This Month's Highlights

Prevention and the Future of Psychiatry

“Prevention in psychiatry is possible. A scientific base of evidence shows that we can prevent many mental, emotional, and behavioral disorders before they begin.” The introduction to this month's lead article reminds professionals that they can draw on their knowledge and experience not only to improve outcomes for their patients with mental illnesses but also to reduce people's risk of developing mental illnesses. William R. Beardslee, M.D., and coauthors highlight and expand key points from a landmark 2009 Institute of Medicine (IOM) report titled Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Because half of all lifetime cases of mental, emotional, and behavioral disorders start by age 14—and symptoms typically occur two to four years before diagnosis—prevention focuses primarily on young people. The authors discuss evidence for prevention from a developmental perspective, including biological and psychosocial risk factors, developmental plasticity, and preventive interventions, such as parenting programs and interventions for groups at high risk of depression. Dr. Beardslee and colleagues highlight the cost savings that can be achieved with prevention, which are multiplied over the lifetimes of affected youths. The authors summarize two sets of IOM recommendations for incorporating prevention principles into practice—one for individual clinicians and the other for mental health systems. They call on clinicians to envision and work toward a future in which the health care system is organized on these principles (page 247).

Mixed-Methods Designs in Services Research

For more than a decade, the National Institutes of Health (NIH) has encouraged mental health services researchers to blend quantitative and qualitative methods in order to examine issues from multiple perspectives and gain a more nuanced understanding of service delivery and receipt. To better understand the impact of these efforts and to determine how mixed methods are being applied, Lawrence A. Palinkas, Ph.D., and colleagues searched databases for recent (2005–2009) studies published in peer-reviewed journals and NIH-funded projects based on mixed-methods designs. The authors documented a notable increase over the five-year period in mixed-methods studies published (N=50) and grants funded (N=60). Of the 50 published articles, ten (20%) appeared in Psychiatric Services, and several of the others were coauthored by Psychiatric Services' editorial board members and published elsewhere. The review revealed five types of aims for these studies and projects; three categories of rationale for use of mixed methods; seven structural arrangements for their use; five functions of mixed methods; and three ways of linking qualitative and quantitative data. The authors note that use of a common set of designs suggests a developing consensus on how mixed methods can and should be used in mental health services research (page 255).

Traumatic Injury and Psychiatric Disorders

More than nine million children and adolescents visit U.S. emergency departments and other medical settings each year after incurring traumatic physical injuries. To investigate the hypothesis that these youths would have elevated rates of psychiatric disorders in the years after their injury, Douglas F. Zatzick, M.D., and David C. Grossman, M.D., M.P.H., used data from a large health plan to compare disorders diagnosed in 2002–2004 among youths aged ten to 19 who sustained an injury in 2001 (N=6,116) or did not (N=14,391). They found that the injured youths had significantly greater odds than the noninjured youths of later being given a diagnosis of anxiety or acute stress, depression, or a substance use disorder and of receiving a prescription for psychotropic medication. The authors recommend screening to detect postinjury psychiatric disturbances and computerized strategies that link pediatric primary care providers with collaborative care consultation (page 264).

Better Outcomes in Day Hospitals

Day hospitals were widely established as part of mental health reforms in the 1970s, and the term has been applied to programs with a range of service intensities. When research provided little evidence for the effectiveness of day treatment centers offering long-term vocational activities, such programs largely disappeared. However, day hospitals where patients receive acute treatment as an alternative to inpatient care have held up to research scrutiny and may offer opportunities from reform of hospital care in the 21st century. Using data from the 2000–2003 European Day Hospital Evaluation, Stefan Priebe, F.R.C.Psych., Dr. med. habil., and colleagues found several patient characteristics that were significantly associated with better outcomes in a day hospital compared with an inpatient ward, including gender and education level (page 278).