May 22, 1998
Contact:
Ann Marie Deer Owens, (615) 322-2706
System reform not full answer to improved mental health services, Vanderbilt policy expert says
NASHVILLE, Tenn. -- Recent major investments in enhanced systems of mental health care have not resulted in improved lives for children and adolescents with serious emotional problems, according to a Vanderbilt University professor who led two recently completed major mental health studies.
"Investing major resources in reforming systems of mental health care for children and adolescents appears to be ill advised," said Leonard Bickman, director of the Center for Mental Health Policy at the Vanderbilt Institute for Public Policy Studies. Providing an organized and comprehensive system of mental health services will not, by itself,improve the lives of children and adolescents with serious emotional problems, Bickman concluded from the studies. "While we found the services in an organized network to be more accessible than those in the traditional, fragmented health care system, children receiving well-organized mental health services fared about the same as those receiving usual care over a five-year period," Bickman said. "Unfortunately, the system of care cost a great deal more."
Bickman said that the disappointing results of the two large-scale studies signal the need for improvement of the services being delivered to children and their families in addition to changes in systems of care.
The evaluation of the Fort Bragg Demonstration Project, which involved nearly 1,000 children at Fort Bragg, N.C., and two comparison sites, was implemented in 1990 by the Department of the Army through an $94 million contract for services with the state of North Carolina.
The five-year project tested whether a comprehensive network of mental health and substance abuse services for children and adolescents is more cost-effective than traditional services. Bickman said that some of the guiding principles were to avoid hospitalizing children whenever possible by providing services in the community such as in-home and day treatment and to use case management and interdisciplinary treatment teams to bridge the gaps between services.
The Fort Bragg study did show that the organized care provided more client satisfaction. "The organized system of care was supposed to increase access, and it did," he said. "The percentage of children served went from two to nine percent. However, the way the children functioned with their families and friends and in school was the same in both groups."
Bickman noted that while therapists in the organized system tried to avoid the expense of unnecessary hospitalization, they saw more patients and saw them for longer periods of time and provided them with a greater variety of services. Therefore, the organized system turned out to be more expensive than the traditional system. A second study funded by the National Institute of Mental Health involved 350 families who sought services for children from community agencies in Stark County, Ohio. The families were randomly assigned to either an organized system of care or the control group, which received the usual care in that community. Analysis by the Mental Health Policy Center at Vanderbilt after two years has shown no differences between the control and systems group in the children's symptoms or behavior.
Bickman concludes from these studies that system reforms do not, by themselves, improve outcomes for children receiving mental health services. "It may be more difficult than we realized for changes in health care systems to affect clinician-client interactions," he said. Another possible explanation for the negative results is that traditional assumptions about what services are appropriate and about clinicians' ability to assign children to the appropriate services are wrong.
Bickman said his center conducted a separate study that showed there was little agreement among health care providers about the services needed by children with specific emotional problems. "The research literature shows little evidence for the effectiveness of mental health treatment of children in ordinary clinics, either the usual treatment or innovative community-based treatments, such as home-based care or day treatment," Bickman said. "I am not saying that the treatments are ineffective, but there is not sufficient evidence that they are working in the real world." Bickman calls for the development of research-validated practice standards, improved supervision of clinicians and better ways to measure the results of children's mental health services. "Unless mental health professionals establish the effectiveness of their services, funding for mental health services will continue to decline," he said.
For more news about Vanderbilt, visit the News and Public Affairs home page on the Internet at www.vanderbilt.edu/News/
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