February 2009: This Month's Highlights

Several studies have found that people who experience major depression are at increased risk of early mortality from natural causes. However, fewer studies have investigated premature death associated with bipolar disorder. This month's lead article—a comprehensive literature review of 17 studies involving more than 331,000 patients—presents evidence of a significantly higher risk of early death among individuals with bipolar spectrum disorders. Babak Roshanaei-Moghaddam, M.D., and Wayne Katon, M.D., found that mortality from natural causes, such as cardiovascular, respiratory, and cerebrovascular disorders, was from 35% to twofold higher in this patient group than in the general population. Unhealthy lifestyle, biological factors, adverse pharmacological effects, and disparities in health care are possible underlying causes ( page 147 ).

Two studies in this issue looked at adherence to psychotropic medications in Latino populations. Nicole M. Lanouette, M.D., and colleagues reviewed studies published since 1980 that provided data on adherence to antipsychotics, antidepressants, and mood stabilizers among U.S. Latino adults. In the four studies that focused only on Latinos, mean nonadherence was 44%. In the 17 studies that included Latinos and other groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans. Inability to speak English, lack of health insurance, access barriers to care, and lower socioeconomic status were risk factors for nonadherence. Protective factors included family support and psychotherapy ( page 157 ). In a study of nearly 8,000 Medi-Cal beneficiaries with schizophrenia, Todd P. Gilmer, Ph.D., and colleagues found that Latinos with limited English proficiency were significantly more likely than English-proficient Latinos to be adherent to antipsychotics (41% compared with 36%). The authors speculate that U.S. Latinos with limited English proficiency may benefit from a higher level of familial and social support ( page 175 ).

A large body of research has shown that assertive community treatment (ACT) improves outcomes for persons with serious mental illness. Positive outcomes, however, are at least partly dependent on the extent to which ACT teams faithfully implement the model. In a two-year study of 13 newly implemented ACT teams in two states, Anthony D. Mancini, Ph.D., and colleagues found that licensing processes of the state mental health authority provided critical structural supports for implementation. These supports included a dedicated Medicaid billing structure, start-up funds, ongoing fidelity monitoring, and ACT training and technical assistance. Other important facilitators at the organization level were committed leadership, allocation of sufficient resources, and careful hiring procedures ( page 189 ). In the Veterans Affairs (VA) health system, all veterans with serious mental illness who are at high risk of hospitalization are eligible for VA's ACT program, which is called mental health intensive case management. In a one-year national study of more than 6,500 veterans who were eligible for ACT services but were not yet receiving them, John F. McCarthy, Ph.D., M.P.H., and colleagues found that only 452 (7%) initiated ACT services. A critical barrier to receipt of services was geographical distance from VA ACT teams ( page 196 ).

The illness self-management and recovery program is another promising evidence-based practice. Government and consumer advocacy organizations have called for the widespread adoption of this standardized intervention, which involves psychoeducation, cognitive-behavioral approaches to medication adherence, and training in relapse prevention and social and coping skills. Rob Whitley, Ph.D., and colleagues studied its implementation at 12 community mental health centers over two years and found that key facilitators were strong leadership, an organizational culture that embraces innovation, effective training, and committed staff ( page 202 ). In a pilot study of an eight-week illness self-management intervention called Wellness Recovery Action Planning (WRAP), Judith A. Cook, Ph.D., and colleagues found significant improvements in self-reported symptoms, recovery, hopefulness, self-advocacy, and physical health, especially among those who attended six or more sessions ( page 246 ). Alicia Lucksted, Ph.D., and colleagues report results from the first evaluation of Peer-to-Peer, a self-help relapse prevention and wellness program sponsored by the National Alliance on Mental Illness. The authors found that participants' knowledge and management of their illness improved, and they felt less powerless and more confident and connected with others ( page 250 ).