Two studies this month examine treatment for attention-deficit hyperactivity disorder (ADHD). Several new options for treating ADHD with medications have been used in the past 15 years, including intermediate- and long-acting stimulants and second-generation antipsychotics. Little is known, however, about how new approaches have changed treatment patterns and spending for children with ADHD. In the lead article, Catherine A. Fullerton, M.D., M.P.H., and colleagues present results of their analysis of ten years of data (1996–2005) for children age three to 17 in Florida's Medicaid program who had a diagnosis of ADHD (N=107,486). The authors found that the proportion treated with ADHD drugs increased only slightly over the period—from 60% to 63%—and that the percentage taking antipsychotics more than doubled—from 8% to 18%. Mental health expenditures for children with ADHD increased 61%, with pharmaceutical spending the fastest-rising component (up 192%). Spending on stimulants increased 157%, and by 2005 long-acting stimulants accounted for 90% of stimulant spending. Antipsychotic spending increased nearly 600%, despite the absence of good data on the efficacy and safety of using second-generation antipsychotics in this population (page 115). To better understand how the care of children with ADHD is initiated and evolves over time, Bradley D. Stein, M.D., Ph.D., and colleagues looked at data for 2,077 Medicaid-enrolled children age six to 12 who started ADHD treatment between October 2006 and December 2007. Forty-five percent began with a psychosocial intervention alone, 41% with medication alone, and 14% with a combination. By the end of the treatment episode, 42% of the first group had added medication. By six months, 40% of all the children had discontinued treatment. As noted by the authors, the frequent changes and high dropout suggest dissatisfaction with initial treatment for ADHD and the need for a closer look at factors underlying these patterns (page 122).

From 65% to 70% of youths in the juvenile justice system have mental disorders. A 2004 Congressional report noted that detention centers were often used as “warehouses” for youths with mental disorders. One response has been the creation of juvenile mental health courts (JMHCs), which attempt to divert youths by linking them to community treatment. In December 2009, all JMHCs—41 in 15 states—were surveyed. In the third article in this month's line-up, Lisa Callahan, Ph.D., and colleagues summarize the survey findings, one of which they highlight as disturbing: fewer than half (40%) of the JMHCs dismiss charges upon program completion, whereas nearly two-thirds (63%) require a guilty plea for participation. “The importance of dismissal of charges cannot be overemphasized,” the authors note, describing some of the “far-reaching collateral consequences” of having a conviction record (page 130).

Studies have repeatedly shown that downsizing and closure of state psychiatric hospitals and other long-stay hospitals does not result in negative patient outcomes when resources are shifted to community settings. But most inpatient psychiatric care is acute care provided in community hospitals. What are the impacts on patients and the community of reductions in acute inpatient capacity? For Martha Shumway, Ph.D., and colleagues two service changes at San Francisco General Hospital that reduced acute inpatient capacity by 50% provided a natural experiment to examine effects on patients and the community. Their hypothesis of negative consequences, such as increased demand for psychiatric emergency services, decreased access to emergency and inpatient care, and increased numbers of suicides and jail psychiatric evaluations, was not supported by their analyses of a range of indicators. A key factor was the collaboration of inpatient and outpatient providers, which enabled the hospital to reduce length of stay and thus serve the same number of patients as before the reduction (page 135).

• Authors of the first Open Forum in this issue argue that consumer self-determination—personal choice informed by shared decision making and a recovery orientation—has replaced treatment adherence as the care paradigm for people with serious mental illnesses (page 169).

• The second Open Forum explores whether psychosocial programs that bring together young people with psychosis—and perhaps encourage bonding and marriage—may unwittingly promote “assortative mating,” with ill effects for offspring (page 174).

• The Mental Health Reforms in Europe column describes how a 2000 Israeli law shifted the locus of treatment from institutions to the community (page 110).