This Month’s Highlights

The Critical Role of Geography

Many studies have shown that when a new or improved treatment becomes available, its diffusion often follows an unpredictable path and its adoption is inconsistent. Two studies in this issue attempted to tease out factors driving the adoption of newly approved drugs. In the lead article, Marcela Horvitz-Lennon, M.D., M.P.H., and colleagues found a “powerful effect of geography” when they examined uptake across the Florida Medicaid program of long-acting injectable risperidone (LAIR), an antipsychotic that received approval in late 2003. An unadjusted analysis of 2004–2006 Medicaid data found that Latino enrollees were significantly less likely than white enrollees) to receive LAIR. However, when the analysis controlled for place of residence, the disparity disappeared. The geographic concentration of Latino Medicaid beneficiaries in a low-adoption area explained the difference, although the authors could only speculate about why such geographic variation existed in a fee-for-service state program where all enrollees are subject to the same policies (page Original article: 1171). Researchers who analyzed 2002–2009 data from 21 Veterans Integrated Service Networks (VISNs) nationwide also found substantial geographic variation in timing and speed of adoption of aripiprazole to treat bipolar disorder, an indication for which the drug received FDA approval in 2004. Robert B. Penfold, Ph.D., and colleagues observed that “scientific approval”—publication of positive findings from placebo-controlled trials of the drug before FDA approval—also influenced VISN prescription patterns (page Original article: 1178). In Taking Issue, Stephen Goldfinger, M.D., wonders what factors explain the delayed uptake of evidence-based practices (page Original article: 1161).

Housing Homeless Veterans: Two Studies

Since the 1980s, when homelessness emerged as a major national problem, the U.S. Department of Veterans Affairs (VA) has been a leader in creating housing programs. Two studies report outcomes for homeless veterans served by VA supported housing programs. Provision of intensive case management (ICM), a key component of the VA programs, makes heavy demands in terms of staff time and VA resources, and it may not be the most recovery-oriented or practical approach for many clients. Can peer support serve as an effective substitute? Jack Tsai, Ph.D., and Robert A. Rosenheck, M.D., evaluated a new supported housing model that replaces ICM with intensive peer support delivered in a group format designed to support veterans in moving from housing voucher to apartment to community life. The authors found several promising outcomes, particularly in regard to self-reported social integration of participants (page Original article: 1186). To better inform approaches to VA supported housing, Maria J. O’Connell, Ph.D., and colleagues conducted a subgroup analysis of data from a VA housing demonstration project (1992–1995). Their findings confirmed that a model combining ICM with housing vouchers was especially beneficial for some high-risk groups, including those with co-occurring disorders (page Original article: 1195).

Improving VA Service Delivery

Making sure that veterans with mental disorders receive timely and effective care is an issue drawing national attention. Three additional reports from VA research groups underline some of the challenges. When Shira Maguen, Ph.D., and colleagues analyzed 2001–2011 national data on outpatient care for veterans with a psychiatric diagnosis (N=314,717), they found a substantial delay in treatment initiation: the median time from the end of the last deployment to engagement in mental health care was over two years, and the lag time to initiation of minimally adequate care was 7.5 years (page Original article: 1206). In 2008 the VA implemented a quality indicator whereby all discharged psychiatric inpatients were required to have a follow-up outpatient contact within seven days of discharge. Paul N. Pfeiffer, M.D., and other VA researchers found that introduction of this measure substantially increased the percentage of veterans who received timely follow-up but did not reduce rates of readmission or increase rates of adequate antidepressant treatment (page Original article: 1239). The Vet-to-Vet program is a recovery-oriented peer-led education and support group for veterans with mental illness. In a randomized trial that compared Vet-to-Vet with a similar clinician-led program and usual treatment, Susan V. Eisen, Ph.D., and colleagues found improvements for all participants but no significant differences between treatment groups (page Original article: 1243).

Briefly Noted . . .

Authors of the Open Forum describe health care reform and integrated care as a “golden opportunity” for preventive psychiatry and outline the role that psychiatrists can play (page Original article: 1247).

A survey of community practitioners indicated that, in the absence of clear guidelines, patients with attenuated psychosis syndrome are treated in much the same way as patients with full psychotic disorders (page Original article: 1252).