Lloyd I. Sederer

Editorial: Understanding and Measuring Recovery

In 2003, 25 years after Rosalynn Carter chaired the first Presidential Commission on Mental Health, she testified before the New Freedom Commission on Mental Health, chaired by Michael Hogan.1 When asked what the greatest advance had been in the intervening years, she said it was adopting the belief that people with serious mental illness could recover.

State Mental Health Policy: Physical Health Screening in State Mental Health Clinics: The New York Health Indicators Initiative

The New York State Office of Mental Health recently mandated that all adult outpatient clinics regularly monitor three health indicators--body mass index, blood pressure, and smoking status. After the population was defined, medical equipment was distributed. Regular training and quality improvement meetings were held to improve the electronic database for indicator data. Clinical directors were provided regular feedback on performance monitoring. Learning collaboratives allowed sharing of implementation strategies. After only four months of this coordinated effort, approximately 7,500 people with mental illnesses had been screened for the three health indicators across New York State.

Training Psychiatry Residents in Quality Improvement: An Integrated, Year-Long Curriculum.

ObjectiveThe authors describe a curriculum for psychiatry residents in Quality Improvement (QI) methodology.MethodsAll PGY3 residents (N=12) participated in a QI curriculum that included a year-long group project. Knowledge and attitudes were assessed before and after the curriculum, using a modified Quality Improvement Knowledge Assessment Tool (QIKAT) and a QI Self-Assessment survey.ResultsQIKAT scores were significantly higher for residents after participating in the curriculum when compared with pretest scores. Self-efficacy ratings in QI improved after the course for each item. Residents demonstrated gains in QI skills through participation in the group projects in which they increased rates of depression-screening and monitoring in an outpatient clinic.ConclusionsCombining didactic and experiential learning can be an effective means for training psychiatry residents in QI.

An Initiative to Improve Clozapine Prescribing in New York State

Clozapine remains the only medication approved for treatment-resistant schizophrenia. But underuse is the norm. In 2010, the New York State Office of Mental Health began a multifaceted initiative to promote the evidence-based use of clozapine. From 2009 to 2013, in the absence of a well-funded pharmaceutical marketing campaign, the proportion of new clozapine trials among all new outpatient antipsychotic trials increased 40% among adult New York Medicaid recipients with a diagnosis of schizophrenia. The largest gains occurred in state-operated clinics. New Yorks experience demonstrates the feasibility of making clozapine more accessible to patients who stand to benefit most.

Fixing the Troubled Mental Health System

Untreated and poorly treated serious mental illness affects the lives of individuals, families, and communities every day. Each year, approximately 39 000 people commit suicide,1 and the majority of them have acute mental illness. More than half of suicides are the result of a self-inflicted gunshot wound.1 Many other persons with serious mental illness have lives of isolation, are homeless, or are incarcerated. Because of the stigma of mental illness, an inability to know that they are ill, or troubling experiences with mental health services, people with mental illness often do not seek or follow through with treatment. In New York State, more than 5 million individuals have Medicaid coverage. The most costly medical care is used by those with mental and substance use disorders who also have chronic physical illnesses.2 Primary medical costs for these people are for hospitalizations for heart disease, diabetes, pneumonia, and trauma— not for mental illness. In some health policy circles, these individuals are described as having trimorbid illness, reflecting their morbidity across a variety of diseases. A

Inpatient psychiatry: Perspectives from the general, the private, and the state hospital

Although it is widely recognized that inpatient psychiatry is different as it is practiced in the general, private, and state hospital, why and how it is different have not been clearly articulated. In this paper, the directors of inpatient units in a general hospital, a private hospital, and a state hospital first provide an analysis of how the history and the organizational structures of these units have shaped their identity. The authors then specifically detail the different patient populations, referral sources, financial bases, leadership arrangements, milieu philosophies, research and training activities, and lengths of stay on these units. Finally, on the basis of the reality and the value of different inpatient settings, a view toward the future of inpatient psychiatry is offered.

Changing the landscape of an urban public mental health system: the 2008 New York State/New York City Mental Health-Criminal Justice Review Panel.

In 2007 to 2008, there were several incidents of violence in New York City (NYC) involving individuals with serious mental illness. Some were dramatic and shocking; all were life-threatening or fatal, and subsequent media coverage and public outcry escalated with calls for a return to greater coercion and institutionalization of people with mental illness. Then New York State (NYS) Governor Eliot Spitzer informed the press there would be an investigation of these events. Governor Spitzer and NYC Mayor Michael Bloomberg called for relevant state and city agency heads and experts to review the incidents of violence and provide recommendations about what might limit future similar incidents. In all, a dozen agencies were convened with a 90-day time frame to produce their report. A list of the members of the panel is included in its report1 (available at: http://www.omh.state.ny.us/omhweb/justice_panel_report/). The panel was chaired by Michael F. Hogan, PhD (Commissioner, NYS Office of Mental Health), Linda I. Gibbs (NYC Deputy Mayor for Health and Human Services), Denise E. O’Donnell (NYS Commissioner for Criminal Justice), and John Feinblatt (NYC Criminal Justice Coordinator). Circumstances like these place enormous demand on public health and safety officials. Diverse stakeholders insist upon immediate action and often have conflicting agendas. Elected officials may support needed action but may lack the resources to realize their aims. Public health and mental health leadership need to represent scientific evidence in the face of emotionally charged claims. Criminal justice leadership needs to ensure the public safety. Critical decisions with far-reaching implications can be made on short notice, with limited time for consultation and deliberation before issuing a public document with meaningful and actionable recommendations. These situations represent unique, if tragic, opportunities for significant social service system improvement and reform.2 The following “case history” describes how NYS and NYC public mental health leaders organized information, experts, and resources to create panel recommendations specific to mental health that established new policies, avoided ineffective escalations in coercive interventions, clarified longstanding regulations, and created a new service to enhance accountability and coordination of services for NYC’s most vulnerable mentally ill individuals.

State Partnerships for First-Episode Psychosis Services

The RAISE (Recovery After an Initial Schizophrenia Episode) Connection Program was a partnership that involved state mental health authorities (SMHAs) in Maryland and New York with research funding from the National Institute of Mental Health. The SMHAs collaborated with researchers to implement a team-based approach designed to serve people with newly emerged schizophrenia to maximize recovery and minimize disability. This column explains why states are interested in first-episode psychosis services and describes the development of the successful partnership, financing mechanisms, and plans to add teams in both states.

The social determinants of mental health

Ninety percent of the determinants of our health derive from our lifetime social and physical environment-not from the provision of health care. The author describes behaviors, such as poor eating, excessive drinking and abuse of drugs, smoking, and physical inactivity, and social factors, such as adverse childhood experiences, poor education, food insecurity, poor housing quality, unemployment, and discrimination, that contribute to ill health and early demise. Better health and mental health can be achieved by understanding and responding to these determinants of health.

Integrated Care: Integrating General Medical and Behavioral Health Care: The New York State Perspective

This column describes recent policy and program initiatives implemented by the New York State Office of Mental Health to enhance integration of general medical and behavioral health services throughout the state public mental health system. Recent initiatives were implemented to improve access to health and wellness-oriented services, redesign managed care programs to improve engagement and retention of high-need individuals, and raise the bar on quality while lowering costs. Taken as a whole, these initiatives represent a 21st-century transformation of a state mental health authority into an accountable and more fully integrated public health delivery system.