April 2009: This Month's Highlights

This month's lead article focuses on activities undertaken by two federal agencies to achieve goal 5 of the President's New Freedom Commission—"Excellent mental health care is delivered and research is accelerated." Kevin D. Hennessy, Ph.D., of the Substance Abuse and Mental Health Services Administration (SAMHSA), and David A. Chambers, Ph.D., of the National Institute of Mental Health, describe initiatives to address the goal's four recommendations: accelerate research, advance evidence-based practices, improve and expand the workforce, and develop knowledge in understudied areas. The authors note that although current economic stresses may "force a reevaluation of what is practical and feasible … they may also provide new and unexpected opportunities to advance long-anticipated objectives related to broader health care reform and system transformation" ( page 433 ). The article is the 14th in a SAMHSA-sponsored series of reports addressing the commission's goals.

To reduce suicide risk, the FDA has recommended close patient monitoring in the 12 weeks after hospitalization and after antidepressant starts and dosage changes. The most stringent recommendation calls for seven outpatient visits. To estimate the costs of adopting this protocol, Marcia Valenstein, M.D., and colleagues analyzed data for 100,000 veterans in depression treatment. The patients averaged only 2.4 visits after antidepressant starts and changes and 4.9 visits after hospitalizations. Providing close monitoring during high-risk periods for all veterans in depression treatment in 2004 would have cost an additional $183–$270 million ( page 439 ). In a related commentary, David Shern, Ph.D., notes that even though some people would criticize cost considerations in the face of a life-saving intervention, it is vital to understand the benefits attendant on health care costs if we are to make the best use of scarce resources ( page 419 ). A cost study of a housing-first program in San Diego by Todd P. Gilmer, Ph.D., and colleagues used a complex design to calculate expenditures and savings across several systems. Substantial increases in case management costs were offset by large savings in other areas ( page 445 ).

Critical time intervention (CTI), which originated as an approach to preventing homelessness, provides an intensified level of services during high-risk periods to promote treatment engagement over the longer term. Lisa Dixon, M.D., M.P.H., and colleagues found that brief CTI targeted at the point of inpatient discharge improved continuity of care in the community for veterans with serious mental illness ( page 451 ). Case managers are often charged with the task of keeping consumers engaged in treatment. Using qualitative methods, Victoria Stanhope, M.S.W., Ph.D., and colleagues analyzed in-depth interviews with case managers of adults who disengaged from housing programs. Although most spoke of disengagement as an inevitable part of their work—and few reflected on the program's role in disengagement—case managers were willing to heal ruptured relationships so that consumers would receive needed services ( page 459 ). To better understand risk factors for homelessness, Katherine H. Shelton, Ph.D., and colleagues interviewed young adults six years after they had enrolled in a national study of adolescent health. About 5% reported ever being homeless, and the most powerful risk factors were related to childhood adversity, such as separation from parents ( page 465 ). Of the many housing interventions for persons with severe mental illness, which achieve the best outcomes? To answer this question, H. Stephen Leff, Ph.D., and colleagues conducted a detailed meta-analysis of 44 unique housing alternatives described in 30 studies ( page 473 ).

Three articles in this month's issue report on programs to help people with serious mental illness focus on their strengths and gain new skills. Michelle P. Salyers, Ph.D., and colleagues evaluated the statewide implementation of the illness management and recovery program in Indiana ( page 483 ). Skye Barbic, M.Sc., and coauthors examined the effectiveness of the Recovery Workbook group intervention ( page 491 ). Marc I. Rosen, M.D., and colleagues conducted a trial of a voluntary money management program with veterans in substance abuse treatment ( page 498 ).

Kristine Jones, Ph.D., and colleagues in New York and Yuting Zhang, Ph.D., and colleagues in Maine conducted economic assessments of important changes in medication policies for Medicaid beneficiaries ( pages 512 and 520 ).

In the Open Forum, Thomas E. Smith, M.D., and Lloyd I. Sederer, M.D., discuss the need for a "mental health home" modeled on the concept of the medical home ( page 528 ).