Toward the incorporation of costs, cost-effectiveness analysis, and cost-benefit analysis into clinical research.

Most research in clinical psychology and related disciplines does not measure, report, or analyze costs, cost-effectiveness, or cost-benefit analysis. Reasons for this are discussed. It may be thought, for example, that costs are trivial to measure. Data are presented to show that the values of resources consumed in treatment (i.e., costs) actually can be quite complex to assess accurately and completely. Research findings are assembled to show that costs, as experienced by clients, may be beneficial to assess in that they can be significantly related to the outcomes of treatment. Empirical findings also show that costs also can be useful to measure because costs and outcomes can be related inversely rather than directly (i.e., clients may benefit most from treatments that cost less than several viable alternatives). Finally, perceived impediments to assessing costs and to cost-effectiveness and cost-benefit analysis in psychology are considered. Dialogue is encouraged on the scientific study of relationships between (a) monetary and other costs, (b) treatment techniques and treatment delivery systems, and (c) psychological and economic outcomes.

Cost-benefit analysis of six alternative payment incentives for child therapists.

The outcomes and costs of 6 different methods of motivating therapists to meet service delivery goals at a community mental health center for children and adolescents were evaluated over a 5-year period. The costs and cost-savings benefits of each motivational method were compared with each other and with two baselines. Four incentive interventions generated more cost savings than they required in monetary outlays. Most cost-beneficial were bonuses paid to therapists for each hour of service they delivered over their monthly goals and bonus plans that rewarded therapists for exceeding their goals while also rewarding staff if total department goals were exceeded. The most cost-beneficial system saved $25,542 over 6 months that would have been paid to compensate for therapy hours not delivered, for an incentive investment of $9,726 over the 6 months. This yielded a net benefit of $15,816, or $31,632 annually.

Predicting hospital adjustment by adolescent inpatients.

Data about 145 adolescent inpatients were used to examine the relationship between past patterns of aggressive behavior and behavior during the initial period of psychiatric hospitalization. During their first month in the hospital, adolescents with a history of externally directed aggression were more likely to present management problems, compared with adolescents without this history. Adolescents with a history of internally directed aggression were more likely to be self-destructive. However, no association was found between adolescents' preadmission patterns of aggression and the likelihood that they would experience depressive symptoms in the hospital. Associations were found between adolescents' patterns of aggression and diagnoses. The authors suggest strategies to enhance treatment of adolescents with various patterns of aggression during the initial phase of hospitalization.

Cost effectiveness of three child mental health assessment methods: computer-assisted assessment is effective and inexpensive.

In order to survive severe funding reductions, community mental health centers (CMHCs) have implemented a number of systems-level interventions that attempt to minimize the impact of budget cuts on treatment effectiveness. The present study focused on ways to maintain the effectiveness of clinical assessment while lowering the assessment cost. The present study evaluated the relative cost effectiveness of three methods for collecting information and developing clinical assessment reports on children at a CMHC: (a) a traditional narrative clinical assessment report; (b) a form-style clinical assessment; and (c) a computer-assisted clinical assessment. The results revealed that the computer-assisted assessments was at least as effective as the two alternative assessment methods and only 20 percent to 45 percent as costly. The effect of using the computer-assisted assessments was reported to be favorable by therapists. While computer technology can be used to cut service delivery costs, the use of computers in CMHCs has generally been limited to administrative tasks, and clinical applications have been ignored.

Grandparent deaths and severe maternal reaction in the etiology of adolescent psychopathology.

Relationships between the extent of psychopathology and the occurrence of 21 major life events during five developmental periods (prebirth, infancy, childhood, latency, and adolescence) were examined with multiple regression and X2 analyses for 114 hospitalized male and female adolescents. Psychopathology was assessed with the Global Assessment Scale (GAS) at admission to long-term residential treatment in a private psychiatric hospital. Data on deaths, physical illnesses, psychological disturbances, and socioenvironmental events experienced by patients before admission were gleaned from interviews and institutional records. Life events and GAS were scored independently. Only deaths and socioenvironmental events were significantly associated with psychopathology. Specifically, deaths of grandparents during infancy corresponded to lower functioning at admission. Additional analyses showed that severe reactions of patients' mothers to grandparent deaths had been more common among those adolescents who were most disturbed at the time they were admitted to the hospital. These findings were largely serendipitous, however, and need replication.

Psychosis, aggression, and self-destructive behavior in hospitalized adolescents.

The authors studied the history of aggressive and self-destructive behaviors in psychotic and nonpsychotic hospitalized adolescents (N = 137). A multidimensional measure of self- and other-directed aggression was retrospectively applied to each patient's social and developmental history. Nonsignificant gender and diagnostic differences were obtained on ratings of violence and suicide. Broader definitions of internal and external aggression yielded nonsignificant diagnostic differences, but gender differences were observed on both internal and external aggression measures. Females displayed greater internal aggression, and males reported higher external aggression scores. These results, compared to those of other investigators, suggest the importance of social and cultural variables in understanding adolescent psychosis and aggression.

Combined use of psychotherapy and drugs in chronic, treatment-resistant schizophrenic patients. A retrospective study.

This retrospective study attempts to document in objective terms--not definitively prove--the phenomenon noted clinically of new signs of improvement emerging in chronic treatment-resistant schizophrenic patients when initially withdrawn from medication and then subsequently remedicated after a prolonged regressive phase. Correlations made from independent ratings on several measures tend to support two hypotheses: first, new signs of improvement will emerge both symptomatically and in overall clinical improvement; and second, this improvement after remedication will correlate with the patient's progression in a primitive psychotherapeutic relatedness. The discussion emphasizes the tentative nature of the findings and focuses on questions for further study, particularly the need for further clarification of what may be the crucial components of the unmedicated regression, whether active, "placebo promoting" aspects are important or passive, "breakdown and rebuilding" components are important, or both. It is also particularly unclear whether the period of unmedicated regression is absolutely necessary, or can be circumvented under certain conditions.

Collecting mental health self-evaluations. Effectiveness and cost of three third-party techniques.

The effectiveness and cost of three techniques for obtaining client ratings of their own levels of functioning were assessed in a private, outpatient, mental health clinic. Seventy-five clients were asked to rate the adequacy of their own functioning on vocational, family, social, personal, and overall dimensions. Clients were randomly assigned to (a) mail, (b) telephone, or (c) mail followed (if necessary) by telephone administration of the ratings questionnaire. Mail followed if necessary by phone administration was found to be more cost effective than either mail alone or telephone alone.

Improving the cost-effectiveness of obesity programs: three basic strategies for reducing the cost per pound.

Empirical support is provided for three basic strategies of improving the cost-effectiveness of treatments for obesity. The importance of analyzing both the effectiveness and cost of different program components when attempting to improve cost-effectiveness is illustrated in the first two studies. First, the strength of relationships between changes in different eating behaviors and changes in obesity was assessed for a small sample of obese individuals. Change in only one of eight behaviors investigated was significantly and strongly correlated with change in obesity. Data also were collected on the subjective costs and benefits of changing 36 eating behaviors that are commonly included in treatments for obesity. Some eating behaviors were found to differ greatly in subjective cost and perceived benefit, as measured by clients' ratings of component difficulty and component usefulness. A final, quasi-experimental study demonstrated the importance of developing cost-effective systems for translating principles of treatment for obesity into actual treatment. The impact on cost-effectiveness in mind is illustrated in a comparison of dollars paid by clients in relation to percent reduction in obesity for two weight reduction programs. The studies are discussed as highlighting the importance of measuring the cost and effectiveness of alternative delivery systems for, and different components of, treatments for obesity.