approaches to integrating care have been found successful in the treatment of depression (Katon et al., 1996; Katon et al., 1999; Smith et al., 2000). Its utility for suicidality is being studied through ongoing trials (Mulsant et al., 2001; Reynolds et al., 2001).

Services research has focused for the past decades in developing better models of care that bridge these different sectors of care to deliver more integrated mental health care. Several successful models have been developed, most notably wraparound services including multisystemic treatment, for children and adolescents with serious emotional problems and assertive community treatment, a form of intensive case management for people with serious mental illness, combined services for people with mental and substance abuse disorders, and management programs for late life depression in primary care settings (US DHHS, 1999). One major problem, however, is lack of availability to these state-of-the-art services. Many communities simply do not provide them, and, when they do, there are often waiting times for treatment (US DHHS, 1999). Low availability of mental health services (of any kind) is a major problem in rural areas (Beeson et al., 1998; Fortney et al., 1999) and communities with large minority populations (US DHHS, 1999; US DHHS, 2001). People in rural areas report significantly more suicide attempts than their urban counterparts, partly as a result of lower access to mental health services (Rost et al., 1998).

Another major problem is adapting model services to the unique needs of different communities or populations. Programs found successful for some populations may not translate into other settings. For example, a new primary care program for veterans designed to expand access to specialty mental health failed to do so (Rosenheck, 2000), despite the success of similarly designed gateway programs for other populations. Tailoring programs to the needs of distinct populations, including minority groups, is essential, given that they are less likely to access mental health treatment than are whites (US DHHS, 2001).

Managed Care

In the past two decades, managed care has grown from relative obscurity to cover almost 72 percent of Americans with health insurance in 1999 (OPEN MINDS, 1999). Driven by the goal of cost-containment, managed care refers to a variety of strategies for organizing, delivering, and/ or paying for health services. Its promise has been to improve access to health care by lowering its cost, reducing inappropriate utilization, relying on clinical practice guidelines to standardize care, promoting organizational linkages, and by emphasizing prevention and primary care. Managed care’s emphasis on treatment of mental health problems in primary



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