This Month's Highlights

Medicare Part D prescription drug plans specifically exclude coverage of benzodiazepines, largely because of concerns over safety and inappropriate use. However, even before Part D plans were implemented in January 2006, concerns were raised about the exclusion's impact on people with anxiety disorders, the population most likely to be adversely affected. To investigate the impact, Michael K. Ong, M.D., Ph.D., and colleagues analyzed claims data for more than 8,300 Medicare enrollees with new diagnoses of anxiety. The authors found that the benzodiazepine exclusion resulted in significantly increased use and days' supply of nonbenzodiazepine psychotropic drugs, specifically antidepressants and other anxiolytics, and in an overall decline in claims for psychotropic medications. The overall decline may reflect a reduction in the treatment of anxiety, the authors note, because they did not find evidence of an increase in use of outpatient care to substitute for psychotropic medications. Expenditures for psychotropic medications increased even though fewer claims were filed, reflecting the higher costs of some nonbenzodiazepine alternatives (page 637). In Taking Issue, Martha Sajatovic, M.D., draws parallels between the benzodiazepine exclusion and the failed U.S. policy of Prohibition (page 627).

In most states, individuals who are experiencing a mental health crisis can be hospitalized on a temporary detention order (TDO) from four to eight days before a civil commitment hearing must be held. Virginia is one of three states that require a hearing within 48 hours. Because a short detention period may not allow sufficient time to stabilize and evaluate a patient, Virginia is considering extending the 48-hour limit. Tanya Nicole Wanchek, Ph.D., J.D., and Richard J. Bonnie, LL.B., examined whether lengthening the TDO period would result in fewer and shorter subsequent civil commitments. They took advantage of natural variation in TDO length in Virginia resulting from holiday weekends, during which a TDO can extend up to five days. In a sample of 500 Medicaid recipients with at least one TDO, the authors found that longer detention periods were correlated with fewer involuntary commitments and with shorter hospital stays. Reducing civil commitments is an important policy goal because of the stigma and trauma that can result, the authors note (page 643).

Although many studies have explored public attitudes about mental illnesses, few have focused on the youngest generation of Americans. Negative attitudes and misperceptions are likely to be rooted in childhood, when efforts to reduce stigma may be particularly effective. When Otto Wahl, Ph.D., and colleagues administered a self-report questionnaire to nearly 200 seventh- and eighth-grade students, they found important gaps in knowledge, particularly with respect to the signs and symptoms of specific disorders. Most youths expressed uncertainty about whether mental illness has a biological cause, and only about a third believed that medicine is a useful treatment. Asked whether mental illness is the same as mental retardation, most agreed or were uncertain. Attitudes toward and social acceptance of peers with a mental illness were generally positive, but a substantial proportion of students held negative views (page 649).

Media analysts and critics have faulted movies for perpetuating negative stereotypes of people with mental illnesses. In this issue, Patricia R. Owen, Ph.D., reports findings from a review of 41 English-language movies released between 1990 and 2010 that featured at least one main character with schizophrenia. Most characters displayed dangerous or violent behaviors, and nearly a third engaged in homicidal behavior. The cause of schizophrenia was infrequently noted, although a fourth of movies implied that a traumatic life event played a role. The myth that love can cure schizophrenia was found in a quarter of the movies. Some characterizations were fairly accurate. For example, almost half of the characters were of low socioeconomic status, consistent with current epidemiological data. More research is needed, the author notes, to inform optimal use of entertainment media to correct misinformation and increase empathy and understanding (page 655).