This Month's Highlights

As consumers turn increasingly to the World Wide Web to learn about health care, concerns have grown about the quality of available information. Web sites can be operated by virtually anyone, with minimal regulation, and no mechanisms are in place to correct misinformation. In this issue, Thomas L. Lissman, M.D., and James K. Boehnlein, M.D., review the quality of information produced by online searches for Web sites that discuss the treatment of depression. They entered the phrase "depression and treatment" into ten major Internet search engines and examined the first 20 sites generated by each. The authors found that the information is generally of poor quality, particularly among for-profit sites. Although many high-quality sites discussing depression are available, only two appeared among the first 20 items in these searches (see page 1046).

The co-occurrence of mental and substance use disorders is widespread and complicates delivery of appropriate care. In this issue, Katherine E. Watkins, M.D., M.S.H.S., and colleagues, using data from the 1997-1998 Healthcare for Communities survey, examine the adequacy and appropriateness of the care delivered to persons with probable co-occurring mental and substance use disorders. They found that the majority of those identified as having probable co-occurring disorders had received neither mental health treatment nor substance abuse treatment during the previous year. Among those who had received some treatment, most had not received treatment for both disorders. Men and persons who lacked health insurance were least likely to have received appropriate treatment. Those who had been on probation or in prison in the previous year were the most likely to have received substance abuse treatment (see page 1062).

Although the number of homicides committed by mentally ill persons constitutes only a small proportion of the total, these incidents often receive wide media coverage. In this issue, Marion E. Sherman, M.D., and coauthors evaluate a firearms risk management program that was developed and implemented in their psychiatric care system. Assessments are conducted at admission to identify at-risk patients, notably those who have access to firearms and have made threats to harm self or others. Treatment plans are then designed to address risk factors, such as by having family members remove firearms from the patient's home and by enrolling the patient in group therapy to develop self-control and coping skills (see page 1057).

Rates of cocaine abuse are higher among persons who have schizophrenia than in the general population, and treatment of patients who have schizophrenia and abuse cocaine is often challenging. In this issue, Genata Carol, Ph.D., and colleagues report a preliminary study comparing cocaine craving among cocaine abusers with and without schizophrenia. They used a questionnaire to measure intensity of craving among study subjects, and they administered the questionnaire again 72 hours later to evaluate craving stability. They found that although craving stability was similar for the two groups, participants with schizophrenia reported significantly higher levels of craving and of the subcomponent measures of depression and energy level and worse feelings (see page 1029).

In this month's Psychopharmacology column, Steven J. Kingsbury, M.D., and his colleagues discuss some of the pitfalls of polypharmacy, which they define as use of one or more drugs of the same class in the treatment of a single disorder. Any polypharmacy, they note, can increase the risk of drug interactions and adverse effects as well as patient noncompliance with the medication regimen. Some forms of rational polypharmacy are inevitable, such as using one drug to treat the side effects of another for which no better alternative is available. However, irrational polypharmacy, such as using more than one benzodiazepine or antipsychotic, is almost always avoidable (see page 1033).

• William H. Fisher, Ph.D., and his colleagues identify some of the characteristics of patients who in recent years have had long stays in state psychiatric hospitals (see page 1051).

• Roderick Shaner, M.D., describes the experience of the Los Angeles County Department of Mental Health in developing practice guidelines for psychotherapy (see page 1021).

• This month's books section starts with two books on the enduring effects divorce has on children after they become adults (see page 1108).