July 2008: This Month's Highlights

Designs for mental health services research increasingly aim to include both qualitative and quantitative components. Qualitative approaches have helped uncover previously unrecognized factors affecting service use and delivery. However, qualitative researchers often find themselves invited to collaborate in mixed-methods studies almost as an afterthought—long after the study design has been approved and the project is under way. In addition, quantitative researchers who lead such projects often have limited knowledge of qualitative methods. These and other first-hand experiences and frustrations were discussed by a small group of qualitative researchers at a meeting sponsored by the National Institute of Mental Health. A summary of the meeting, which includes recommendations for improving collaborations between quantitative and qualitative researchers, is presented in the lead article in this month's issue. Cynthia S. Robins, Ph.D., and her coauthors describe how the two approaches are based on different notions of what constitutes truth and the conflicts that can arise ( page 727 ). In a related Taking Issue commentary Kim Hopper, Ph.D., notes that "this long-running civil war between methods of inquiry has outlived its utility" ( page 711 ). A study by Emily M. Woltmann, M.S.W., and colleagues successfully blended quantitative and qualitative data to examine the impact of staff turnover on implementation of evidence-based practices ( page 732 ).

The third article in this month's issue illustrates use of purely qualitative methods. Lawrence A. Palinkas, Ph.D., and colleagues undertook an ethnographic approach—participant observation, extended interviews, and grounded-theory analytic methods—to tease out factors involved in the implementation of evidence-based practices for children, which are not widely used despite their demonstrated effectiveness. The study found that frontline workers who had been trained in the practices fell into three groups in terms of their intentions to implement them: application with fidelity, abandonment of the treatments, and selective or partial implementation. Important explanatory factors were the lag time between training and practice, a clinician's level of engagement in the project, and whether the innovative practices fit with the clinician's usual approach ( page 738 ).

Two articles in this issue report studies that sought to improve outcomes of patients with bipolar disorder who were receiving treatment at Department of Veterans Affairs (VA) facilities. Martha Sajatovic, M.D., and colleagues examined factors associated with medication adherence and nonadherence over three years among more than 300 veterans with the disorder. More than three-quarters of the sample were largely adherent to treatment. Nonadherent patients received less intensive psychopharmacologic treatments, had more suicide attempts, and experienced more barriers to care, which highlights the fact that patient factors as well as system factors contribute to nonadherence ( page 753 ). Amy M. Kilbourne, PhD., M.P.H., and coauthors present data from a VA pilot study examining medical and psychiatric outcomes of 58 patients with bipolar disorder who had risk factors for cardiovascular disease. Patients were assigned to two groups: usual care and the bipolar disorder medical care model. Patients in usual care experienced greater declines in health at six months ( page 760 ).

Three studies from Italian research teams highlight that country's focus on improving treatment and systems. In this issue, Paola Bollini, M.D., Dr.P.H., and colleagues report on the efforts of senior clinicians and researchers to develop a set of core quality indicators to assess the appropriateness of schizophrenia treatment. The indicators, which were then tested with a sample of more than 800 patients in the Piedmont region of Italy, helped identify areas for improvement ( page 782 ). Lorenza Magliano, M.D., Ph.D., and co-authors present the results of a multisite survey that explored the views of nearly 250 patients with schizophrenia about their disorder. Survey results were then shared with a large subgroup of patients to elicit their opinions about how the findings could be used to improve care and aid recovery ( page 795 ). In the second appearance of a new column launched in May about mental health care reforms in Europe, Andrea Gaddini, M.D., and colleagues report on a one-day nationwide census of acute psychiatric facilities in Italy. The study sought to determine the point prevalence rate of admissions and to explore differences between public and private facilities ( page 722 ).

The Law & Psychiatry column describes the differing views of circuit courts about whether a "dangerous patient exception" to psychiatrist-patient privilege exists ( page 714 ).