This Month’s Highlights

In the 21st century, the Internet is providing new options for treatment delivery, as described in two reports in this issue. In the lead article, Enid M. Hunkeler, M.A., and coauthors report outcomes of a randomized trial of an Internet-delivered care management and illness self-management program for patients with recurrent or chronic depression. The program—eCare for Moods—is delivered via a secure Web site that offers participants personalized self-monitoring tools, messaging with their eCare manager, eight modules of depression education, and a discussion group. The program is integrated with ongoing depression care. Participants’ eCare managers monitor the site and consult with treating clinicians as needed. Participants in eCare and in usual specialty mental health care were assessed at baseline and at six, 12, 18, and 24 months after enrollment. eCare participants experienced a greater reduction in depressive symptoms, along with other positive outcomes (page 1063). The Veterans Health Administration (VHA) was an early adopter of telehealth care, in large part to serve rural veterans with poor access to VHA facilities. Tisha L. Deen, Ph.D., and colleagues examined 2005–2010 national data on various types of VHA telemental health encounters (diagnostic assessment, medication management, and individual and group psychotherapy). Each type of encounter increased substantially, and individual psychotherapy with medication management was the most frequently delivered service (page 1131). In a Taking Issue commentary, Amy M. Kilbourne, Ph.D., M.P.H., acknowledges the potential of e-health technologies and describes several key challenges in regard to their adoption and sustainability (page 1059).

It is estimated that one in seven veterans returning from Iraq and Afghanistan has posttraumatic stress disorder (PTSD). Problems related to PTSD can diminish work-related quality of life. Paula P. Schnurr, Ph.D., and Carole A. Lunney, M.A., examined whether changes experienced during PTSD treatment improved work-related outcomes for female veterans and service members. Participants were assigned to ten weekly sessions of prolonged-exposure or present-centered therapy and assessed before and after treatment and at three- and six-month follow-ups. At the end of treatment, participants in either group who no longer met diagnostic criteria for PTSD had greater improvement in all domains of work-related quality of life than those who still had PTSD. The authors emphasize the importance of continuing PTSD treatment until clinically meaningful change has been attained (page 1072).

Use of anticonvulsants to treat psychiatric conditions among U.S. children and adolescents has expanded considerably in recent years, according to regional studies. To fill knowledge gaps about national trends, Allen R. Tran, Pharm.D., and colleagues analyzed 1996–2009 data from two large federally sponsored surveys. As a proportion of all physician or hospital visits for anticonvulsants by youths, visits with a psychiatric diagnosis increased 1.7 fold, whereas seizure-related visits did not change significantly. The analysis found decreased use of divalproex and increased use of lamotrigine. Results also indicated a growing trend toward concomitant psychotropic regimens involving anticonvulsants—a trend that was especially significant in the off-label treatment of disruptive disorders (page 1095).

Antipsychotic drug therapy is the cornerstone of schizophrenia treatment. However, harmful interactions with other drugs are possible because of the way in which antipsychotics are metabolized. To examine the proportion of patients exposed to such interactions, Jeff Jianfei Guo, B.Pharm., Ph.D., and colleagues examined three years of claims data from a large state Medicaid program. Among nearly 28,000 adult patients with a diagnosis of schizophrenia and at least one antipsychotic prescription, 23% were exposed to 14,213 potentially harmful drug-drug interactions. Large proportions of this group had at least one exposure from the same pharmacy or the same physician. The authors call on practitioners and pharmacies to implement simple interventions to reduce the incidence of potentially harmful drug-drug interactions for patients with schizophrenia (page 1080).

The effectiveness of assertive community treatment (ACT) depends largely on teamwork, and researchers have developed and tested a scale to measure ACT team processes (page 1108).

When psychiatric residents used a structured tool to assess violence risk among inpatients, their accuracy at predicting violence rose nearly to the level of experienced psychiatrists (page 1089).

A national survey of specialized PTSD treatment programs in the Department of Veterans Affairs found that most offered treatments involving complementary and alternative medicine (page 1134).