This Month's Highlights

The journal continues to celebrate its 50th anniversary year by examining important developments in the mental health field over the past five decades. Clozapine, the prototype atypical antipsychotic, was approved for use in 1990, and the reprinted 1993 article by Alan Brier, M.D., and his colleagues reports 12-month outcomes for a group of chronically ill outpatients taking clozapine (see page 1249). The study results supported those found in clinical trials. More than half of the patients responded to the new medication. They experienced sustained improvement in positive symptoms and significantly fewer hospitalizations. In a related commentary, Jeffrey A. Lieberman, M.D., and his colleagues discuss the significant changes brought about by the introduction of second-generation medications, including atypical antipsychotics and selective serotonin reuptake inhibitors (page 1254). In Taking Issue, Robert A. Rosenheck, M.D., notes that although it is important to celebrate the undeniable progress in pharmacotherapy, we should be cautious in not misleading the public (page 1213).

To determine the prevalence of dementia among elderly persons newly admitted to nursing homes, Daniel Weintraub, M.D., and his colleagues looked at a sample of 1,695 patients in nursing homes in Maryland. An expert panel of clinicians determined that 60 percent of the residents had dementia. Among the 280 black residents, the prevalence of dementia was 77 percent, compared with 57 percent among the 1,415 white residents. This significant difference in the prevalence of dementia among the newly admitted residents held up even when the analyses controlled for demographic and health characteristics known to be associated with dementia. The researchers speculate that elderly black persons with cognitive impairments may remain in the community longer than their white counterparts because of limited financial resources and greater psychosocial support (see page 1259).

The results of previous studies of whether clients who are assigned therapists of the same racial or ethnic background have better outcomes are difficult to interpret, largely because of methodological problems. Matthew J. Chinman, Ph.D., and his colleagues examined a rich array of outcome data for 1,785 clients of the ACCESS program sponsored by the Center for Mental Health Services. The program provided outreach and intensive case management to homeless persons with mental illness in 15 U.S. cities. The authors found that service use and outcomes for the African-American and white clients who were racially matched to case managers did not differ from those for clients who received treatment from case managers of a different racial or ethnic background. They conclude that case managers can treat homeless mentally ill persons of a different race as effectively as they can treat clients of their own race (see page 1265).

Burton Reifler, M.D., M.P.H., and his colleagues describe the development of a program operated by an academic psychiatry department to manage the care of enrollees in QualChoice, a health maintenance organization (HMO). The HMO was established at the Wake Forest University Baptist Medical Center in North Carolina in 1994. When the psychiatry department at the Wake Forest School of Medicine realized it could not yet provide case management and utilization review for the HMO, it hired a national for-profit managed behavioral health care organization. In 1996 the department was able to take over care management from the for-profit organization. The department-operated program was able to offer competitive rates for its services and effectively manage the care of QualChoice enrollees, producing higher clinical revenues for the department (see page 1273).

Researchers have begun to take advantage of the opportunity to examine the extensive database made available by United Behavioral Health (UBH), a large national managed behavioral health care organization. Scott N. Compton, Ph.D., and his colleagues looked at data from an enrollee group of 145,000 persons in Ohio to determine whether use of outpatient treatment sessions and costs would increase when UBH raised the preauthorized limit on sessions from five to ten. They found no differences between the five-session and ten-session periods. The authors hope that the findings will encourage managed behavioral health care organizations to explore the benefits of increasing limits on outpatient care. They note that these benefits may include lower operational costs of managing care and better relationships with providers and consumers (see page 1223).