In an era of managed care, when competition in the United States for managed behavioral health care contracts continues to favor the lowest-cost bidders, this volume offers a guide for those who would like to see the ground rules change. If quality of care is ever to become a competitive factor in U.S. mental health services, the availability of credible mental health outcome measures is essential. Professors Thornicroft and Tansella have commissioned or selected outstanding articles that survey the available outcome measures of concern to patients and professionals alike. These include measures of patient satisfaction, quality of life, social role disability, global functioning, quality of services, and cost of services in addition to the usual assessment measures for diagnoses and symptom levels.

Lest any colleague think that patient perspectives on mental health services are unsophisticated and measures of satisfaction naive, the scholarly chapter by Dr. Ruggeri covers both the methodological advances and the conceptual underpinnings for serious work in this area. For services to patients with severe mental disorders, Anthony Lehman provides a comprehensive review of the quality of life measures now available as outcome measures. Such measures cover a range of domains, including functional status, access to resources and opportunities, subjective well-being, family burden, and assessments of community safety.

In the current managed care context of needing measures of "medical necessity" to determine eligibility for care, the section by Durk Wiersma on measuring disability and the section by Phelan et al. on assessing global functioning are particularly relevant. Both call for a clear separation between diagnostic symptoms and the measurement of disability in social role functioning. Since current diagnostic criteria cover a wide range of functional states, additional measures to operationalize the new World Health Organization (WHO) International Classification of Impairments, Disabilities, and Handicaps are proposed. Such instruments are intended to provide better measures of the need for specific types of mental health services and to provide outcome indicators of treatment effects. Sartorius and Janca provide a complete and impressive guide to all of the WHO instruments developed by international collaborative teams over the past 30 years that have served as springboards for several instruments reviewed in more detail in other chapters.

Although there is a strong focus on individual outcome measures and implicit encouragement for their use in clinical settings, it is important to note the cautions offered in several chapters that a casual implementation of such measures may result in uninterpretable results. More optimistic and equally sophisticated is the multidimensional assessment of outcome approach in the chapter by Biggeri et al., which demonstrates an attempt to combine several of these measures and interpret their results in a routine clinical practice setting.

Given the relevance of these chapters for an American audience struggling with managed care, it is noteworthy that the editors and most authors are from European countries facing different but no less daunting challenges. Regardless of whether the purchasers of mental health services are private industries employing managed care companies or governments paying for a state or national health service, there is mounting pressure to measure quality and outcome of services in addition to costs. Although the perfect instruments for all settings have not yet appeared, this volume should accelerate development of a consensus on the most reliable and valid approaches in each of these outcome areas.