February 2010: This Month's Highlights

Off-Label Use of Antipsychotics

Recent media reports have raised concerns about the use of second-generation antipsychotics to treat children. Child psychiatrists and others, worried in turn that these reports will discourage parents from seeking help, have urged the public not to take research findings out of context and to consider the potential dangers of not treating serious symptoms. These paired concerns are reflected in this month's issue. The lead article reports that 41% of children in a state Medicaid population who received an antipsychotic had diagnoses for which there was no evidence to support its use. Analyses of claims data by Prathamesh Pathak, M.S., B.Pharm., and colleagues determined that 11,700 children received a new prescription for a second-generation antipsychotic between 2001 and 2005. As the authors note, none of these agents were approved for pediatric use until 2006, although findings from more than 80 clinical studies of pediatric use of these agents for a range of diagnoses were available to prescribers before the end of 2005. The authors classified these findings as providing strong, plausible, weak, or no evidence of effectiveness. Their review of diagnoses given to the 11,700 children found that 4,834 did not have a disorder for which published evidence supported the agent's use ( Original article: page 123 ). In Taking Issue, Bonnie T. Zima, M.D., M.P.H., points out that assigning weight to scientific evidence requires careful deliberation, and she calls for scrutiny of the study's findings because they are liable to be misinterpreted ( Original article: page 107 ). In a study of second-generation antipsychotic use by nearly 309,000 elderly nursing home residents in 2004, Pravin Kamble, B.Pharm., M.S., and colleagues found that 86% received them for indications that were off label during the study period and 57% received them for an evidence-based use ( Original article: page 130 ).

Evaluation of Outpatient Commitment

Outpatient commitment is another intervention about which there are strong opposing views. Some regard it as necessary and effective, whereas others see it as coercive and stigmatizing. Forty-two states now have laws mandating outpatient commitment, and research is needed to better understand its consequences. In this issue Jo C. Phelan, Ph.D., and colleagues report findings from a quasi-experimental, longitudinal study evaluating the effects of Kendra's Law, the 1999 legislation that established outpatient commitment in New York State. These authors compared 184 patients discharged from psychiatric hospitals—76 who were mandated to outpatient treatment and 108 who received treatment in the same outpatient facilities as the mandated patients. Mandated patients were less likely to perpetrate serious violence or attempt suicide in the year after discharge. They also had higher levels of social functioning, although the two groups did not differ in severity of psychotic symptoms and quality of life. The negative consequences of perceived stigma and coercion were not observed in the intervention group ( Original article: page 137 ).

The Value of Primary Care Screening

Screening for depression in primary care settings also has its critics. Although undetected depression can result in substantial morbidity, critics have argued that screening is costly and that undetected depression tends to be milder and often resolves without intervention. However, few long-term follow-ups have been conducted of patients with positive screens, in particular those who were not receiving any mental health treatment at the time of the screening. In a study by Myrna M. Weissman, Ph.D., and colleagues, 348 low-income primary care patients who screened positive for major depression and other common mental disorders underwent a structured diagnostic interview about four years after the initial screen. Patients with positive screens for depression were significantly more likely than those who screened negative to receive a clinical diagnosis of depression at follow-up, to be impaired, and to have made emergency department visits for psychiatric reasons in the past year. The authors note that although critics question the value of treating mild symptoms, the study's findings "indicate that simple screening procedures, especially for major depression, can identify primary care patients with milder symptoms that are nevertheless persistent and enduring mental health problems" ( Original article: page 151 ).

Briefly Noted …

• A collaborative care model implemented in primary care settings in Puerto Rico improved symptoms and functioning of depressed patients with chronic general medical conditions ( Original article: page 144 ).

• A public-academic partnership in Pittsburgh has overcome challenges to improve depression care for disadvantaged adults ( Original article: page 110 ).

• Federally regulated definitions of "research" may inadvertently increase risk to human subjects and hinder valuable investigations ( Original article: page 180 ).