This Month's Highlights

Four papers in this month's issue present and discuss the main results of the ACCESS program (Access to Community Care and Effective Services and Supports), a five-year demonstration project funded by the Center for Mental Health Services. In the first paper, Frances Randolph, Dr.P.H., and her colleagues present an overview of the ACCESS program, which provided funds and technical assistance to nine community sites from 1994 to 1998 to reduce the fragmentation of services for homeless persons with severe mental illness (see page 945). Two of the four papers report the main findings of the evaluation study. The first, by Joseph P. Morrissey, Ph.D., and his associates, focuses on one of the two core questions: Does implementing strategies to change service systems lead to better integration of the systems? Contrary to expectations, the nine sites that received assistance did not demonstrate significantly greater overall systems integration than nine comparison sites in the same communities. However, at the agency level, the effects of the integration efforts were more evident, and more extensive implementation of systems change strategies was associated with a higher level of integration, at both the systems level and the agency level (see page 949). The second paper reporting the main findings, by Robert A. Rosenheck, M.D., and his colleagues, focuses on the second core question of the evaluation study: Does better integration of service systems improve the treatment outcomes of homeless persons with severe mental illness? Contrary to expectations, the mental health and housing outcomes of clients at the nine experimental sites were not significantly better than those of clients at the comparison sites. Outcomes improved for clients at all sites, but they were not related to the extent of implementation of the systems integration strategies. However, clients of sites that became more integrated had better housing outcomes, regardless of the degree of implementation or whether the sites were experimental or comparison sites (see page 958). In the fourth paper, Howard H. Goldman, M.D., Ph.D., and his coauthors summarize the lessons learned from the ACCESS program (see page 967).

The September 11 terrorist attacks have focused attention on the vulnerability of children to traumatic events. In 1994 the Cuban government, fearing the possibility of a civil war, opened its borders and allowed discontented individuals to leave the island. In the massive exodus by sea on boats and rafts, adults and children witnessed people dying from starvation and thirst and corpses being devoured by sharks. More than 32,000 people were intercepted by the U.S. Coast Guard and taken to refugee camps where they lived in tents for six to eight months. In this issue, Eugenio M. Rothe, M.D., and his colleagues examine the lasting effects of these experiences on children, a majority of whom reported moderate to severe symptoms of posttraumatic stress disorder several months after arriving in the United States and entering a transitional school (see page 970).

The link between social inequality and physical health has been recognized since the 19th century and was recently highlighted in the U.S. Surgeon General's report on disparities in health care among ethnic minority groups. In the mid-20th century the association between social inequality and mental health began to be examined. In this month's Economic Grand Rounds column, Carl I. Cohen, M.D., describes "compelling reasons for psychiatry to begin a serious engagement of social inequality." First, such engagement can promote linkages between psychiatry and other areas of medicine by highlighting common social factors in the etiologies of mental and physical diseases and by demonstrating psychiatry's critical role in the prevention and treatment of many physical disorders. Second, such an approach can reinvigorate community psychiatry's key mission of extending its therapeutic role to the community. Third, it can stimulate research and innovative treatment methods to address the psychosocial effects of social inequality on individuals (see page 937).

• A California study found significant differences in the practice patterns of psychiatrists and psychologists even after attempts by managed care to streamline staffing arrangements and treatment strategies (see page 977).

• A nationwide study of employment discrimination complaints to the Equal Employment Opportunity Commission (EEOC) under the Americans With Disabilities Act has found that people with mental disorders are less likely than people with physical disorders to be referred to the EEOC's highly successful mediation program (see page 988).