"Doing it right the first time" has become a mantra for business, although it is often easier said than done. The right way, of course, is the way that leads to the desired business outcomes, and without excessive cost. Mental health care also has a right way to do things the first time, but the principles that underlie quality are not always obvious to a casual observer. Much of what passes for quality care these days is not, and even experts can sometimes have trouble determining where superior care can be found. So, is quality mental health care possible? Of course it is, as long as attention is paid to some basic principles.

     For a start, you have to know where you want to end up. From an employer perspective, that means effective and cost effective care for employee problems. Ideally, quality mental health care outlays will be more than offset by savings in such employer costs as absenteeism, recruitment and training, reduced productivity, and other health care expenses. From the employee's perspective, the desired outcome is accurate identification of the problem, appropriate treatment, and resolution of problems.

      Next, quality mental health care requires ready access for employees in need. Multiple referral routes improve the odds of appropriate help seeking. Internists, EAPs, and self-referral can be supplemented by worksite self-assessment programs. Actual or perceived lack of confidentiality can be major barriers to access, along with paperwork and authorization requirements. Prompt access to initial care is essential.

      Perhaps most important is the initial clinical evaluation. Significant emotional distress often has multiple causes, and the central factor is usually not obvious. The initial evaluation should be broad and thorough, with careful attention to personal life, workplace factors, commonplace anxiety and depressive disorders, drug and alcohol use, concurrent and causal medical illness, and much more. Although many current clinical systems use evaluators with narrower training and experience, this is where highly skilled clinicians with broad and advanced training are most essential. Evaluators with narrower skills are not aware of what they don't see. It is too easy to ease a divorce, rather than treat an underlying anxiety disorder and thus repair a marriage. Dissatisfaction at work is often caused by unpleasant changes at home. Poor job performance attributed to work stress can be due to a hidden conflict with a supervisor, an unrecognized depression, or even an undiagnosed medical illness. And, a small percentage of the time, emotional distress can be the presenting symptom of such problems like thyroid disease, cancer, or other medical illnesses. Just as in medical care, doing it right the first time starts with the right initial diagnosis!

      Treatment can then focus where it well help best, and fastest. Psychotherapy does this when it focuses not only on the apparent issues, but also on less obvious core issues. For most people, good psychotherapy is both more useful and shorter than supportive ("hand holding") treatment. Medication helps treatment work effectively and quickly when it is used accurately for treatment of the anxiety and depressive disorders that are so common in distressed employees. Used properly, medication and psychotherapy make each other more effective. Only rarely are they equally effective alternatives for the same problem, and rarer still are the times when medication alone is fully sufficient. Treatment providers should have experience and skill in their treatment areas, but broad training in all of psychotherapy, medication and also medicine is not always needed.

      Even if you know what to do, quality mental health care is not easy to bring about. To get there, start by setting basic standards and guidelines, and perhaps your own clinical oversight group. Standards in mental health care should resemble those in medical care. Existing professional diagnostic (DSM-IV) and treatment (American Psychiatric Association, and others) guidelines are a good place to start, along with basic principles of the good psychiatric care that senior managers might seek for themselves. Finding the right psychiatrists, psychologists and social workers is vital, as is understanding the important differences in training, skills and expertise of these three mental health disciplines. Talk to managed care, insurance, consulting and other companies about your new guidelines for quality mental health care.

      Unfortunately, it has been too easy in mental health to pass off lesser levels of care as optimal. Employees may recognize friendly care, but will rarely know when something important has been missed, or when an evaluator's skills are too narrow. While much of mental health care is not what it could be, not all treatment is the same. Quality mental health care requires both forethought, and ongoing attention to effectiveness. Existing measurement tools tend to focus on patient satisfaction more than on the triad of accurate diagnosis, appropriate treatment, and patient recovery. While care must be taken to protect confidentiality, there are appropriate ways to assess and encourage quality diagnosis and treatment. Overall mental health treatment costs should also be weighed against measurements of workforce effectiveness and other cost offsets. Understanding the basic principles of quality mental health care makes it a very possible goal.

      Jeffrey P. Kahn, M.D. is President of WorkPsych Associates, a NYBGH member. WorkPsych (WorkPsych@aol.com) provides a range of executive assessment, development and treatment services, as well as corporate benefits and management consultation. He is also editor of Mental Health in the Workplace: A Practical Psychiatric Guide, active in the business relations efforts of the American Psychiatric Association, and Past President of the Academy of Organizational and Occupational Psychiatry.