Implementation of evidence-based practices within systems of care has improved outcomes for children with serious emotional disturbances. Treatment foster care (TFC) is one of the few community-based treatment options for which there is a substantial evidence base. More than 2,000 U.S. agencies have TFC programs, although most do not provide the evidence-based version. Elizabeth M. Z. Farmer, Ph.D., and colleagues report on a five-year randomized controlled trial conducted at 14 "usual care" TFC agencies. The intervention—Together Facing the Challenge—is a hybrid TFC model that combines elements from evidence-based practice with approaches used effectively by usual care agencies. The study provided training, supervision, and consultation to TFC supervisors and training to treatment parents. Data from interviews with treatment parents indicated that youths in the intervention group showed greater improvement than those in the control group in the three focal domains—symptoms, behaviors, and strengths. Effects were significant for all outcomes at six months and remained significant for behaviors at 12 months (page 555).

Community hospitals are the primary source of inpatient psychiatric care in the United States. Patients can be admitted to separate psychiatric units or to medical-surgical beds (scatter beds). Using 2003 discharge data from 12 states, Tami L. Mark, Ph.D., M.B.A., and colleagues found that only 6.8% of discharges (N=26,969) were from scatter beds; compared with patients treated in psychiatric units (N=370,984), those in scatter beds were more likely to have somatic conditions and half as likely to have a co-occurring substance use disorder (page 562). Little is known about the care environment for psychiatric patients in general hospitals. When Nancy P. Hanrahan, Ph.D., R.N., and colleagues linked hospital data with results of a nurse survey at 67 Pennsylvania hospitals, they found that adverse events occurred frequently and were associated with organizational factors, such as nurse-patient staffing ratios and the quality of nurse-physician relationships (page 569). David Hartley, Ph.D., and colleagues surveyed 74 small rural hospitals with a psychiatric unit. On average, the units had ten beds and 230 annual admissions. Staff had better-than-expected access to postdischarge community-based services; most of the unit clinicians provided outpatient services locally. Changes in Medicare reimbursement threaten to close some units (page 620).

Untreated mental health and substance abuse problems among soldiers returning from Iran and Afghanistan can lead to casualties for these individuals and their families. Three studies in this issue focused on cohorts of returning veterans. Patcho N. Santiago, M.D., M.P.H., and colleagues worked with data from a military health screening conducted for all returnees three to six months postdeployment. The assessment includes two questions to detect alcohol misuse, but because referral to alcohol treatment after positive responses was very low (<1%), officials wondered whether the questions measured alcohol misuse or other, less worrisome factors, such as prosocial use associated with support seeking from other veterans. The study demonstrated the questions' utility by uncovering strong associations between positive responses and high-risk drinking behaviors reported by 6,527 veterans in an anonymous survey (page 575). In another study with an anonymous survey, 10,386 active duty or National Guard soldiers reported on use of mental health care, stigma, and barriers at three and 12 months after returning from Iraq. At both time points, Paul Y. Kim, M.A., and colleagues found that about 45% of active duty soldiers reported a mental health problem, compared with about 35% of National Guard soldiers. However, service use was twice as high among the latter group (27% versus 13%), which may have resulted from significantly stronger endorsement of stigma and barriers among active duty soldiers (page 582). Nina A. Sayer, Ph.D., and colleagues explored community reintegration problems in a national sample of 754 Iraq and Afghanistan veterans. From 25% to 56% reported difficulty in a range of areas, such as social functioning and self-care, and at least a third reported divorce, dangerous driving, increased substance use, and anger control problems. Almost all (96%) expressed an interest in services to help readjust to civilian life (page 589). Combat veterans were represented in the sample of 463 adults with posttraumatic stress disorder studied by Stefan Priebe, F.R.C.Psych., Dr.Med.Habil., and colleagues, who evaluated outcomes at specialized treatment centers established after the war in former Yugoslavia. The authors found low rates of recovery and little improvement (page 598).