This Month's Highlights

Can the combination of two evidence-based practices—supported employment and permanent supportive housing—mean the end of chronic homelessness among adults with mental illness? A commitment to ending homelessness was the impetus behind a 2003 federal initiative that funded five demonstration projects to combine these practices through ambitious interagency cooperation agreements. The lead article in this issue describes outcomes for clients in one of these projects, LA's HOPE—Los Angeles' Homeless Opportunity Providing Employment. Martha R. Burt, Ph.D., of the Urban Institute, presents comparison data for clients of LA's HOPE and clients of similar homeless programs in Los Angeles who received usual services. Housing outcome data showed that LA's HOPE clients were many times more likely to achieve permanent supportive housing than the comparison group, and they moved into it more quickly. With respect to employment, 57% of LA's HOPE clients found work, 27% in competitive jobs—high rates for individuals who had been homeless for a long time and who had substantial psychiatric disabilities. The project fulfilled its purpose, the author notes, by demonstrating that combining targeted housing and employment supports can offer hope to a challenged population (page 209).

Assertive community treatment—an evidence-based practice supported by decades of research—is the focus of two studies in this issue. The first examined ACT's effects on social support among patients in a U.K. study, the Lambeth Early Onset Trial, which followed 144 patients who sought treatment for a first episode of psychosis and were randomly assigned to an intervention modeled on ACT or to standard care. Raymond Tempier, M.D., F.R.C.P.C., and colleagues looked at outcomes for social support. At 18 months patients in the intervention reported a higher number of significant others in their social network, which the authors linked to the superior clinical outcomes also found for this patient group (page 216). Since ACT's inception, the provision of time-unlimited services has been a central principle. However, when ACT was created, few alternative community-based services existed. In New York State, where ACT teams have limited openings, researchers developed the Transition Readiness Scale to help manage ACT team capacity. Sheila A. Donahue, M.A., and colleagues describe the scale's use in assessing nearly 1,400 clients and its level of agreement with ratings of the same patients by ACT team clinicians (page 223).

High rates of comorbid general medical conditions and undertreatment of these conditions among people with mental illness are well documented. Two studies examine use of specialized general medical care in this population. In the first, researchers compared use of obesity-related care among more than 250,000 obese primary care patients with and without mental illness in the Veterans Health Administration. Laurel Anne Copeland, Ph.D., M.P.H., and colleagues found that receipt of obesity-related care—counseling, medications, and bariatric surgery—was more common among patients with psychiatric diagnoses than among those without them (46% versus 31%). The authors linked use of such care to receipt of obesogenic psychotropic drugs (page 230). The second study used administrative claims data to identify nearly 29,000 adults with schizophrenia who received care in a ten-year period in Alberta, Canada. Lauren C. Bresee, Ph.D., and colleagues found that coronary artery disease was significantly more prevalent in this group than among patients without a schizophrenia diagnosis (20% versus 14%). Although patients with schizophrenia had higher rates of general practitioner visits, they were less likely to visit a cardiologist or to undergo coronary revascularization (page 237). Because of the link between second-generation antipsychotics and several cardiometabolic conditions, routine monitoring of risk factors is recommended. The Economic Grand Rounds column presents data from a 2010 survey of major public and private U.S. mental health treatment systems indicating limited adherence to such monitoring (page 202). The column's authors and the authors of Taking Issue (page 199) highlight the costs and consequences of failure to monitor.