This Month’s Highlights

Two research reports, an Open Forum, and two commentaries this month take a closer look at shared decision making. Although this practice is widely promoted and used in general medical care, shared decision making has only recently been regarded as an ethical imperative in mental health care. In a Department of Veterans Affairs (VA) study, Stephanie G. Park, Ph.D., and colleagues asked veterans with serious mental illness about the extent to which they wished to engage in shared decision making. Nearly all wanted their prescribing clinician to suggest a range of treatment options and to ask their opinion. Six in ten veterans preferred to rely on providers to make final decisions about care (page 1409). In another VA study, researchers rated audio recordings of medication appointments to identify moments of shared decision making between consumers and providers. Although Marianne S. Matthias, Ph.D., and colleagues did not find hypothesized associations between higher ratings and a stronger consumer-provider bond, they encourage future researchers to look for more nuanced associations between the therapeutic relationship and shared decisions (page 1488). In an Open Forum essay, Johannes Hamann, M.D., and Stephan Heres, M.D., argue that standard shared decision making may not be appropriate for all decisions and all patients. For patients with severe mental illness, they propose an adaptation called SDM-PLUS and outline a framework for using it (page 1483). In a commentary, Patricia E. Deegan, Ph.D., counters that such an adaptation is not needed. She urges practitioners to focus on adoption not adaptation (page 1487). Finally, in Taking Issue, Howard H. Goldman, M.D., Ph.D., notes that shared decision making—a concept whose time has come—is “an idea with roots in antiquity.” Citizens of ancient Greece expected to enter into a dialogue with their physician (page 1399).

Five articles address issues in service use and delivery among children and adolescents. Ka Ho Brian Chor, Ph.D., and colleagues evaluated the extent to which 346 clinics serving youths and their families took advantage of a range of training opportunities offered by New York State. Thirty-three clinics were “super-adopters” (page 1439). In an analysis of Medicaid data from 36 states, Ramesh Raghavan, M.D., Ph.D., and colleagues noted that expenditures on psychotropic drugs—especially antidepressants and antimanic drugs—were higher for maltreated children than for other children (page 1445). Among 1,500 foster care children age six and under, Susan dosReis, Ph.D., and colleagues found that 12% received at least one psychotropic drug. Concomitant use of three or more psychotropics began among children as young as four (page 1452). Brendan Saloner, Ph.D., and colleagues assessed whether the structure of Medicaid mental health programs makes a difference in rates of second-generation antipsychotic use by children. Use was 31% higher among foster care children in fee-for-service arrangements, and carve-outs were associated with lower use (page 1458). When Shelly Ben-David, M.S.W., and colleagues listened closely to interviews with 27 young people (ages 16 to 27) with schizophrenia, they noted several themes that differed between males and females. Males said they felt “broken” and described fantasies of escape. Females told stories of family members and described their own struggles to begin careers and adult lives (page 1499).

In a review of medical records for more than 39,000 Iraq and Afghanistan veterans who had received a postdeployment PTSD diagnosis, Shira Maguen, Ph.D., and colleagues found that those who waited longer to get treatment were less likely to experience PTSD symptom improvement. Even with treatment, some subgroups were not as likely as others to improve (page 1414). In a study of nearly 5,000 Iraq and Afghanistan veterans in five states, Teresa J. Hudson, Pharm.D., and colleagues found that urban or rural residence did not make a difference in whether veterans received routine screening for depression and PTSD. However, rural or urban residence affected rates of diagnosis and treatment—but not in the way that the researchers had hypothesized (page 1420). Disability payments can reduce incentives for employment and rehabilitation. Marc I. Rosen, M.D., and colleagues conducted a randomized controlled trial among veterans who had recently applied for service-connected compensation for a psychiatric condition. Some participants received four sessions of a benefits counseling intervention that used motivational interviewing techniques to increase veterans’ desire to work. Six months later, these veterans had significantly more days of paid work than those who did not receive counseling. Attempts to steer applicants toward employment can be effective if begun early, the authors noted (page 1426).