Carole Siegel, PhD, Director

From the Director

Since our last newsletter, dramatic changes have occurred in the staffing, organizational structure, and priorities of the Office of Mental Health. These changes in turn have affected the organization and focus of our Center and will strongly affect the answers to a number of questions currently being addressed by the Executive Committee. Key among them is: How should the structure of the Center be adapted to allow mental health policy issues on both the state and local levels to be its focus? On both the national and state levels, planning and implementation of behavioral health managed care arrangements are rapidly taking place. In response, the Center has added to its research portfolio several projects addressing managed care concerns. These include the development of a taxonomy to describe the many different scenarios that are emerging and an evaluation of the State's Prepaid Mental Health Care plan as de-signed and implemented by a large State psychiatric center.

Since assuming leadership of the Center last fall, I have met with investigators to learn first hand the progress on projects. I have been impressed by the quality of the work and commitment of the researchers to the goals of our Center.

The National Advisory Board meeting held in May focused in part on strategies to ensure the continuity of the Center as it begins its fourth year of funding. I look forward to continuing this conversation with project investigators and other individuals contributing to the Center's ongoing development. Related to the theme of change, I am pleased to announce the appointment of our new Assistant Director, Dixianne Penney, DrPH. In her role as Assistant Director of the Center, Dr. Penney will draw on her diverse experience in mental health services to coordinate and manage the daily operations of the Center, to facilitate communication among key stakeholders, to assist in the development and conduct of research and to create, implement and evaluate dissemination strategies.

National Advisory Board meets

The Center's efforts to be responsive to a rapidly changing environment in which mental health services are being delivered was of primary concern at the May meeting of the National Advisory Board and Executive Committee.

A major task was to reconsider the Center’s mission -- to develop a research program motivated by the informational and inquiry needs of a state mental health authority -- in light of recent changes at the local, state, and federal levels.

The Executive Committee and National Advisory Board examined recent political changes in New York State, reviewed the Center's portfolio of research, learned about the process moving New York State toward a managed care environment, explored societal issues affecting the service system and heard details of reforms yet to be enacted, such as an integrated delivery system that would unite all funding streams and distribute funds in the form of block grants to the counties.

The Board and Executive Committee then discussed a number of issues related to change:

• The role of research in a dynamic services environment and how research can be responsive to the needs of policymakers. Noted were efforts by the Center to explore the possibilities of "real time" research and to investigate techniques to reduce time requirements.
• The Center's research role nationally and the importance of remaining in the public mental health arena, despite its instability, to help define the research questions.
• The need to have investigations that cross service systems to address critical issues such as the migration of recipients from one system to another and cost shifting by provider agencies.
• The relationship of the New York State Legislature and of other state officials to the Center, which by necessity have been limited to presentations of factual material rather than political advocacy. It was recommended that continued informative contacts continue.
• Research opportunities presented by the implementation of managed care initiatives. Areas identified included benefit packages, provisions of services to individuals who are poor, accountability, capitation and other funding strategies, and risk management.
• A focus on recipient-oriented research. The Center's effort at mounting collaborative research with recipients was endorsed. Emphasis was placed on continuing to expand the ways in which recipients can add their voice to policy debates.
• The importance of disseminating research results and products widely and broadly. The Board endorsed efforts under way to inform not only the mental health community but also related disciplines.

Assistant Director appointed

As the Center's new Assistant Director, Dr. Dixianne Penney has quickly assumed responsibility for the Center’s day-to-day operations. As Assistant Director, Dr. Penney not only manages the daily operations, but also fosters collaborative working relationships among key constituencies, assists in the ongoing development of the research agenda, and creates public information strategies to disseminate research findings and tools.

"We're delighted that Dr. Penney has joined us and we look forward to working with her," said Dr. Carole Siegel, Center Director. "Dr. Penney brings a unique blend of public mental health experience and knowledge to the position that will permit her to make significant contributions to the Center's ongoing development."

Prior to joining the Center, Dr. Penney served as Director of Public Information for the Westchester Developmental Disabilities Services Office. Previously, she was the Assistant Regional Director of Adult Operations for the New York City Regional Office of the Office of Mental Health and Director of Community Education and Information for the Harlem Valley Psychiatric Center.

A member of the Statewide Advisory Board to the Senate Mental Hygiene Committee in New York State from 1986-92, Dr. Penney is currently a founding member of the Board of Directors of the Treatment and Research Advancements Association for Personality Disorders (TARA) and a member of the Board of Directors of "A HOME," a nonprofit agency providing long-term housing for disadvantaged individuals.

Dr. Penney received her doctoral degree in public health from the Columbia University School of Public Health, Division of Health Policy and Management.

Dr. Videka-Sherman named Fulbright Fellow

Executive Committee member Lynn Videka-Sherman, PhD, Dean of the School of Social Welfare at the Nelson A. Rockefeller College of Public Affairs and Policy at the University at Albany, is spending the fall 1996 semester as a Fulbright Fellow in Bulgaria, where her research will focus on child maltreatment and mental health. During Dr. Videka-Sherman’s absence, Dr. Jeryl Mum-power, Department of Public Administration at Rockefeller College, will be serving as the College’s Executive Committee representative.

Center receives funding to develop Mental Health Indices

The New York City Department of Mental Health, Mental Retardation and Alcoholism Services recently awarded a $25,000 contract to the Center for the development and testing of two Community Mental Health Indices for New York City. The first index is aimed at characterizing the social and mental well-being of the community, while the second is being designed to measure the extent and severity of mental illness, the response of the mental health system, and the outcomes for persons with mental illness.

According to Principal Investigator Carole Siegel, PhD, the indices are intended as tools for broadly monitoring:

• Social and economic factors relating to community mental well-being and mental illness
• Need as measured by the magnitude of vulnerable/problem populations and the size of the population of individuals with mental illness
• Availability and utilization of support systems
• Social and mental well-being of the community
• Outcomes of individuals with mental illness

Both indices are being based on a model of influence that relates (1) need to economic and social factors, (2) support systems to need, and (3) outcome measures to support systems. Each index is composed of several indicators that measure factors within the domains of the model. Criteria for selection of the indicators have been specified and a consensus process involving various stakeholders of the mental health system in New York City will be used in weighting indicators to form each index. Development of both indices is expected to be completed this December.

New Faculty join Center

Recent appointments to the Center faculty include Julian Chun-Chung Chow, PhD, Diane M. Dewar, PhD, and Robert Brent, PhD.

Dr. Chow, an Assistant Professor in the School of Social Welfare at the Rockefeller College of Public Affairs and Policy, is a member of the Special Populations Core. His research interests include identifying ways in which service delivery could be more culturally relevant and responsive to the needs of the ethnic/minority community. He is a former National Institute of Mental Health National Research Service Award recipient through the Council on Social Work Education's Minority Fellowship Program.

An Assistant Professor in the Department of Health Policy and Management at the University of Albany, Dr. Dewar is a member of the System Initiatives and Methodology Cores. She teaches health economics and health policy and conducts health care expenditure and cost research. Among her recent projects has been the identification of risk adjusters for capitation rates for special needs populations in managed care plans. Currently, she is involved in a cost analysis of mental health service utilization in New York.

Dr. Brent, a research scientist and economist with the Epidemiology and Health Services Research Laboratory at The Nathan Kline Institute and Professor in the Department of Economics, Fordham University, is a member of the Methodology Core. He is an economist whose fields of interest include health, public economics, and development. In 1992 he served as a fellow and visiting professor of economics at the National Institute of Public Finance and Policy in New Delhi, India.

Faculty interest groups established

In an effort to encourage new research collaborations and involve faculty more actively in Center-sponsored activities, the Executive Committee conducted an interests' survey in January. Information generated from the survey has already been used to identify and recruit faculty members to participate in a multicultural agenda-building initiative sponsored by the Center.

Survey responses were received from 64% of faculty and Executive Committee members. While the range of responses varied, the primary interests of the faculty included:

• Disorders: Schizophrenia, mental illness and chemical abuse, and major affective disorders
• Populations: Adults in the community, families, home-less individuals, and individuals from minority groups
• Topics: Coercion, cost-effectiveness of care, reimbursement, service system effectiveness, work, and quality of care

The survey results are continuing to be used to nurture the common interests of faculty and to encourage multidisciplinary collaborations. Additionally, common interest groups are expected to facilitate the development of new research proposals stemming from projects currently being conducted.

Executive Committee transitions

New appointments to the Executive Committee of the Center include John Hornik, PhD, Director of the Bureau of Planning, Assistance and Coordination, New York State Office of Mental Health; Thomas Craig, MD, Clinical Manager for the Veterans Integrated Service Network (VISN) #3 of the Department of Veterans Affairs; Mary Jane Alexander, PhD, Research Scientist, Epidemiology and Health Services Research Laboratory, The Nathan S. Kline Institute for Psychiatric Research; and Rene Grosser, PhD, Director of the Bureau of Evaluation and Services Research, Office of Mental Health.

Dr. Hornik, who is serving as Co-Director of the Methodology Core, has a diverse background in mental health services research primarily in the areas of severe mental illness, alcohol abuse, social rehabilitation services, and advocacy and legal services. Prior to joining the Office of Mental Health in 1986, he served as Director of Evaluation and Client Tracking for the Massachusetts Department of Mental Health.

Dr. Craig is a Clinical Psychiatrist and Professor of Psychiatry at the University at Stony Brook, State University of New York. He previously served as Clinical Deputy Director of the Rockland Psychiatric Center and most recently as Medical Director of Alcohol and Substance Abuse at the Northport Veterans Administration Center. Dr. Craig has an extensive background in psychiatric epidemiology and in health services research.

Dr. Alexander is serving as Co-Director of the Special Populations Core, where she is currently conducting two studies on mental illness and chemical abuse. She is a recent recipient of an NIMH grant award to study dual diagnosis and service use among women in treatment.

In his role as Director of the Bureau of Evaluation and Services Research, Dr. Grosser is responsible for evaluative research activities designed to inform policy on issues of access to, outcomes of, and costs of mental health services. He formerly served as Director of the Needs Assessment Unit at the Office of Mental Health. Dr. Grosser is the Co-Director of the System Initiatives Core of the Center.

Resigning from the Executive Committee over the last year have been David Wollner, MPA, who joined the New York State Department of Health last fall as a legislative liaison, and Dr. Russell Massaro, who retired as Director of Managed Care Services for OMH. Dr. Mary E. Evans resigned her position as Interim Director of the Bureau of Evaluation and Services Research in June 1996. While Dr. Evans will no longer co-direct the System Initiatives Core, she will remain a member of the Executive Committee.

Researchers from Center collaborating on involuntary outpatient commitment study

Center faculty members Kim Hopper, PhD, David Shern, PhD, and Jeanne Dumont, PhD, are collaborating with researchers from Policy Research Associates of Delmar, New York, and Duke University to evaluate a pilot program on involuntary outpatient commitment under way at Bellevue Hospital in New York City.

Under a 1994 enabling law, the Involuntary Outpatient Commitment Pilot Treatment program targets persons who have had two involuntary admissions in the last 18 months and are judged clinically to be incapable of surviving safely in the community without supervision.

Both implementation and outcome are being addressed in the pilot program evaluation. A research team of two full- time ethnographers is now in place. Data are being gathered on the referral and decision-making process, the deliberations of the court, and the reception accorded the program by both clinical staff and participating agencies. Subjects are being enrolled in the outcome study; up to 160 patients screened for program eligibility are being randomly assigned to either a court hearing for outpatient commitment or a comparable services group. Outcome data will be collected at one, five, and eleven months after discharge. Follow-up assessment will focus on structured data pertaining to clinical status, quality of life, social networks and support, and experiences of perceived coercion; rehospitalizations and rearrests will also be charted. Using traditional ethnographic methods, the research team will follow up to 18 subjects, enabling the team to construct a more detailed account of the subjects' experiences in the program.

A six-member recipient and family advisory panel will meet periodically and review all aspects of the research. In December of 1997, a report is due to the New York City Department of Mental Health, which in turn is mandated to report to the New York State Legislature early in its 1998 legislative session.

Nationwide Managed Care Research Survey under way

Judith Samuels, MBA, a member of the Center faculty, has teamed up with Howard Goldman, MD, PhD, Research Director, and Abdi Hirad, BS, Research Assistant, of the National Association of State Mental Health Program Directors Research Institute, to conduct a survey on the quantity, types, and focus of mental/behavioral health managed care research occurring nationally.

In addition to formulating a complete picture of mental/ behavioral health managed care research under way around the nation, the survey aims to identify gaps in research, to develop a database of current research projects as a resource for key stakeholders in state mental health systems, and to clarify variations in state plans and their impact.

Additionally, the study will include an extensive published literature review of research covering the full range of managed care related topics as outlined in the survey tool. Upon completion of data collection and analysis, a summary of research findings will be provided to all survey participants.

Surveys have been distributed to a comprehensive list of mental health services researchers. If you did not receive a copy and wish to participate, please contact Ms. Samuels at (914) 365-2000 (e-mail at: samuels@iris.rfmh.org) or Mr. Hirad at (703) 739-9333, Ext. 25 (e-mail at abdi.hirad@ nasmhpd.org). The survey is available electronically via the World Wide Web at the following address: http://www.rfmh.org/csipmh/mcsurvey.htm.

Services research seminars held

Services research seminars sponsored by the Center and The Nathan S. Kline Institute for Psychiatric Research over the past few months have been the following:

• Process Issues for Mental Health Services Research: Inside the Black Box, by Gregory B. Teague, PhD, Research Assistant Professor of Psychiatry and of Community and Family Medicine, Dartmouth Medical School. Dr. Teague’s talk focused on the fidelity of program implementation and its importance in evaluating the effectiveness of a clinical program model. He described application of an implementation evaluation to a model adapted for individuals who abuse substances.
• Preliminary Findings on Two-Year Course Post First Admission for Treatment of Psychoses, by Evelyn Bromet, PhD, Professor of Psychiatry, Department of Psychiatry, University at Stony Brook, State University of New York. In her talk, Dr. Bromet highlighted the instability of diagnosis made early in an initial treatment episode and the implications for service delivery.
• Analysis of Longitudinal Binary Data with Informative Dropout, by Christine Waternaux, PhD, Director, Biostatistics Division, New York State Psychiatric Institute. Dr. Waternaux presented a statistical model that allowed the comparison of two groups with respect to neurologic impairment over 10 visits. The binary outcome -- impaired, unimpaired -- was modeled over time by a logistic function. Four models of dropout were then considered, including one in which the dropout mechanism depends on unobserved factors. Results of the analysis based on the different models were compared.
• Cost Saving and Shifting in the Cost-Benefit Analysis of Deinstitutionalization in Mental Health, by Robert J. Brent, PhD, Professor, Department of Economics, Ford-ham University, and Research Scientist/Economist, The Nathan S. Kline Institute. The implications of deinstitutionalization were addressed by Dr. Brent in terms of the marginal cost of public funds (MCF). The MCF helps to gauge distortions created by different tax bases. Since each state and the federal government use different tax mixes, estimated MCFs allow each state government to examine tax distortions that would be created by hospital populations into the community.
• Managing Scarce Community Mental Health Resources, by Fred Osher, MD, Associate Professor and Director of Community Psychiatry, University of Maryland School of Medicine. Addressing the question, "How come systems don't always implement services that have a proven effectiveness?" Dr. Osher focused his presentation on a model of care for individuals receiving mental health services in Baltimore. Underlying the development of the model were the beliefs that the public sector must implement strategies proven by research and that movement must be made from efficiency to effectiveness.

The seminars are designed to promote the exchange of knowledge and foster active collaborations among mental health services researchers, recipients, policy makers, and practitioners affiliated with the Center.

New projects added to research portfolio

Three faculty members recently initiated two projects expanding the Center portfolio in the areas of dual diagnosis and childhood sexual abuse.

A study being conducted by Barry Loneck, PhD, Assistant Professor, School of Social Welfare, University at Albany, is developing and testing the effectiveness of a modified version of the Johnson Intervention for clients with dual diagnosis. A specialized therapeutic technique, the Johnson Intervention has proven valuable in the field of substance abuse. With this technique, members from the person's social network (e.g., family members, friends), following a period of formal training and rehearsal, confront the person about the damage the drinking or drug use has caused and the action to be taken if help is rejected.

Engagement and retention of clients with dual diagnoses of mental illness and substance abuse is particularly problematic because these individuals often deny their alcohol/ other drug problems and the need for help. The problem is compounded by an increased consideration of legal coercion. Thus, this modified intervention is seen as an alter-native to waiting for voluntary participation on the part of the client, on the one hand, and legal coercion, on the other.

As a first step in preparing to evaluate a standardized psycho-educational intervention for sexual abuse versus treatment and support group approaches, Kristina Muenzenmaier, MD, a psychiatrist with the Creedmoor Psychiatric Center, and Jeanne Dumont, PhD, Director of the Crisis Hostel Project in Ithaca, are focusing on developing domains for use in creating outcome measures. Concept mapping is being used to create valid standardized measures to assess stress and coping from the perspective of the survivor. Underlying their research effort is the belief that a reduction in symptomatology and a greater chance for recovery occurs when past traumatic experiences and the stigma associated with the abuse are addressed.

Multicultural research agenda building in progress

The Mental Health Empowerment Project, the Multicultural Education, Research and Training Institute at Ford-ham University, and the Center are actively working together to generate a research agenda relevant to mental health and to Native American, African American, Hispanic and Asian recipient issues. The effort is being headed by Dr. Ed Knight, Director of the Mental Health Empowerment Project and member of the Executive Committee of the Center.

The collaboration, which is focused on expanding the role of recovery in communities of color, has involved the active participation of recipients of color in a series of dialogues at four sites around the state. The dialogues, which were held in February, examined (1) what is disempowering about being diagnosed and being a recipient of color or a Native American, (2) what needs to happen to increase access to the mental health system and to empower individuals served by it, and (3) what issues and concerns need to be the focus of research over the next few years.

Following the dialogues, participants gathered together for a two-day conference with researchers and faculty from the Center to review the information gathered and to define broad questions appropriate for further research. Seven areas associated with disempowerment were identified: loss of self and cultural identity, lack of choice, stigmatization, lack of education about mental illness and recovery, cultural insensitivity, economic disadvantage, and language barriers. Likely research directions were then explored and discussed.

A full report of the conference proceedings is being pre-pared and a subcommittee of the Executive Committee, chaired by Kim Hopper, PhD, is acting upon the recommendations generated.

Center opens World Wide Web site

Following the introduction last fall of the Internet discussion group MHPOLICY Forum, the Center has added a World Web site (WWW) to its dissemination strategy. Accessed at http://www.rfmh.org/csipmh, the WWW site offers visitors a complete and up-to-date overview of the mission, structure, and research portfolio of the Center.

Research projects are highlighted and are easily accessed via a thematically arranged index. Visitors can quickly learn about Center initiatives in areas such as recovery and managed care by clicking on highlighted text that is linked to the appropriate descriptions.

Through the Web site, visitors may join MHPOLICY Forum, the electronic discussion group aimed at fostering dialogue among policymakers, researchers, practitioners, and recipients of mental health services.

The developer of the Center's WWW site is Chip J. Felton, MSW.

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Update Sept. 1995

Update April 1997

Last updated on November 8, 1996, by Elizabeth Pease