May 2009: This Month's Highlights

A column by A. Kathryn Power, M.Ed., wraps up the journal's two-year series of reports addressing goals established by the President's New Freedom Commission on Mental Health. Ms. Power, who is director of the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA), reviews the center's progress vis-à-vis system transformation since the commission's report was published in 2003 and discusses challenges and opportunities that will arise in the next five years. She presents a strategic forecast, based on a public health model of mental health, to guide policy formulation and resource allocation in ways that will ensure "a life in the community for everyone" ( page 580 ). The final report in the series, by Dorn Schuffman, M.A., and colleagues, describes a transformation initiative in Missouri to integrate primary care services provided by federally qualified health centers and behavioral health services provided by community mental health centers ( page 585 ). The reports in this SAMHSA-sponsored series, which include updates of issue papers from the subcommittees of the President's Commission, articles that develop the commission's central themes, and accounts of transformation efforts in several states, will be published in a compendium that will be available from SAMHSA later this year.

Three studies in this issue used large representative samples to examine policies and trends in medication use. Joyce C. West, Ph.D., M.P.P., and colleagues surveyed psychiatrists in ten states to assess the impact of drug utilization management strategies used by state Medicaid programs. Patient data from 857 psychiatrists indicated that nearly half the patients had encountered a past-year access problem. The most common problems were patients' lack of access to clinically indicated drugs that were not covered by Medicaid and clinicians' having to prescribe a drug that was not clinically preferred. Patients in states with more access problems had significantly higher rates of adverse events ( page 601 ). In an analysis of U.S. data for 2000–2004, Jeffrey S. Harman, Ph.D., and colleagues found that the increasing rates of antidepressant use noted in the 1990s have turned around, driven largely by a decrease in use of selective serotonin reuptake inhibitors, especially among children and middle-aged adults with depression—a trend that began before the black-box warnings ( page 611 ). Steven C. Marcus, Ph.D., and colleagues examined factors associated with early switching of antidepressants among more than 56,000 commercially insured adults. Overall, 8.6% of patients switched drugs in the first 90 days, and an additional 2.4% added a second antidepressant without stopping the first. Although several markers of illness severity accounted for a large proportion of switching, the findings also emphasize the importance of initial drug choice and dosing ( page 617 ).

What factors influence providers' adoption of evidence-based practices, and what steps can be taken to improve dissemination? These questions were the focus of three teams of investigators, who report their findings in this issue. Joan M. Cook, Ph.D., and colleagues looked at responses of more than 2,600 psychotherapists to a Web-based survey and found that empirical evidence did not have a strong direct influence on their adoption of new treatments. Practitioners tended to stay with the approach learned in their initial training. However, many reported that a mentor's endorsement of a new treatment and a sense of self-efficacy would strongly influence their adoption of it ( page 671 ). In a study by Cameo F. Borntrager, Ph.D., and associates, the attitudes of 59 therapists toward evidence-based practices were assessed. Findings suggest that therapists did not harbor negative attitudes about evidence-based practices per se; rather, they were concerned about inflexible use of treatment manuals that would not permit them to individualize treatment ( page 677 ). In the Open Forum Sandra G. Resnick, Ph.D., and Robert A. Rosenheck, M.D., describe a four-year process undertaken by the Department of Veterans Affairs (VA) to implement an evidence-based practice—supported employment—at 166 VA medical centers across the country. Lessons learned from the VA experience have implications for scaling up dissemination of practices to large systems and long-term time frames ( page 682 ). In the Taking Issue commentary, Lloyd I. Sederer, M.D., notes that such intensive dissemination efforts require "leadership, courage, and commitment" ( page 575 ).

When a brief instrument was used to assess mental capacity to vote in a sample of persons with serious mental illness, 92% had high performance scores ( page 624 ).