November: This Month's Highlights

STAR*D Special Section

This issue features a special section on the implications for practice and policy of the STAR*D findings. Sequenced Treatment Alternatives to Relieve Depression (2000–2004), which sought to determine the most effective next steps for individuals whose symptoms do not remit after an initial antidepressant trial. Key features were its recruitment of a diverse sample of "real-world" patients and its four-level algorithm design, in which clinicians in both specialty and primary care used a measurement-based approach to address treatment-resistant depression. The idea for the special section came from Guest Editor Grayson S. Norquist, M.D., M.S.P.H., a Psychiatric Services editorial board member, who notes in his introduction that another important aim of the NIMH-funded trial was to create an infrastructure that would build capacity and provide a platform for state-of-the-art clinical research ( Original article: page 1437 ). The special section begins with an overview of STAR*D and its findings ( Original article: page 1439 ) and a review of STAR*D's contributions to pharmacogenetics research—nearly 2,000 participants provided DNA samples ( Original article: page 1446 ). The perspectives of four stakeholder groups follow: consumers ( Original article: page 1458 ), primary care providers ( Original article: page 1460 ), insurers ( Original article: page 1463 ), and NIMH ( Original article: page 1466 ).

Focus on First-Episode Psychosis

Five articles and a column address issues in the treatment of first-episode psychosis, an area that will receive increasing attention as the NIMH-funded RAISE project (Recovery After an Initial Schizophrenia Episode) gets under way. The first article presents promising results from a two-year trial of cognitive enhancement therapy for early-course outpatients with schizophrenia ( Original article: page 1468 ). In the second study researchers used statistical simulation to show the cost-effectiveness and possible cost savings of multifamily psychoeducation for individuals with first-episode psychosis and their families ( Original article: page 1477 ). The third article describes lessons learned by stakeholders in England involved in implementing a national effort to ensure early intervention in psychosis ( Original article: page 1484 ). Researchers in the fourth study identified factors that contribute to a longer duration of untreated first-episode psychosis among African Americans ( Original article: page 1489 ). The fifth article presents data showing that apathy is prevalent in this patient group and is a strong contributor to poor functioning ( Original article: page 1495 ). Finally, the Public-Academic Partnerships column describes a community mental health center program designed to be a nationally relevant model of early intervention for psychotic disorders ( Original article: page 1426 ).

Implications of Medicaid Policy Changes

Medicaid is the nation's primary payer for mental health services, and policy changes in the Medicaid program can have unintended consequences for state mental health systems and providers. Jeffrey A. Buck, Ph.D., describes five themes central to recent Medicaid policy changes and their implications for mental health services. For example, concerns at the federal level about states' use of matching funds to support programs that could be funded by other state and federal agencies have led to efforts to enforce the authority of state Medicaid agencies, resulting in less flexibility in use of funds and greater focus on provider accountability. Dr. Buck describes other Medicaid policies that will work toward mainstreaming of mental health services into the general health care system ( Original article: page 1504 ).

Education and Mental Health Policy

An expanding body of literature supports the assertion that children's mental health and their educational outcomes are deeply intertwined. However, research and policy in the two fields operate within very different paradigms. In the second policy paper in this month's line-up, Sheryl H. Kataoka, M.D., M.S.H.S., and colleagues review historical developments from the Progressive Era to the present that have led both to No Child Left Behind and to the Individuals With Disabilities Education Act (IDEA), which mandates free public education for children with disabilities and now permits use of special education funding for early intervention with at-risk children. Dr. Katakoa and coauthors call for a paradigm change that would focus researchers in both fields on new ways to ensure that attending to children's mental health is part of the nation's educational mission ( Original article: page 1510 ).