July 2009: This Month's Highlights

This month's lead article addresses an issue on which there is broad consensus: the behavioral health workforce is facing a crisis. What needs to be done to ensure that students and working professionals receive the training they need to deliver effective services? How can the field recruit and retain capable and dedicated individuals who will be its future leaders? In 2001 the Annapolis Coalition on the Behavioral Health Workforce, with support from the Substance Abuse and Mental Health Services Administration (SAMHSA), began to study these and other challenges and devise solutions. The result is An Action Plan for Behavioral Health Workforce Development, which distills the efforts of a dozen expert panels charged with examining every sector of the field. In an article describing the Annapolis Coalition's efforts, Michael A. Hoge, Ph.D., and colleagues focus on the seven strategic goals that emerged from a two-year planning process that involved more than 5,000 individuals and included substantial input from consumers and families. The goals, which serve as the cornerstone of the action plan, cover three broad areas: broadening the concept of workforce, strengthening the workforce, and enhancing structures that support the workforce. As the authors note, SAMHSA and other organizations have already begun to use the plan to launch national- and state-level workforce initiatives ( page 883 ).

An article in the October 1974 issue of this journal described "an unusual community treatment program" in Madison, Wisconsin. The article included preliminary data from the first outcome evaluation—for 89 patients—of what is now known as assertive community treatment (ACT). This issue of Psychiatric Services includes three new reports on ACT, which has held up under 35 years of scrutiny. Paul McCrone, Ph.D., and colleagues in London conducted an 18-month cost-effectiveness analysis of ACT and of usual care provided by community teams. Although costs did not differ significantly, ACT participants reported greater satisfaction and treatment engagement, which prompted the authors to estimate the cost of a one-unit improvement in satisfaction ( page 908 ). Somaia Mohamed, M.D., Ph.D., and colleagues, researchers from the Department of Veterans Affairs (VA), examined whether VA's ACT program is effective in reaching veterans in rural areas. The findings highlight challenges in providing ACT services to rural clients with the frequency and intensity required for this treatment approach ( page 914 ). ACT is not without its critics, and some claim that ACT teams are inherently coercive. In a statewide survey of 23 ACT teams, Lorna L. Moser, Ph.D., and Gary R. Bond, Ph.D., assessed the extent of teams' use of "agency control," including such practices as involuntary outpatient commitment, representative payeeship, and intensive medication monitoring ( page 922 ).

Estimating the number of nursing home residents with mental illness is the focus of two research reports in this issue. For more than 20 years federal law has required that all nursing home applicants receive preadmission screening for mental illnesses. Several national data sets incorporate these data for research purposes, but estimates of the size of the nursing home population with mental illnesses have varied because the data sets capture the information in different ways. Ann D. Bagchi, Ph.D., and colleagues analyzed features of three large data sets to determine which produced the most valid national estimate of nursing home residents with a primary diagnosis of mental illness (6.8%) and why ( page 958 ). Catherine Anne Fullerton, M.D., M.P.H., and colleagues looked at 1999–2005 data on first-time nursing home admissions to identify trends. They found that the proportion of residents with a mental illness, particularly depression, has overtaken the proportion with dementia ( page 965 )

Approximately one-fifth (22%) of U.S. patients drop out of outpatient mental health treatment prematurely, and the highest dropout rate (32%) is from care received in the general medical sector ( page 898 ).

An initiative at community mental health centers in Kentucky that trained clinicians to follow evidence-based prescribing guidelines for patients with schizophrenia had mixed results ( page 929 ).

This month's Law & Psychiatry column describes a decade of Supreme Court decisions that undermined the original intent of the Americans With Disabilities Act (ADA) and recent legislation designed to reinvigorate the ADA ( page 878 ).

Children's beliefs about the causes of childhood depression and ADHD indicate a consistent presence of stigmatization ( page 950 ).