Studies have shown that about half of all individuals with first episodes of psychosis present for treatment with a current substance use disorder. Little is known about such disorders in this group, although it is well known that co-occurring substance use disorders are associated with many adverse outcomes in long-term psychosis. Jennifer P. Wisdom, Ph.D., M.P.H., and colleagues conducted a literature search to answer two questions. First, do some clients become abstinent after a first episode without specialized substance abuse treatment? Second, among clients who continue to use substances after a first episode, does receipt of specialized substance abuse treatment enhance outcomes? The search yielded nine studies in which participants received psychiatric treatment only and four studies in which participants also received specialized substance abuse treatment. Approximately half of all clients became abstinent or significantly reduced their substance use after a first episode of psychosis. The four studies of specialized treatment did not find better rates of abstinence or reduction of use. The authors note that research on specialized substance abuse treatment for this population is still in its infancy, and they recommend elements that researchers should include in future studies (page 1007).

Many studies have indicated a serious shortage of psychiatrists in the United States. Current estimates place the shortage at around 45,000. The situation is likely to worsen as the population grows and as health care reform extends mental health coverage to large groups of previously untreated persons. It is important to attract more medical students to psychiatry. To understand factors affecting the career satisfaction of psychiatrists, Jim DeMello, D.B.A., and Satish P. Deshpande, Ph.D., examined data from 314 psychiatrists who participated in the 2008 Health Tracking Physician Survey. They found that the threat of malpractice and having to consider a patient's out-of-pocket costs in making treatment decisions had a significant negative impact on career satisfaction. Being able to spend adequate time with patients had a significant positive impact. Another factor that increased satisfaction was working in a practice that accepted new Medicaid patients. None of the compensation-related factors examined were significant (page 1013).

Research has shown that nonwhite populations have a greater disability burden from depression and anxiety because they are less likely than whites to receive high-quality care. Is the racial-ethnic composition of the practices where they seek care a factor? Isabel T. Lagomasino, M.D., M.P.H., and colleagues investigated this question by analyzing data from 58,826 adult visits to office-based primary care physicians and psychiatrists from the National Ambulatory Medical Care Survey. They found that visits to primary care physicians by blacks and Hispanics were less likely than visits by whites to result in an antidepressant prescription or in any care for depression or anxiety. Visits by blacks to psychiatrists were also less likely to result in an antidepressant prescription. Most visits by blacks and Hispanics to both primary care physicians and psychiatrists were to practices that served a high percentage of nonwhite patients. However, disparities in primary care settings persisted even after analyses controlled for whether the practices served a high or low percentage of nonwhite patients. The authors conclude that the racial-ethnic composition of a practice is only one factor in ongoing disparities in care for depression and anxiety (page 1019).

Ethnic disparities in treatment were also the focus of a study in British Columbia, in which Joseph H. Puyat, M.Sc., M.A., and colleagues examined antipsychotic prescription refill data in a large population with significant Asian representation. They found evidence of persistent disparities among Chinese individuals (page 1026). Two other studies in this issue examined prescription data. In a U.S. study, Karen L. Rascati, R.Ph., Ph.D., and colleagues examined Medicaid claims data for 2,446 patients with bipolar disorder for whom five different second-generation antipsychotics were prescribed. They found no significant differences in adherence between medication groups. However, fewer than half of the patients received a clinically recommended dosage (page 1032). In Israel, Liat Ayalon, Ph.D., and colleagues examined data from a national sample of 30,000 adult primary care patients, 19% of whom received antidepressant or antianxiety medications. They found disparities between population groups despite universal health coverage (page 1041).