Two approaches to improving mental health care: positivist/quantitative versus skill-based/qualitative.

The quality improvement model currently used in medicine and mental health was adopted from industry, where it developed out of early 20th-century efforts to apply a positivist/quantitative agenda to improving manufacturing. This article questions the application of this model to mental health care. It argues that (1) developing "operational definitions" for something as value-laden as "quality" risks conflating two realms, what we measure with what we value; (2) when measurements that are tied to individuals are aggregated to establish benchmarks and goals, unwarranted mathematical assumptions are made; (3) choosing clinical outcomes is problematic; (4) there is little relationship between process measures and clinical outcomes; and (5) since changes in quality indices do not relate to improved clinical care, management's reliance on such indices provides an illusory sense of control.

Clinical expertise and the limits of explicit knowledge.

This article questions the view that medical decision-making can be reduced to a series of explicit rules, adherence to which will necessarily improve outcomes. Instead, it attempts to rehabilitate the concepts of clinical expertise and clinical experience, arguing that medicine, like other areas of expertise, depends on forms of implicit knowledge that can only be acquired through years of experience. Recent research on "fast and frugal" heuristics in medical decision-making suggest that statistical techniques are not necessarily superior to clinician judgment.

Quantifying the contribution of VA service-connected disability pensions to the "check effect".

Objective: The study attempted to quantify the effect of receiving a disability pension check at the beginning of the month on the timing of substance-related hospitalizations in Department of Veterans Affairs (VA) facilities.

Methods: All substance-related hospitalizations during fiscal year 2005 were identified in the VA National Psychosis Registry (13,402 hospitalizations among 8,813 individuals) and in a random sample of VA patients without serious mental illness (689 hospitalizations among 508 individuals). Multivariable logistic regression examined the impact of pension check receipt on timing of hospitalizations while controlling for other predictors of substance-related hospitalizations.

Depression screening as a quality indicator.

Objective Although practice guidelines for depression screening are evidence based, with their development relying on reviews of controlled studies, their adaptation and use as quality indicators have not been subject to rigorous study. This paper will therefore review the evidence supporting this practice.Methods A rational evaluation was carried out on both controlled studies and other sources of evidence related to the technical, clinical and policy assumptions underlying the use of depression screening guidelines as quality indicators.

Demand characteristics and quality improvement: who is fooling whom?

Since some of the data used for quality assurance purposes (i.e. rating scales) requires the active participation of clinicians, administrators use various mandates or incentives to insure its collection.

The electronic medical record: optimizing human not computer capabilities.

The widespread adoption of computerized medical records provides medical administrators and payers the means to promote more standardized and thorough medical records by insuring clinicians complete mandatory screens, history and physical templates, and formatted treatment plans. But there is a dearth of evidence that such measures, whether computerized or not, improve clinical outcomes and reason to suspect that they may impede care. While these measures maximize the computer's capabilities they are insensitive to human capabilities.

Glaucoma screening of patients with and without dementia.

Glaucoma's damage to peripheral vision compromises mobility to a greater extent than ocular pathology limiting central vision. Half of glaucoma is undiagnosed, as the majority of primary care physicians do not screen for glaucoma. Glaucoma is more prevalent in older adults with dementia than without dementia.

Improving care, improving performance, or just improving numbers?

This Open Forum reviews the literature on computerized systems that purport to either assess or improve clinical care in mental health. There is little empirical support for these claims. These limitations are in keeping with the author's own experience in developing and using such systems.

The impact of immigration on psychiatric hospitalization in Illinois from 1993 to 2003.

Objective: Illinois public hospitalizations over a ten-year period were studied to determine the impact of recent immigration. The study also explored clinical and demographic differences between immigrant groups and native-born Americans.

Methods: Information was collected from the state hospital Clinical Information System for 1993, 1998, and 2003.

Lawyers' attitudes toward involuntary treatment.

This study examined whether lawyers' attributions of responsibility for mental illnesses affect their decisions about involuntary treatment. A survey that was mailed in 2003 to Illinois lawyers involved in involuntary commitment elicited recommendations for involuntary treatment for characters presented in vignettes. The survey also sought respondents' attributions of personal responsibility for the onset and recurrence of mental illnesses.

Computerized performance monitoring systems: learning and living with its limitations.

Computer technology now allows clinical administrators to collect and analyze large data sets for performance monitoring. Despite the obvious usefulness of this technology, there are limitations. The indices that we can measure are at best proxies that might correlate with good clinical care but can also become dissociated from it in a variety of ways.

Cost-effectiveness of atypical antipsychotic medications versus conventional medication.

For almost 50 years, typical antipsychotics were the mainstay of pharmacological treatment for schizophrenia. However, during the last decade, the widespread use of expensive atypical antipsychotic medications has led to a dramatic increase in the proportion of the direct costs of schizophrenia being allocated for medications. Although there is evidence that the atypical antipsychotic clozapine may lead to cost savings in patients with refractory schizophrenia, the cost-effectiveness of the other atypical antipsychotics remains in question.