Four research reports in this issue highlight some of the many ways in which co-occurring substance use disorders complicate treatment and worsen outcomes for people with mental illness. Robin E. Clark, Ph.D., and colleagues analyzed Medicaid claims data from six states for nearly 150,000 adult enrollees with mental disorders. For the large subgroup with co-occurring substance use disorders (29%), expenditures for medical care for physical health problems were substantially higher in five states. In fact, the cost of providing such care was greater than the direct cost of mental health and addictions treatment for this subgroup (page 35). Jeffrey D. Baxter, M.D., and colleagues used two measures to examine the quality of asthma care for more than 19,000 adult Medicaid enrollees who had behavioral health disorders and comorbid asthma. Those with substance use disorders were particularly likely to receive poor-quality asthma care (page 43). In a study of nearly 3,000 veterans with bipolar disorder, Jennifer C. Hoblyn, M.D., M.P.H., and colleagues found that 20% had a psychiatric hospitalization during the study year. Three variables conferred a 100% risk of hospitalization: all veterans in this group who had both an alcohol use disorder and polysubstance dependence and who were separated from their spouse or partner were hospitalized (page 50). Marlys Staudt, Ph.D., M.S.W., and Donna Cherry, Ph.D., M.S.W., used data from a national study of the child welfare system to investigate whether parents with mental or substance use disorders were offered and received appropriate services. Parents in both groups used services at a higher rate than in the general population, indicating that child welfare caseworkers facilitated treatment; however, those with substance use problems were significantly less likely to be offered treatment (page 56).

The dramatic declines in the number of residents in state psychiatric hospitals since the 1950s and in the number of admissions since the 1970s are well documented. However, a study by Ronald W. Manderscheid, Ph.D., and colleagues indicates a marked reversal of these long-term trends. The authors analyzed state-level data submitted annually to the Center for Mental Health Services. Between 2002 and 2005, the number of state hospital admissions nationwide increased by 21% and the number of residents increased slightly (1%). State mental health agency staff attributed the increases principally to a single factor—an increase in forensic admissions and forensic residents. Because the new trends may indicate important long-term changes, the authors issue "an urgent call" for research to investigate "the precise dynamics through which a person with mental illness moves from the community to become a forensically involved patient in a state psychiatric hospital" (page 29).

Health care reform is likely to be high on the national agenda in 2009. The last serious national debate about reform was in 1993, during the Clinton Administration. In this month's Economic Grand Rounds column, Chris Koyanagi, policy director at the Bazelon Center for Mental Health Law, looks back at mental health policy issues that were central to the 1993 reform plan—such as parity, comprehensive benefits, and integration of care—and discusses their continued relevance to future efforts by the Obama Administration. Although much has changed since 1993, she notes, particularly in the acceptance of parity by employers and the insurance industry, much remains to be done. Integration of behavioral health services in general medical care is still a distant goal, and provision of a full range of benefits to more than 46 million uninsured Americans will be difficult. However, new reforms can be built on a much more solid base of evidence for the effectiveness of treatments, Ms. Koyanagi notes (page 17).

The goal of pay-for-performance programs is to improve the quality of care. In many areas of medicine, such programs, especially those that use structure and process measures, have yielded positive results. In this month's Open Forum, Benjamin Liptzin, M.D., describes an insurer-initiated program in Massachusetts for behavioral health care providers that he regards as a "radical departure." The program ties providers' annual fee increases to improvements in patient outcomes, which are measured by a 70-item instrument. Dr. Liptzin discusses six major problems with programs that use broad-based outcome measures (page 108). In a related commentary, Mark A. Blais, Ph.D., and colleagues argue that despite the problems identified by Dr. Liptzin, outcomes measurement in pay for performance "makes good sense" in behavioral health care (page 112).