This Month’s Highlights

This issue features the final literature review in the Assessing the Evidence Base (AEB) Series. Sharon Reif, Ph.D., and colleagues found a moderate level of evidence for the effectiveness of peer recovery support for individuals with substance use disorders. Peer recovery support providers highlight their own lived experience and act as recovery catalysts to motivate and empower clients. They help clients acquire resources to restructure their lives and achieve and maintain recovery, often acting as liaisons with formal behavioral and general medical treatment services, housing and employment programs, and other systems. More broadly, peer providers serve as advocates for the individual and for the recovery community. Research has demonstrated reduced relapse rates, increased treatment retention, improved relationships with treatment providers, and increased satisfaction with the overall treatment experience. Dr. Reif and colleagues conclude by describing research needed to build a more robust evidence base for these services, which remain outside the traditional provider spectrum and are thus inconsistently reimbursed (page 853). The AEB Series, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), has provided updates of research on 13 commonly used interventions for people with serious mental illnesses. In a Taking Issue commentary, SAMHSA Administrator Pamela S. Hyde, J.D., and Miriam Delphin-Rittmon, Ph.D., an AEB Series author, underline the importance of implementing services with demonstrated effectiveness, as well as the need for innovation and ongoing research to improve outcomes for individuals, families, and communities (page 841).

How prevalent is mental illness in U.S. state prisons? Despite consistent research attention to this topic, only two federal self-report surveys are typically cited—more than 1,100 times according to a recent Google Scholar query. To provide a broader picture of the issue, Seth J. Prins, M.P.H., undertook a systematic review that included 28 articles published between 1989 and 2013. Estimates of current and lifetime prevalence of mental illnesses varied widely—likely as a result of differences in the definitions of mental illnesses, sampling strategies, and case ascertainment strategies used. For example, estimates among state prisoners ranged from 9% to 29% for current major depression, from 5.5% to 16.1% for bipolar disorder, and from 2% to 6.5% for schizophrenia. Ranges were much greater—and tended to be higher—in prisons than in community samples. The author notes that because the United States incarcerates a greater number of individuals than any other country, no discussion of community mental health is complete without consideration of the prevalence of mental illness in prisons and the policies that contribute to it (page 862). In a commentary, Jeffrey Draine, Ph.D., and Miguel Muñoz-Laboy, Dr.P.H., call for “deinstitutionalization of the justice system,” which would move incarcerated individuals from prisons and jails and into less conventional, community correctional settings (page 873).

Patients who continue to exhibit symptoms of psychosis despite adequate trials of medication can benefit from cognitive-behavioral therapy (CBT), according to a meta-analytic review of 16 published articles from 12 randomized controlled trials. Amy M. N. Burns, M.Ed., and colleagues summarize evidence that CBT is associated with robust improvements in the positive symptoms of psychotic disorders. Their meta-analysis indicated an overall mean weighted effect size for positive symptoms of .47, indicating a medium effect size on completion of treatment. Findings suggest that patients with medication-resistant psychosis may derive more benefit from CBT than from being prescribed adjunctive medications, the authors note (page 874).

This month’s Law & Psychiatry column highlights the results of two recent court cases suggesting that the original promise of the Americans with Disabilities Act (ADA) is finally being realized—nearly 25 years after its enactment. The two settlement agreements between the U.S. Department of Justice and the states of New York and Rhode Island promise sweeping change in housing and employment for thousands of individuals with mental disabilities. John Petrila, J.D., LL.M., notes that the settlements “are the latest examples of what appears to be a broad effort on the part of the current Department of Justice leadership to aggressively use the ADA and the mandate of Olmstead to leverage the integration of people with mental illnesses into community life in areas essential to community tenure” (page 847).

◆The Open Forum describes a clinical staging model that allows clinicians to better match the needs of children and adolescents with the appropriate level of care (page 939).

◆The Case Studies in Public-Sector Leadership column highlights how psychiatry residency training is changing to promote new competencies (page 844).