September 2010: This Month's Highlights

Research has shown that between 7% and 13% of Medicaid enrollees use mental health or substance abuse services in a given year. Most of this use is by those who qualify for Medicaid on the basis of disability—and about one-third of these enrollees have psychiatric conditions. More accurate information about the characteristics and service use patterns of this Medicaid subgroup can help inform policies and programs. Henry T. Ireys, Ph.D., and colleagues analyzed claims data for individuals enrolled in Medicaid fee-for-service plans in 13 states. Of the nearly 12 million plan enrollees, 11.7% used either mental health services (10.9%) or substance abuse services (.7%). Among mental health service users, 47.4% had visited an emergency room in the past year, 7.8% had received inpatient treatment, and 70.4% had received prescriptions for psychotropic medications. Corresponding rates among users of substance abuse treatment were 60.7%, 12.6%, and 46.1%. Among beneficiaries who did not use mental health or substance abuse services, 29.0% visited an emergency room, 12.7% received inpatient care, and 10.1% received psychotropic medications (see page 871 ).

In recent years the number of emergency department visits has increased more rapidly among persons with mental disorders or substance use disorders than among any other patient group. Combined with shortages of psychiatric inpatient beds and specialty providers, this suggests that visits for this group may also be getting longer and that hospitals are incurring higher costs to stabilize these patients. To explore this question, Eric P. Slade, Ph.D., and colleagues examined trends in national data from 2001 to 2006. They found that the duration of all visits—for both mental health and non-mental health reasons—increased at an annual rate of 2.3%. However, throughout the period the average duration of mental health visits exceeded that of other visits by 42%, a difference of about 1.25 hours (4.25 hours versus 3.0 hours). Visits by individuals with serious mental disorders or substance use illness were especially long, as were mental health visits that ended in transfer to another facility (see page 878 ).

Two studies in this issue report on interventions to detect serious general medical conditions among people with mental illness. Stanley D. Rosenberg, Ph.D., and colleagues conducted a randomized trial of the "STIRR" model to detect blood-borne infections. The trial tested the feasibility of the intervention, which incorporates Screening, Testing, Immunization, Risk reduction counseling, and treatment Referral, in an urban sample of clients with serious mental illness and a substance use disorder—a group with a markedly elevated risk of HIV and hepatitis infection. Although clients in the STIRR intervention were more likely to be tested and immunized and to increase their knowledge about hepatitis, they did not reduce risky behaviors, were no more likely to be referred to care, and showed no increase in HIV knowledge. The average per patient cost was $541 (see page 885 ). Between 2005 and 2008, Pfizer, Inc., funded voluntary health fairs that offered free cardiometabolic screening and same-day feedback to outpatients with mental illness at community clinics across the country. In this issue, Christoph U. Correll, M.D., and colleagues report findings for 10,084 patients at 219 sites. Results on several indicators raised concern for more than half of these patients: 52% had metabolic syndrome, 52% were obese, and 51% were hypertensive. Of the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment (see page 892 ).

High rates of smoking are also a cause for concern among people with serious mental illness. Many psychiatric hospitals have adopted no-smoking policies. In 2006 and 2008 the National Association of State Mental Health Program Directors Research Institute surveyed state psychiatric hospitals about smoking policies. Vera Hollen, M.A., and colleagues examined survey data to determine how going smoke free affected key factors in the treatment setting. As found in many other studies, rates of certain adverse events fell substantially. However, even though more hospitals were smoke free in 2008 than in 2006, the number offering nicotine replacement therapy or providing staff with special training to help patients quit did not change substantially (see page 899 ). In a Taking Issue commentary on these findings, Gregory A. Miller., M.D., M.B.A., and Lisa B. Dixon, M.D., M.P.H., note that adopting a smoke-free policy is only a first step and that the tremendous growth in knowledge about smoking and serious mental illness must inform new treatment interventions (see page 859 ).