This Month’s Highlights

Mental disorders often present between the ages of 18 and 24, when young people are leaving home to forge new identities and paths toward success. Four studies this month focus on ways to help ensure that individuals with mental disorders receive the services they need to stay on those paths. In a literature review, Wenjing Li, B.Psych., and colleagues identified 18 studies with a total of more than 96,000 participants that examined predictors of mental health service use in this age group. Prior service contact was the strongest predictor. Other factors were being homosexual or bisexual, female, or Caucasian. “Findings support the importance of enhancing young adults’ satisfaction with services by promoting positive experiences in order to facilitate future use,” the authors conclude (page 946). A second review, by Nancy S. Downs, M.D., and coauthors, describes how advances in evidence-based practices can enhance college students’ satisfaction with services. The authors focus on the initial student evaluation, risk assessment, treatment planning and goal setting, and steps to optimize academic functioning during treatment. At the center of these best practices is a campus-based collaborative team that works to engage students in learning about their mental health (page 957). A mixed-methods study by Victoria D. Ojeda, Ph.D., M.P.H., and colleagues showed that revenues from a California “millionaire’s tax” implemented by public referendum in 2004 to fund public mental health services have been used to expand programs and services for transition-age youths (ages 18 to 25) and to promote their engagement in service planning and delivery (page 970). Finally, Mir M. Ali, Ph.D., and colleagues found that after 2010, when the Affordable Care Act began to allow young adults to remain on family private health plans until age 26, out-of-pocket spending on health care by young adults fell substantially—an important outcome for an age group characterized by high debt burden, the authors note (page 977).

Attention-deficit hyperactivity disorder (ADHD) is the most commonly diagnosed mental disorder of childhood. In recent years, attention has focused on rising rates of childhood ADHD diagnosis. In 2011, a national survey found that 11% of children ages four to 17 had a parent-reported ADHD diagnosis, representing a 42% increase in eight years. Have rates risen as steeply among adults? To answer this question, Elisabeth M. Oehrlein, B.A., and colleagues analyzed more than ten years of national data on office-based visits for ADHD and found that although fewer adults than youths received an ADHD diagnosis, the diagnosis rate increased proportionally more among adults, particularly among women, Caucasians, the privately insured, and those who visited a psychiatrist. From 2003 to 2010, stimulant prescribing was frequent in ADHD visits both for youths (72%) and for adults (75%) (page 964). In a Taking Issue commentary, Sheryl H. Kataoka, M.D., underlines the authors’ warning about potential misuse of stimulants by adults and notes that individuals with ADHD would benefit from a focus on prevention of substance use disorders in their overall treatment (page 937).

In 2012, the Institute of Medicine (IOM) called for a transformation of the U.S. health system into a “learning” health system—one that engages in a continuous improvement cycle. In this month’s Open Forum, Bradley D. Stein, M.D., Ph.D., and coauthors discuss innovative research endeavors, promising study designs, and challenges involved in integrating behavioral health services research within the framework of a learning behavioral health care system. Researchers must settle important practical challenges, such as how to measure high-quality care, how to connect research and clinical settings, and how to pool data gathered during patient encounters at various sites. “We have reached a point at which the value of researchers’ connections to service systems is paramount; a new paradigm of partnerships and embeddedness, of contextual value of research, and of ongoing learning is upon us,” the authors conclude (page 1019).

Two brief reports describe testing of new instruments. Donald Addington, M.B.B.S., and colleagues tested the reliability and validity of a fidelity scale based on 32 previously identified essential components of first-episode psychosis (FEP) services. The scale was tested in six U.S. and Canadian programs and was found to be a “feasible, compact, reliable, and valid measure of adherence to evidence-based practices” for FEP services (page 1023). David Beiser, M.D., M.S., and colleagues found good test-retest reliability for the CAT Depression Inventory, a computerized adaptive screener, among adults in an academic emergency department (page 1039).