This Month's Highlights

Implementing Assertive Community Treatment

In this issue Psychiatric Services continues its series on evidence-based practices with an article by Susan D. Phillips, M.S.W., and her colleagues that summarizes research on the effectiveness of assertive community treatment and places it in the context of an evidence-based practice. Evidence-based practices are those for which clinical services research has found substantial evidence of effectiveness and that therefore should be routinely offered in clinical settings. Ms. Phillips and her coauthors describe the critical components of assertive community treatment programs and challenges that are typically faced by mental health system administrators, program directors and team members, and consumers in ensuring the proper implementation of this proven approach to improving outcomes for persons with severe mental illness (see page 771). Robert E. Drake, M.D., Ph.D., and Howard H. Goldman, M.D., Ph.D., are editors of this monthly series.

Improving the Informed-Consent Process

Mental health researchers are becoming increasingly sensitized to the need to obtain their subjects' informed consent, in particular the consent of individuals with severe mental illness. Paul G. Stiles, J.D., Ph.D., and his associates examined the effectiveness of different consent processes by assessing patients' understanding of the disclosure of personal information. For patients with schizophrenia, they found that the use of a disclosure form with a graphic format—as opposed to a typical dense-text, paragraph format—did not improve understanding, nor did the presence of a facilitator who mediated the consent process. However, patients' understanding was improved by a process that emphasized repetition and retesting (see page 780).

The Myth of Medical Cost Offset

In the Economic Grand Rounds column, Roland Sturm, Ph.D., reconsiders empirical evidence for the claim that increased access to or use of behavioral health care can substantially reduce expenditures for other medical care services. He concludes that although specific interventions that target selected patients can indeed reduce their medical costs, no larger-scale studies have supported sweeping cost-offset claims. Dr. Sturm warns mental health professionals and advocates that cost-offset considerations are not a sound basis for social policy, because requiring evidence that services at least partially pay for themselves, regardless of the benefits to patients, invites discrimination across health conditions and patient subgroups. He encourages an emphasis on cost-effectiveness rather than cost offsets (see page 738).

Focusing on Children

Three papers in this month's issue examine services for children. In the State Health Care Reform column, Marcia C. Peck, M.D., M.P.H., describes the evolution of parity laws in California since 1983, especially as they apply to children. The most current law, enacted in 1999, mandates equal coverage for the diagnosis and treatment of nine severe mental illnesses and serious emotional disturbances among children (see page 743). Dana A. Weiner, Ph.D., and her associates found high rates of substance abuse among children and adolescents with serious emotional or behavioral disturbances who were in residential treatment. These children were significantly more likely to be at risk of suicide, elopement from residential treatment, and discharge to institutional placements (see page 793). In another study of children's services, Marc Navon, M.S.W., L.I.C.S.W., and his associates found that the Pediatric Symptom Checklist was a simple and reliable tool for identifying youth in primary care settings who were at risk of behavioral health problems. They describe a strategy to help professionals recognize and address children's unmet mental health needs (see page 800).

Services for Trauma Victims

In 1999 the South Carolina Department of Mental Health took the first steps in an initiative to improve the public mental health system's response to the clinical needs of persons who are victims of trauma. At least 15 other states have launched similar efforts. B. Christopher Frueh, Ph.D., and his colleagues describe early efforts in the implementation of the South Carolina initiative. The goals of the initiative are to develop and implement standardized trauma assessment protocols and specialized treatment programs and to support ongoing research efforts (see page 812). In a commentary, Sally L. Satel, M.D., argues that although trauma initiatives are well intentioned, they are a "dubious enterprise." She points out that a good description of "trauma-sensitive" services is lacking and that it is unwarranted to assume that all patients in the public mental health system will benefit from focusing on traumatic past experiences. Dr. Satel urges that implementation of a unique form of treatment for the sequelae of these experiences be undertaken only with great care (see page 815).