Showing papers on "Mental health published in 1996"

The neighborhood context of adolescent mental health.

Abstract: Mental health disorders in adolescence are pervasive, often carry into adulthood, and appear to be inversely associated with social status. We examine how structural aspects of neighborhood context, specifically, socioeconomic stratification and racial/ethnic segregation, affect adolescent emotional well-being by shaping subjective perceptions of their neighborhoods. Using a community-based sample of 877 adolescents in Los Angeles County, we find that youth in low socioeconomic status (SES) neighborhoods perceive greater ambient hazards such as crime, violence, drug use, and graffiti than those in high SES neighborhoods. The perception of the neighborhood as dangerous, in turn, influences the mental health of adolescents: the more threatening the neighborhood, the more common the symptoms of depression, anxiety, oppositional defiant disorder, and conduct disorder. Social stability and, to a lesser extent, social cohesion, also emerge as contributors to adolescent disorder. This investigation demonstrates that research into the mental health of young people should consider the socioeconomic and demographic environments in which they live.

Psychological Well-Being: Meaning, Measurement, and Implications for Psychotherapy Research

Abstract: A model of positive psychological functioning that emerges from diverse domains of theory and philosophy is presented. Six key dimensions of wellness are defined, and empirical research summarizing their empirical translation and sociodemographic correlates is presented. Variations in well-being are explored via studies of discrete life events and enduring human experiences. Life histories of the psychologically vulnerable and resilient, defined via the cross-classification of depression and well-being, are summarized. Implications of the focus on positive functioning for research on psychotherapy, quality of life, and mind/body linkages are reviewed.

Psychiatric disorder in a birth cohort of young adults: prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21.

Abstract: Mental health data were gathered at ages 11, 13, 15, 18, and 21 in an epidemiological sample using standardized diagnostic assessments. Prevalence of Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised; American Psychiatric Association, 1987) mental disorders increased longitudinally from late childhood (18%) through mid-(22%) to late-adolescence (41%) and young adulthood (40%). Nearly half of age-21 cases had comorbid diagnoses; and comorbidity was associated with severity of impairment. The incidence of cases with adult onset was only 10.6%: 73.8% of adults diagnosed at age 21 had a developmental history of mental disorder. Relative to new cases, those with developmental histories were more severely impaired and more likely to have comorbid diagnoses. The high prevalence rate and significant impairment associated with a diagnosis of mental disorder suggests that treatment resources need to target the young adult sector of the population. The low new-case incidence in young adulthood, however, suggests that primary prevention and etiological research efforts need to target children and adolescents.

Mental health service use in the community and schools: Results from the four-community MECA study

Abstract: Objective To describe the use of mental health and substance abuse services by children and adolescents as reported from the four community sites included in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Method As part of the MECA survey, questions were developed to identify children and adolescents utilizing mental health and substance abuse services. Youths aged 9 through 17 years and a parent/ caretaker were interviewed. Because the investigators had concerns about the capacities of the younger children in the study to describe their use of mental health services, more extensive questions were asked of parents than of youths. Results The procedures developed by the MECA project identified patterns of service use that varied in the four communities surveyed. Agreement between reports of parents and youths regarding the use of mental health and substance abuse services showed substantial Inconsistencies, similar to reports of psychiatric disorders. At three of the four sites, the majority of children meeting criteria for a psychiatric disorder and scoring 60 or less on the Children's Global Assessment Scale reported some mental health–related service in the previous year, although at two of the sites fewer than 25% of these youths were seen in the mental health specialty sector. Conclusion Community surveys show great promise for monitoring the need for mental health and substance abuse services and for identifying patterns of use.

Psychiatric implications of displacement: Contributions from the psychology of place.

Abstract: Objective : The purpose of this article is to describe the psychological processes that are affected by geographic displacement. Method : The literature from the fields of geography, psychology, anthropology, and psychiatry was reviewed to develop a psychology of place and to determine the manner in which place-related psychological processes are affected by upheaval in the environment. Results : The psychology of place is an emerging area of research that explores the connection between individuals and their intimate environments. The psychology of place posits that individuals require a good enough environment in which to live. They are linked to that environment through three key psychological processes : attachment, familiarity, and identity. Place attachment, which parallels, but is distinct from, attachment to person, is a mutual caretaking bond between a person and a beloved place. Familiarity refers to the processes by which people develop detailed cognitive knowledge of their environs. Place identity is concerned with the extraction of a sense of self based on the places in which one passes one's life. Each of these psychological processes-attachment, familiarity, and place identity-is threatened by displacement, and the problems of nostalgia, disorientation, and alienation may ensue. Conclusions : As a result of war, decolonization, epidemics, natural disasters, and other disruptive events, millions of people are currently displaced from their homes. Protecting and restoring their mental health pose urgent problems for the mental health community.

Health and Unemployment

Abstract: This paper reviews the relationship between health and inadequate employment, especially unemployment. Poor physical or mental health can lead, via poor work performance, to job loss; however, studies that control for such selection effects are still scarce except for a few health outcomes. For example, aggregate-level studies typically find a positive association between unemployment and suicide rates over time. At the individual level of analysis, panel surveys of laid-off workers tend to find increased psychiatric problems such as depression and substance abuse. Few studies have evaluated interventions to prevent or reduce the adverse health effects of job loss. There have been even fewer studies of the health effects of other types of inadequate employment such as the increasingly prevalent forms of underemployment.

Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the Medical Outcomes Study.

Abstract: Objective. —To compare physical and mental health outcomes of chronically ill adults, including elderly and poor subgroups, treated in health maintenance organization (HMO) and fee-for-service (FFS) systems. Study Design. —A 4-year observational study of 2235 patients (18 to 97 years of age) with hypertension, non—insulin-dependent diabetes mellitus (NIDDM), recent acute myocardial infarction, congestive heart failure, and depressive disorder sampled from HMO and FFS systems in 1986 and followed up through 1990. Those aged 65 years and older covered under Medicare and low-income patients (200% of poverty) were analyzed separately. Setting and Participants. —Offices of physicians practicing family medicine, internal medicine, endocrinology, cardiology, and psychiatry, in HMO and FFS systems of care. Types of practices included both prepaid group (72% of patients) and independent practice association (28%) types of HMOs, large multispecialty groups, and solo or small, single-specialty practices in Boston, Mass, Chicago, III, and Los Angeles, Calif. Outcome Measures. —Differences between initial and 4-year follow-up scores of summary physical and mental health scales from the Medical Outcomes Study 36-ltem Short-Form Health Survey (SF-36) for all patients and practice settings. Results. —On average, physical health declined and mental health remained stable during the 4-year follow-up period, with physical declines larger for the elderly than for the nonelderly (P Conclusions. —During the study period, elderly and poor chronically ill patients had worse physical health outcomes in HMOs than in FFS systems; mental health outcomes varied by study site and patient characteristics. Current health care plans should carefully monitor the health outcomes of these vulnerable subgroups.

Mental disorder and crime. Evidence from a Danish birth cohort.

Abstract: Background: Evidence has accumulated since the mid 1960s from a number of different countries indicating an association between mental disorder and crime and particularly between the major mental disorders and violence. Registries in Denmark were used to identify a birth cohort and to document all psychiatric admissions and all criminal proceedings of the 324 401 members of this cohort up to the age of 43 years. Methods: Persons who had been admitted to a psychiatric ward were assigned to a diagnostic category according to a hierarchy of principal discharge diagnoses. They were compared with persons never admitted to a psychiatric ward as to the prevalence, type, and frequency of criminal convictions. Results: Women and men who had been hospitalized in psychiatric wards were more likely to have been convicted of a criminal offense than persons with no history of psychiatric hospitalization. The offenders who were hospitalized committed all types and, on average, as many offenses as did the never-hospitalized group of the same sex. Conclusions: These findings confirm those from 2 other post-World War II Scandinavian birth cohorts that have found an association between psychiatric hospitalization and criminal convictions. They also concur with findings that patients discharged from psychiatric wards are more likely than other persons living in the same community to commit crimes and with results from North America showing elevated rates of major mental disorders among incarcerated offenders. Generalization of these findings is limited to nations with similar criminal justice, mental health, and social welfare systems.

Racism and the physical and mental health status of African Americans: a thirteen year national panel study.

Abstract: This paper examined the relationships between the experiences and perceptions of racism and the physical and mental health status of African Americans. The study was based upon thirteen year (1979 to 1992), four wave, national panel data (n = 623) from the National Survey of Black Americans. Personal experiences of racism were found to have both adverse and salubrious immediate and cumulative effects on the physical and mental well-being of African Americans. In 1979-80, reports of poor treatment due to race were inversely related to subjective well-being and positively associated with the number of reported physical health problems. Reports of negative racial encounters over the 13-year period were weakly predictive of poor subjective well-being in 1992. A more general measure of racial beliefs, perceiving that whites want to keep blacks down, was found to be related to poorer physical health in 1979-80, better physical health in 1992, and predicted increased psychological distress, as well as, lower levels of subjective well-being in 1992. In conclusion, the authors suggested future research on possible factors contributing to the relationship between racism and health status among African Americans.

Prevalence of psychiatric disorders among incarcerated women. II. Convicted felons entering prison

Abstract: Background: No unbiased estimates of the rates of psychiatric disorder among women prison inmates are available. Nonetheless, available data suggest that some psychiatric disorders are prevalent in this population. The objective of the study was to determine the rates, risk factors, and outcomes of specific psychiatric disorders among women prison inmates. Methods: A virtual census of women felons (N=805) entering prison in North Carolina was assessed using in-person interviews. Assessments were conducted for 8 disorders, using the Composite International Diagnostic Interview as the primary assessment measure. For validation purposes, one quarter of the inmates were reassessed for 2 of these disorders, using structured clinical interviews. Results: Inmates were found to have high rates of substance abuse and dependence and antisocial and borderline personality disorders compared with women in community epidemiologic studies. Rates among inmates were also somewhat elevated for mood disorders but not for anxiety disorders. The rate of reports of lifetime exposure to traumatic events was also high. Rates of disorder tended to be higher among white than among African American women. Conclusion: High rates of substance abuse, psychiatric disorder, and psychological distress associated with exposure to traumatic events suggest that women in prison have a need for treatment for substance abuse and other mental health problems.

The War Experiences and Psychosocial Development of Children in Lebanon

Abstract: This study examines the number and types of war traumas children face growing up in a war-torn country and the relation of such traumatic experiences to their psychosocial development. A sample of 224 Lebanese children (10-16 years old) were interviewed using measures of war exposure, mental health symptoms, adaptational outcomes, and Post-Traumatic Stress Disorder (PTSD). The number and type of children's war traumas varied meaningfully in number and type by their age, gender, father's occupational status, and mother's educational level. As predicted, the number of war traumas experienced by a child was positively related to PTSD symptoms; and various types of war traumas were differentially related to PTSD, mental health symptoms, and adaptational outcomes. For example, children who were exposed to multiple war traumas, were bereaved, became victims of violent acts, witnessed violent acts, and/or were exposed to shelling or combat exhibited more PTSD symptoms. Children who were separated from parents reported more depressive symptoms and children who experience bereavement and were not displaced reported more planful behavior. Lastly, children who were separated from parents and who witnessed violent acts reported more prosocial behavior. Implications for program interventions and directions for future research on the effects of war on the psychosocial development of children are explored.

Trajectories of poverty and children's mental health.

Abstract: Using data from three waves of the Children of the National Longitudinal Surveys of Youth data set (1986, 1988, 1990), we examine the dynamic relationship between children's family histories of poverty and their developmental trajectories of mental health. Children who were poor in 1986 or who had prior histories of poverty had higher levels of depression and antisocial behavior in that year. Furthermore, subsequent poverty histories were also related to children's mental health trajectories. The number of years that children were poor between 1986 and 1990 correlates significantly with changes in children's antisocial behavior during those years. Finally, rates of increase in antisocial behavior were substantially higher for children with histories of persistent poverty during those years than for transiently poor or nonpoor children. These results demonstrate the accelerating behavioral disadvantages faced by persistently poor children.

The New Hampshire study of supported employment for people with severe mental illness.

Abstract: This study compared supported employment services in 2 contrasting programs: (a) Group Skills Training, a professional rehabilitation agency outside of the mental health center that provided pre-employment skills training and support in obtaining and maintaining jobs, or (b) the Individual Placement and Support (IPS) model, which integrated clinical and vocational services within the mental health center. People with severe mental disorders who expressed interest in competitive employment (N = 143) were randomly assigned to 1 of these 2 programs. Results showed that clients in the IPS program were more likely to be competitively employed throughout most of the 18-month follow-up. Among those who obtained jobs, there were few group differences, although workers in the IPS program did work more total hours and earn more total wages during the 18-month follow-up. There were no group differences on nonvocational outcomes.

Becoming married and mental health: A longitudinal study of a cohort of young adults.

Abstract: Despite the assumption that marriage enhances psychological well-being, little evidence exists that the social role of marriage, rather than the characteristics of individuals who get married, accounts for the benefits of marriage. We use a sample of 18-, 21-, and 24-year-old men and women who either remained unmarried or got married and remained married over a 7-year period to examine whether, after controlling for premarital rates of disorder, marriage enhances mental health. In addition, we consider whether or not females derive more mental health benefits from marriage than males. The results indicate that, with controls for premarital rates of mental health, young adults who get and stay married do have higher levels of well-being than those who remain single. In addition, although men-but not women-who become married report less depression, women-but not men-who become married report fewer alcohol problems. Thus, when both male-prevalent and female-prevalent outcome measures are used, both men and women benefit from marriage. Key Words: marriage, mental health, social selection, young adults. For the past century, sociologists have assumed that marriage enhances psychological well-being. A hundred years ago, Durkheim (1897/1951) postulated that the low suicide rates of married people were due to their greater social integration, protection from life strains, and sense of security, meaningfulness, and purpose. Many studies since that time show that marriage is associated with less morbidity, mortality, mental illness, substance abuse, and distress (e.g., Adler, 1953; Bloom, Asher, & White, 1978; Gove, 1972; Ross, Mirowsky, & Goldstein, 1990; Ross, 1995; Umberson, 1987; Waite, 1995). Indeed, one survey of the literature states that no social variable is more consistently or more powerfully related with the distribution of psychopathology than marital status (Bloom et al., 1978). Another survey concludes that one of four major social patterns of distress is that "married people are less distressed than unmarried ones" (Mirowsky & Ross, 1989, p. 90). Despite the widespread consensus regarding the benefits of marriage, a number of questions persist about the relationship between marital status and mental health. Although married people have better mental health than unmarried people, little evidence indicates that the social role of being married, rather than the characteristics of individuals who get married, is responsible for this advantage. The relationship between marital status and well-being might exist because healthier people get married, not because marriage makes people healthier. People with better psychological well-being may be more likely to get married in the first place and to remain married. Conversely, poor mental health might be a hindrance to marriage and a precursor of marital dissolution. Without controls for preexisting psychological states, the possibility that people with better psychological health are selected into marriage and the most distressed remain unmarried cannot be ruled out (Mastekaasa, 1992). Yet, most studies of marriage and mental health are crosssectional so they cannot test the possibility of selection effects into varying marital statuses. Not only possible selection effects, but also the failure to separate different unmarried statuses create difficulties in interpreting how marriage affects well-being. Some studies combine different unmarried statuses, such as separated, divorced, and widowed people, with never-married people in comparisons with the married (e.g. Pearlin & Johnson, 1977; Thoits, 1987). Yet the advantage of the married is clearest when compared with separated or divorced people (e.g., Gerstel & Reissman, 1984; Umberson, 1987; Williams, Takeuchi, & Adair, 1992). In contrast, little empirical support exists for the mental health advantages of marriage compared with never marrying, with the exception of psychotic disorders (Eaton, 1980). …

Drug and alcohol problems among individuals with severe mental illness in south London.

Abstract: BACKGROUND High rates of comorbid alcohol and drug disorders have previously been found among individuals with severe mental illnesses such as schizophrenia and bipolar affective disorders. Clinical and social outcomes have been reported to be worse in this group and service costs greater than in individuals with severe mental illness only. These 'dual diagnosis' patients have mainly been investigated in the USA, and there has been very little research in Europe, where patterns of substance abuse may be different. METHOD All patients with psychotic illnesses who had any contact with the mental health services in a geographically defined sector in South London over a specified period were studied. Individuals with problems related to alcohol or drugs were identified using standardised interviews with subjects and their keyworkers. Data on psychiatric service use during the previous 2 years were also obtained. RESULTS One hundred and seventy-one subjects with psychotic illnesses were interviewed (response rate: 78.4%). The one-year prevalence rate for any substance problem was 36.3% (95% CI = 29.1-43.5), for alcohol problems it was 31.6% (95% CI = 24.6-38.5), and for drug problems 15.8% (95% CI = 10.3-21.3). Young male subjects were at higher risk of having substance problems. Patients with substance problems had spent almost twice as many days in hospital as those without such problems over the previous two years (difference = 26.3 days, 95% CI = 3.8-48.7). CONCLUSIONS The prevalence of substance problems among people suffering from severe mental disorders is high, and seems to be associated with greater use of in-patient services. This is a significant clinical problem, with cost implications. Further investigation is needed for adequate service provision.

Quality of life for patients with obsessive-compulsive disorder.

Abstract: Objective: The health-related quality of life ofpatients with obsessive-compulsive disorder was comnpared to published norms for the general U.S. population and for patients with either depressive disorders or diabetes. Method: Sixty medication-free outpatients with moderate to severe obsessive-compulsive disorder were evaluated by using the Structured Clinical Interview for DSM-III-R and the Yale-Brown Obsessive Compulsive Scale. Health-related quality of life was measured with the self-rated Medical Outcomes Study 36-Item Short-Form Health Survey. Results: The instrumental role performance and social functioning of the patients with obsessive-compulsive disorder were worse than those of the general population and of diabetes patiemits. The more severe the obsessive-compulsive disorder, the lower were the patients ‘ social f unctioning scores, even after depression ratings were controlled for; scores on instrumental role performnance did miot correlate with severity ofobsessive-compulsive disorder. The ratings of the obsessive-compulsive disorder patients on physical health domains resembled those of the general population and exceeded those of the diabetes patients. The general health and physical health ratings of the obsessive-comnpulsive disorder patients exceeded those of the depressed patients. in mental health domains, after adjustment for differences in gender distribution, quality of life ratings were similar for the patients with obsessive-compulsive disorder amid those with depressive disorders. Conclusions: Moderate to severe obsessive-compulsive disorder is associated with impaired social functioning and impaired instrumental role performance, but only impairment in social functioning is linearly related to severity of obsessii’e-compulsive disorder. (Am J Psychiatry 1996; 153:783-788)

[Validity and reliability of the Duke-UNC-11 questionnaire of functional social support].

Abstract: Objective The aim of this study is to analyse the validity and reliability of the functional social support questionnaire, Duke-UNC-11. Design Descriptive. Crossover study. Setting Urban health centre. Patients 656 patients were interviewed in their homes. 60 had the questionnaire repeated (30 self-filled and 30 using an interviewer) an average of 6 days later. Measurements and main results The intraclass correlation coefficients of the 11 items in the Duke-UNC-11 were above 0.50, for both self-filled and interviewer questionnaires; the ones on the scale were 0.92 and 0.80, respectively. The factorial analysis separated two sub-scales, confidential support (7 items) and affective support (4 items). Low social support was significantly associated to: being over 40, widowed or divorced, living alone, over-user, worse subjective health, greater chronic morbidity, mental health disorder and family dysfunction. The multiple linear regression equation managed to explain 30% of the variability of social support, in which family function (family APGAR) explained 23.5%, education 3.3%, perception of internal health control 2%, mental health 1.2% and perception of susceptibility to/seriousness of illness 0.3%. Conclusions The questionnaire Duke-UNC-11 is valid and reliable.

Motherhood and mental health

Abstract: 1. The desire for children 2. Pregnancy and mental health 3. A portfolio of postpartum disorders 4. Puerperal psychosis 5. Infant loss 6. The mother-infant relationship 7. Child abuse and neglect 8. Infanticide 9. Drugs, prescribed and abused 10. Postpartum mental illness and the family 11. Services

Adult mental health and social outcomes of adolescent girls with depression and conduct disorder.

Abstract: Follow-up studies of adolescent depression and conduct disorder have pointed to homotypic continuity, but less information exists about outcomes beyond mental disorders and about the extent to which adolescents with different disorders experience different versus similar difficulties during the transition to adulthood. We assessed the continuity of adolescent disorder by following girls in a complete birth cohort who at age 15 were depressed (n = 27), conduct disordered (n = 37), or without a mental health disorder (n = 341) into young adulthood (age 21) to identify their outcomes in three domains: mental health and illegal behavior, human capital, and relationship and family formation. We found homotypic continuity; in general, depressed girls became depressed women and conduct disordered girls developed antisocial personality disorder symptoms by age 21. Conduct disorder exclusively predicted at age 21: antisocial personality disorder, substance dependence, illegal behavior, dependence on multiple welfare sources, early home leaving, multiple cohabitation partners, and physical partner violence. Depression exclusively predicted depression at age 21. Examples of equifinality (where alternate pathways lead to the same outcome) surfaced, as both adolescent disorders predicted at age 21: anxiety disorder, multiple drug use, early school leaving, low school attainment, any cohabitation, pregnancy, and early child bearing.

Psychotic symptoms and disorders and the risk of violent behaviour in the community

Abstract: This study uses data from the Epidemiologic Catchment Area (ECA) surveys to examine the strength of the association between psychotic symptoms and violent behaviour, controlling for underlying mental disorder, substance abuse, sociodemographic characteristics and use of mental health services, in a representative sample of community residents. A replication is conducted of a study that found an increased risk of violence associated with a particular cluster of psychotic symptoms involving perceived threat and internal control-override (TCO). Respondents who reported TCO symptoms were about twice as likely to engage in assaultive behaviour as those with hallucinations or other psychotic symptoms, and about five times as likely as those with no mental disorder. The combination of substance use disorders with TCO symptoms added significantly to the risk of violent behaviour. Those with a history of using mental health services also posed a higher risk of violence, probably due to the differential selection of more severely ill and ‘dangerous’ individuals into treatment settings. Copyright © 1996 Whurr Publishers Ltd.

A continuum of care: More is not always better.

Abstract: This article describes an $80-million project designed to test whether a continuum of mental health and substance abuse services for children and adolescents is more cost-effective than services delivered in the more typical fragmented system. The study showed that an integrated continuum was successfully implemented that had better access, greater continuity of care, more client satisfaction, and treated children in less restrictive environments. However, the cost was higher, and clinical outcomes were no better than those at the comparison site. The article concludes that reform of mental health systems alone is unlikely to affect clinical outcomes. Cooperation is needed between mental health providers and researchers to better understand how to improve services delivered in the community.

National Adolescent and Child Treatment Study (NACTS) Outcomes for Children with Serious Emotional and Behavioral Disturbance

Abstract: The specific purpose of the study was to compile descriptive data on children with serious emotional disturbance (SED), including (a) demographic and family characteristics, (b) level of psychological and adaptive functioning, (c) services received, and (d) outcomes or how the children fared over time. The sample consisted of 812 children, ages 8 to 18 years (M = 13.89 years, SD = 2.35), who had been identified as having SED and were being served by either mental health (46%) or public school (54%) systems in accordance with P.L. 94–142. Data were collected annually during a 7-year period. Results indicated that, at entry into the study, the children already had serious problems in many domains and the problems remained serious for these children at the end of the study.

Focus groups in mental health research: enhancing the validity of user and provider questionnaires.

Abstract: Most mental health researchers rely upon quantitative methods of data collection Whilst such methods are commonly seen as reliable, qualitative methods are often seen as more valid Despite the value of qualitative methods of data collection, however, many researchers denigrate their use Qualitative research is often viewed as lacking in scientific rigour This paper explores the use of the focus group as a qualitative instrument to enhance the validity of existing questionnaires for mental health service users and providers Between July and August 1995 four focus groups were conducted in Exeter and Taunton among service users (with severe or long-term mental health problems) and providers (community psychiatric nurses, social workers and occupational therapists) It is demonstrated that focus groups enhance the validity of existing questionnaires by highlighting those concerns held by users and providers that would otherwise have been neglected

The course, treatment, and outcome of substance disorder in persons with severe mental illness

Abstract: Individuals with co-occurring substance abuse and severe mental illness are particularly vulnerable to negative outcomes. This paper reviews findings on the longitudinal course of dual disorders in traditional treatment systems, which provide separate mental health and substance-abuse programs; describes the movement toward programs that integrate both types of treatment at the clinical level; reviews evidence related to outcomes in integrated treatment programs; and discusses health-care policy changes that would encourage effective treatments.