August 2009: This Month's Highlights

Changes in Attitudes Toward Medications

Americans' opinions about the benefits of psychiatric medications have become more favorable in the past decade, according to data reported in this month's lead article, and their willingness to take them has increased. Ramin Mojtabai, M.D., Ph.D., examined participants' responses to questions posed in the 1998 and 2006 U.S. General Social Survey. Significant increases were evident in the percentage who thought that medications help people to deal with daily stresses (78% in 1998 and 83% in 2006), help people feel better about themselves (60% and 68%), and make things easier in personal relationships (68% and 76%). Beliefs about risks did not change significantly. In both years slightly more than a quarter of respondents believed that these medications were "harmful to the body" and about 45% believed that they interfere with daily activities. Willingness to take medications was probed in four hypothetical cases, only two of which described psychiatric disorders: for panic attacks (56% in 1998 and 64% in 2006), for depression (41% and 49%), to cope with life stresses (36% and 47%), and for trouble in one's personal life (23% and 29%) ( Original article: page 1015 ).

Disparities and Cultural Competence

As evidence of racial and ethnic disparities in use of mental health services and attitudes toward treatment accumulates, the need for cultural competence in service provision is undisputed. Two reports in this issue document disparities, and a third article proposes a conceptual model that links culturally competent practices to service parity. Marcela Horvitz-Lennon, M.D., and colleagues found disparities in recent use of services by more than 6,800 black, Latino, and non-Latino white homeless adults who had serious mental illness. Compared with non-Latino whites, black participants made fewer outpatient visits and Latinos used more case management services. However, when the analysis controlled for education, the black-white disparity was no longer significant ( Original article: page 1032 ). Examining data for 1,370 youths, Sunny Hyucksun Shin, Ph.D., and Timothy A. Brown, Psy.D., found a link between disparities in children's use of services and caregiver strain. Caregivers of African-American children perceived less strain in caring for a child with emotional or behavioral problems. Thus the lower level of service use among these children appeared to be mediated by caregiver strain ( Original article: page 1039 ). Mario Hernandez, Ph.D., and colleagues propose a model that places cultural competence squarely in an organizational context and emphasizes attention to small local communities ( Original article: page 1046 ).

Focus on Children's Mental Health

Four reports examine issues in children's mental health and treatment of children, including youths in the child welfare system and in the criminal justice system. To address concerns about appropriate diagnosis of attention-deficit hyperactivity disorder (ADHD) and medication use, Brent D. Fulton, Ph.D., and colleagues examined two factors that might contribute to observed U.S. regional variation in ADHD diagnosis and treatment: types of providers and their number per capita and policies in some of the nation's school systems that might influence personnel to recommend medication for children with ADHD ( Original article: page 1075 ). An analysis of longitudinal data by Heather Ringeisen, M.S., Ph.D., and colleagues found that mental health problems were prevalent among young adults with a history of maltreatment who had "aged out" of the child welfare system, but their use of mental health services was low, especially when compared with their use as adolescents ( Original article: page 1084 ). Daniel C. Murrie, Ph.D., and colleagues found high rates of mental health problems among Texas youths aged 16 and 17 incarcerated in a prison for adults ( Original article: page 1092 ). Claims data for nearly 3,000 youths indicated that in the year before they received a new diagnosis of bipolar disorder, nearly half had been given a diagnosis of depression and more than a third a diagnosis of disruptive behavior disorder. However, for many youths the bipolar diagnosis did not recur in claims data after the index diagnosis ( Original article: page 1098 ).

Decisions About Shared Decision Making

A survey of German psychiatrists by Johannes Hamann, M.D., and colleagues indicated that 51% regularly engaged in shared decision making with their patients with schizophrenia, but they did so mainly with well-informed, adherent patients and mainly for decisions about psychosocial treatments. Many did not endorse this approach for patients with impaired decisional capacity and for decisions about medical care ( Original article: page 1107 ). In a Taking Issue commentary, Robert E. Drake, M.D., Ph.D., and Patricia E. Deegan, Ph.D., note that "like fish unable to discover water, many psychiatrists struggle to recognize their own paternalism" ( Original article: page 1007 ).