Evidence-based psychotherapy for schizophrenia: 2011 update.

Many patients with schizophrenia have psychological distress and receive some form of psychotherapy. Several different psychotherapeutic approaches for schizophrenia have been developed and studied. Of these approaches, cognitive behavior therapy (CBT) has the strongest evidence base and has shown benefit for symptom reduction in outpatients with residual symptoms. In addition to CBT, other approaches include compliance therapy, personal therapy, acceptance and commitment therapy, and supportive therapy. Although usually studied as distinct approaches, these therapies overlap with each other in their therapeutic elements. Psychotherapy for schizophrenia continues to evolve with the recent advent of such approaches as metacognitive therapy, narrative therapies, and mindfulness therapy. Future research may also consider three different goals of psychotherapy in this patient population: to provide emotional support, to enhance functional recovery, and to alter the underlying illness process.

Pattern of mortality in a sample of Maryland residents with severe mental illness.

In a cohort of Maryland Medicaid recipients with severe mental illness followed from 1993-2001, we compared mortality with rates in the Maryland general population including race and gender subgroups. Persons with severe mental illness died at a mean age of 51.8 years, with a standardized mortality ratio of 3.7 (95%CI, 3.6-3.7).

Changes over time and disparities in schizophrenia treatment quality.

BACKGROUND: Schizophrenia medication and psychosocial treatment options have expanded since the Schizophrenia PORT was conducted. However, there also have been considerable changes in the delivery of mental health care in the public sector, as well as increasing state concerns about Medicaid cost containment. OBJECTIVES: To examine trends and patient characteristics associated with differences in schizophrenia medication and visit treatment quality in a Medicaid population. RESEARCH DESIGN: Observational study of claims data from July 1, 1996 to June 30, 2001. SUBJECTS: Florida Medicaid enrollees diagnosed with schizophrenia (N = 23,619). MEASURES: We examined the likelihood of meeting any 1 and all 4 of the following quality standards: (1) receiving antipsychotic medication, (2) antipsychotic continuity, (3) dosing consistent with PORT recommendations, and (4) mental health visit continuity. Separate models were fit for acute and maintenance phases of treatment. RESULTS: Approximately 18% of acute and 7% of maintenance phases met all 4 quality standards. Antipsychotic quality improved (largely driven by an increasingly likelihood of receiving any antipsychotic), while visit continuity declined. The greatest disparities were seen for persons with co-occurring substance use disorders and of black race. Quality differences were often phase specific and at times in opposite directions across treatment phases. CONCLUSIONS: The improvement in antipsychotic treatment quality is encouraging. However, visit continuity declined. This study highlights the importance of quality measurement that includes focus on different treatment modalities and phases of care, as well as for potentially vulnerable populations (such as persons with co-occurring substance use disorders and racial/ethnic minorities).

Antipsychotic treatment patterns and hospitalizations among adults with schizophrenia.

OBJECTIVE(S): To characterize the longitudinal patterns of antipsychotic treatment and to investigate the relationship between antipsychotic treatment patterns and acute hospitalizations among adults with schizophrenia. We hypothesized that continuous antipsychotic treatment would be associated with fewer hospitalizations and shorter lengths of stay. METHOD: Seven years of retrospective Maryland Medicaid administrative data were used to examine inpatient medical encounters and outpatient psychotropic treatment in community-based settings from 1993 through 2000. The sample consisted of 1727 adults continuously enrolled in the Maryland Medicaid program from July 1992 through June 1994, and diagnosed with schizophrenia. The main outcome measures were a) any schizophrenia hospitalization; b) number of schizophrenia hospitalizations; and c) inpatient days associated with a primary diagnosis of schizophrenia. RESULTS: The average duration of antipsychotic use was six months in any single year and four and one-half years across the entire study period. Compared to individuals with a more continuous pattern of antipsychotic treatment, individuals with moderate or light use had odds of hospitalization for schizophrenia that were 52 or 72% greater (95%CI: 30-75% greater, 49-100% greater respectively). Light users of antipsychotics have an average length of stay per hospitalization that is approximately 20% longer than the average for continuous users (95%CI: 2-39% longer). CONCLUSIONS: Findings emphasize the benefit of continuous antipsychotic treatment for individuals with schizophrenia.

Clozapine utilization and outcomes by race in a public mental health system: 1994-2000.

OBJECTIVE: This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing. METHOD: Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database. RESULTS: A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041). CONCLUSION: Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.

Integration of psychiatric and vocational services: a multisite randomized, controlled trial of supported employment.

OBJECTIVE: Although large-scale surveys indicate that patients with severe mental illness want to work, their unemployment rate is three to five times that of the general adult population. This multisite, randomized implementation effectiveness trial examined the impact of highly integrated psychiatric and vocational rehabilitation services on the likelihood of successful work outcomes. METHOD: At seven sites nationwide, 1,273 outpatients with severe mental illness were randomly assigned either to an experimental supported employment program or to a comparison/services-as-usual condition and followed for 24 months. Data collection involved monthly services tracking, semiannual in-person interviews, recording of all paid employment, and program ratings made by using a services-integration measure. The likelihood of competitive employment and working 40 or more hours per month was examined by using mixed-effects random regression analysis. RESULTS: Subjects served by models that integrated psychiatric and vocational service delivery were more than twice as likely to be competitively employed and almost 1(1/2) times as likely to work at least 40 hours per month when the authors controlled for time, demographic, clinical, and work history confounds. In addition, higher cumulative amounts of vocational services were associated with better employment outcomes, whereas higher cumulative amounts of psychiatric services were associated with poorer outcomes. CONCLUSIONS: Supported employment models with high levels of integration of psychiatric and vocational services were more effective than models with low levels of service integration.

An empirical conceptualization of the recovery orientation.

OBJECTIVE: The recovery movement is having a growing impact on policy for people with severe mental illness. The empirical literature on the recovery orientation, however, is scant, and no empirical conceptualization of recovery has been published. METHOD: We identified items reflecting recovery themes and measuring aspects of subjective experience, and used principle components and confirmatory factor analyses to develop an empirical conceptualization of the recovery orientation, using data from a large, systematic study of schizophrenia. RESULTS: We identified four domains of the recovery orientation: empowerment, hope and optimism, knowledge and life satisfaction. CONCLUSIONS: We propose here an initial approach to measuring and conceptualizing recovery attitudes. We also suggest that the evidence-based practice (EBP) movement may help to identify interventions that promote the recovery orientation and help to advance recovery attitudes. We suggest that there is a bidirectional relationship between recovery attitudes and the positive clinical outcomes that are the goals of EBPs. Through the use of empirically derived conceptualizations of recovery, EBPs can provide a mechanism for identifying treatments that promote the recovery orientation. The conceptualization proposed here can, thus, serve as a tool to assess changes in recovery attitudes during participation in specific EBPs.

The effect of a managed behavioral health carve-out on quality of care for medicaid patients diagnosed as having schizophrenia.

CONTEXT: Managed behavioral health carve-outs (MBHCOs) are a regular feature of public and private mental health care systems and have been successful in reducing costs. The evidence on quality impacts is limited and suggests comparable quality overall, except that people with severe psychiatric disorders may be those most disadvantaged by MBHCOs. OBJECTIVE: To explore the effect of implementing an MBHCO on the quality of outpatient care received by enrollees diagnosed as having schizophrenia. DESIGN AND PARTICIPANTS: Observational retrospective cohort study using a quasi-experimental design of state Medicaid enrollees diagnosed as having schizophrenia, aged 18 to 64 years between 1994 and 2000 in the carve-out and comparison regions (8082 person-years). SETTING: Ambulatory care. MAIN OUTCOME MEASURES: Quality indicators derived from the Schizophrenia Patient Outcomes Research Team recommendations. RESULTS: There was no statistical difference between the carve-out and integrated arrangements in the likelihood of receiving any antipsychotic medication (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.81-1.29), second-generation antipsychotics (including clozapine: OR, 1.05; 95% CI, 0.86-1.28; not including clozapine: OR, 1.05; 95% CI, 0.85-1.29), or antiextrapyramidal medication (OR, 1.36; 95% CI, 0.84-2.19). The carve-out was negatively associated with receiving any individual therapy (OR, 0.27; 95% CI, 0.22-0.33), group therapy (OR, 0.19; 95% CI, 0.14-0.25), and psychosocial rehabilitation (OR, 0.31; 95% CI, 0.26-0.38). Family therapy occurred for less than 1% of this population in both carve-out and integrated regions. CONCLUSIONS: The MBHCO was not associated with changes in medication quality (for which it was not at financial risk). It was significantly associated with sharp decreases in the likelihood of receiving psychosocial treatments (for which it was financially at risk)-independent of whether a clinical evidence base supported them.

Improving employment outcomes for persons with severe mental illnesses.

BACKGROUND: Unemployment remains a major consequence of schizophrenia and other severe mental illnesses. This study assesses the effectiveness of the Individual Placement and Support model of supportive employment relative to usual psychosocial rehabilitation services for improving employment among inner-city patients with these disorders. METHODS: Two hundred nineteen outpatients with severe mental illnesses, 75% with chronic psychoses, from an inner-city catchment area were randomly assigned to either the Individual Placement and Support program or a comparison psychosocial rehabilitation program. Participants completed a battery of assessments at study enrollment and every 6 months for 2 years. Employment data, including details about each job, were collected weekly. RESULTS: Individual Placement and Support program participants were more likely than the comparison patients to work (42% vs 11%; P<.001; odds ratio, 5.58) and to be employed competitively (27% vs 7%; P<.001; odds ratio, 5.58). Employment effects were associated with significant differences in cumulative hours worked (t(211) = -5.0, P =.00000003) and wages earned (t = -5.5, P =.00000003). Among those who achieved employment, however, there were no group differences in time to first job or in number or length of jobs held. Also, both groups experienced difficulties with job retention. CONCLUSIONS: As hypothesized, the Individual Placement and Support program was more effective than the psychosocial rehabilitation program in helping patients achieve employment goals. Achieving job retention remains a challenge with both interventions.

Cognitive correlates of job tenure among patients with severe mental illness.

OBJECTIVE: There is clear evidence that cognitive performance is a correlate of functional outcome among patients with schizophrenia. However, few studies have specifically examined the cognitive correlates of competitive employment performance or the longer-term outcomes of vocational rehabilitation. The objective of the present study was to examine the cognitive predictors of vocational functioning in the context of a controlled clinical trial by comparing two approaches to vocational rehabilitation. METHOD: A broad neuropsychological battery was administered to 150 patients upon entry into the vocational rehabilitation trial. Vocational performance was assessed over a 24-month follow-up interval. RESULTS: There were no differences in baseline cognitive performance between the 40 patients who obtained competitive employment and the 110 patients who remained unemployed over the follow-up interval. In contrast, multiple cognitive measures were significantly correlated with the total number of hours that patients were employed. The cognition-job tenure relationship appears to be fairly general, involving measures of IQ, attention, working memory, and problem solving. CONCLUSIONS: Cognitive performance was a significant predictor of job tenure but not job attainment in the context of a clinical trial of two vocational rehabilitation approaches. It appears that many persistently unemployed patients are capable of obtaining competitive employment with effective vocational services. Longer-term employment success, however, may be related to multiple aspects of baseline cognitive performance.

The heterogeneity of schizophrenia in disease states.

PREVIOUS PRESENTATION: Some of the contents of this paper have been previously presented at the 16th Annual Meeting of the International Society for Technology Assessment in Health Care June 20, 2000 in the Hague, Netherlands and at the 21st Annual Meeting of the Society for Medical Decision Making as a poster on October 3, 1999 in Reno, NV. BACKGROUND: Studies of schizophrenia treatment often oversimplify the array of health outcomes among patients. Our objective was to derive a set of disease states for schizophrenia using the Positive and Negative Symptom Assessment Scale (PANSS) that captured the heterogeneity of symptom responses. METHODS: Using data from a 1-year clinical trial that collected PANSS scores and costs on schizophrenic patients (N=663), we conducted a k-means cluster analyses on PANSS scores for items in five factor domains. Results of the cluster analysis were compared with a conceptual framework of disease states developed by an expert panel. Final disease states were defined by combining our conceptual framework with the empirical results. We tested its utility by examining the influence of disease state on treatment costs and prognosis. RESULTS: Analyses led to an eight-state framework with varying levels of positive, negative, and cognitive impairment. The extent of hostile/aggressive symptoms and mood disorders correlated with severity of disease states. Direct treatment costs for schizophrenia vary significantly across disease states (F=27.47, df=7, p<0.0001), and disease state at baseline was among the most important predictors of treatment outcomes. CONCLUSION: The disease states we describe offer a useful paradigm for understanding the links between symptom profiles and outcomes.

Antipsychotic dosing and concurrent psychotropic treatments for Medicaid-insured individuals with schizophrenia.

Antipsychotic medications have been first line treatment for schizophrenia for half a century, yet few studies have assessed outpatient maintenance treatment in large populations. This article describes oral antipsychotic dosing patterns and psychotropic treatments using computerized Medicaid claims data for individuals who were diagnosed with schizophrenia and received treatment on an outpatient basis during 1991. The findings show that the mean daily oral antipsychotic dose was 729 +/- 586 chlorpromazine equivalents (CPZ-EQ) for high-potency agents and 304 +/- 328 CPZ-EQ for low-potency agents. Males, younger individuals, and African-Americans received larger mean daily doses of high-potency agents, ranging from 747 to 800 CPZ-EQ. Antiparkinsonian agents were prescribed for over 90 percent of the outpatient antipsychotic treatment exposure. In summary, young adults, males, and African-Americans were given high-potency antipsychotic medications at outpatient maintenance doses that exceeded the maximum recommended levels, despite well-established evidence that high-dose treatment offers no additional benefit. Likewise, concurrent antiparkinsonian treatment exceeded the 1990 World Health Organization recommendations.

Racial disparity in the pharmacological management of schizophrenia.

This study investigated racial differences in the prescription of psychopharmacologic treatments to individuals with schizophrenia. Data were derived from a patient survey and medical record review for 344 persons with schizophrenia recruited from outpatient psychiatric facilities in two States in the Schizophrenia Patient Outcomes Research Team study. African-Americans were three times more likely to receive depot antipsychotic medications (odds ratio [OR]: 2.91; 95% confidence interval [CI]: 1.68-5.01) and 76 percent less likely to receive new-generation antipsychotic medications (OR: 0.24; 95% CI: 0.12-0.46), compared to their Caucasian counterparts. Chlorpromazine-equivalent antipsychotic dosages did not differ significantly between African-American and Caucasian patients. Compared to Caucasians, a larger proportion of African-Americans received antiparkinsonian medications (63% vs. 48%, chi2 = 7.01; df = 1; p = 0.008), but African-Americans were less than half as likely to receive adjunctive psychopharmacologic treatments (OR: 0.43; 95% CI: 0.27-0.71). Pronounced racial variations in the psychopharmacologic management of schizophrenia in typical clinical practice settings were observed and persisted when analyses were adjusted for selected patient demographic and clinical characteristics. A prospective, longitudinal evaluation is warranted to determine whether the observed patterns of prescribing are associated with poorer therapeutic outcomes in minority patients.

The Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ): an instrument to assess outcomes of schizophrenia care.

Advances in treatment technologies and development of evidence-based standards of care demand better methods for routine assessment of outcomes for schizophrenia in systems of care. This article describes the development and psychometrics of a new instrument to assess outcomes of routine care for persons with schizophrenia in service systems. Candidate items for the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ) were drawn from existing measures. Domains covered include disease outcomes (symptoms, subjective medication effects, substance abuse), functional status, health status, quality of life, and public safety. A sample of 1,584 patients with schizophrenia or schizoaffective disorder who were recruited into a large prospective, naturalistic study on the course of treatment for schizophrenia completed the SCAP-HQ at baseline and 1 year later (n = 434), providing data for factor analysis, assessment of internal consistency, convergent validity, and responsiveness to change. A subsample of 121 patients completed a test-retest protocol. Fifteen scales were derived by factor analysis from 55 outcome items on the SCAP-HQ. These factors covered psychiatric symptoms, life satisfaction, instrumental activities of daily living, health-related disability, subjective medication side effects, vitality, legal problems, social relations, mental health-related disability, suicidality, drug and alcohol use, daily activities, victimization, violence, and employment. For most scales, standard psychometric parameters, including internal consistency and test-retest reliability, convergent validity, and responsiveness to change, were acceptable for application to large sample evaluations of care systems. This new measure represents an advance in the development of outcome measures for schizophrenia for use in large-scale studies of routine care.

The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003.

Since publication of the original Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations in 1998, considerable scientific advances have occurred in our knowledge about how to help persons with schizophrenia. Today an even stronger body of research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment, and skills training. The most significant advances lie in the increased options for pharmacotherapy, with the introduction of second generation antipsychotic medications, and greater confidence and specificity in the application of psychosocial interventions. Currently available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. Nonetheless, major challenges remain, including the need for (1) better knowledge about the underlying etiologies of the neurocognitive impairments and deficit symptoms that account for much of the disability still associated with schizophrenia; (2) treatments that more directly address functional impairments and that promote recovery; and (3) approaches that facilitate access to scientifically based treatments for patients, the vast majority of whom currently do not have such access.

Evidence-based treatment for schizophrenia.

Taken together, the research on what treatments help people with schizophrenia point to the value of treatment programs that combine medications with a range of psychosocial services. Provision of such packages of services likely reduces the need for crisis-oriented care hospitalizations and emergency room visits and enables greater recovery. For most people with schizophrenia, the combination of psychopharmacological and psychosocial interventions improves outcomes. Several psychosocial treatments have demonstrated efficacy. These include family intervention, supported employment, assertive community treatment, skills training, and CBT. In the same way that psychopharmacologic management must be tailored individually to the needs and preferences of the patient, so too should the selection of psychosocial treatments. At the very least, all people with schizophrenia should be provided with education about their illness. Beyond illness education, all of the recommended psychosocial interventions would be used rarely during any one phase of illness for an individual. Some psychosocial treatments share treatment components, and patients have different clinical and social needs at different points in their illness course. Knowledge regarding how best to combine treatments to optimize outcomes is scarce.

An exploratory analysis of correlates of recovery.

OBJECTIVE: The concept of recovery has received increasing emphasis in the delivery of services to persons with schizophrenia. This study was an initial effort to develop an empirically based model of factors associated with a recovery orientation. METHODS: The authors reanalyzed data from 825 persons with schizophrenia who were assessed in the Schizophrenia Patient Outcomes Research Team (PORT) client survey. Multiple regression models were used to identify client and service use variables associated with each of four domains identified as important to a recovery orientation: life satisfaction, hope and optimism, knowledge about mental illness and services, and empowerment. RESULTS: In each regression model, the strongest relationship was observed between recovery orientation and lower severity of depressive symptoms. Both receipt of family psychoeducation and fewer side effects of medications were significantly and positively related to three of the four recovery domains. Psychotic symptoms were associated with less life satisfaction. Receipt of various services, including day treatment and legal services, was positively associated with knowledge about illness and services. CONCLUSIONS: Severity of psychiatric symptoms, a core feature of the biomedical perspective of mental illness, was negatively associated with a recovery orientation, and use of a variety of standard services were positively associated with a recovery orientation. Thus a polarized view of biomedical and recovery perspectives on mental illness may be unfounded, given that these perspectives appear to be mutually reinforcing.

Preadmission care as a new mental health performance indicator.

OBJECTIVE: This study examined the relationship between receipt of preadmission outpatient care during the month before an episode of hospitalization and the patients' subsequent treatment. METHODS: A total of 37,852 psychiatric inpatients who were discharged from 122 Veterans Affairs medical centers between October 1, 1997, and March 31, 1998, were studied. Linear and logistic regression were used to examine the relationship between receipt of preadmission outpatient care and length of hospital stay, use of postdischarge aftercare, and readmission. RESULTS: Having at least one outpatient visit in the month before admission was associated with a significantly shorter inpatient stay (16 days compared with 26 days, a difference of more than 60 percent) and with significantly greater use of postdischarge aftercare (odds ratio=1.83). However, the number of outpatient visits beyond one visit in the month before admission did not increase the effect on length of stay. These effects were strongest among patients with schizophrenia. CONCLUSIONS: Patients who have received outpatient care before hospital admission have shorter hospital stays and are more likely to use postdischarge aftercare than those who have not received outpatient care in the month before admission. Receipt of preadmission care itself rather than the intensity of such care seems to be the greatest predictor of length of stay.

The role of mental health service research in promoting effective treatment for adults with schizophrenia*

BACKGROUND: Significant gaps exist between scientific knowledge about the efficacy of treatments for mental disorders and the availability of efficacious treatments in routine practice. Mental health service research can help bridge this gap between basic clinical research and the usual care afforded adults with mental disorders. AIMS: To illustrate this potential, data on the efficacy of treatment for schizophrenia are reviewed. METHODS: The treatments reviewed include pharmacotherapies, psychological interventions, family interventions, vocational rehabilitation and assertive community treatment and case management. Using treatment recommendations based upon outcome data about these treatments and the results of a large survey of usual care for schizophrenia from the Schizophrenia Patient Outcomes Research Team (PORT) project, examples of current deficiencies in the usual treatment of adult mental disorders and relevant questions that need to be addressed by mental health services research are identified. RESULTS: Major deficiencies in treatment that were identified include inappropriate dosing with antipsychotic agents, underutilization of adjunctive antidepressant therapy, very low rates of prescription of psychosocial interventions and lack of continuity between inpatient and outpatient settings. DISCUSSION: These findings raise serious concerns about access to care and the appropriateness and quality of care that is offered. IMPLICATIONS: This knowledge about what treatments work for schizophrenia and the patterns of current care suggest the following major questions be addressed by mental health services research: What is the nature of care currently being offered adults with mental disorders? To what degree does this care measure up to scientifically derived quality of care and treatment standards? What is the effectiveness of new technologies under usual practice conditions? For which patients are they cost-effective and under what conditions? How should financial incentives be structured within systems of care to promote the most cost-effective use of new technologies? How should service systems themselves be organized to promote appropriate access and utilization? What educational, organizational and financing interventions promote adoption of effective interventions? Do we have valid methods for assessing quality of care? What strategies (interventions) are effective at improving the quality of care? In addition, we need to develop strategies that transfer mental health services research technologies into practice. These include: (i) development of outcome measures that meet scientific standards and that are practical for general application in service systems to facilitate "outcome management"; (ii) development of quality of care assessment methodologies that are practical and scientifically sound and (iii) cost-effectiveness methodologies. Mental health services research can facilitate the translation of knowledge developed from basic clinical research into more effective systems of care. The tools used by health services research to this end include examination of patterns of usual care in relation to scientifically established standards of efficacious care, interventions to improve the effectiveness of care and examination of the impacts of the organization and financing of services on outcomes and costs. In short, mental health service research holds high on its agenda the translation of basic and clinical research into practice. All of us must face the challenges posed by our rapidly changing mental health care system, changes driven not only by managed care and cost containment, but by exciting new developments in the treatment of mental disorders. We take on these challenges as researchers, clinicians, administrators, patients, families and taxpayers. Here I seek to provide a perspective on what we know about the treatment of adults with mental disorders and to discuss the implications of this knowledge for the work of mental health service research. Each of us has a particular window on this scene; mine is primarily that of a clinical mental health services researcher who studies schizophrenia. I will briefly summarize current knowledge about the efficacy of treatments for schizophrenia and the services research questions that this knowledge raises in its translation to clinical practice. The lessons from this examination readily generalize to the treatment of other adult mental disorders.