This Month's Highlights

In this issue Psychiatric Services continues its series on evidence-based practices with two articles. In the first article, Kimberly Hoagwood, Ph.D., and her colleagues summarize the literature on evidence-based practice in children's mental health services. They caution that the evidence base for children's services is relatively new and that large-scale efforts to disseminate validated treatments for children should await further research on how these treatments fit into real-world practice settings (see page 1179). In the second article, Sonja K. Schoenwald, Ph.D., and Dr. Hoagwood discuss the growing literature on the diffusion of innovations, such as in agriculture and technology, and describe how knowledge gained from those studies can inform efforts to incorporate efficacious treatments into usual-care settings (see page 1190). Robert E. Drake, M.D., Ph.D., and Howard H. Goldman, M.D., Ph.D., are editors of the evidence-based practice series.

Mandating adherence to mental health treatment in the community through outpatient commitment is among the most contested issues in mental health law. John Monahan, Ph.D., and his colleagues note that focusing solely on outpatient commitment often leads to ideological posturing that must be replaced by an evidence-based approach. They describe outpatient commitment as only one of a number of legal tools that are used to mandate treatment adherence among patients in the community. For example, money—through the appointment of a representative payee—is often used as leverage to encourage adherence. The authors highlight areas for research on leveraged treatment and discuss legal, ethical, and political questions that must be addressed (see page 1198).

Another contentious issue in the mental health field is the extent to which 1996 legislation to halt Supplemental Security Income (SSI) payments to persons whose disability is related to substance abuse may have limited the care received by a vulnerable population with substantial psychiatric and medical problems. Katherine E. Watkins, M.D., M.S.H.S., and her associates report the results of a study of a random sample of 400 SSI beneficiaries in Los Angeles who were receiving benefits because of a substance-related disability when the legislation took effect in 1997. They found that the mental health of their subjects did not worsen, even in the case of individuals who were not reclassified under another disability and who therefore lost SSI benefits. Use of emergency services and hospitalization did not increase in the group that lost benefits. The authors speculate that local safety nets and a strong economy may have mitigated the effects of the federal policy change (see page 1210).

Many people with schizophrenia have comorbid psychiatric disorders that can exact a heavy toll on the quality of their lives. As part of the Schizophrenia Patient Outcomes Research Team study, 685 patients receiving treatment for schizophrenia were interviewed about other diagnoses that they had received. Lisa Dixon, M.D., M.P.H., and her coworkers report that nearly half of the interviewees had a lifetime diagnosis of depression and that a third had been told that they had an anxiety disorder. Caucasians were significantly more likely than African Americans to have received a diagnosis of depression or an anxiety disorder, even when other factors were controlled for. Caucasians were also significantly more likely to be receiving current treatment for comorbid disorders. The authors call for more cross-cultural competence among treatment professionals (see page 1216).

A study of nearly 600 patients in methadone treatment confirmed the importance of therapeutic rapport in engaging and retaining patients in treatment and improving outcomes. George W. Joe, Ed.D., and his colleagues asked counselors to rate rapport with their patients by using a multi-item instrument. Outcomes were measured at interviews conducted 12 and 18 months later. Rapport was significantly associated with five of six treatment outcomes, including opiate- and cocaine-negative urine tests and less frequent self-reported cocaine use, illegal activity, and arrests, even when the analyses adjusted for treatment retention, satisfaction with treatment, and posttreatment status. The authors describe five therapeutic strategies associated with rapport (see page 1223). Matthew J. Carlson, Ph.D., and Roy M. Gabriel, Ph.D., analyzed data from interviews with more than 300 patients in publicly funded substance abuse treatment at six months and one year. Satisfaction with access and effectiveness of services predicted service use at six months; these two variables plus service use were significantly associated with abstinence at one year, after demographic characteristics and baseline abstinence were controlled for (see page 1230).