Mental Health Outcome Measures
The book's editors, Professors Graham Thornicroft from London and Michele Tansella from Verona, are active practitioners in the field of evaluation of community-based programs for seriously mentally ill people. In their introduction, they point out the serious limitations of using the narrow assessments of symptoms and service use as outcome measures in evaluations of the shift from institutional to community care.
This collection of articles is intended to support evaluations that widen the range of outcome assessment. The readership of this timely volume of papers is evaluators, and they have been given a banquet of useful information to enrich their research. It is not likely to be useful for clinicians faced with demands for outcome data from their clinical practice, and some readers may be disappointed that the editors do not quite live up to their promise to "assess the psychometric adequacy of commonly used measures . . . and to propose how they should be further developed." Nevertheless, this volume has much to recommend it.
Take, for example, the chapter on "Mental Health Care Costs: Paucity of Measurement," by McCrone and Weich, which succinctly presents the case for including costs as part of an evaluation, hits all the conceptual and methodological issues square on the head, and then summarizes the component findings (in tabular form as well as text) of some 49 studies of community care that included an economic evaluation. Another example is the chapter by Ruggeri on satisfaction measures. It offers a fine discussion of why consumers' views have not been regarded as making a "relevant contribution to service evaluation" and argues that they are a necessary but not sufficient component in outcome studies. The author also summarizes the findings from 16 studies of satisfaction.
The book offers chapters on categories of outcome measures, such as satisfaction with services, quality of life, and family burden; chapters on study design and statistical methods; chapters on conceptual issues such as how to define social disabilities or quality of care so that they can be measured; and a fine closing chapter by Rachel Jenkins, principal medical officer of the U.K. Department of Health, who briefly summarizes the importance of doing this work and how it can inform policy decisions about government spending priorities. Most chapters have extensive references.
The European and British slant on outcome measures is apparent (and understandable), and many instruments well known to Americans are not included. On the other hand, the instrument-development work done by the World Health Organization as part of its multisite collaborative studies of schizophrenia is covered in three separate chapters. Although the measures are not reproduced, all the instruments developed through WHO are described, and there is a very interesting segment on the steps that must be taken in the development of equivalent versions of instruments in different languages. Given the purpose for which these instruments were developed, it is not surprising that they are fairly lengthy and that mental health professionals require training to use them. As a consequence, most of the WHO instruments described are not easy to use nor inexpensive to administer.
I can quibble a little with the overall organization of the chapters and the number of typos. However,Mental Health Outcome Measures should be in the library of mental health services researchers interested in outcome measurement. It does not provide a chapter on every issue nor a complete discussion of all the issues that are raised, but the central theme of expanding the horizon of expected outcomes when studying community care is consistently and thoughtfully addressed.
Dr. Dickey is associate professor in the department of psychiatry at Harvard Medical School and director of mental health services research at McLean Hospital in Belmont, Massachusetts.
