The Global Assessment Scale was used by multiple clinicians to rate 108 chronically mentally ill outpatients for 18 months. With prior training, high interrater reliability was obtained. Analysis suggests that fluctuations in patients' scores were not attributable to measurement error due to the sequential ratings of multiple clinicians. Moreover, GAS means were inversely correlated with decompensations over the study period. Results indicate that the DMS-III-R recommended use of the GAS in multiple-rater outpatient facilities can be both reliable and clinically useful when supported by thorough staff training.

With cultural issues prominent in the United States today and with ongoing rapid changes in health care management and delivery, this paper discusses the shift from a genetic-type psychiatry (i.e., assuming that humans the world over are no different, and will react to given stressors in life in the same manner) to one recognizing that cultural beliefs, mores, peer pressure, family expectations, and other ingredients operate in unique combinations in various cultures and ethnic groups. These social and cultural factors can and will impact treatment modalities and outcomes. Literature reviewed herein illustrates the progressive stages of awareness and incorporation of cultural differences and the many ways they impact treatment. Unfortunately, the rise in managed, rationed health care threatens the future of this progression. It is essential that culturally-based managed care programs be developed and funded to ensure the availability of cost-effective treatment, through an integrated system of services, to patients of all cultural and economic backgrounds.

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Attitudes have been a neglected variable in the development of public sector clinicians. Clinicians of differing disciplines may commonly possess attitudes which would affect their role in the public sector. The Houston Consortium assessed some of these attitudes in their students and faculty. The results may have heuristic implications for improving mental health care.

The development of comprehensive health and mental health services depends on a number of factors. One overlooked factor, especially for the public sector, seems to be the attitudes of the health care providers. In an attempt to address this and related issues, the Houston Consortium was designed as a prototype training model. As part of that endeavor, the attitudes of mental health trainees toward the poor, interdisciplinary interaction, and community mental health were assessed. While the ethnic identity of the students had some influence, the major findings concerned the discipline of the students. Social work students, in particular, seemed to possess or be able to develop attitudes relevant to a prominent role in primary health care.