December 2008: This Month's Highlights

Three articles in this issue present research findings on depression. To determine the prevalence of depression and examine behavioral risk factors, Tara W. Strine, M.P.H., and colleagues analyzed data from a 38-state telephone survey of more than 217,000 participants. They found an overall prevalence rate of current depressive symptoms of 8.7%, with state rates ranging from 5.3% to 13.7%. Cardiovascular disease, diabetes, asthma, smoking, and obesity were all significantly associated with current symptoms ( page 1383 ). Two studies looked at the quality of depression care. Alexander S. Young, M.D., M.S.H.S., and colleagues examined 2.5-year follow-up data from a large sample of adults who had persistent depression or anxiety and found considerable problems with the care they received. Only a third reported receiving any treatment at baseline. At follow-up more than 40% reported persistent symptoms, but the researchers found only a modest increase from baseline in medication use and no increase in use of counseling ( page 1391 ). Using 1999–2005 records from a national Veterans Health Administration database, Jeffrey A. Cully, Ph.D., and colleagues examined the adequacy of care (medication and follow-up visits) for more than 205,000 veterans with new-onset depression. Provision of adequate follow-up care was associated with a significant decrease in all-cause mortality in the year after illness onset ( page 1399 ). In a Taking Issue commentary, Greer Sullivan, M.D., M.S.P.H., describes two gaps in care—the engagement gap and the quality gap. When a person with depression makes it across the engagement gap but not across the quality gap, she notes, the pattern of care could be described as "inappropriately complacent" ( page 1367 ).

Programs to eliminate coercive measures and reduce injuries on inpatient units are described in two reports—one on a unit for children and adolescents and one on an adult unit. Andrés Martin, M.D., M.P.H., and colleagues report findings from an evaluation of collaborative problem solving, a manualized therapeutic program for working with aggressive youths. One-and-a-half years after it was implemented, the program led to a 38-fold reduction in episodes of restraint and a 46-fold reduction in cumulative hours of restraint use per month ( page 1406 ). Robert Short, M.A., and his coworkers at an Ohio adult inpatient facility developed written safety guidelines for injury-free patient management that incorporate a variety of best practices. An implementation initiative that involved all staff and departments decreased staff injuries by 90% ( page 1376 ).

Three studies in this issue examined service use patterns among women. Louise M. Howard, Ph.D., M.R.C. Psych., and her London colleagues looked at pathways to admission to either a psychiatric hospital or a women's crisis house—a residential facility for women who would otherwise be considered for hospital admission. Their findings indicate that the houses are a viable alternative to traditional wards for a large subgroup of women experiencing a mental health crisis ( page 1443 ). Using data from a telephone survey of a representative sample of U.S. women, Ananda B. Amstadter, Ph.D., and colleagues assessed lifetime help-seeking for emotional problems for women who reported a history of rape. Forty percent had never sought help ( page 1450 ). In a national study of more than 1,600 women entering substance abuse treatment programs, Mandi L. Burnette, Ph.D., and colleagues examined whether women who reported a history of prostitution received additional services to meet their distinct treatment needs ( page 1458 ).

More than 150 pay-for-performance programs for medical and surgical care are operating across the United States, covering 50 million health plan enrollees. For several reasons, the behavioral health field has been slower to adopt this approach to quality improvement. Robert W. Bremer, Ph.D., M.A., and coinvestigators undertook a nationwide effort to identify such programs in behavioral health settings and describe their components. Their semistructured interviews with administrators of the 24 identified programs revealed preliminary lessons and suggested ways to increase the effectiveness of pay for performance in behavioral health. The authors summarize core program components in extensive tables ( page 1419 ).

• More than 175 men and women in recovery from schizophrenia told interviewers about clinicians who pushed them to take new risks—some pushed gently and some too hard ( page 1430 ).