May 2005: This Month's Highlights

A substantial segment of this month's issue is devoted to the important topic of stigmatization of mental illness. In three separate articles, Patrick W. Corrigan, Psy.D., and his associates examine adolescents' perceptions of the stigma associated with mental illness and alcohol abuse (see page 544) and structural—or institutionalized—stigma as evidenced by newspaper articles (page 551) and state legislation (page 557). In an article (on page 564), Iris Sher, Psy.D., and her coauthors discuss the relationship between caregivers' attitudes to mental illness and patients' adherence to antidepressant treatment. In another article, Richard Warner, M.B., D.P.M., describes local projects of the World Psychiatric Association's program for reducing stigma and discrimination (page 570). And in a brief report (on page 599), Cheng-Fang Yen, M.D., Ph.D., and colleagues present the results of a study on self-stigmatization and its correlates among outpatients with depressive disorders. The issue of stigma is also addressed in the letters section (page 610).

In his Taking Issue contribution, Paul S. Appelbaum, M.D., raises stigmatization in the context of advance directives for people with serious mental illness—another important theme of this month's issue of the journal. Dr. Appelbaum reminds us that individuals who have serious mental illness suffer from physical ailments just as other people do, and he poses the question of why such individuals have been neglected in efforts to promote the use of advance directives (see page 515). Two articles by Mary Ellen Foti, M.D., and her colleagues present data on medical advance care planning (page 576) and end-of-life treatment preferences (page 585) among persons with serious mental illness. In another article, Debra S. Srebnik, Ph.D., and her coauthors present the results of their study of the content and clinical utility of psychiatric advance directives (see page 592).

Interventions that have been shown to be both clinically effective and cost-effective within a system of care are rarely sustained beyond the period of external funding. Why is this the case? According to Greer Sullivan, M.D., M.S.P.H., and coauthors, the reason may be that such interventions are often developed and implemented with little input from frontline clinicians. These authors describe a "bottom-up" approach to testing interventions within a program of the Veterans Healthcare Administration that has been implemented in eight states. Through this program, clinicians themselves devise interventions that they then test in conjunction with services researchers. The article goes on to discuss the likelihood that such a program will be successful, as well as the obstacles it will face (see page 537). In a related commentary, "Medicine-Based Evidence in Mental Health," Benjamin G. Druss, M.D., M.P.H., notes that the program described by Dr. Sullivan and associates is "part of a broader class of participatory research that seeks to involve users of evidence throughout the research process." He urges researchers and practitioners to continue to work together so that they can learn from one another and maximize their accomplishments (see page 543).

The final report of the President's New Freedom Commission on Mental Health was released in July 2003. Although a number of initiatives were created in response to the report, little information has been collected on how the mental health community has responded. In a brief report (on page 605), Silke A. von Esenwein, M.A., and her colleagues present the results of a survey of national mental health leaders that was conducted to gain insight into their perceptions of the impact of the commission's recommendations. The survey respondents were participants in the 19th annual Rosalynn Carter Symposium on Mental Health, which focused on the New Freedom Commission and how its recommendations could be implemented to transform the mental health care system. The results of the study suggest that the commission has had a substantial impact on the organizations surveyed.

• The Economic Grand Rounds column describes a model, developed on the basis of a resource paper by the American Psychiatric Association's committee on managed care, that can be used to analyze any health care financing system and its potential effect on the role of psychiatry (see page 534).

• The Child & Adolescent Psychiatry column discusses possible reasons for and implications of increased diagnosis of bipolar disorder among youths (see page 529).