This Month's Highlights

The Shame of the States, published in 1948, exposed the shocking conditions at 20 state mental hospitals and was one of the factors contributing to the deinstitutionalization movement. Forty-two years later, deinstitutionalization itself was labeled the second shame of the states, in part because of the lack of adequate services in many communities and the related rise in homelessness and incarceration among persons with mental illness. In this issue, Carol T. Mowbray, Ph.D., and her coauthors argue that implementation of managed behavioral care in the public sector threatens to become the third shame of the states unless policy makers, planners, and all stakeholders learn from the failures of deinstitutionalization. The authors discuss parallels between the course of that movement and the growth of managed care. They describe the benefits and the negative effects of each movement and present recommendations for improving public-sector managed care on the basis of lessons learned from deinstitutionalization (see page 157).

U.S. employers report annual losses of $24 billion from absenteeism and reduced productivity related to depression in the workforce. The annual loss to business and industry from substance use disorders is estimated at $100 billion. In the Economic Grand Rounds column, Lloyd I. Sederer, M.D., and Norman A. Clemens, M.D., paint a detailed picture of the high costs to employers of untreated psychiatric illness among workers. They describe an initiative launched by the American Psychiatric Association in 2001 to meet with corporate and industry leaders to present the business case that mental health care is a good investment and that every dollar spent on providing high-quality care will return more than that dollar to the purchaser of care—the employer (see page 143).

According to a 1999 U.S. Bureau of Justice survey, 16 percent of male state prisoners have a mental illness—four times the community rate. The figure is 24 percent for female state prisoners, which is six times the community rate. In response to the growing need for mental health services in correctional systems, the University of Massachusetts Medical School, in partnership with a private vendor of correctional health care, began providing mental health services to the Massachusetts Department of Correction in 1998. Kenneth L. Appelbaum, M.D., and his associates describe the benefits to medical schools of expanding their services to include the correctional population. They also describe the accomplishments of the university-state-corporation partnership in Massachusetts and some of the elements that have been critical to its success (see page 185).

Danielle L. Loosbrock, M.H.A., and her colleagues examined data for more than 3,200 patients who received first-time prescriptions from either a psychiatrist or a primary care physician for one of six commonly used serotonergic antidepressants. They assessed whether the drug was appropriate for the indication for which it was prescribed and whether the starting dosages were those recommended by the manufacturer. They found that depressive disorders accounted for the majority of prescriptions for the six drugs (between 74 percent and 86.2 percent). The next most common indications for use were anxiety (4.1 percent to 12.6 percent) and obsessive-compulsive disorder (1.3 percent to 3.3 percent). The mean starting dosage for each drug was close to the recommended dosage. Psychiatrists tended to prescribe slightly higher initial dosages than primary care physicians (see page 179).

Dialectical behavior therapy (DBT) is a cognitive-behavioral approach to treating borderline personality disorder. It is the only psychosocial treatment for this disorder that has demonstrated success in several controlled trials, although empirical results are not sufficient to establish DBT as an evidence-based practice in community settings. In this issue, Charles R. Swenson, M.D., and his coauthors briefly describe DBT, review and critique its research base, speculate on the reasons for DBT's appeal to practitioners, identify barriers to implementing DBT in public mental health systems, and describe strategies for overcoming those barriers (see page 171).

• In the Practical Psychotherapy column, Raymond S. Hoffman, M.D., argues that clinicians providing supportive psychotherapy do not always have to steer clear of a patient's defenses (see page 141).

• The Best Practices column describes strategies used by mental health authorities in New York State to implement evidence-based practices for people with serious mental disorders (see page 153).