This Month's Highlights

In this first issue of 2001, Psychiatric Services initiates a year-long series of articles on implementing evidence-based practices across a number of treatment settings and with a variety of populations. As journal editor John A. Talbott, M.D., notes in Taking Issue (page 7), a major focus of the journal this year will be on helping clinicians change what may no longer be working. Evidence-based practices are those for which clinical services research has found substantial evidence of effectiveness and which therefore should be routinely offered in clinical settings. As William C. Torrey, M.D., and his colleagues point out, such practices have not found their way into most mental health systems. These authors describe a project to help clinicians and administrators initiate changes in their behaviors and in treatment systems to ensure that persons with serious mental illness benefit from services that have been shown to work (page 45). Robert E. Drake, M.D., Ph.D., and Howard H. Goldman, M.D., Ph.D., are editors of the series. Future issues will feature articles on implementing evidence-based practices in supported employment, for patients with dual diagnoses, and for children's services, among other topics.

Another important focus of the journal in 2001 will be on disease management, beginning with a series of papers on improving the treatment of depression edited by Charles L. Bowden, M.D. Later in the year Kimberly A. Yonkers, M.D., will present a similar series on the treatment of anxiety disorders. In this issue Dr. Bowden initiates the depression series with an article describing ways to improve the diagnosis of bipolar depression. He notes that bipolar depression will receive substantial attention in the series because of emerging evidence that the prevalence of bipolar disorder is similar to that of major depression. Dr. Bowden discusses factors that make it difficult to distinguish bipolar from unipolar depression and describes strategies for ensuring an accurate diagnosis (page 51).

In 1993 the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality, released a set of guidelines for the treatment of major depression based on research and clinical evidence of effectiveness. John Fortney, Ph.D., and his colleagues examined whether patients treated according to these guidelines have better outcomes than those who do not receive such treatment. They found that only 29 percent of the patients in their sample received guideline-concordant care. For those with major depression, guideline-concordant care was significantly and substantially associated with improvements in depressive symptoms (page 56).

Michael A. Hoge, Ph.D., and Joseph A. Flaherty, M.D., examined how psychiatry departments in academic medical settings around the country have changed in order to adjust and survive in a marketplace dominated by managed care. From a variety of examples, they distilled nine common elements of the change process and six models of change. In addition to these elements and models, they describe factors common to academic settings that impede change and the conditions under which successful change is most likely to occur. Dr. Hoge and Dr. Flaherty conclude that to be successful in the long term, academic psychiatry must define its unique contribution and create unique value for the public and purchasers. They outline three avenues for achieving those objectives (page 63).

Researchers are continuing to investigate the underpinnings of many childhood disorders, particularly violent behavior. Donald R. Bars, Ph.D., and his coworkers examined data from electroencephalograms (EEGs), including data from visual evoked-potential studies, from 326 children and adolescents in treatment at a psychiatric clinic. Dr. Bars and his colleagues were interested in children with assaultive, explosive, and out-of-control behaviors, and they found that many of these children exhibited distinctive EEG wave forms and particular responses in the evoked-potential studies. They speculate that such testing can be used to identify a subgroup of children with explosive behaviors, perhaps those with temporal lobe syndrome or frontal inhibition problems. With proper identification, such children can be referred to appropriate treatment regimens (page 81).

• Are current guidelines advocating lower dosing of antipsychotic medications being followed? A study looks at dosing practices in three treatment settings (page 96).

• Should patient satisfaction studies take into account first-time patients' "satisfaction" with other patients? A study reveals an important dimension for clinicians to explore (page 104).