The President's New Freedom Commission has drawn national attention to the persisting social problem of social exclusion for individuals trying to rebuild their lives after the onset of serious mental illness. In this issue Norma C. Ware, Ph.D., and colleagues report on a study in which they constructed a new definition of community integration in the context of psychiatric disability—one focused not on impairments and limitations but on possibilities for development and growth. The authors interviewed 56 people who, after becoming psychiatrically disabled, had been able to become more socially integrated. The research team also made one- or two-day ethnographic visits to five service sites that work to promote social integration. After painstaking qualitative data analysis, the authors propose a definition of social integration structured by two critical categories: connectedness and citizenship. Connectedness denotes the construction and successful maintenance of reciprocal interpersonal relationships. Citizenship refers to the rights and privileges enjoyed by members of a democratic society and to the responsibilities these rights engender. The definition sets an ideal but not unrealistic standard that all can aim for (page 469).

In the first of three articles reporting research on medication use, Elizabeth Bromley, M.D., M.A., notes that although the development of cognition-enhancing drugs for patients with schizophrenia has been given a high priority, much less attention has been paid to planning how to use these drugs in everyday practice. She explains why clinicians may have trouble identifying patients with schizophrenia who should receive cognition-enhancing drugs and further difficulty in assessing improvements (page 475). Lizheng Shi, Ph.D., and colleagues examined data from a large U.S. study and identified characteristics of patients who received depot antipsychotics rather than oral agents (page 482). In a Taking Issue commentary on this study, William M. Glazer, M.D., expresses his dismay over results suggesting that clinicians prescribe depot antipsychotics "with erroneous assumptions that reveal some prejudices" (page 437).

A Veterans Affairs study by Julie Kreyenbuhl, Pharm.D., Ph.D., found extensive use of long-term antipsychotic polypharmacy. In a sample of more than 61,000 patients with schizophrenia or schizoaffective disorder, 9.5% received two or more oral antipsychotics for at least 90 consecutive days. This treatment approach, for which there is little evidence of safety or efficacy, appeared to be reserved for the most severely ill patients (page 489).

Two articles in this month's issue look at trends in the use of hospitalization in treatment. Shinobu Watanabe-Galloway, Ph.D., and Wanqing Zhang, M.D., M.Ed., found that despite efforts to reduce hospital use by persons with serious mental illness, rates have increased significantly. An examination of data on 327,000 discharges from a national survey of general hospitals showed that discharges involving serious mental illness increased by about 35% between 1995 and 2002—from 29 discharges per 10,000 in the adult U.S. population to 39 per 10,000 (page 496). Using an 11-state database, a group of researchers led by Kathryn Rost, Ph.D., found that rural patients with depression had a significantly greater chance of being hospitalized than their urban counterparts. The authors note that greater use of the hospital does not appear to produce any clinical benefits, because rural and urban patients with depression report identical outcomes over one year (page 503).

Improving the health of people with serious mental illness is the focus of two articles. Richard W. Goldberg, Ph.D., and colleagues looked at indicators of quality of diabetes care in a sample of 300 patients and found that the 201 individuals who had serious mental illness were less likely to receive the full complement of recommended services and support (page 536). In Taiwan Mei-Kuei Wu, M.S., and colleagues designed a six-month diet and physical activity program for clozapine-treated inpatients with obesity. The 28 patients who participated showed a significant decrease in body weight and improved metabolic profiles compared with the control group (page 544).

• The Economic Grand Rounds column describes a pay-for-performance program for behavioral health care practitioners that was implemented in 1999 (page 442).

• Are brain-wave analysis and neuroimaging reliable methods of lie detection? The Law & Psychiatry column examines the evidence (page 460).