October 2008: This Month's Highlights

Several articles in this month's issue report research on medication use, including six on antidepressants and antipsychotics. A meta-analysis of data from 27 randomly controlled trials demonstrated the overall benefits of the newer antidepressants in continuation- and maintenance-phase treatment of major depression, although trials comparing the newer drugs to each other are needed ( page 1121 ). An analysis of data from two national epidemiological surveys found a significantly lower rate of antidepressant use among black respondents with depressive or anxiety disorders than among white respondents with these disorders (14.6% and 32.4%). An unexpected finding was the association of antidepressant use and common medical conditions related to vascular disease—use that was independent of the presence of psychiatric illness ( page 1131 ). A study of nearly 4,000 veterans with both major depression and diabetes found that half (51%) were treated with antidepressants, and two-thirds of this group (62%) received treatment that was consistent with current guidelines ( page 1139 ). Analyses of 2002–2005 Medicaid claims data for 1.2 million Florida children showed that rapid increases in antipsychotic use stopped in the spring of 2004, shortly after black-box warnings about metabolic effects were required for antipsychotics and about the same time that warnings in regard to suicidal thoughts were required for pediatric antidepressant prescriptions ( page 1162 ). Implementation of Medicare's new Part D drug benefit decreased out-of-pocket costs for antidepressants and antipsychotics among elderly persons, thus improving access ( page 1191 ). Veterans taking antipsychotics were more likely to experience decreased adherence when their dosing frequency was changed to more than once a day ( page 1207 ).

A growing number of psychotropic agents—mood stabilizers (including anticonvulsants), antipsychotics, and antidepressants—are being used to treat bipolar disorder, both alone and in combination. A study of nearly 1,500 Medicaid beneficiaries in California who had bipolar disorder found a shift between 2001 and 2004 toward greater use of antipsychotics; mood stabilizer monotherapy declined and antipsychotic monotherapy increased; racial-ethnic disparities in medication use were also noted ( page 1169 ). A study of nearly 7,500 patients with newly diagnosed bipolar disorder who were enrolled in a national health plan showed that a third were started on polytherapy and a third were still receiving polytherapy at one year; 37% were not taking any psychotropic at one year ( page 1175 ). Of 10,636 privately insured adults with posttraumatic stress disorder (PTSD), 60% were being treated with psychotropic medication; three-quarters of this group received antidepressants, and a similar proportion received anxiolytics or sedative-hypnotics ( page 1184 ).

California's public mental health system has been engaged in a process of planning and change since 2004, when a 1% tax on annual personal income over $1 million was imposed and the funds earmarked for system change. As of May 2008 all 58 county- and city-operated mental health agencies had submitted plans to reorient services toward recovery and consumer and family preferences. State guidelines mandate creation of full-service partnerships (FSPs), which are rooted in the assertive community treatment and wraparound models. Cheryl Cashin, Ph.D., and colleagues conducted a qualitative content analysis of a sample of 12 such plans, from agencies that represented 62% of the state's population. The authors found that state guidelines were successful in generating remarkable consistency across counties in the creation of FSPs. However, the authors found a wide array of strategies for achieving transformation, reflecting not only the diversity of the 12 counties but also the lack of clear policy and guidance on evidence-based practices ( page 1107 ). The article is the 11th in a series of reports addressing the goals that were established by the President's New Freedom Commission on Mental Health. The series is supported by a contract with the Substance Abuse and Mental Health Services Administration.

• A survey in Australia indicated that youths and their parents differed from clinicians in their beliefs about the helpfulness of interventions for early psychosis ( page 1115 ).

• Should the law allow people with mental illness to act as their own attorney? The Law & Psychiatry column looks at past and recent court decisions ( page 1096 ).