May 2006: This Months Highlights

In this month's issue Larry Davidson, Ph.D., and his colleagues, who conduct training sessions on recovery-oriented care, describe the top ten concerns that they have encountered among professionals. Two themes are common—concerns about resources and risk. The authors address some of the misconceptions about recovery-oriented care that lie behind these concerns ( page 640 ). The article is the second in a series on system transformation supported by a grant to Psychiatric Services from the Substance Abuse and Mental Health Services Administration. In his accompanying commentaries, Paolo del Vecchio, M.S.W., focuses on ways to overcome stigma and discrimination ( page 646 ). In a second commentary, Faith B. Dickerson, Ph.D., raises several questions from the standpoint of "an empirically oriented practitioner" ( page 647 ).

Most of the articles in this issue are related to the use and costs of psychotropic medications. The lead article reviews the quality of antidepressant treatment in primary care. The authors discuss four points in the process when many physicians deviate from guideline-concordant care, and they present evidence supporting guideline adherence ( page 623 ). A team from the Texas Medication Algorithm Project used extensive analyses to break down annual costs of algorithm-based care into more meaningful components ( page 648 ). To obtain a picture of the standard of care for bipolar disorder, investigators from the STEP-BD study (Systematic Treatment Enhancement Program for Bipolar Disorder) looked at the types of medications that were being taken at study entry by the first 500 participants ( page 660 ). In another study of bipolar disorder, researchers found racial differences in the prescription of concomitant medications (polypharmacy) and medication switching in a sample of 1,113 adults ( page 666 ). Among 13,000 patients newly treated for anxiety disorders, medication nonadherence at six months was common—and costly in terms of medical care ( page 673 ). An analysis of Medicaid claims data found widespread off-label use of anticonvulsants for psychiatric disorders among children and adolescents ( page 681 ). A study in Oregon documented negative consequences for patients when the state Medicaid program cut methadone benefits for some groups ( page 686 ). Analyses of national survey data from past-year users of mental health treatment found that alcohol-dependent respondents who received psychiatric medications were much more likely than those who did not to report that their treatment was effective ( page 692 ). A prospective survey of psychiatrists at five German hospitals identified factors in the early adoption by some psychiatrists of an antipsychotic after its marketplace introduction ( page 700 ).

To identify contextual factors in the U.S. health care system that might be modified to improve service use, researchers compared treatment seeking for depression in Canada and the United States. Ramin Mojtabai, M.D., Ph.D., and Mark Olfson, M.D., M.P.H., analyzed data from 751 individuals with probable past-year major depression who participated in the 2002-2003 Joint Canada/United States Survey of Health. The prevalence of contacts with providers was similar in both countries. However, the authors found a closer correspondence between the severity of depression and treatment seeking in Canada, suggesting that allocation of mental health resources may be more efficient in that country ( page 631 ).

In a study of children receiving community-based care, Carrie W. Rishel, Ph.D., and her colleagues assessed 272 mother-child pairs at treatment entry and three months later. Children of mothers with mental health problems had a significantly poorer treatment response than children of mentally healthy mothers, suggesting that concomitant interventions with mothers could improve children's treatment ( page 716 ). The Frontline Reports column describes the Clubhouse Family Legal Support Project in Massachusetts, which offers pro bono representation to parents at risk of losing custody of their children, and an inpatient psychiatric unit in Switzerland that provides assessment and treatment in a supportive environment for mothers experiencing postpartum depression, psychosis, or substance-related disorders—often through joint hospitalization of mothers and infants ( page 720 ).

• An expanded books section reviews first-person accounts of mental illness ( page 726 ), and in Taking Issue, Jeffrey L. Geller, M.D., M.P.H., the book review editor, describes the important role of such accounts in the history of psychiatry ( page 607 ).