June 2004: This Month's Highlights

Although significant efforts have been made to encourage the adoption of evidence-based practices in routine care settings, progress has been disappointing. The possibility has been raised that there is insufficient published evidence to persuade clinicians and policy makers to adopt such practices. Martha Shumway, Ph.D., and Tetine L. Sentell, Ph.D., examined whether the data needed to inform evidence-based practice can be found in leading mental health journals. They reviewed 1,076 research articles published in 12 mental health journals in 1999. Their overall finding was that the data needed to inform and advance evidence-based practice does not have the prominent place it deserves in such journals. Twenty-seven percent of the articles reviewed described research that evaluated interventions. Of these, 84 percent described studies conducted in specialty mental health settings, and very few (4 percent) described studies conducted in public mental health or managed care environments. Evidence of the effectiveness of treatments for diagnoses other than schizophrenia and mood disorders was limited (see page 649).

Patients who exhibit aggressive or criminal behavior are at high risk of rehospitalization and rearrest after discharge from an inpatient facility. Michael Kunz, M.D., and his colleagues report on the impact of a long-term behaviorally based cognitive skills program administered to a group of such high-risk inpatients. Of 85 patients followed for between six months and two years after discharge, 33 remained stable in the community, 35 were rehospitalized, and 17 were arrested. Several predischarge variables were associated with rehospitalization or arrest: comorbid antisocial personality disorder, higher score on the Psychopathy Checklist, history of arrests for violent crimes, and history of learning disability. Patients who developed substance use problems or did not adhere to medication treatment after discharge were more likely to be rehospitalized or arrested.The authors envision the use of these predictors of poor outcome to develop a follow-up program that focuses on high-risk patients (see page 654).

Persons with severe mental illness, particularly those with a history of comorbid substance use disorders, have a highly elevated risk of HIV, hepatitis B, and hepatitis C infection. However, most clients with severe mental illness do not receive basic best-practice services such as prevention, early detection, and effective treatment of these diseases. Stanley Rosenberg, Ph.D., and his colleagues describe a public health model intervention designed to deliver basic best-practice services for blood-borne diseases to clients with severe mental illness and co-occurring substance use disorders. The brief intervention, called STIRR (screen, test, immunize, reduce risk, and refer), is delivered at the site of mental health care by a mobile team of specialists. The authors also describe a pilot study to evaluate the STIRR model in two publicly funded community mental health centers, the results of which are promising (see page 660).

Patients over the age of 65 are statistically underrepresented in psychiatric emergency departments. Various special considerations exist for geriatric patients in this setting—for example, their high rate of comorbid medical and neurologic problems. In this month's Emergency Psychiatry column, Ole J. Thienhaus, M.D., and Melissa P. Piasecki, M.D., provide ten guidelines for clinicians in the psychiatric emergency service to consider when treating older patients, including the need to communicate with a third party, to assess cognitive functioning, to thoroughly screen for suicidal ideation and behavior, to consider the situation that awaits the patient after discharge, and to consider the possibility of elder abuse. The authors note that the careful assessment of geriatric patients should be the first step in a well-designed treatment plan and that it will greatly enhance the prospect of a safe disposition (see page 639).

• In a study of variations in the use of second-generation antipsychotics among patients from ethnic minorities, African Americans tended to receive medications that are not first-line recommended treatments and that have a greater risk of side effects (see page 677).

• A study of the health and well-being of black women who were caring for their adult offspring with schizophrenia revealed elevated rates of chronic health conditions among these women, including high blood pressure, arthritis, and eye problems (see page 711).