This Month's Highlights

The Fraying Safety Net

Two studies in this issue examined loss of insurance coverage among people with schizophrenia. Recent budget shortfalls have led many states to cut or to contemplate cuts to their Medicaid programs. Data on the impact of such cuts are of interest to mental health policy makers, because Medicaid pays for services for many if not most people with schizophrenia. In the lead article, Bentson H. McFarland, M.D., Ph.D., and Jon C. Collins, Ph.D., report data from a natural experiment that occurred in Oregon in 2003 when declining state revenues led to massive cuts in the state's generous Medicaid benefits for people with schizophrenia. The authors looked at involuntary state psychiatric hospitalizations in three cohorts: those who lost Medicaid coverage in 2003, those who lost coverage in 2004, and those who maintained coverage from 2002 through 2004. Among those who lost coverage, the authors found that such admissions increased markedly over time (p<.003), whereas there was little change in the cohort that maintained coverage. Because Medicaid does not cover state hospital care, the findings point to a trade-off between savings on Medicaid and growth in expenditures for state hospital admissions (Original article: page 871). In the second study, Connecticut researchers documented loss of insurance—both public and private—among patients with recently diagnosed psychosis. Discontinuities in coverage that create barriers to care are of particular concern for this group because many studies have shown that receipt of services early in the course of psychosis can make a critical difference in long-term outcomes. Tyler J. Dodds, M.D., and colleagues found that less than one-third of participants maintained continuous insurance coverage in the year after onset of psychosis. The authors emphasize that specialty services for people experiencing first-episode psychosis need to address the reality that insurance coverage for this population is likely to be interrupted at a critical juncture in treatment (Original article: page 878). In a Taking Issue commentary on these studies, Marvin S. Swartz, M.D., describes benefits and risks of Medicaid's expanded role in the public mental health safety net (Original article: page 821).

Listening to Patients

The authors of three studies in this issue used qualitative methods to analyze patients ' stories: about being a first-time service user, about learning to become adherent to antipsychotics, and about internalized stigma. In the first study, Helen Lester, M.B.B.Ch., M.D., and fellow researchers in the United Kingdom interviewed young people at two points after enrollment in early intervention services for first-episode psychosis, which in that country are designed to continue for the first three years of illness. Patients placed a high value on the support they received from their families and key workers; however, about a third felt that three years of sustained engagement was too intensive. Many spoke of the emergence of a new self-identity, often associated with a sense of loss of the person they were before becoming ill (Original article: page 882). The second study elicited narratives about illness and medication use from patients with schizophrenia who had been in treatment for up to 34 years. Constantin Tranulis, M.D., and colleagues asked patients to focus on key turning points in the process of becoming adherent to antipsychotics. Patients' stories revealed a complex picture of medication use and refusal, in which ongoing adherence was the result of a long and painful fight with a debilitating disorder (Original article: page 888). Finally, Derrick A. Kranke, Ph.D., M.A., and colleagues interviewed a sample of adolescents who took psychiatric medications. The authors' goal was to construct a model of self-stigma among young people. The youths' narratives included three primary “plot components”: stereotype, differentiate, and protect. Being labeled “crazy” and “psycho,” feeling different from their peers, and protecting their self-image and reputation by hiding details that linked them to a mental illness were aspects of most interviewees' stories. Important differences between this model and models of self-stigma among adults are discussed (Original article: page 893).

Briefly Noted …