August 2010: This Month's Highlights

Integrating behavioral and primary health care is a key strategy for increasing access, especially for people with serious mental illness. In this month's lead article, Rebecca Wells, Ph.D., M.H.S.A., and colleagues present evidence of "a major advance in integration of mental health and primary care within the U.S. safety net." The authors analyzed 1998–2007 data from more than 1,000 community health centers providing primary care in underserved areas. The authors assessed the effects of two federal efforts to broaden access. An initiative that began in 2002 led to a 43% increase in the number of centers between 2001 and 2007—from 748 to 1,067. Also in 2002 the federal government directed state Medicaid agencies to begin reimbursing behavioral health care provided at the centers. The researchers found that by 2007 more than three-quarters of the centers (77%) had mental health specialists on site—up from 62% in 2001. The number of centers offering substance abuse treatment and 24-hour crisis intervention increased by 58% and 70%, respectively. Both the 2009 federal stimulus package and health reform substantially increased funding for these centers, the authors point out, which combined with provisions in the new parity law may further widen the safety net ( page 759 ).

Two literature reviews address critical issues in the lives of many patients who rely on the safety net: language barriers to treatment and elevated rates of morbidity and mortality. Amy M. Bauer, M.D., M.S., and Margarita Alegría, Ph.D., examined effects on treatment quality of patients' limited English proficiency and the use of interpreters in mental health settings. The limited research in this area indicates that evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Both trained and untrained interpreters make errors, but use of professional interpreters may improve patient disclosure, referral to specialty care, and patient satisfaction ( page 765 ). A healthier lifestyle is a key aspect of recovery among people with serious mental illness, and many interventions have been developed to improve diet and promote physical activity in this population. Leopoldo J. Cabassa, Ph.D., and colleagues examined three decades of outcomes research on such interventions. Twelve of the 23 U.S. studies reviewed found significant improvements in health. However, people from racial-ethnic minority groups were underrepresented ( page 774 ).

Seven studies in this issue looked at subpopulations of children in need of services. An analysis of school survey data by researchers in Norway found that among 990 adolescents who reported deliberate self-harm, 25% received professional help afterward and 50% received informal help ( page 783 ). California researchers watched more than 1,200 videotapes of treatment sessions to document therapy processes used by 96 psychotherapists in the usual outpatient care of children with disruptive behavior problems. One aim of the study was to assess the extent to which evidence-based treatment strategies were used ( page 788 ). In 1967–1971 a cohort of children with court-documented abuse and neglect were matched with nonvictimized children, and both groups were followed into adulthood. Data from 2003–2004 (mean age 41 years) showed that those with childhood maltreatment were more likely to be users of mental health services in middle adulthood, an association partly mediated by psychiatric status in young adulthood ( page 796 ). Researchers in Britain compared 2004 national survey data with 1999 data to determine whether policy changes and dissemination of research findings improved the low rate of identification and diagnosis of children with attention-deficit hyperactivity disorder (ADHD) ( page 803 ). Researchers in a U.S. city interviewed 48 parents of children with a new diagnosis of ADHD about their experiences leading up to the diagnosis. More than three-fourths reported stigmatizing experiences, and a qualitative analysis indicated that stigma came from a wide range of sources ( page 811 ). Researchers at three residential substance abuse treatment programs interviewed staff, adolescents, and their parents about how they would know when the adolescent no longer needed treatment. Among the findings was a clear indication that staff need to better understand treatment goals and articulate them to adolescents and their parents ( page 817 ). An examination of national Medicaid data for nearly 29,000 children newly diagnosed with an autism spectrum disorder indicated that the average age at autism diagnosis fell by five months between 2002 and 2004 (59.3 months), but the authors note that diagnosis among Medicaid-enrolled children occurred later than it should ( page 822 ).