April 2006: This Month's Highlights

Under the Ticket to Work program, individuals with disabilities receive vouchers to redeem for vocational services from local providers of their own choosing. The program seeks to create competition among providers of such services, thereby improving access and quality. Providers receive payments from the program only for months in which clients' earnings reach a certain threshold. A study in this issue demonstrates that the provider payment mechanisms do not reflect the reality of vocational rehabilitation for people with psychiatric disabilities. Judith A. Cook, Ph.D., and colleagues examined earnings data for 450 participants in a large multisite study—the Employment Intervention Demonstration Program—to determine the extent of reimbursement that vocational service providers would have received had the sample been enrolled in the Ticket to Work program. The authors calculated outcomes on the basis of the program's two reimbursement methods. Under the first method, participants' earnings seldom reached levels that would have triggered payments to providers. Under the second, payments would not have covered providers' costs. The authors recommend changes in the Ticket to Work program to make it more effective for people with psychiatric disabilities ( page 465 ).

Three studies examine issues in the provision of care to children. In a literature review, Jeanie Tse, M.D., found little research on the effectiveness of day programs, despite their prevalence as a treatment modality for preschoolers with disruptive disorders. She also found that many interventions shown to be effective among children with disruptive disorders have not made their way into clinical settings. Among them are social-skills and problem-solving training that are part of several manualized curricula and particular types of parent and teacher training ( see page 477 ). Bethany R. Lee, M.S.W., and colleagues explored the experiences of 389 older adolescents in foster care who were receiving mental health services. Comments in interviews of 144 youths who reported having a positive service experience and 101 who reported a negative experience highlighted the importance of supportive relationships with mental health professionals who listen and are accessible ( page 487 ). In a study of more than 4,800 mothers who were Medicaid beneficiaries, Jun Min Park, Ph.D., and colleagues found that those with serious mental illness were three times as likely as other mothers to have children placed in out-of-home care or to receive in-home preventive services from the child welfare system ( page 493 )

Two articles report studies of the effects of race or ethnicity and gender on use of and need for services. Craig Anne Heflinger, Ph.D., and colleagues used Medicaid data from more than 170,000 adolescents in the TennCare program to examine differences in use of substance abuse services. The researchers found that less than 1 percent had used a substance abuse service in the past year; rates of use for white and male enrollees were twice as high as those for black and female enrollees ( page 504 ). Frederick Y. Huang, M.D., and coauthors examined functional impairment associated with depression among Latinos, African Americans, and non-Hispanic whites. The three groups did not differ in severity of depression, but Latinos reported significantly less functional impairment than non-Hispanic whites. The authors note that stoicism in the face of depressive symptoms may partly explain the high levels of unmet need for treatment among some racial and ethnic groups ( page 498 ).

In this month's Law & Psychiatry column, Patricia R. Recupero, J.D., M.D., describes ways in which problems can arise for psychiatrists who fail to apprise themselves of legal and ethical concerns related to Web sites. For example, certain statements made on Web sites constitute advertising and may be considered express warranties. On interactive sites, advice giving—even if no fee is involved—may be sufficient to establish a physician-patient relationship and a duty of care. Moreover, a psychiatrist who uses a highly interactive site to provide services to an out-of-state client may be unwittingly practicing without a license in the visitor's home state. Dr. Recupero provides a list of recommendations to help guide decisions about Web site structure and content ( page 450 ).

• A report by the American Psychiatric Association's task force on research ethics details issues related to conducting research involving persons with mental illness ( page 552 ).