Showing papers by "Robert A. Rosenheck published in 1998"

Compliance With Medication Regimens for Mental and Physical Disorders

Abstract: OBJECTIVE: The authors reviewed research on medication compliance in psychiatric treatment and compared compliance rates with compliance rates in treatment of physical disorders. METHODS: MEDLINE was used to locate reports in the literature on medication compliance in psychiatric treatment for the years 1975 through 1996. These reports and studies cited in the reports were reviewed to determine the methods used to assess compliance and the compliance rates reported. Ten reports describing assessment methods and including medication compliance rates for antidepressant medication and 24 reports for antipsychotic medication were selected. They were compared with 12 reports that used microelectronic monitoring to assess medication compliance of patients with a range of nonpsychiatric disorders. RESULTS: Studies of psychiatric patients used various methods of estimating medication compliance, including interviews with patients, clinicians' judgment, and pill counts, but overall showed low rates of compliance. ...

Mental Disorders and Access to Medical Care in the United States

Abstract: Objective:The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults.Method:The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables.Results:While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were...

Psychological benefits and liabilities of traumatic exposure in the war zone

Abstract: Data from the National Vietnam Veterans Readjustment Study on 1,198 Vietnam theater veterans were used to examine the psychological benefits and liabilities of traumatic exposure in the war zone. Psychological benefits and liabilities were found to be largely independent of one another and to be related positively to the dose of traumatic exposure. Additionally, there was a curvilinear trend in the form of an inverted U, such that psychological benefits, most notably solidarity with others, were stronger at intermediate compared to high and low levels of exposure. Psychological benefits counteracted and psychological liabilities passed through the effects of traumatic exposure on posttraumatic stress disorder (PTSD). The psychological benefit of self-improvement moderated the effects of the psychological liability of self-impoverishment on PTSD.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness.

Abstract: OBJECTIVES: This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes METHODS: As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site) RESULTS: Complete follow-up data were obtained from 1340 clients (73%) After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies CONCLUSIONS: Service system integration is related to improved acce

The effect of victimization on clinical outcomes of homeless persons with serious mental illness.

Abstract: OBJECTIVE: The study examined the prevalence and correlates of criminal victimization and the relationship between victimization and client outcomes for homeless clients with mental illness. METHODS: Subjects were clients in community treatment programs participating in the Access to Community Care and Effective Services and Supports (ACCESS) program of the Center for Mental Health Services. Data were obtained through interviews conducted at program entry and at three and 12 months after entry with ACCESS clients in 18 sites during the first year of program operation (N=1,839). Self-reports of victimization during the past two months as well as data on sociodemographic, health, and social adjustment indicators were obtained at each time point. Multiple regression was used to determine both the correlates of victimization among this population and the effect of recent victimization on client outcomes three and 12 months after program entry. RESULTS: Forty-four percent of the clients were the victims of at ...

Transgenerational effects of abusive violence on the children of Vietnam combat veterans

Abstract: This study examined the relationship between participation in abusive violence in Vietnam and behavioral disturbances among children aged 6-16 in the next generation. As part of the National Vietnam Veterans Readjustment Study (NVVRS) detailed data were obtained on a national sample of male veterans who were living in households with children aged 6-16 (N = 257). Interviews with spouses/partners were used to evaluate current family relationships and child behavior. Children of veterans who participated in abusive violence showed more behavioral disturbance than children of other Vietnam veterans even after multivariate analysis was used to adjust for other factors such as PTSD symptoms, combat exposure, and postmilitary family relationships. Participation in abusive violence appears to affect parent-child relationships in a way that adversely influences children living at home.

Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment.

Abstract: OBJECTIVE: The stressful experiences of women serving in the military have been a focus of increasing concern. A model of the impact of stress related to military duty and stress related to sexual abuse and harassment on the development of posttraumatic stress disorder (PTSD) among female veterans was evaluated. METHODS: Structural equation modeling was applied to data from 327 women treated in a VA clinical program for women with stress disorders. The model was a chronological one and included variables related to the women's premilitary experience, their military service, and their postmilitary experience. RESULTS: Altogether 48 percent of the sample served overseas, and 12 percent were exposed to enemy fire. A total of 63 percent reported experiences of physical sexual harassment during military service, and 43 percent reported rape or attempted rape. Both duty-related and sexual stress were found to contribute separately and significantly to the development of PTSD. Sexual stress was found to be almos...

Cost-effectiveness of intensive psychiatric community care for high users of inpatient services.

Abstract: Background This 2-year experimental study evaluated the effectiveness and cost of 10 intensive psychiatric community care (IPCC) programs at Department of Veterans Affairs medical centers in the northeastern United States. Methods High users of inpatient services were randomly assigned to either IPCC or standard Department of Veterans Affairs care at 6 general medical and surgical hospitals (n=271 vs 257) and 4 neuropsychiatric hospitals (n=183 vs 162). Patient interviews every 6 months and national computerized data were used to assess clinical outcomes, health service use, health care costs, and non–health care costs. Results There was only 1 significant clinical difference between groups across follow-up periods: IPCC patients at general medical and surgical sites had higher community living skills. However, at the final interview, IPCC patients at general medical and surgical sites showed significantly lower symptoms, higher functioning, and greater satisfaction with services. Treatment with IPCC significantly reduced hospital use only at neuropsychiatric sites (320 vs 513 days, P P P P =.26). Conclusions At acute care hospitals, IPCC treatment is associated with greater long-term clinical improvement and, when fully implemented, is cost-neutral. At long-stay hospitals treating older, less-functional patients, it is not associated with clinical or functional improvement but generates substantial cost savings. Intensive psychiatric community care thus has beneficial, but somewhat different, outcome profiles at different types of hospitals.

Does Participation in Psychosocial Treatment Augment the Benefit of Clozapine

Abstract: Background This study examines the role of participation in psychosocial treatment as a mediator of the clinical effectiveness of clozapine. Methods Subjects participated in a 12-month double-blind random-assignment trial comparing clozapine and haloperidol in patients hospitalized 30 to 364 days for refractory schizophrenia at 15 Department of Veterans Affairs medical centers. A broker-advocate case management intervention was used to facilitate participation in psychosocial treatments and to document such participation. Results Between those who continued receiving clozapine (n=122) or a conventional antipsychotic drug (n=169) for 12 months, those receiving clozapine were more likely to participate in psychosocial rehabilitation treatment. Although they were no more likely to receive clinical recommendations for such treatments, they were more likely to both verbally accept recommendations and to act on them. Structural equation modeling shows that participation in psychosocial treatment did not play a mediating role in clozapine's effect on outcomes at 6 months, but was associated with both reduced symptoms and improved quality of life at 12 months. Conclusions Clozapine facilitates participation in psychosocial treatment, and such enhanced participation is associated with improved quality-of-life and symptom outcomes. Psychosocial rehabilitation should be offered concomitantly with clozapine.

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders.

Abstract: OBJECTIVES This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.

Homelessness: health service use and related costs.

Abstract: OBJECTIVES This study examines health service use and costs for homeless and domiciled veterans hospitalized in psychiatric and substance abuse units at Department of Veterans Affairs (VA) medical centers, nationwide. METHODS A national survey of residential status at the time of admission was conducted on all VA inpatients hospitalized in acute mental health care units on September 30, 1995. Survey data were merged with computerized workload data bases to assess service use and cost during the 6 months before and after the date of discharge from the index hospitalization. RESULTS Of 9,108 veterans with complete survey data, 1,797 (20%) had been literally homeless at the time of admission, and 1,380 (15%) were doubled up temporarily, for a total homelessness rate of 35%. Combining patients from general psychiatry and substance abuse programs, the average annual cost of care for homeless veterans, after adjusting for other factors, was $27,206; $3,196 (13.3%) higher than the cost of care for domiciled veterans (P < 0.0001). Approximately 26% of annual inpatient VA mental health expenditures ($404 million) are spent on the care of homeless persons. CONCLUSIONS Homelessness adds substantially to the cost of health care services for persons with mental illness in VA, and most likely, in other "safety net" systems that serve the poor. These high costs, along with the prospect of declining public funding for health and social welfare programs, and an anticipated increase in the numbers of homeless mentally ill persons, portend a difficult time ahead for both homeless patients and the organizations that care for them.

A mental health program report card: a multidimensional approach to performance monitoring in public sector programs.

Abstract: This report presents a comprehensive,multi-dimensional mental health program performancemonitoring system that has recently been implemented inthe Department of Veterans Affairs. Principlesunderlying the development of the system are reviewed and68 specific monitors are described addressing four majorperformance domains: access, inpatient care, outpatientcare, and economic performance. Simple methods are presented for identifying outliers, forgenerating summary performance scores across series' ofrelated monitors, and for adjusting results fordifferences in patient characteristics across locales. Although still technically imperfect, andtherefore requiring continuous improvement, monitoringsystems such as the one presented can be useful toolsguiding and improving service delivery and mental health system performance, and providing a medium ofaccountability to consumers and otherstakeholders.

Warrior Fathers and Warrior Sons

Abstract: This chapter considers whether Vietnam veterans whose fathers served in combat have an increased risk of posttraumatic stress disorder and other postwar adjustment problems when compared with other Vietnam veterans. Samples are Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study (NVVRS) and veterans seeking treatment for PTSD from the Department of Veterans Affairs (VA). In the total NVVRS sample there were no differences between these two groups. However, within the subgroup of veterans who met criteria for PTSD,those whose fathers had been exposed to combat had more severe problems on several measures. In the VA sample, too, veterans whose fathers served in combat scored higher in PTSD symptoms, suicidality, guilt, and loss of religious faith. We conclude that intergenerational effects of trauma emerge when the second generation itself has PTSD, and show that these transgenerational effects are related to intergenerational processes during the homecoming period rather than to differences in premilitary experience.

Female veterans' use of Department of Veterans Affairs health care services.

Abstract: OBJECTIVES As access of women to mental health services has become increasingly important, empirical research has begun to examine the determinants of mental health care utilization across gender. This article examines the effect of being an extreme minority on utilization of Department of Veterans Affairs (VA) health services by female veterans. METHODS Data were collected on a representative national sample of veterans in 1992 as part of the National Survey of Veterans. These data included information on sociodemographic variables, military service variables, physical health and disability, and health services utilization. The authors examined whether women who used health services in 1992, and who were eligible for VA care, differed from men on the likelihood of using any VA health services and on the likelihood of use of VA outpatient and inpatient health services. In addition, we compared VA health care utilization among subgroups of veterans with physical and mental disorders, and compared self-reported reasons for choice of health care provider, across gender. RESULTS Results indicated that female veterans were less likely than male veterans to use VA health services. This difference was explained by lower utilization by women of VA outpatient services, since inpatient admission rates were the same across gender. The lower outpatient utilization was specific to women with self-reported mental disorders. Women with physical conditions did not differ from men with similar conditions in their VA outpatient utilization. Finally, men and women did not differ on their reasons for choosing VA or non-VA care. CONCLUSIONS The authors conclude that extreme gender minority status appears to affect outpatient utilization rates at the VA among women with mental disorders, perhaps because of the more personal or sensitive nature of the services involved. Further research is needed to understand why certain women may be underutilizing VA outpatient services and on the consequences of minority gender status for health service utilization, more generally.

Access to public mental health services: determinants of population coverage.

Abstract: OBJECTIVES This study examined factors that affect access to Veterans Administration mental health services. METHODS Data from national Veterans Affairs databases and the 1990 Decennial Census were used to estimate rates of Veterans Affairs mental health service use in each US county (n = 3,156) among all US veterans and in three subpopulations defined by eligibility and clinical status. Independent variables examined in standard multivariate analyses and using hierarchical linear modeling techniques included county-level sociodemographic characteristics (age, race, and income); "unmanaged" service system characteristics (those not directly controlled by Veterans Affairs program managers, eg, distance from residence to Veterans Affairs and to non-Veterans Affairs services, local supply of non-Veterans Affairs services); and "managed" service system factors (those directly controlled by Veterans Affairs program managers, eg, per capita Veterans Affairs funding level and the efficiency of Veterans Affairs service delivery). RESULTS Altogether, 2.0% of US veterans used Veterans Affairs mental health services. More than one third (36%) of the variance in utilization was explained by sociodemographic factors; 8% was explained by unmanaged service system factors and 7% was explained by managed service system factors, with variations among subgroups. Substitution effects were demonstrated between Veterans Affairs and non-Veterans Affairs systems and appeared to be diagnosis-specific. CONCLUSIONS Both per capita funding levels and efficient service delivery were significantly associated with increased access to mental health services. Implications for health system performance assessment and management are discussed.

Effects of Compensation-seeking on Treatment Outcomes among Veterans with Posttraumatic Stress Disorder

Abstract: The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation. Outcome was measured as pre/post improvement in symptoms and work performance over the course of 1 year after the initiation of treatment. No compensation-seeking effect was observed among outpatients, but a significant effect was found for some inpatients. The effect for inpatients was manifested essentially by patients in a program type which was designed to have an extremely long length of stay, thus triggering a virtually automatic increase in payments. Like outpatients, inpatients in programs with a moderate length of stay did not manifest a compensation-seeking effect on improvement. Although not permitting a definitive explanation, the preponderance of the evidence favors the overstatement of symptoms rather than either the severity or the chronicity of the disorder as the most likely explanation for the compensation-seeking effect that was observed. For patients treated in standard outpatient and short-stay inpatient programs, compensation does not seem to affect clinical outcomes adversely.

Participation and Outcome in a Residential Treatment and Work Therapy Program for Addictive Disorders: The Effects of Race

Abstract: OBJECTIVE: The authors examined differences in program participation and outcome between black and white veterans with addictive disorders who participated in an intensive Department of Veterans Affairs (VA) residential work therapy program. METHOD: Data on 962 veterans treated in the VA Compensated Work Therapy/Transitional Residence Program were gathered. Multivariate analyses were used to compare black and white veterans on admission characteristics, program participation, and 3-month outcome. RESULTS: The black subjects were younger than the white veterans and had more severe drug abuse problems, less severe alcohol and psychiatric problems, and more extensive social support networks. There were no differences between groups in 11 of 13 measures of program participation, although the blacks felt more positively about the therapeutic milieu and worked more hours per month in the work therapy program than the whites. The black veterans also showed more improvement in alcohol use and housing. The proport...

The use of VA and non-VA mental health services by female veterans.

Abstract: OBJECTIVES This study compared Department of Veterans Affairs (VA) and non-VA mental health service use among male and female veterans. Because female veterans are a distinct minority in VA, it was hypothesized that they would be less likely to use VA mental health care than would male veterans. METHODS Using data from a national sample of Vietnam and Vietnam-era male (n = 1,612) and female (n = 736) veterans, the following were examined: (1) gender differences in use of VA mental health services, (2) gender differences in use of non-VA mental health services, and (3) differences in utilization of mental health services across subgroups defined by psychiatric diagnosis, adjusting for sociodemographic and need variables. RESULTS Female veterans were equally likely to use VA mental health services as male veterans, but were substantially more likely to use non-VA mental health services. This suggests that the demand for mental health services overall is substantially greater among female veterans than among male veterans and, by implication, that the equal levels of observed VA service use actually represent underutilization of VA services on the part of female veterans. Logistic regression models showed that these utilization patterns were consistent across diagnostic subgroups. CONCLUSIONS Special efforts, such as the development of women's specialty mental health clinics, may be needed to enhance the acceptability of VA mental health services to female veterans. This study also highlights the importance of considering overall demand for services in addition to more objective diagnostic data in evaluating the adequacy of service delivery and its accessibility.

Multiple outcome assessment in a study of the cost-effectiveness of clozapine in the treatment of refractory schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia.

Abstract: OBJECTIVE: To develop new methods for combining results from multiple outcome domains and to demonstrate their application in a study of the cost-effectiveness of clozapine in treating hospitalized patients with refractory schizophrenia. DATA SOURCES/STUDY SETTING: Interview assessments, and administrative utilization and cost data, concerning 423 patients with refractory schizophrenia who had been hospitalized for 30-364 days during the year before study entry, at 15 VA medical centers. STUDY DESIGN: A 12-month double-blind trial compared clozapine (n = 205) and haloperidol (n = 218) in the treatment of refractory schizophrenia. DATA COLLECTION/EXTRACTION METHODS: Data from standard assessment instruments, gathered at baseline and at 6 weeks, and at 3, 6, 9, and 12 months, were used to develop a Composite Health Index for Schizophrenia, a measure that addresses outcome in six domains, weighted by patient or provider preferences. Cumulative improvement was estimated by computing the area under the improvement curve. This measure was then combined with cost data, reflecting consumption of societal resources to estimate incremental cost-effectiveness ratios. PRINCIPAL FINDINGS: Clozapine was significantly more effective than haloperidol on measures of symptoms (p = .02) and side effects (p < .0001), with nonsignificant trends in the positive direction on community role functioning (p = .06), family relationships (p = .23), social relationships (p = .30), and daily activities (p = .20). Clozapine was also more effective than haloperidol on the one-year cumulative Composite Health Index for Schizophrenia (p < .0001 for all weighting schemes). After converting this measure to a 0-1 Worst Health-Good Health Scale analogous to Quality Adjusted Life Years, clozapine was found to yield a small improvement of .049 Worst Health-Good Health Units as compared to an improvement of only .027 Units for haloperidol (p < .0001). Average annual costs were $2,733 lower for clozapine (95% C.I. = -$9,220 to $3,754). Although clozapine was significantly more effective than haloperidol, the summary cost-effectiveness ratio had a wide 95 percent confidence interval ranging from -$431,585 to $177,352. CONCLUSIONS: Methods demonstrate an approach to using conventional disease-specific measures to evaluate the cumulative effectiveness of novel treatments for psychotic disorders and for expressing their economic effect as cost-effectiveness ratios. Among high hospital users with refractory schizophrenia, clozapine is more cost-effective than standard treatment, although the magnitude of its effect is small and there is considerable uncertainty about the cost estimates.

Substance use and psychiatric problems of homeless Native American veterans.

Abstract: OBJECTIVE: This study estimated the proportion and representation of Native Americans among homeless veterans and compared their psychiatric and substance abuse problems with those of other ethnic groups of homeless veterans. METHODS: The study was based on data from the Department of Veterans Affairs' Health Care for Homeless Veterans program, a national outreach program operating at 71 sites across the country. Alcohol, drug, and psychiatric problems of Native American veterans (N=950) reported during intake assessment were compared with problems reported by white, black, and Hispanic veterans (N=36,938). RESULTS: Native Americans constituted 1.6 percent of veterans in the program. Age-adjusted analyses suggested that relative to the general veteran population (of which 1.3 percent are Native Americans), Native Americans are overrepresented in the homeless population by approximately 19 percent. Regression analyses controlling for demographic characteristics found that Native American veterans reported ...

Preventive health care for mentally ill women

Abstract: Utilization of preventive medical care was compared for two low-income groups—47 women with serious mental illness in an urban mental health center and 17 women patients at a primary care center. Appropriate preventive care was defined as at least one physical examination, a Pap test, and a breast examination in the past five years and a mammogram if the patient was over age 40. Receipt of preventive care by women in both settings was similar. Histories of physical and sexual abuse were prevalent in both groups, and a history of abuse was associated with less frequent receipt of preventive care. Results indicate that procedures to identify and provide services to women with abuse histories should be further developed.

Use of Alternative Medicine in Major Depression

Abstract: T use of alternative medicine has increased in the U.S. in recent years, fueled by a growing acceptance of these treatments as alternatives to traditional therapies (1,2). This report assesses the degree to which nonconventional drug therapies are currently supplementing or replacing prescription antidepressants among individuals with major depression. To examine this issue, we used data from the 1988–1994 National Health and Nutrition Examination Survey (NHANES) conducted by the National Center for Health Statistics. A total of 7,589 participants aged 15 to 39 were administered the depression module of the Diagnostic Inventory Schedule and answered detailed questions about their use of prescription and nonprescription medications in the past month. For the 312 individuals meeting criteria for current major depression, we examined the use of antidepressants and nonprescription dietary supplements other than vitamins and minerals, such as herbal medicines and homeopathic remedies. Overall, 190 individuals without major depression (2.6 percent) and 14 with major depression (4.5 percent) were taking a nonprescription dietary supplement other than vitamins or minerals. Although major depression was a significant predictor of both antidepressant use (χ2=111, df=1, p< .001) and nonprescription dietary supplement use (χ2=4.03, df=1, p< .05), the majority of persons with major depression (89 percent) took neither (see Figure 1). The NHANES data set has several limitations for fully assessing the use of alternative medicine in depression. First, we did not have data on nonpharmacological forms of traditional and alternative treatments, such as psychotherapy, chiropractic, and meditation. Thus the results likely underestimate the full range of treatments used by depressed individuals. Second, no information was available on why the survey participants were taking the medications, although the increased use of these medications among people with depression suggests the likelihood of some self-medication for depressive symptoms. Perhaps most striking is the finding that the vast majority of depressed patients in the sample went untreated with either antidepressants or nonprescription medications. This finding underscores concerns about the undertreatment of depression in the U.S., a problem that likely results from a complex array of patient, provider, and health system factors (3). The low rate of alternative medication use in this sample suggests that the problem is not simply a function of depressed persons’ substituting nonconventional therapies for mainstream medical treatment. ♦

Intensive Community-Focused Treatment of Veterans With Dual Diagnoses

Abstract: This case presentation follows two veterans through a 5-year course of intensive outpatient care as they made the transition from lives centered on repeated cycles of crisis and hospitalization to lives that are stably centered in the community. The veterans have both major psychiatric disorders and severe substance abuse, and their outpatient treatment demanded intensive, highly individualized care. The treatment programs in which these patients participated were costly, and their development required a substantial shift of inpatient staffing and resources to the outpatient sector (1‐4). These clinical histories illustrate the need for both flexibility and close coordination of the efforts of multiple providers, programs, and agencies. Since these patients were participants in national Veterans Affairs (VA) demonstration programs that include built-in program evaluation and outcome-monitoring efforts, the care they received was an example of the new evidencebased medicine in which the tools of empirical science are used to inform clinical decision making and in which high levels of accountability become a standard part of the everyday practice of medicine (5‐7). CASE PRESENTATION

The Quality of VA Mental Health Services

Abstract: This study examines whether male and female veterans differ on either subjective or objective measures of the quality of VA mental health care. The study sample were all discharged with a psychiatric diagnosis from a VA inpatient mental health program. Results indicate that women were less satisfied with inpatient care, but were mixed on their satisfaction with overall mental health care. Males and females did not differ on the quality of inpatient care, but women had significantly higher quality of outpatient care. These results not only highlight the need to stratify or adjust quality measures by gender, but also highlight the potential confounding effect of sub-group specific health behaviors on measures of quality.

Obligation to the Least Well Off in Setting Mental Health Service Priorities: A Consensus Statement

Abstract: Introduction by the column editor Any health care system that provides care to individuals in the context of a budget for a population must establish priorities for allocating resources. Establishing priorities is ultimately a process of questioning our values; it is, in other words, a process of ethics. A severe weakness of the U.S. market-based system is that to date it lacks any guiding ethical vision (1). In this column, Robert Rosenheck, M.D., and his colleagues report on an important effort by the Department of Veterans Affairs to articulate an ethical vision for a VA resource allocation policy. Future columns will present other efforts in the managed care arena to make ethical considerations an active force in shaping policy and practice.