Due to the deinstitutionalization movement which began over thirty years ago, community treatment programs for persons with severe mental illness have had to be developed to replace the services and support that were previously available in psychiatric hospitals. Apart from the Assertive Community Treatment (ACT) model, which has been much studied and shown to be superior both to other types of treatment and to controls, few consistent differences have been found among the different community treatment models. This may be partially due to the fact that the contribution of worker characteristics to client well being has not previously been taken into account. The effect that the individual worker has on the client and on treatment outcomes is comparable to therapist effects in the psychotherapy literature. This study was designed to examine the effects of worker characteristics on the well being of persons with severe mental illness living in the community. A sample of 65 people served by an ACT program were interviewed to obtain self-reports of subjective quality of life, symptoms and the relationship with their worker. The workers also rated their clients' level of functioning and each completed a self-report measure of attitudes toward mental illness. In addition, supervisors were asked to rate workers' competence on a newly-developed Competency Rating Scale. It was hypothesized that greater worker competency, a more positive attitude to mental illness, and a greater number of years working in the mental health field would have both direct and indirect effects (through the working alliance) on client well being in the form of better quality of life, fewer symptoms and improved functioning. It was found that a closer working alliance was associated with greater client well being in the form of greater quality of life and better functioning. Surprisingly, the strongest association found was between a greater number of worker years in mental health and quality of life, with workers who had more years experience in the field of mental health having clients who reported a lower subjective quality of life. It was suggested that workers who started in the field earlier may have learned and adopted a more restrictive philosophy about mental health treatment than that which is currently being taught.

Previous studies have indicated a tendency for older adults to under-utilize available services and medications for depression. Three studies were undertaken to provide representative Canadian data on rates of mental health service use by older Canadian adults with depression, in three domains: (1) mental health consultations with health care professionals, (2) utilization of psychoactive medications commonly used in treatment of late-life depression, and (3) mental health-related utilization of alternative or complementary services and products. An additional objective was to examine the relative effect of age on service utilization after accounting for other potentially relevant sociodemographic and clinical characteristics. Data for the studies was obtained from Statistics Canada's Canadian Community Health Survey, Cycles 1.1 (Study 1) and 1.2 (Studies 2 and 3). Older adults were less likely than middle-aged adults to seek mental health care services from any health care professionals, and especially from specialty mental health professionals (psychologists or psychiatrists). Compared to middle-aged adults, older adults used antidepressant medications at a lower rate and benzodiazepines at a higher rate. Age-related patterns in mental health-related use of CAM did not directly correspond to age-related patterns in conventional mental health care utilization. The results of the three dissertation studies clearly indicate that mental health utilization patterns continue to differ significantly among middle-aged, younger- and older-older adults with depression. These findings have significant implications in terms of initiatives to improve the recognition and treatment of late-life depression.

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