Search

The behavioral health system's peer support workforce must be adequately trained to perform peer support services, but evidence of the adequacy of their training needs to be improved. With survey data from 667 certified peer support specialists (CPSS) from North Carolina, Kentucky, Virginia, and Tennessee, this study used (a) binomial probability test to assess perceptions about the adequacy of the workforce's training, (b) latent profile analysis to identify patterns and predictors of perceptions about the SAMHSA core competencies covered in their training, and (c) thematic analysis to identify additional training needs. Most respondents identified as White (72%), female (73%), and had some college education (83%). Most of the workforce (> 90%) felt prepared to provide services, regardless of their state. Highly and moderately sufficient coverage emerged as two distinct response patterns regarding coverage of the SAMSHA core competencies, with respondents' years of experience, state of residence, education level, race, and sense of preparedness predicting the probability of fitting into either profile. Participants desired additional training in trauma-informed practices, motivational interviewing, and new treatment approaches. Peers' experiences and perspectives were similar across different states. The findings suggest booster training sessions or continuing education opportunities are needed to maintain a robust and well-prepared peer support workforce. States should consider reciprocity agreements to enable the trained workforce to practice across states. A key implication for the training content is the need to incorporate contemporary issues relating to mental health and substance use disorders to better meet behavioral health needs., (© 2024. National Council for Mental Wellbeing.)

Rates of mental health problems and disorders in children and youth have been increasing for at least three decades, and these have escalated due to the pandemic and multiple other societal stressors. It is increasingly recognized that students and families frequently struggle to receive needed care through traditional locations such as specialty mental health centers. Upstream mental health promotion and prevention strategies are gaining support as a public health approach to supporting overall population well-being, better utilizing a limited specialty workforce, and reducing illness. Based on these recognitions, there has been a progressive and escalating movement toward the delivery of mental health support to children and youth "where they are," with a prominent and more ecologically valid environment being schools. This paper will provide a brief review of the escalating mental health needs of children and youth, advantages of school mental health (SMH) programs in better meeting these needs, example model SMH programs from the United States and Canada, and national and international SMH centers/networks. We conclude with strategies for further propelling the global advancement of the SMH field through interconnected practice, policy, and research., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Integrated behavioral health care (IBHC) models are a growing trend for health care delivery, particularly in the primary setting. Clinicians working within IBHC contexts provide a spectrum of behavioral health services, including screening, prevention and health promotion, assessment, and treatment services. Integration of behavioral health providers into primary and specialty medical settings addresses the significant need for behavioral health services, improves care quality, improves patient experience, and reduces costs of care, access issues, and delays in service provision. While benefits are clear, what type of model to implement and which behavioral health care providers to include in that model remain elusive. This is partly due to the failure of IBHC models to include all behavioral health providers in their design, a lack of clarity of the expertise of each provider, and how providers work together. IBHC models are also complicated by contextual issues such as the relative availability of each profession, population health needs in different clinic populations, and financial factors. The purpose of this manuscript is to the clarify roles and responsibilities of different behavioral health professions including similarities and differences in their training, areas of unique expertise (role distinctions), shared responsibilities (role overlap), and relative cost and availability in the United States., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The supply / demand issue in behavioral health care is a well-established fact, and the mental health toll of the COVID-19 pandemic continues to add challenges to an already taxed system. Existing healthcare models are not set up to adequately address the increasing mental health related needs. As such, innovative models are needed to provide patients with access to appropriate, evidence-based behavioral health care within routine clinical care. This paper introduces Precision Behavioral Health (PBH) as an example of such a model. PBH is an innovative, digital first care delivery model that provides an ecosystem of evidence-based digital mental health interventions to patients as a frontline behavioral health treatment within routine care in a large multispecialty group medical center in the United States. This paper describes the implementation of PBH within a practice research network set-up as part of an integrated behavioral health department. We will present how our team leveraged the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance; "What is RE-AIM?," n.d.) implementation science framework, which emphasizes the design, dissemination, and implementation processes at the individual, staff, and organizational levels, to prioritize key implementation constructs to enhance the successful integration of PBH within routine care. We describe how each of these constructs were operationalized to aid data gathering for rapid evaluation and lessons learned. We discuss the benefits of these types of initiatives across multiple stakeholders including patients, providers, organizations, payers, and digital intervention vendors., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The current demand for mental health services is exacerbated by an ongoing shortage of behavioral health care providers in the United States. The Health Resources and Services Administration has identified 5,833 Mental Health Professional Shortage Areas (MHPSAs), many of which are rural, and could be served by Certified Peer Specialists (CPSs). This paper examines the relationship between CPS employment and MHPSA residency. Data are from a 2020 survey of 572 CPS certified in one of four states. Random effects logistic regression models were used to test the relationship between MHPSA residence and employment outcomes. Of 166 unique counties identified by participant zip codes, 47 were characterized as being MHPSAs with 14% of participants residing in one of these counties. A higher proportion of those living in MHPSAs were employed in peer support jobs (rather than other job types or unemployed) compared to those living in non-MHPSAs (68% vs. 54%, p = .020). MHPSA residential status was not a significant predictor of employment status (OR = 1.14, p = .728) but was significantly associated with greater likelihood of employment in peer support compared to other jobs, both for the entire sample (OR = 2.13, p = .026), and among those currently employed (OR = 2.90, p = .032). The greater likelihood of working in peer support among those residing in MHPSAs suggests that CPSs may leverage their credential to address shortages. As a result, peer support may become a more necessary part of the traditional service array. Policies that enable CPS to practice in MHPSAs should be encouraged., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Clinical health psychologists provide adaptive, evidenced-based interventions that incorporate behavioral medicine and behavioral health strategies, with the potential to integrate broadly across the medical system. Veterans Affairs (VA) healthcare strives to meet the needs of an increasingly diverse patient population with complex behavioral health needs. This conceptual paper describes an example of health psychology at one VA healthcare system, with a focus on adaptive and culturally responsive services reaching Black, Indigenous and People of Color/Veterans of Color (BIPOC). The clinical health psychology services and cases described aim to reach Veterans who may not participate in, or benefit as fully from, traditional disease self-management or mental health services. The authors offer recommendations, to secure the value and sustainability of these integrated health psychology services, and hopefully contribute to addressing healthcare inequities., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The Substance Abuse and Mental Health Services Administration's Children's Mental Health Initiative (CMHI) Cooperative Agreements support the development of children's systems of care (SOCs). The National Evaluation of CMHI interviewed representatives from Mental Health Authorities (MHA) and Medicaid agencies in 25 state, county, and municipal jurisdictions in the FY13 and FY14 grant cohorts in grant years 2 and 4. This paper analyzes funding for five services (wraparound planning; intensive care coordination; family peer support; youth peer support; and flexible funding) that are a core part of SOCs, and grantee descriptions of sustainability strategies and challenges. The analysis found that, of the five pathways described in the literature: securing Medicaid coverage; obtaining state MH system funding; braiding funding with other child-serving systems; modifying payment structures to support workforce development; and redeploying funds from higher cost to lower cost services, grantees most frequently used Medicaid coverage, often combined with MHA funding., (© 2021. National Council for Behavioral Health.)

The COVID-19 pandemic exacerbates the mental, emotional, and behavioral (MEB) health problems of children and adolescents in the United States (U.S.). A collective and coordinated national economic and social reconstruction effort aimed at shoring up services to promote children's MEB, like the Marshall Plan that helped rebuild Europe post-World War II, has been proposed to buttress against the expected retrenchment. The plan prioritizes children's well-being as a social objective. We propose strategically reconstructing the public safety-net systems serving youth, including early education, maternal and child health, child welfare, corrections, and mental health. That plan called for a concentrated focus on coalition-building and contracting by state mental health systems to establish a foundation for an improved health system. This paper offers a complementary set of suggestions for the four non-mental health systems mentioned above by recommending actionable steps based on scientific evidence to support improved services for children at risk for MEB problems. For each system we describe examples of evidence-informed services, policies or programs that (1) prevent disabilities and promote health, (2) protect and preserve families and neighborhoods, and (3) provide quality care. Prioritizing the promotion of children's MEB health by all state systems can shape U.S. children's health and well-being for generations to come.

This paper analyzes the impact of mental health treatment on suicide attempts. While prior work demonstrates the effectiveness of mental health treatment at reducing suicide risk, few studies examine nationally representative populations or use broad measures of access to mental health services. A methodological problem can arise in studies of mental health treatment and suicidal behavior because a suicide attempt can result in the use of more mental health services. Using nationally representative survey data combined with national estimates of provider availability, this paper employs a methodological correction to address that potential problem of reverse causation. This paper uses measures of the density of health care providers in an area as statistical instruments for use of mental health treatment in an analysis of the impact of mental health treatment on suicide attempts. This study finds that mental health treatment significantly reduces suicide attempts.

Measurement-based care (MBC), a mechanism through which feedback is given to providers and patients, is increasingly being used in mental health care and has a number of benefits. These include providing information about treatment progress, encouraging a discussion around these topics, providing a method for shared decision-making and personalized treatment, and improving treatment outcomes. Although there are many benefits to using MBC, it is still not being used regularly. Barriers include time to administer measures and uncertainty regarding which measures to administer. This paper will briefly describe MBC and its use in mental health care and then will focus on the use and implementation of MBC within the Veteran's Health Administration (VHA). The VHA is a large healthcare system in which there have been ongoing efforts to implement MBC. Suggestions for successful implementation will be discussed.

Advancements in evidence-based psychosocial interventions, digital technologies, and implementation strategies (i.e., health services research products) for youth mental health services have yet to yield significant improvement in public health outcomes. Achieving such impact will require that these research products are easy to use, useful, and contextually appropriate. This paper describes how human-centered design (HCD), an approach that aligns product development with the needs of the people and settings that use those products, can be leveraged to improve youth mental health services. We articulate how HCD can advance accessibility, effectiveness, and equity, with specific consideration of unique aspects of youth mental health services.

This paper describes key findings of two states that sought to integrate physical and behavioral health services by delivering them through one Medicaid managed care contract. The purpose was to explore how managed care organizations (MCOs) could improve physical and behavioral health integration. Promising practices include leveraging data accumulated by MCOs about beneficiaries to support providers and enhanced case management, encouraging MCOs to pay providers for care coordination and care collocation, and offering protections to providers and beneficiaries. Finally, in the absence of a shared vision among key stakeholders regarding how to best promote integrated care, a state can make progress by promoting stakeholder innovation.

Real-world challenges continue to impede the dissemination, implementation and sustainment of high-quality, evidence-based practices, resulting in too many individuals not receiving the effective mental health care that they urgently need. The field of implementation science is poised to generate new solutions to address this important public health problem. Training a new generation of researchers in implementation science is one solution. The Implementation Research Institute (IRI) offers one approach to such training. The papers in this series, authored by some of the IRI graduates, illustrate the depth and breadth of the intellectual scope of IRI graduates' contributions to the implementation science field, chronicles important lessons learned, and underscores the IRI's training capacity. This commentary reflects upon the series in terms of a framework and themes that relate to core implementation science principles and to future research that corresponds to the National Institute of Mental Health research priorities and strategic plan.

The purpose of this paper was to investigate disparities in mental healthcare delivery in American Indian/Alaska Native populations from three perspectives: public health, legal policy and mental healthcare and provide evidence-based recommendations toward reducing those disparities. Data on mental health funding to tribes were obtained from the Substance Abuse and Mental Health Services Administration. As a result of analysis of these data, vital statistics and current literature, we propose three recommendations to reduce mental health disparities. First, where possible, increase mental health funding opportunities for federally-recognized tribes. Second, model funding practices on principles of tribal self-determination. Finally, support diverse interventions that are culturally-based and culturally-appropriate.

Since 1993, the Substance Abuse and Mental Health Services Administration has invested more than $1 billion establishing systems of care (SOC) in over 173 local communities to provide services to children with mental, emotional, and behavioral problems and their families. The SOC model requires that effective partnerships be developed between parents and professionals and also among different service sectors and agencies. To date, there has been no systematic examination of these interagency partnerships associated with the presence of conflict and its management. This paper reports the findings from a survey of the members of the governing boards of currently funded and graduated SOC sites related to interorganizational conflict. The results indicated that conflict was common in SOC regardless of the stage of the system's development. The most common types of conflict included incompatible goals, interpersonal relationships, and overlapping authority. When conflict occurred, a number of management efforts were used including analyzing the conflict and developing a strategy to deal with it and dealing with the conflict behind the scenes. Suggestions are provided for identifying and managing conflict.

Over the centuries, slavery has become embedded into the social fabric of Mauritania with generations of abid and bizan (Mauritanian slaves and slave masters, respectively) born and raised knowing nothing but the institution of chattel slavery. Abid fleeing their station in Mauritania come to the USA with unique psychological needs that will affect all of their interactions with the medical community. This paper aims to assist health professionals and others concerned with the welfare of former chattel slaves in competently serving this vulnerable population. Discussion includes an overview of Mauritanian chattel slavery, deduced sequelae of chattel slavery, preliminary recommendations for mental health and medical treatment protocols, and suggestions for future research. A confidential Institutional Review Board (IRB)-approved case report will be used to illustrate these objectives.

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

Psychology and other behavioral health professions have amassed a broad empirical and clinical literature suggesting many medical presentations are best responded to with the addition of evidence based behavioral interventions. Despite this, psychology has not achieved a regular presence as part of medical practice. We suggest specific reasons for the current state of affairs including clinical, operational, societal labels, financial and training dimensions. Medical, psychological, administrative, and financial perspectives are reviewed. If the goals of health care system reform are to be reached then we must identify and challenge the current limitations of health care. This paper will identify the elements that need to be changed in order for psychology to be integrated into medicine rather than excluded from its policy, planning and operations.

Outcome data collection systems provide the opportunity for comparing agencies, programs, and therapists. However, the political stakes of comparisons raise important issues regarding their perceived validity. The goal of case-mix adjustment is to eliminate potential biasing factors that might render comparisons as inappropriate or irrelevant. In this paper, case-mix adjustment variables are identified using regression analysis followed by developing models of case mix adjustment using a sample of youth participants in the Ohio Mental Health Consumer Outcomes System. Results indicate that certain client level variables do predict outcomes. The total variance accounted for by variables other than baseline ratings of the outcome measure was small. When comparing agencies using adjusted and unadjusted models, some agencies did vary relative to other agencies. As with previous studies, however, the rank order of agencies was largely unchanged and the correlation between adjusted and unadjusted outcomes among agencies was significant.

The organizational social context in which mental health services are provided is believed to affect the adoption and implementation of evidence-based practices (EBPs) as well as the quality and outcomes of the services. A fully developed science of implementation effectiveness requires conceptual models that include organizational social context and tools for assessing social context that have been tested in a broad cross-section of mental health systems. This paper describes the role of organizational social context in services and implementation research and evaluates a comprehensive contextual measure, labeled Organizational Social Context (OSC), designed to assess the key latent constructs of culture, climate and work attitudes. The psychometric properties of the OSC measure were assessed in a nationwide study of 1,154 clinicians in 100 mental health clinics with a second-order confirmatory factor analysis of clinician responses, estimates of scale reliabilities, and indices of within-clinic agreement and between-clinic differences among clinicians. Finally, the paper illustrates the use of nationwide norms in describing the OSC profiles of individual mental health clinics and examines the cross-level association of organizational-level culture and climate with clinician-level work attitudes.

This paper presents a brief review of organizational measures related to implementation of new practices and technologies in sectors other than mental health, and discusses potential application of these measures to mental health implementation research. A few standardized organizational measures are presented along with considerations regarding the appropriateness of adapting existing measures rather than creating novel ones or using additional methodologies. Challenges and opportunities for researchers in measuring key organizational constructs related to implementation in mental health settings are discussed.

Mental health clinicians rely on a range of legal mandates and interpersonal strategies of encouragement and pressure to address nonadherence to treatment. This paper describes the development and testing of a scale to assess formal and informal strategies used by clinicians to encourage adherence to medication. The 16-item measure was administered to 271 clinicians and analyzed using Rasch measurement modeling. Subsequently, items were revised and readministered to a second sample of 44 clinicians in an urban mental health clinic. Rasch analysis of the items yielded a coherent and internally consistent unidimensional measure of strategies used to promote adherence that vary on a continuum of pressure or social control. Criterion-related validity was assessed by observing the association of the measure with clinician ratings of client adherence. The resulting measure may be employed in future studies to examine the ways in which clinician behavior relates to medication adherence and to consumer perceptions of treatment alliance, quality of care, and perceived coercion.

Evidence-based prevention and intervention programs are increasingly being implemented in schools and it therefore is becoming increasingly important to understand the complexities of program implementation under real-world conditions. Much research has focused on the contextual factors that influence program implementation but less work has attempted to provide an integrated understanding of mechanisms (e.g., teacher-training processes) that affect teachers' program implementation. In this paper, we review literature on factors related to teachers' implementation of school-based prevention and intervention programs, then from this review abstract what we believe are four basic ingredients that characterize potentially sustainable teacher-implemented classroom programs. Finally, we present a sequential model, based on these ingredients, of the naturalistic processes underlying sustainability of teachers' program implementation and describe how this sustainability can be enhanced through provision of teacher training and performance feedback from a classroom consultant.

Interactive Voice Response (IVR), an automated system that administers surveys over the phone, is a potentially important technology for mental health services research. Although a number of studies have compared IVR to live interviews, few have looked at IVR in comparison to pencil-and-paper survey administration. Further, few studies have included subjects from those populations most likely to benefit from IVR technology, namely patients with lower education levels and non-English-speaking patients. This randomized clinical study, conducted at a community health center serving low-income English- and Spanish-speaking populations, assessed the reliability of an IVR-administered Brief Symptom Inventory (BSI) relative to a paper-and-pencil version. The study was adequately powered. Results showed that patients gave similar responses to the IVR and paper-and-pencil surveys; in addition, patients were generally equally satisfied with both experiences. We conclude that, while more large-scale research is needed, IVR can be a useful survey administration tool.

This paper describes the views of primary care providers about treating depression among adult Medicaid patients and their experiences with managed behavioral health care. It also shows the outcomes of an intervention project that provides a care manager to facilitate connections among PCPs, patients, and behavioral health providers. Despite widespread initiatives to improve depression management in primary care and to manage behavioral health services, it appears that links between the two systems and the use of evidence-based approaches to managing patients are rare. A pilot project to initiate practice redesign, the use of a care manager to assist in patient support, and compliance with both medical and behavioral health treatment has been shown to improve communication and results in positive patient outcomes. Managed behavioral health care can result in incentive structures that create gaps between primary care and behavioral health systems. This project illustrates an initiative co-sponsored by the Massachusetts behavioral health program designed to strengthen links between behavioral health and primary care, and increase rates and effectiveness of depression treatment.

A jail diversion program was implemented for offenders with co-occurring mental health and substance abuse disorders (COD) in Lane County, Oregon. This paper discusses whether the program resulted in any sustained community service systems change. Interviewees were asked questions about any systems-level changes that interviewees were aware of in corrections, criminal justice, or treatment where offenders with COD were involved. Results showed evidence of system-level changes in corrections, criminal justice, and treatment that were attributed to various aspects of our "boundary spanning" jail diversion approach with the COD population. The researchers also interpreted the results as evidence of the efficacy of using research to promote change.

Increasing competition in the market for mental health and substance abuse MHSA services and the potential to realize significant administrative savings have created an imperative to monitor, evaluate, and control spending on administrative functions. This paper develops a generic model that evaluates spending on administrative personnel by a group of providers. The precision of the model is demonstrated by examining a set of data assembled from five MHSA service providers. The model examines a differential cost construction derived from inter-facility comparisons of administrative expenses. After controlling for the scale of operations, the results enable MHSA programs to control the efficiency of administrative personnel and related rates of compensation. The results indicate that the efficiency of using the administrative complement and the scale of operations represent the lion's share of the total differential cost. The analysis also indicates that a modest improvement in the use of administrative personnel results in substantial cost savings, an increase in the net cash flow derived from operations, an improvement in the fiscal performance of the provider, and a decline in opportunity costs that assume the form of foregone direct patient care.

In seeking to understand how the goal of providing efficient and effective mental health services can best be attained, services researchers have developed principles and methods that distinguish it from other research approaches. In 2000, the National Institute of Mental Health called for translational research paradigms that seek to expand the conceptual and methodological base of mental health services with knowledge gained from basic behavioral sciences such as cognitive, developmental, and social psychology. The goal of this paper is to enter the discussion of what is translational research by illustrating a services research program of the Chicago Consortium for Stigma Research on mental illness stigma. Our research strives to explain the prejudice and discrimination that some landlords and employers show toward people with mental illness in terms of basic research from social psychology and contextual sociology. We end the paper with a discussion of the implications of this research approach for the very practical issues of trying to change mental illness stigma.

One approach to improving the quality of care for severe mental illnesses (SMI) such as schizophrenia is through the improvement of provider competencies; the attitudes, knowledge, and skills needed to deliver high-quality care. This paper describes a new instrument designed to measure such a set of competencies. A total of 341 providers of services to clients with SMI at 38 clinics within 5 publicly financed treatment organizations in 2 western states were asked to complete a paper-and-pencil survey including the new Competency Assessment Instrument (CAI: 15 scales, each assessing a particular provider competency), and additional measures used to establish validity (Recovery Attitude Questionnaire--7, Client Optimism Scale). Seventy-nine percent (N = 269) responded at baseline, 83% (N = 282) responded at 2 weeks. Ninety-seven percent of baseline respondents completed the survey at 2 weeks. Most CAI scales have good internal consistency (Cronbach's alphas = .52-.93), test-retest reliability (scales ranged from .42 to .78), and validity, and should be useful in efforts to improve care.

This paper reviews what is known about the organizational context of children's mental health services and describes organizational constructs, conceptual models, research methods, and intervention strategies that can be used to link organizational context to service quality and outcomes. Using evidence from studies of business and industrial organizations as well as studies of children's service organizations, the paper presents a model of organizational effectiveness that depends on several contextual characteristics that include organizational culture, structure, climate, and work attitudes. These characteristics are believed to affect the adoption of efficacious treatments (EBPs [evidence-based practices]), adherence to treatment protocols, therapeutic alliance, and the availability, responsiveness, and continuity of services. Finally, 10 components of the ARC(Availability Responsiveness and Continuity) organizational intervention are described as examples of strategies that can be used to develop organizational contexts with the prescribed characteristics. Mental health researchers are encouraged to consider including these constructs, conceptual models, research methods, and intervention strategies in dissemination, effectiveness, and implementation studies that address the gap between research-based knowledge about mental health treatment and what is actually offered in the community.

This paper addresses market failure due to externalities, as well as information asymmetries and public policy problems that need to be solved to ensure high quality care for affective disorders. We delineate the problems in parity legislation, managed care, as well as Medicare and Medicaid that need to be addressed to reduce the burden of illness affective disorders. A research agenda is developed for formulating and implementing public policy.

Studies designed to reduce the burden of affective disorders should apply and develop theories and methods from diverse social sciences that could strengthen current interventions. A series of papers from diverse fields, such as quality engineering, behavioral economics, etc. might be a needed first step. Methodological research on design strategies such as group-level randomized trials, or instrumental variables analyses are needed. Finaly, qualitative studies to understand diverse stakeholder views are also needed. To pursue these areas, interdisciplinary training programs are needed to develop skilled researchers to study communities and community-based delivery settings. New research infrastructures are needed to support community and research collaborations, as well as supporting development of new technologies to enable diffusion of care.

A version of this paper was presented as a keynote address entitled "Strategies for Catalyzing Change" at the September 2001 Annapolis Conference on Behavioral Health Workforce Education and Training. It explores some of the problems inherent in our present health care system and suggests that ultimately, revamping pre-professional training is the key to sustained system change. While the paper approaches the problems inherent in our behavioral health care system from a psychiatric perspective, it is believed that similar issues and concerns exist across disciplines and that ultimately the solution requires our ability to transcend narrower perspectives.

This paper identifies issues and trends affecting the quality and comprehensiveness of Latino mental health research and services. These issues include current patterns of need and services use, rapid expansion of the Latino population, extraordinary rates of uninsured, social and language barriers to care, transformation in treatment science and technology, and the sheer complexity and rapid changes in the delivery system. Progress in the field requires coordination and investments from both public and private sectors. Scientific journals should provide assistance for creating a high quality knowledge base and rapidly disseminating this information to students, practitioners, and policy makers. Vigorous activity is needed to (1) augment the supply of people entering the "pipeline" for researcher and practitioner training, and (2) support research in priority areas such as outcome studies for diverse treatments and different sectors of care, cultural competence, treatment models for youth and aging populations, quality of care, and barriers to mental health care.

Using the research framework recommended by L. Rogler, R. Malgady, and D. Rodriguez (1989), the current paper examines the barriers to providing effective mental health services to Asian Americans. Beginning with the recognition that Asian Americans consists of numerous heterogeneous subgroups, the issue of the stereotype of Asian Americans as the "model minority" was also discussed. The primary focus of the paper is on Stages 2, 3, and 4 within the Rogler et al. (1989) model and the identification and discussion of cultural factors that hinder the delivery of mental health services to Asian Americans. The paper is therefore organized into these three sections: (a) help-seeking or mental health service utilization, (b) evaluation of mental health problems, and (c) psychotherapeutic services. In each of the sections, not only are the barriers to delivery of effective mental health services discussed but so are the research and methodological problems as well as some directions for future research. This critical review of the literature has been prepared with the goal of serving as a "blueprint" for us to pursue rigorous but relevant research to identify and reduce these cultural barriers to providing effective mental health services to Asian Americans.

Nearly everyone writing on homelessness over the past 15 years has called for comprehensive integrated systems of care to address the multiple and complex needs of people who become homeless, especially those with mental illness. What is often overlooked is that calls for systems integration are far from new. Although the names have changed over the years, the underlying concepts have not. The purposes of this paper are fourfold: (1) to clarify the distinction between services integration and systems integration; (2) to map the evolution of federal programs to demonstrate that most of these really have been focused on services integration rather than systems integration; (3) to assess the extent that data from these programs supports the idea of systems integration; and (4) to show how the current ACCESS demonstration for persons who are homeless and mentally ill is likely to provide answers that prior programs have not. Without these new data, systems integration, as one solution to the problems of homelessness, remains a theory without empirical evidence; albeit a theory with persuasive conceptual underpinnings.

My assignment was to critique and integrate the previous papers. I have organized this paper as follows: (1) a description and rationale for a checklist which can be used in judging the quality of a fidelity measure; (2) a critique of the Schaedle and Epstein paper; (4) a critique of the Lucca paper; and (4) a review of the paper by Bond, Evans, Salyers, Williams, and Kim.

Mental health organizations are in the midst of massive changes brought about by managed care. This paper explores attitudes and reactions of leaders in mental health organizations to these changes. The leader's own conflicts regarding this approach to mental health care is a major determinant of why some organizations adapt more readily than others. Strategies for leaders that recognize the need to address conflict within the individual and the organization are discussed. The importance of facilitating dynamic interactional processes between leaders and non-leaders in regard to mutual expectations also is emphasized.

This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models--diversification, linkage, referral and enhancement--which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Several states have designed and implemented innovative programs for Medicaid beneficiaries that carve-out the provision of mental health from general health care. This paper describes several such programs and outlines the choices states face in designing these services. Major decisions include the selection of a public or private agency, how that agency is chosen, reimbursement schemes, eligibility criteria, and benefits to be covered. While carve-out programs have yielded initial savings, more research is needed on their effect on quality of care and general health care costs.