November 2006: This Month's Highlights

Four articles in this month's issue report on child and adolescent mental health services research. In the first study Tami L. Mark, Ph.D., and Jeffrey A. Buck, Ph.D., analyzed data from a national sample of more than 10,000 youths and found that those with serious emotional disturbances were overrepresented among low-income families, among those who had public insurance or were uninsured, and among African Americans and Hispanics ( page 1573 ). The second and third articles take a closer look at wraparound services. Janet S. Walker, Ph.D., and Eric J. Bruns, Ph.D., used consensus building with a multidisciplinary group of national experts to develop a four-phase model of the wraparound process that encompasses a core set of activities ( page 1579 ). Dr. Bruns and other colleagues surveyed families and administrators at eight sites that were providing wraparound services in seven states. They found wide variation in fidelity to the process and a lack of important organization- and system-level supports for effective implementation ( page 1586 ). In the fourth article Maryann Davis, Ph.D., and colleagues present data from a U.S. survey showing that states provide minimal services to support the transition from adolescence to adulthood of youths with serious mental health conditions ( page 1594 ).

Analyzing ten years of data from a psychiatric case register in Australia, Steven P. Segal, Ph.D., and Philip M. Burgess, Ph.D., found a high rate of conditional release—the use of court orders by mental health professionals to ensure oversight of individuals in the community and to facilitate their rehospitalization if symptoms warrant. For the nearly 9,000 patients who were conditionally released, inpatient episodes were briefer than they were for the 16,000 who were not conditionally released, but the former group spent significantly more time in restrictive care—inpatient care plus the conditional release period ( page 1600 ). Although the death rate over 13.5 years was higher for psychiatric patients than for the general population, those who experienced conditional release had a lower mortality risk ( page 1607 ). The authors also found that use of conditional release early in the course of illness appeared to contribute to reduced subsequent use of inpatient care. They investigated patient characteristics associated with early use of this intervention ( page 1614 ). In a related Taking Issue, Robert Bernstein, Ph.D., notes that clinicians' reliance on conditional release may send an incorrect message that the ineffectiveness of community services offers no recourse but the legal system ( page 1553 ).

In this month's Open Forum Patricia E. Deegan, Ph.D., and Robert E. Drake, M.D., Ph.D., argue that the concept of treatment compliance is rooted in medical paternalism and at odds with person-centered care and evidence-based medicine. They present a rationale for adoption of the shared decision-making approach in which the client and practitioner work through decisional conflicts together. The practitioner's role is not to ensure compliance but to help the client learn to use medications and other coping strategies in the process of learning to manage his or her illness. The authors discuss how the language of medical authority and coercion is replaced with other terms and concepts ( page 1636 ).

A critical ethical concern in schizophrenia research is the extent to which people with serious mental illness understand the risks of participating. Laura Weiss Roberts, M.D., and her colleagues looked at how 43 people with schizophrenia and 68 psychiatrists rated the risk of 12 research procedures. The groups agreed on the four riskiest procedures—for example, induction of psychotic symptoms and medication discontinuation for two weeks. They also agreed that the risks of the 12 procedures did not differ greatly from the usual daily risks of living with schizophrenia. The authors note that if these results are considered benchmarks, then the 12 procedures may fall under the "minimal risk" standards used in an institutional review board review ( page 1629 ).

• The State Mental Health Policy column describes Ohio's implementation of crisis intervention teams ( page 1569 ).

• A research team from New York and South Africa reports on the effectiveness of an HIV intervention program for mental health care professionals ( page 1644 ).

• In Innovations: Evidence-Based Practices, a six-step method is described for calculating the population impact of introducing an evidence-based intervention ( page 1558 ).