This Month’s Highlights

The Affordable Care Act is moving the U.S. health system toward service delivery models that will require greater integration of primary and behavioral health care. This month the journal introduces the Integrated Care column, edited by Benjamin G. Druss, M.D., M.P.H., of the Rollins School of Public Health at Emory University. The column will focus on initiatives to promote integration. As Dr. Druss notes in his introduction, contributions to the column will answer key questions: What are the active ingredients in integrated models? What are the roles of different provider groups? And how well do different approaches work? In the inaugural column, Margaret A. Swarbrick, Ph.D., a leader in designing and evaluating consumer-led wellness programs for people with serious mental illness, describes how the peer movement has grown to include wellness as a component of recovery and what roles peer wellness specialists can play on integrated care teams (page 723). Three other articles report on “whole-health” approaches to care. In a controlled trial, Stephen J. Bartels, M.D, M.S., and colleagues found significant improvements in cardiorespiratory fitness among people with serious mental illness who were given a fitness club membership and a health mentor (page 729). Richard W. Goldberg, Ph.D., and coauthors describe negative findings from a weight loss program for veterans with serious mental illness that highlight challenges in designing and implementing lifestyle interventions for this population (page 737). Derek D. Satre, Ph.D., and colleagues analyzed data from a sample of nearly 2,500 HIV-infected patients to determine the role of behavioral disorders in treatment seeking (page 745).

To ensure that consumer perspectives inform service design and delivery, many research groups are eliciting input from service users, as indicated by three studies. In East London, Claudia Hallett, B.Sc., and colleagues interviewed outpatients with schizophrenia and bipolar disorder to explore what they wanted to learn about their illness and what sources and formats they preferred for learning this information. About two-thirds reported wanting to learn more, and “cause of the illness” was the top information need. Nine of ten patients preferred to learn through one-to-one conversations with their psychiatrist (page 764). For people with serious mental illness, disengagement from care can lead to repeated hospitalizations, homelessness, and incarceration. When Thomas E. Smith, M.D., and colleagues interviewed individuals in New York City with established histories of service disengagement, they learned that most were willing to participate in services and endorsed their value but said that the services were not relevant to their needs. Their care providers, however, expressed different views (page 770). In seven focus groups with New York service users, Sara M. Bergstresser, Ph.D., M.P.H., and colleagues explored how voting and other forms of political engagement are related to a sense of social inclusion and “social recovery” (page 819).

Environmental factors can have deleterious or beneficial effects on functioning and disability. A study of Philadelphia neighborhoods that have high concentrations of persons with serious mental illness highlights the environmental challenges of living in the community. When Thomas Byrne, Ph.D., and colleagues used U.S. census data to characterize the neighborhoods of more than 15,000 adults with serious mental illness, they found that the neighborhoods had higher levels of physical and structural inadequacy, drug-related activity, and crime than those of a randomly generated comparison sample of Philadelphia adults (page 782). Two studies examined aspects of the built environment of psychiatric units, the therapeutic—and nontherapeutic—aspects of which have long been recognized. In England, Bart Sheehan, M.D., D.M., and colleagues evaluated the designs of nearly 100 inpatient psychiatric wards and found that staff satisfaction was associated with two features: a non-corridor design and personal bathrooms for patients (page 789). A Canadian research team surveyed individuals who had received care for mood and anxiety disorders on an inpatient unit—some before and some after its redesign. Karen A. Urbanoski, Ph.D., and colleagues found that patients treated on the newly designed unit perceived greater peer support and autonomy, which appeared to be related to certain design features (page 804).