OBJECTIVE: Although mobile crisis services have been widely accepted as an effective approach to emergency service delivery, no systematic studies have documented the prevalence or effectiveness of these services. This survey gathered national data on the use and evaluation of mobile crisis services. METHODS: In 1993 mental health agencies in 50 states, the District of Columbia, and U.S. territories were surveyed. Repeated follow-up was done to ensure a 100 percent response. RESULTS: A total of 39 states have implemented mobile crisis services, dispatching teams to a range of settings. Although respondents reported that use of mobile crisis services is associated with favorable outcomes for patients and families and with lower hospitalization rates, the survey found that few service systems collect evaluative data on the effectiveness of these services. CONCLUSIONS: The claims of efficacy made for mobile crisis services, which have led to their widespread dissemination, are based on little or no empirical evidence. More rigorous evaluation of new and existing modes of service delivery is needed. The need for such evaluation will increase in the climate promulgated by managed care, in which greater emphasis is placed on cost-effectiveness.

Rothschild AJ, Viguera AC: Acute grief and disaster victims. In: Hyman Se, Tesar GE (eds.) Manual of psychiatric emergencies, third edition. Boston: Little Brown, 1994:38-44. ISBN 0316387282, 9780316387286.

One function of contemporary psychiatric emergency services is to divert patient admissions from state hospitals. Underlying this mandate are a series of untested assumptions about the positive effects of admission diversion. The author examines these assumptions using data on inpatient admissions from a crisis intervention service. Although the service was successful in preventing first admissions to the state hospital, the rate of recidivist admissions increased. Inpatient treatment in general or private hospitals did not result in shorter lengths of stay or fewer bed days than state hospital treatment. Because patients could be sent to any of several hospitals, some located far from the catchment area, continuity of care and treatment in the local community were not advanced by diverting admissions from the state hospital.

Birthed in Memphis, Tennessee, in 1988, Crisis Intervention Teams (CITs) have had remarkable growth spurts with few, if any, developmental milestones to document their progress. Compton and colleagues investigated the evidence basis for CIT and found very little. They perhaps found even more than there actually is. There are contributions to CIT outcomes that are rooted in local variations in mental health services and regional culture. These are considered in this commentary, using Memphis as the example. None of us should be surprised that reform is evidence-absent. The mental illness delivery system and the criminal justice system have been instituting reform, and these reforms have had reverberating changes between the two systems, with little or no data to support the changes, for centuries. That there would be unexpected consequences should be obvious. But apparently not so evident that we don't continue to take one blind step after another. Is CIT on firm footing, or just another fool's journey?

OBJECTIVE: The study evaluated the impact of Medicaid managed care on decision making during emergency mental health screening and the outcomes of such screening for children and adolescents. METHODS: Data on client attributes and on system characteristics (payer, referral source, and disposition) were available for 297 Medicaid and non-Medicaid episodes of emergency mental health screening that occurred one year before the implementation of a statewide managed Medicaid program in Massachusetts and 393 episodes that occurred one year after implementation. Outcomes included changes in the volume of service provided and in the pattern of dispositions, particularly inpatient admissions. RESULTS: Although the total volume of child and adolescent emergency screening episodes significantly increased after implementation of Medicaid managed care, inpatient admissions decreased significantly. Among episodes not covered by Medicaid, no significant changes were noted after implementation on any variables. In the Medicaid group, significant differences were found in client attributes and system characteristics. After implementation the volume of emergency screening episodes for Medicaid clients increased significantly, and inpatient admissions decreased significantly. The pattern of dispositions changed significantly, with increased use of newly available crisis stabilization services. CONCLUSIONS: Although implementation of Medicaid managed care achieved the short-term goal of a decrease in hospitalizations, and probably concomitant savings, issues of quality of care for children and adolescents, and savings over the longer term, remain to be addressed.