse, and mental health (ADM) services using three different measures of need—diagnosable disorders, dysfunction in everyday living, and demoralization. Only the first of these measures was dichotomous, allowing clear specification of which survey respondents qualified as “cases” of need. For the CES-D scale-based measure of demoralization, a widely accepted cutting score established by other researchers was used to determine “caseness.” For everyday dysfunction scales, three different methods of designating cases among respondents were studied—a clinical judgment approach, a statistical deviation approach, and a patient criterion groups approach. The clinical judgment approach used the respondents endorsement of at least two “critical” dysfunction items previously judged by research clinicians to indicate reasonably clear need for ADM services. The statistical deviation approach involved a respondent scoring in the highest 10% of the general population sample on two or more scales assessing dysfunction in different domains of everyday functioning. The criterion groups approach was based on a respondent scoring at or above the median score for CSHS outpatient and inpatient comparison groups on at least two domain dysfunction scales. Results for all procedures were examined for validity, using criteria ranging from agreement with the epidemiological literature to comparisons with dysfunction ratings for samples of Colorado public mental health system outpatients and inpatients. On the basis of best performance against these criteria, the clinical judgment caseness-determination procedure was chosen as the primary method for designating respondents as dysfunctional in everyday living for all phases of this needs-assessment study. The statistical deviation criterion was used as a “backup” caseness-determining procedure.