August 2007: This Month's Highlights

According to data in this month's lead article, total spending on mental health treatment in the United States grew from $33 billion in 1986 to $100 billion in 2003. Per capita spending increased from $205 to $345. However, as a percentage of total health care, spending on mental health treatment fell from 8% in 1986 to 6% in 2003. The research team, which was led by Tami L. Mark, Ph.D., found a large shift away from spending on inpatient mental health care—41% of total mental health expenditures in 1986 and 24% in 2003—to spending on psychoactive prescription drugs—7% in 1986 and 23% in 2003. Medicaid has assumed a more prominent payer role, accounting for 26% of mental health expenditures in 2003, up from 16% in 1986. One conclusion from these findings is that more people are receiving treatment for mental illness—an increase partly driven by the growing use of pharmacotherapy. In addition, the authors call for greater monitoring of the quality of care to ensure that Americans are getting an adequate return on their investment ( page 1041 ).

To what extent have the recommendations of the President's New Freedom Commission influenced how decision makers and professionals think about the future of mental health care? In this issue two groups of authors provide some answers. The State Mental Health Policy column summarizes responses of 35 Medicaid directors to questions about key challenges in mental health care. Barbara Coulter Edwards, M.P.P., and Vernon K. Smith, Ph.D., who conducted the survey, found that Medicaid officials were aware of the call for recovery-oriented services. However, directors were concerned about a "disconnect" between providers' desire to implement evidence-based practices to achieve the commission's goals and the Centers for Medicare and Medicaid Services' pursuit of tighter compliance with a medical model that limits the services that Medicaid is able to cover ( page 1032 ). A brief report by Joseph A. Rogers, A.A., and colleagues discusses 12 major barriers to promoting recovery identified by a group of community psychiatrists and their recommendations for overcoming them ( page 1119 ). The column and brief report are part of Psychiatric Services' series on system transformation, which is supported by a contract with the Substance Abuse and Mental Health Services Administration. In a related commentary Larry Davidson, Ph.D., expresses concerns that local mental health systems, under the rubric of recovery and transformation, risk repackaging old wine in new bottles ( page 1029 ). Finally, in the Open Forum Miriam C. Tepper, M.D., proposes a strategy to address the tension between clinicians who advocate for full recovery and those who call for more modest goals ( page 1116 ).

Six reports in this month's issue address treatment of affective disorders. Lisa V. Rubenstein, M.D., M.S.P.H., and colleagues describe a new instrument that predicted six-month outcomes among nearly 1,500 primary care patients treated for major depression ( page 1049 ). In a study of 1,801 elderly patients with depression in primary care, Patricia A. Areán, Ph.D., and colleagues found that those with low incomes derived greater treatment benefits in a collaborative model that involved a team approach and a depression care specialist ( page 1057 ). A research group led by Evette J. Ludman, Ph.D., found favorable outcomes among depressed patients whose treatment involved telephone monitoring and participation in peer-led or professionally led groups ( page 1065 ). An analysis of Medicaid claims data for nearly 13,500 patients with bipolar disorder by Jeff J. Guo, B.Pharm., Ph.D., and colleagues, found that treatment of the disorder accounted for only 30% of costs, whereas treatment for key comorbidities, such as drug use disorders and cerebral-vascular disease, accounted for 70% ( page 1073 ). Michelle Munson, Ph.D., and colleagues held a series of focus groups for case managers, who spoke of their desire to help depressed elderly clients in community long-term care and their lack of training and resources to do so ( page 1124 ). Findings from a study of 10,545 depressed veterans reported in Datapoints by John F. McCarthy, Ph.D., and colleagues indicate low rates of guideline-concordant care ( page 1035 ).

• A study of jail diversion programs showed how decision-making processes result in disproportionate representation by gender, race, and age ( page 1095 ).

• The Best Practices column describes a model of collaborative care developed in Australia for people with mental illness ( page 1036 ).