This Month's Highlights

For most of past two decades, California's prison population has exceeded 200% of capacity. Images of gymnasia converted to dormitories filled with triple-bunk beds have been featured in media stories. Since 1995 the prison mental health system in California has been monitored by a special master, appointed after a federal court found that the state was “deliberately indifferent” to prisoners' psychiatric needs. In 2007 the special master reported that any system improvements had “succumbed to the inexorably rising tide of population.” In 2008, concluding that overcrowding was the primary cause of the failure to provide adequate treatment, the court ordered California to reduce its prison population to no more than 137.5% of capacity within two years. In the fall of 2010 California appealed this order to the U.S. Supreme Court. In this month's Law and Psychiatry column, Paul S. Appelbaum, M.D., reviews the Supreme Court case, which has implications for other states with overcrowded prisons (page 1121). In a Taking Issue commentary, Henry J. Steadman, Ph.D, notes that the issue of prison overcrowding will intersect in 2014 with full implementation of health care reform, creating opportunities to prevent unnecessary incarceration of people with mental health needs (page 1117).

As this issue goes to press, the U.S. Census Bureau's report of high rates of poverty and uninsurance among Americans is making headlines. Also in the news is health care reform, with its goal of providing better access to treatment by insuring more Americans. Are people with mental illnesses more likely to be uninsured than people without these disorders? And if so, will full implementation of reform in 2014 lower their uninsurance rates? A study in this issue by Tara W. Strine, Ph.D., M.P.H., and colleagues sought to document trends in uninsurance rates in the U.S. population during four time periods since 1993 in order to provide baseline data for assessing whether health care reform is accompanied by the expected changes. The authors examined 1993–2009 data from the Behavioral Risk Factor Surveillance System to determine the prevalence of uninsurance by self-report of frequent mental distress and frequent physical distress. Uninsurance rates were disproportionately high among adults with frequent mental distress (22.6%), compared with those who reported frequent physical distress only (17.7%) (page 1131).

This month's Best Practices column examines the long-term impact of an initiative to reduce overprescription of antipsychotics in the New York State Office of Mental Health's (OMH's) inpatient network of 20 adult psychiatric hospitals. Molly T. Finnerty, M.D., and colleagues describe the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES), a Web-based application that promotes adherence to practice guidelines by supporting clinical decision making and quality improvement. PSYCKES was implemented in 2005 at the same time that OMH leaders began to question the value of prescribing a third antipsychotic for any inpatient. The authors show how PSYCKES helped reduce the prevalence of antipsychotic polypharmacy over two implementation phases—from 16.9 patients per 1,000 to 3.9 per 1,000—as well as over the long term (page 1124).

Research has shown that physical symptoms that do not have a clear medical explanation are much more disabling than symptoms of general medical conditions or mental disorders such as depression. A study by Shula Minsky, Ed.D., and colleagues examined the relationship of physical symptoms to use of services among adults seeking treatment at a community mental health center (CMHC). Nearly three-quarters of intake patients reported three or more physical symptoms. This subgroup used significantly more services. Both the number and the costs of services increased with the number of physical symptoms at intake, even after analyses controlled for confounders (page 1146).

From 1979 through 2006, the proportion of hospitalizations with a primary diagnosis of bipolar disorder has increased 10% per year, according to analyses of National Hospital Discharge Survey data conducted by Natalya S. Weber, M.D., M.P.H., and colleagues. Discharge records of patients with a primary diagnosis of bipolar disorder showed higher proportions of most psychiatric conditions and some general medical conditions. The authors note that patients with bipolar disorder have a high disease burden and that physicians' awareness of comorbidity in this population is critical to improving prognosis (page 1152).