This Month's Highlights

Family- and consumer-driven care is at the center of a transformed system. Family members play important roles in the lives of most adults with serious mental illness. They need information and skills to help their loved one, as well as the support of others to fulfill their caregiver role without being overwhelmed by distress and burden. The Family-to-Family Education Program (FTF), introduced in the early 1990s by the National Alliance on Mental Illness, is the most widely disseminated mutual-support program for family members of people with mental illness. Although an estimated 250,000 family members have participated in FTF, little research has focused on family self-help. In the lead article this month, Lisa B. Dixon, M.D., M.P.H., and colleagues report the results of the first randomized controlled trial of the effectiveness of FTF, which involved assignment of 318 family members from five Maryland counties to FTF or a waiting list. At three months (course termination), FTF participants had significantly greater improvements in problem-focused coping, as measured by empowerment and illness knowledge. Their emotion-focused coping was also significantly enhanced, and they had less distress and better problem-solving skills. These empirical findings confirm the word-of-mouth popularity of FTF among participants, the authors note, and provide support for consideration of brief family-driven educational programs as an evidence-based practice (page 591).

Assertive community treatment (ACT) is an evidence-based practice that has consistently been shown to lower use of inpatient care and improve other key outcomes for people with serious mental illness. More than three decades of encouraging findings have led to high expectations whenever ACT is implemented with fidelity. Can ACT also reduce racial-ethnic disparities in service use, an area of particular concern to policy makers in recent years? Marcela Horvitz-Lennon, M.D., and colleagues assessed the “equity effects” of ACT by analyzing data for nearly 7,000 black, Latino, and white homeless adults with severe mental illness who received ACT services through the ACCESS study (Access to Community Care and Effective Services and Support). The authors found that over time ACT narrowed disparities in use of outpatient care between black and white participants but not between Latinos and whites. The authors speculate that the difference in equity effects may be attributable to ACT's not being delivered in a way that met the specific cultural and linguistic needs of Latino ACCESS participants (page 598). In a commentary on this article, Deborah K. Padgett, Ph.D., and Benjamin F. Henwood, Ph.D., raise interesting questions about this gold-standard program as ACT enters its fourth decade in the era of recovery (page 605).

The illness management and recovery (IMR) program includes several components that have empirical support in the treatment of schizophrenia. An article in this issue by Rickard Färdig, M.Sc., and a Swedish research group describes the first controlled study of the IMR program delivered exclusively to persons with a diagnosis of schizophrenia. The sample was recruited from six psychiatric outpatient rehabilitation centers in Sweden. Forty-one participants were randomly assigned either to an IMR group for nine months or to treatment as usual. As measured by self-report and ratings of nonblinded clinicians at nine and 21 months, IMR program participants demonstrated significantly greater improvement in illness management than participants in the control condition. A statistically significant decrease in suicidal ideation between baseline and follow-up was also found for IMR program participants (page 606).

Although treatment disparities have been convincingly demonstrated for several mental disorders, no national studies have examined such disparities for schizophrenia. Using 1999–2007 data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Medical Survey, Kathryn Rost, Ph.D., and colleagues used four logistic regression models to test the relationship of sociodemographic variables to antipsychotic medication management during office visits by persons with schizophrenia and to hospitalization after such visits. In at least three of the four models, visits by non-Hispanic black patients were significantly more likely than visits by non-Hispanic whites to involve antipsychotic medication management and to result in hospitalization. These consistent differences by race-ethnicity over nine years of data, which were difficult to explain by clinical severity or receipt of specialty care, likely point to the existence of long-standing disparities, the authors conclude (page 613).