Conclusions

Here we discuss the central challenges that psychiatric service evaluation will face in the future ( Table 12).

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Table 12 Key challenges to rigorous and relevant evaluation of psychiatric services

The first issue to address is the need to clarify who is asking the research question and why. On occasions, a call for funding is initiated by a central governmental or research body acting for the wider health service, and for commissioning targeted research that has been identified as a national priority. On the other hand, it is also common for research workers to take the initiative and bid for grants to fund studies to test hypotheses that the researchers themselves have formulated or selected. These two different approaches have important implications. Externally commissioned research programmes to investigate specific issues are often linked to political or policy initiatives which have shorter time constraints. By comparison, investigator-initiated studies may have a far more limited impact, since they may reflect concerns of the research staff more than those of service planners or clinicians.

There are still relatively few published studies of psychiatric service evaluation that have asked clear research questions. In part, this is because the tradition of research in this field is primarily that of unfocused descriptive studies, and because only recently have the methodological tools necessary for analytical studies (which address specific and refutable hypotheses) been used at the service level.

A further challenge is the imbalance between the evaluation of new service models compared with research upon established clinical practice. In most service systems the majority of expenditure is for traditional inpatient and outpatient provision, about which there is remarkably little research-based evidence. Therefore, in future, it will be important to evaluate post hoc current but unproven service configurations, particularly those that are widespread and expensive, as well as innovative interventions. In future, such studies will more often need longer term funding, commensurate with the frequently, long-term course of the mental disorders treated by the services they evaluate. At the same time, an increasing investment in health services research in many economically developed countries needs to be accompanied by a commitment to systems of quality assurance for research proposals, so that only studies which can answer their stated hypotheses are funded.

A continuing dilemma facing mental health service research is to balance internal and external validity. Internal validity is most often satisfied by randomized controlled trials which examine questions of the efficacy of specific interventions. On the other hand, external validity (generalizability) is usually better addressed by larger-scale clinical studies in routine settings, under which conditions the randomized controlled trial design may not be feasible. It will often be appropriate to see these two designs as sequential: first establish whether an intervention is efficacious, and then test whether it is effective.

A common limitation in psychiatric service evaluation studies is a failure to specify the interventions to be tested, and to give a detailed description of the control condition. While it is common to find a description of the overall service organization, what is often missing is detail about the treatment capacity of the services being studied, and the precise nature of the interventions provided to patients. This issue has bedevilled research reviews and systematic overviews, for example, on the range of services that have variously been described as assertive community treatment, intensive case management, and community care arrangements.(66 6465 and66>

Next, the active ingredients of such services will have to be identified, which is a major research agenda. It will be necessary to distinguish and assess the separate effects of the following:

1. size of the case load;

2. clarity of local operational policies and programme fidelity;

3. qualifications and skills of the care workers;

4. degree of continuity of care;

5. the specific illnesses/disorders of the patients treated;

6. the number of hours during which the service is provided;

7. patient compliance with the treatments offered, particularly medication;

8. flexibility of the programme such that individualized treatment packages can be provided.

An additional challenge is to specify the key characteristics of the patient groups to be treated. In the past, this has most often been done in terms of diagnostic group. Rather than proceed to further dissection of diagnostic categories, it may be more useful to have valid descriptors for typical clinical populations, which may in future include biological and genetic markers. At present it is necessary, for research purposes, to be much more specific about such ill-defined terms as 'severe mental illness'.(67) Related to this is the challenge to include patients who are clinically or epidemiologically representative. The former are patient samples, which are essentially similar to larger groups of patients under treatment in a similar type of service elsewhere, while the latter are population-based samples.

As we discussed earlier, an important requirement within psychiatric evaluation is that only standardized measures are used. While this is now common, it has not yet been established whether translations of the original instruments need to be restandardized in their secondary languages, or that the application of measures used for one particular patient group to another distinct group should not proceed until the scale has been restandardized and recalibrated to the second population. This issue becomes increasingly important in times of high rates of international migration.

An impediment that occurs fairly frequently in practice, in many types of service research, is resistance from clinical staff. There are several reasons that contribute to these negative attitudes. As Sartorius(5> has pointed out, they include the following: evaluation has often been used for cost cutting instead of to advance a treatment programme; research may lead to a reform of services, which staff find unwelcome; the results of evaluation are sometimes used to justify a decision that has already been made; studies absorb resources that could be dedicated for clinical purposes; the analysis of results often takes so long that they cannot be used for any practical purpose. For research to proceed, such staff concerns may need to be adequately addressed.

Finally, one of the most severe challenges is to ensure that the results of psychiatric evaluation are disseminated and that, when the evidence is strong enough, research findings are translated into policy and clinical implications which are then implemented.

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