Can program evaluation be saved from its enthusiasts?

Program evaluation--the use of scientific techniques to measure the value of an agency's work--has become the focus of major attention and enthusiasm in mental health service planning and administration. However, the author points out that completed program evaluation studies are few in number and provide no evidence of great impact on the operation of programs or agencies and that unrealistic enthusiasm for program evaluation can lead to unrealistic rejection when performance fails to reach promise. He concludes that program evaluation should be applied only when it can have an impact, i.e., in a limited number of carefully selected cases.

Differences in repeated psychiatric examinations of litigants to a lawsuit.

Repeated psychiatric examinations of 42 litigants were compared to determine reasons for differences in findings by experts hired by the defendant and by the plaintiffs. The lawsuit resulted from the collapse of a coal slag heap in Buffalo Creek, W. Va., in 1972. All psychiatric reports prepared for the trial were screened. Experts for the two sides differed systematically over the extent of recovery from psychiatric symptoms and in other areas. Changes in the plaintiffs' mental statuses over time are shown not to be the cause. Extraneous factors, such as "forensic identification," the subtle influence of adversarial proceedings on initially neutral witnesses, are shown to play a part.

Primary prevention in perspective.

Discussion of primary prevention has been made difficult by lack of clarity of underlying concepts and assumptions. Is the purpose to prevent diagnosable mental illness or to prevent unhappiness and social incompetence? What are the implications of the assumption that societal stress causes mental illness? Is there a clear distinction made between major and minor mental illness? Except for a few specific conditions there is little evidence that primary prevention has been effective. The authors feel that research and program evaluation in prevention is sorely needed but should be funded separately and with discretion. Scarce mental health funds should not be diverted from direct treatment for this purpose.

In defense of community mental health.

Initial enthusiasm for community mental health has given way to a barrage of criticism, musch of it deserved. Originated to deal with abysmal conditions in state hospitals, community mental health focused instead on primary prevention, political activism, and the mildly mentally ill. The authors propose a return to the original fundamentals, stressing that the highest priority be given to community treatment and rehabilitation of the severely mentally ill.

Noninstitutional treatment for sex offenders in Florida.

The authors describe the availability and characteristics of noninstitutional treatment for sex offenders found in a survey of 63 community mental health providers in Florida. The results cover offense categories, referral sources, numbers in treatment, annual case load, and program characteristics. More sex offenders were being treated in the community than in state-operated residential programs, and 21% of the patients currently receiving community treatment were self-referred. The authors recommend that researchers and policy makers direct more attention to community treatment of sex offenders, its efficacy, and training for those delivering the treatment.

Legislating social control of the mentally ill in California.

The Lanterman-Petris-Short Act in California has been acclaimed for protecting the civil rights of the mentally ill and curbing unnecessary involuntary psychiatric hospitalization. Its passage, however, has not prevented an increase in the rate of involuntary admissions to state hospitals and a marked decrease in the rate of voluntary admissions. This has greatly changed the functions and problems of state hospitals. In local as well as state hospitals large numbers of people continue to become involuntary psychiatric patients. In many cases this results from gaps between the law and its implementation. It appears that professionals, the courts, families, and society generally feel a continuing need for social control of the mentally ill.

Syngeneic bone marrow transplantation in a patient with metastatic neuroblastoma refractory to conventional therapy.

A child with metastatic neuroblastoma refractory to conventional chemotherapy was treated with lethal doses of chemotherapy and total body irradiation followed by syngeneic bone marrow transplantation. A complete remission was achieved. However, the tumor recurred after six months, and the patient succumbed to disseminated neuroblastoma nine months after marrow grafting.

A study of thiotepa, etoposide and fractionated total body irradiation as a preparative regimen prior to bone marrow transplantation for poor prognosis patients with neuroblastoma.

We report the toxicity and efficacy of a new conditioning regimen for bone marrow transplantation (BMT) in children with poor prognosis neuroblastoma (NBL). Twenty-seven patients with poor prognosis NBL were treated with teniposide (360 mg/m2) or etoposide (500 mg/m2), thiotepa (600-900 mg/m2), and 1200 cGy fractionated total body irradiation (fTBI) followed by autologous marrow rescue (n = 19) or allogeneic BMT from HLA-identical siblings (n = 8). The two patients who received teniposide, 600 mg/m2 thiotepa and fTBI had minimal toxicity but relapsed 4 and 12 months post-auto BMT. The next two patients received 750 mg/m2 thiotepa, 500 mg/m2 etoposide and TBI. They tolerated the conditioning regimen well and are alive and in remission 77 and 75 months post-BMT. At the next thiotepa dose level (900 mg/m2), the first two allograft recipients both experienced fatal regimen-related toxicity. All subsequent allograft recipients received 750 mg/m2 thiotepa and autograft recipients received 900 mg/m2 thiotepa. As of 1 April 1995, eight of the 19 patients who received autologous marrow are surviving disease-free 21 to 77 months post-BMT. Nine autograft recipients relapsed at 2 to 37 months following transplantation. One patient died of hepatic veno-occlusive disease 2 months after auto BMT, and one of pneumonia 6 months post-transplantation. Three allograft recipients have relapsed at 6, 10 and 39 months post-transplant and three are alive and in remission 75, 53 and 27 months post-BMT. Overall, 11/27 patients (41%) are alive and in remission 21-77 months (median 47 months) following BMT. A conditioning regimen consisting of 500 mg/m2 etoposide, thiotepa (750 mg/m2 for allograft recipients and 900 mg/m2 for autograft recipients) and 1200 cGy fTBI has acceptable toxicity and is at least as effective as melphalan-containing regimens in the treatment of high-risk NBL.

Benign hemangioendothelioma--a rare type of posterior mediastinal mass in children.

Two infants with benign hemangioendotheliomas of the posterior mediastinum are reported here. The neoplasms did not produce symptoms and were fortuitously discovered by chest roentgenograms. Computed tomography (CT) was useful in delineating the extent of the lesions preoperatively.

Moving from quality assurance to continuous quality improvement.

Though numerous proponents of the change from quality assurance (QA) to continuous quality improvement (CQI) have emphasized the drawbacks of the former and the advantages of the latter, there has been relatively little systematic consideration and comparison of the costs and benefits of each. A proper comparison is probably not possible, because the data seem to be lacking. Instead, much of the discourse has been based upon anecdotes, analogies from other industries, and unsupported assertions. This article grows out of a concern that, in making the switch from QA to CQI, we will discard or inadvertently lose much of value in QA and may not achieve many of the things that proponents expect CQI will accomplish. QA has served the health care field well. Its achievements ought to be preserved and built upon, not discarded.