September 2009: This Month's Highlights

Since the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for both programs, researchers have focused on those with mental disorders, who constitute about a third of this group. Studies have shown that concerns that were raised before the transition have been borne out. Many of these patients have experienced disruptions in access to medications that can be attributed to features of the Part D plans, such as restricted formularies and utilization management strategies. In the lead article in this month's issue, Haiden A. Huskamp, Ph.D., and colleagues report results of a study that examined consequences of medication access problems—namely, emergency department visits and hospitalizations. Among more than 900 dually eligible individuals in a random sample of psychiatrists' patients, 44% experienced access problems in the final four months of 2006. Prescribed medications were not covered or approved for 35%, and 19% were required to switch to a different drug because refills were not covered or approved. More than a fifth (22%) had access problems because of required copayments. Compared with a matched sample of dually eligible patients whose medication access was not disrupted, those with access problems were significantly more likely to visit an emergency department ( page 1169 ).

In fiscal year 2007 nearly 280,000 patients in the Department of Veterans Affairs (VA) health care system received a prescription for an antipsychotic. In a study reported in this month's issue, Douglas L. Leslie, Ph.D., and colleagues found that 60% of these patients had no record of a diagnosis for which these medications are approved. Antipsychotics are the cornerstone of effective treatment of schizophrenia, and most have been approved for treating bipolar disorder. One—aripiprazole—was approved in late 2007 for adjunctive treatment of major depression. However, after a drug has received approval, clinicians are free to prescribe it for other conditions as they see fit. The VA researchers found that patients with posttraumatic stress disorder accounted for the largest percentage (42%) of off-label prescriptions for antipsychotics, followed by minor depression (40%), major depression (23%), and anxiety disorder (20%). "Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution," the authors conclude ( page 1175 ).

People with serious mental illness are especially vulnerable to risk factors for suicide, including substance abuse, victimization, sparse social networks, and—the best predictor of completed suicide—prior attempts. Extensive resources have been targeted at suicide prevention, but little effort is made to inform these initiatives with the voices of suicide survivors. In this issue Mary Jane Alexander, Ph.D., and colleagues report findings from the Hope Dialogue, a consumer-led 1.5-hour forum to explore strategies for coping with suicidal thoughts. A total of 198 individuals with a history of suicide attempts who attended peer-operated programs in New York State participated in 14 Hope Dialogues. Qualitative analysis of their statements about coping strategies indicated that friends, family, and peers provided critical hope and support ( page 1214 ). The importance of social networks was also underscored in a quantitative analysis of data from the Baltimore cohort of the Epidemiologic Catchment Area study. Pallab K. Maulik, M.D., Ph.D., and colleagues found that participants with mental disorders who had more contacts with their social networks and higher levels of social support used fewer mental health services in both primary and specialty care settings ( page 1222 ).

The effectiveness of the Life Goals Program, a group psychotherapy program for people with bipolar disorder, in promoting medication adherence was evaluated in a controlled trial ( page 1182 ).

The Best Practices column describes an array of tools for improving the quality of care for first-episode psychosis ( page 1164 ).

VA researchers are the first to estimate preference-weighted health status of persons with posttraumatic stress disorder ( page 1230 ).

To what extent do people with serious mental illness use the Internet for health information ( page 1265 )?

What five things can a psychiatrist do to support recovery for people with mental illness ( page 1155 )?