People are different whether well or ill. They belong to different cultures, have different personalities, physical constitutions and personal histories, all of which makes them perceive their diseases in a specific manner. Recently, planning and evaluation services have regained strength under the pressure of economic factors and the population's insistence that they receive more care of better quality. There is also confusion about who is responsible for the implementation of some interventions. Care for the sick members of a society is an ethical imperative, even if significant amounts of money are spent and not recouped. The task of the health care specialist is to provide the best possible treatment or support for those members of society who are not well: the political structure of the country has to decide on the total amount of money that will be spent on health.

Governments around the world are struggling to find ways to improve the health status of their populations. The general population, health professionals and consumer groups all routinely demand new or better health services. Most western countries can point to their form of national health insurance as a safety net. Many of these are reasonably accessible to people with mental illness; even those that are not are slowly moving in that direction. To reduce the pressure for increased funding, governments and other third-party payers try to squeeze more out of the existing funding by increasing the efficiency and effectiveness of services. A clinician's decision to undertake one particular type or occasion of service is also a decision not to undertake another. Rational decision-making about which services should be provided is needed, especially in regard to people whose need will be unmet.

The unmet need on mental health services appears considerable and the discontent among consumers and carers is palpable. The 1990 National Comorbidity Survey (NCS) used a changed Composite International Diagnostic Interview (CIDI) for DSM-IIIR, modified with initial probes and commitment procedures, to identify a range of mental disorders in people aged 15-54. The 1990 Canadian survey used the same methodology as the NCS study. The UK Household survey used a checklist to identify a similar range of disorders to the ECA studies among people aged 16-65. The Australian Survey of Mental Health and Well-Being was a household survey of 10,600 adults aged 18 to 90 that attained an 80% response rate. The World Bank Burden of Disease project has issued a final report which may be of value in informing criteria that are independent of clinician whim and patient pressure, and criteria that will maximize the overall health gains.

This chapter provides a developmental perspective on how the US mental health community has responded to periodic requests to define and quantify the need for mental health services in both public and private insurance sectors. It focuses on a model of epidemiological data that will improve the ability to plan for mental health services. The chapter talks about a research enterprise that is attuned to health policy service delivery innovations, service and economic research parameters, and treatment technologies involving both efficacy and effectiveness outcome measurement. Although most managed care systems have been in the private sector, public sector contracts for Medicaid and Medicare mental health services are growing. To be most effective, the role of epidemiology must be inclusive enough to inform us about the unmet need for treatment in the community. Thus, epidemiology may serve as an integrating discipline for basic science, clinical medicine, public health and health policy.

It is much easier to make an exact calculation of the direct treatment costs of intervention than the often hidden indirect costs of nonintervention. This chapter reviews cost-effectiveness studies that explicitly compare benefits in relation to costs and risks in other areas of medicine. It examines a number of research initiatives currently underway to study the indirect costs of psychiatric disorders and the extent to which these costs can be reversed with intervention. The chapter recommends that mechanisms to assure the quality of interventions have to be developed as part of cost-effectiveness studies if we hope to persuade policy makers to increase the allocation of health care resources to psychiatric disorders. It argues that while process assessments have to play a prominent role in any plan for the quality assurance of psychiatric interventions, special features of psychiatric disorders make them especially appropriate for outcomes assessment.

The relationship between the provision of health care and the needs of its consumers can be examined by looking at the three areas of demand, utilization, and need. Until recently, epidemiological studies in psychiatry produced two sorts of data relevant to these issues: the prevalence of various mental disorders and the extent to which people utilize services. The combination of prevalence and utilization data does at least give a feel for the extent to which treatment needs go unmet. This chapter presents data from the British National Survey of Psychiatric Morbidity. It evaluates more specifically the extent to which needs for psychiatric treatment are being met in the general population. The chapter focuses on depressive and anxiety disorders, since these were the commonest groups. Finally, it presents the needs status in relation to all the care episodes rated for depression and anxiety.

This chapter presents data on past-year mental health service use, and discusses the practical and methodological issues to be considered when developing a core set of questions about people's use of psychiatric services for use in psychiatric epidemiological surveys. It presents preliminary data on mental health service use from the first four countries that have contributed data on this topic to the International Consortium of Psychiatric Epidemiology (ICPE) master data bank. The chapter also illustrates the use of the multiple data sources by comparing use of any services for mental health problems in the 12 months prior to the survey. It is important to examine the utilization rates for mental health services across countries, adjusting for the presence of disorders. The cross-national comparisons offer over a reasonable basis to generate hypotheses about what accounts for similarities and differences in the rates of mental health service use between countries.

This chapter focuses on economic perspectives, and tries to demonstrate how researchers from different disciplines can work together to assist decision makers to formulate mental health policy. Defining the need for treatment is the first requirement, which can be objectively addressed with epidemiological and utilization data on a population-wide basis. From the economic point of view, the purpose of treating mental disorders is to reduce the economic burden of illness on the individual, the family, the community, and on society as a whole. The economic literature has developed three basic methodologies which are used to evaluate the effectiveness of various treatment modalities. These methodologies include: cost-benefit analysis; cost-effectiveness analysis; and cost-utility analysis. Cost comparisons and cost-effectiveness studies in relation to location of care have been undertaken, but more rigorous and complete ones are still required. Cost-benefit, cost-effectiveness, and cost-utility analyses are crucial to decisions about resource allocation in medical care.

Preventive as compared to treatment interventions should be considered in terms of the evidence of their effectiveness in achieving relevant outcomes. Preventive interventions can be focused on those symptoms or syndromes that start in childhood and persist into adulthood. There are significant numbers of randomized controlled trials providing evidence for the effectiveness of prevention and the need for a prevention approach for a group of conditions. It must be emphasized that generic interventions that modify parental discord and enhance parenting skills probably decrease vulnerability to depression, as do interventions that prevent abuse. Curriculum-based programs and more specific programs for early intervention and prevention of depression and related disorders can be used in school. Thus, the unmet need for prevention, as compared to treatment, interventions is established. Effective prevention should, in turn, lessen the burden of mental disorders in adults.

This chapter discusses the attempt to develop evidence-based systems for defining, guiding, and monitoring aspects of psychiatric care in the USA. It provides some of the limitations in these approaches and some recommendations about how to deal with the role of a practice-based research network. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) introduction is clear in defining mental disorders as a grouping of symptoms plus either clinically significant distress or impairment in major role functioning. The financial, organizational, and procedural elements affect the flow and characteristics of patients through the system, and ultimately the selection and utilization of treatments for those patients. This process determines the outcome for both the individual and for the population under care. The chapter also explores how to determine the proper mix of these elements to meet the appropriate needs of a population and to achieve better outcomes for individuals.

This chapter analyses the unmet needs for management of mental disorders in primary care. It focuses on the importance of primary care for mental health care; the definition of need; the current state of mental disorders in primary care; and implications for research and training. Three main parameters are utilized in the definition of need: clients, providers and services. Current studies show that the global burden of mental disorders is considerable and should be a priority. Primary care providers are more likely to recognize and treat if their patient has a moderate or severe disability, that is when the mental disorder impairs social functioning, reduces efficiency, motivation and work productivity. In a WHO study it was found that the patients who became well were those who were recognized by their primary care physician as ill, given appropriate treatment, and who complied with the treatment.

This chapter assesses how much the large and increasing industry of complementary medicine is meeting needs that could or should be met by orthodox medical services. It focuses on a few selected complementary treatments, chosen to illustrate why so many orthodox doctors find it difficult to take this whole subject seriously, particularly if they are interested in medical research. There is one beneficial effect common to many complementary treatments that need to be mentioned first, since there is not likely to be disagreement about it, namely the generally good effect of a session of deep relaxation. This is part of many complementary treatments, and in some it is accompanied by massage and pleasant aromas. The discussion here is referring to people with various forms of less severe depression, dysthymia, and anxiety states. Also included are those with somatic symptoms who may well not qualify for a diagnosis.

Increasing importance is being attached to the needs of those who suffer from schizophrenia. This chapter examines the two levels of need: individual and service. It describes three methods of assessing individual patient's needs (the needs for care assessment, the Camberwell assessment of need, and the cardinal needs schedule), and discusses a study in South London which has used this approach to assess unmet individual needs. The chapter then turns to service-level (or population) needs, and describes four methods appropriate to this level. It offers an example to highlight this method of needs assessment which draws upon a recent detailed review of the needs for mental health services throughout London. An improved understanding of the relationships between sociodemographic factors and service utilization has allowed quantitative indices of need based on the demographic attributes of areas to be developed over the past five years.

In schizophrenia, the first contact with mental health services is frequently preceded by a lengthy, mostly untreated prephase. The few studies assessing the duration of the early period of illness from the first sign of the disorder until the first contact with mental health services give estimates ranging from two to almost nine years. This chapter focuses on when and with what symptoms does schizophrenia start, and explores how the disorder develops before the first episode. It analyses when and how does schizophrenia lead to social consequences and what are the implications for early intervention. The early course of schizophrenia, from the first prodromal sign until the climax of the first psychotic episode, seems to be a decisive period in the total course of the illness. Early detection and early intervention are therefore necessary and meaningful.

Major depression is a common illness with a significant morbidity. The focus for health care has been widened to include definitions and determinants of outcomes and the cost-effectiveness of defined interventions. This chapter outlines the issues and areas of concern from the perspective of five groups of 'stakeholders': clinicians in primary care; clinicians in secondary and tertiary care; depressed individuals and their families; the general community; and the fundholders. Primary care is affected by a number of problems to do with treatment and awareness of depression. There are many different groups concerned with mental health, all of whom have their own particular perspectives of depression. This may lead to conflicts of interest and need. The working definition of unmet need can be defined in the context of areas of dysfunction for which there are potential remedies or interventions, and the chapter proposes four areas to tackle unmet need.

Suicidal behavior is a significant medical, public health and mental health problem in New Zealand, just as it is in many countries. Those who have made suicide attempts are at high risk of making further nonfatal suicide attempts and of suicide. This chapter presents reports of a longitudinal study of 302 individuals who had made medically serious suicide attempts and who were then followed-up for a period of 30 months subsequent to these attempts. It documents the history of this cohort in the following areas of functioning: rates of mortality, suicide and nonfatal suicide attempt; history of psychiatric morbidity; and rates of a series of selected measures of psychosocial functioning including relationship problems, social welfare benefit receipt, criminality and imprisonment. The outcome following serious suicide attempts is often considerably bleak, and is characterized by long-term and severe psychosocial problems and by lives which begin to reflect deprivation of care.

Improved diagnostic techniques have led to better identification of the risk factors for first developing anxiety disorders, secondary psychosocial disability, and psychopathological complications. This chapter reports the preliminary findings of the baseline investigation of a random population sample of 3021 people, aged 14-24, and conducted in the greater Munich area, Germany, in 1994. The data were collected as part of the baseline investigation of the Early Developmental Stages of Psychopathology (EDSP) study funded by the German Ministry of Research and Technology. The psychometric properties of the Munich Composite International Diagnostic Interview (M-CIDI) have been investigated by studying various sites and samples. This assessment module is specifically tailored to the characteristics of mental health care in Germany, taking into account the specific characteristics of the Munich area. A clinician's evaluation of need is heavily dependent on the evaluator's professional background and experience, their knowledge and attitudes towards such disorders.

Cognitive-behavioral treatments effectively reduce the panic, anxiety and associated avoidance behavior in panic disorder and agoraphobia, as well as the social anxiety and avoidance behavior in social phobia. An important issue is whether the treatment protocols of randomized controlled trials and the associated patient improvement can be replicated in routine care. The evidence from epidemiological and clinical samples indicates that while the majority of sufferers seek treatment for their complaint, this nonspecialized treatment appears to have little impact on the course of their disorder. Data presented in this chapter shows that the outcome for some people who leave specialist care is good, and that people in the community with an anxiety disorder are, on average, less disabled than their counterparts who attend specialist treatment programs. Most importantly, all health services must deliver treatments that produce clinically significant change in both symptoms and the disability associated with a disorder.

Alcohol-use disorders are among the most prevalent mental disorders in the general community. The Epidemiologic Catchment Area (ECA) study involved personal interviews with 20,000 Americans in five states. In the ECA study individuals with alcohol-use disorders were at high risk of suffering from other mental disorders. The National Comorbidity Survey (NCS) is a population survey that was undertaken between 1990 and 1992 to examine the extent of comorbidity between substance-use and nonsubstance-use disorders in the USA. A public health approach adopts a broader explanation of the causes of alcohol-related health problems. Alcohol-use disorders complicated by other comorbid mental disorders have been recognized as having a poorer prognosis and being more difficult to treat than those without comorbid disorders. Public education about the risks of alcohol use may be the best way of preventing and ameliorating the public health impact of the prevalent, milder forms of alcohol disorders.

By studying what happens between the initial experience of drugs and the subsequent sharing of drugs with others, it is possible to see that much (though not all) of the person-to-person spread of drugs takes place within a year or so of starting drug use. Drug-dependent people seem to be less likely to introduce others to drugs, perhaps because they are concerned about their own supply. There is considerable appreciation for the evidence on co-occurrence of drug dependence with other psychiatric disturbances, especially antisocial personality disorder but also anxiety and affective syndromes. The diagnostic criteria are just points of departure for a more public-health-oriented model of needs assessment. The increased risk of other psychiatric syndromes among pre-dependent drug users reinforces the argument for earlier rather than later clinical attention being given to these drug users.

This chapter explores the nature of somatisation, describes the epidemiology, and outlines research and clinical issues. Psychiatric classification systems have included the specific disorder of somatization, as well as other disorders of unknown prevalence and questionable validity. Other important categories from a clinical perspective, such as chronic pain disorder, have major impacts on health care utilization across a wide range of disciplines. The vulnerability to somatic distress is not likely to occur simply secondarily to a general liability to the common forms of anxiety and depression. Primary psychogenic pain disorder is relatively rare. The avoidance response to pain often results in complex and even bizarre pain behaviors which are relatively common in pain-unit patients. Patients are particularly unlikely to comply with cognitive-behavioral approaches if they feel that such strategies will just result in their symptoms worsening, unless the physician also provides relevant symptom relief.