Background: A majority of adults with common mental disorders do not seek professional help. To better understand why not, we examined the correlates of various stages of help-seeking, including perceived need for professional help, seeking such help, and from which professionals participants sought help.

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Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

Trust in medicine contributes to effective communication, cooperation in treatment, and the ability to cope with uncertainties. Social trust in medicine reflects public attitudes and is shaped by media and current events. Interpersonal trust depends on the degree to which patients see their doctors as competent, responsible, and caring. The commercialization of medical care, conflicts of interest, media attention to medical uncertainty and error, and the growth of managed care all challenge trust. Trust is encouraged by patient choice, continuity of care, and encounter time that allows, opportunities for feedback, patient instruction, and patient participation in decisions. An informal inquiry of medical leaders indicates that most believe trust is eroding. Institutions are taking measures to help restore trust: eliciting patient feedback; providing more information for patients are the public; improving staff education and sensitivity training; paying attention to clinicians' interpersonal skills; sponsoring support groups; instituting patient empowerment projects; and focusing on ethics issues.

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Patients with schizophrenia at high risk for medication noncompliance after acute hospitalization are characterized by a history of medication noncompliance, recent substance use, difficulty recognizing their own symptoms, a weak alliance with inpatient staff, and family who refuse to become involved in inpatient treatment.

Trust, the expectation that institutions and professionals will act in one's interests, contributes to the effectiveness of medical care. With the rapid privatization of medical care and the growth of managed care, trust may be diminished. Five important aspects of trust are examined: technical and interpersonal competence, physician agency, physician control, confidentiality, and open communication and disclosure. In each case, changing health care arrangements increase the risks of trusting and encourage regulatory interventions that substitute for some aspects of trust. With the increased size and centralization of health care plans, inevitable errors are attributed to health plans rather than to failures of individual judgment. Such generalized criticisms exacerbate distrust and encourage micromanagement of medical care processes.

Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.