October 2007: This Month's Highlights

Subsyndromal depression—depressive symptoms below the threshold for a diagnosis of depression—is common and associated with substantial morbidity. However, there is little evidence for the efficacy of treatments for this condition. In this month's issue Kenneth B. Wells, M.D., M.P.H., and colleagues present findings from a two-year, multisite study of nearly 750 patients indicating that systematic efforts to improve primary care providers' recognition and treatment of depression were cost-effective, especially for patients with subthreshold depression. The quality improvement interventions in the Partners in Care initiative focused on medication adherence and provision of cognitive-behavioral therapy ( page 1269 ). In a related Taking Issue commentary on these findings, Benjamin G. Druss, M.D., M.P.H., speculates about reasons for the positive outcomes for these patients when other studies have found only limited effectiveness for treatment of subthreshold depression ( page 1255 ).

The President's New Freedom Commission has emphasized the critical role of school mental health services in filling gaps in care. In this month's issue, Sharon Hoover Stephan, Ph.D., and colleagues present results of policy analyses that sought to identify the most important connections between the commission's recommendations and school mental health services. In addition to discussing the commission's specific recommendation to improve school programs, the article addresses the special role that schools play in advancing three others—reducing stigma, preventing suicide, and screening and treating comorbid mental and substance use disorders. The authors also present strategies for undertaking system transformation as called for by the commission ( page 1330 ). In an accompanying brief report the authors summarize recommendations for change that were made by focus groups of school stakeholders in three states ( page 1344 ). The article is the eighth in a series addressing the New Freedom Commission's goals. The series is supported by a contract with the Substance Abuse and Mental Health Services Administration. In another article in this issue, Lisa H. Jaycox, Ph.D., and colleagues report on interviews with officials at schools in four states that received students who were displaced by Hurricanes Katrina and Rita ( page 1339 ).

The use of evidence-based practices can improve the lives of people with serious mental illness. However, implementing these interventions in a way that is faithful to the original model is a critical element in their effectiveness. Gregory J. McHugo, Ph.D., and colleagues examined fidelity of implementation of five evidence-based practices—supported employment, assertive community treatment, integrated dual disorders treatment, family psychoeducation, and illness management and recovery. These practices were implemented over two years at 53 community mental health centers in eight states that were participating in the National Implementing Evidence-Based Practices Project. Fidelity was assessed every six months by independent assessors. At the end of two years 53% of the sites showed high-fidelity implementation. Some practices were implemented with significantly greater fidelity. After the 12-month mark fidelity improved little, but sites that had achieved fidelity were able to sustain it for another year ( page 1279 ).

In January 2006 people dually eligible for Medicaid and Medicare, many of whom have serious mental disorders, were required to transition from Medicaid coverage for medications to Medicare Part D drug plans. Advocates have raised concerns about disruptions in medication regimens because of formulary exclusions and utilization controls. Because data for a full assessment of Part D's impact will not be available for some time, Julie Marie Donohue, Ph.D., and Richard Gabriel Frank, Ph.D., used data from several sources to estimate the level of disruption. They found that formulary restrictions on psychotropic medications were common among the drug plans they studied. Estimated rates of medication switching attributable to Medicare Part D were 6%–10% among beneficiaries using antipsychotics, 5%–7% among those using antidepressants, and 2%–4% among those using mood stabilizers. The authors concluded that relatively few dually eligible beneficiaries with mental disorders are likely to experience disruptions. However, beneficiaries in some plans will experience significant barriers to medication access ( page 1285 ).

• Programs that won 2007 Gold, Silver, and Bronze Achievement Awards from the American Psychiatric Association are described in a special report ( pages 1366–1368, 1369–1371, 1372–1374 ).