Mental Health vs Mental Disorders

IN THE CALL FOR PAPERS FOR THIS JAMA THEME ISSUE ON mental health, I noted the irony that in an issue devoted to mental health most of the articles would undoubtedly beaboutmentaldisorders,withthesimpleexplanationthat mental disorders are the problem and mental health is the goal; and that the goal for the JAMA theme issue on mental health was to“beofassistance tocliniciansandpolicymakers inhelping patients, families, and communities move in that positive direction.” Readers can now evaluate the extent to which this themeissueachieves thatgoal.A totalof182submissionswere received for consideration for the theme issue, and 6 major articles, 4 Commentaries, a Cover Story describing the circumstancessurroundingVincentVanGogh’shospitalizations,apowerful A Piece of My Mind essay, and several book reviews and Medical News & Perspectives pieces are now published in it. One area of need is that the number of persons requiring treatment for mental disorders far exceeds the capacity of the mental health specialty sector to provide that treatment. A potential solution for this problem is to expand the capacity to identify and effectively treat mental disorders in the primary care sector. An approach to providing effective evidencebased treatments for mental disorders in primary care is “collaborative care,” in which appropriately trained clinicians collaborate with primary physicians to evaluate and treat primary care patients, with mental health specialty consultation as needed. The effectiveness of this strategy for depressive disorders is now rather well established, but its use for anxiety disorders, despite their frequency in primary care, has not been well studied. The randomized controlled trial reported by Roy-Byrne et al involving an intervention called Coordinated Anxiety Learning and Management (CALM) provides a welcome assessment of a flexible and practical treatment delivery model for common anxiety disorders (panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress disorder) in the primary care setting. This trial was conducted in 17 primary care clinics in 4 US cities and found significantly better improvement in anxiety symptom ratings and also in rates of response and remission using the CALM collaborative care intervention compared with usual care. As the authors note, analyses of the cost of CALM will be important and “implementation of this model will require reimbursement mechanisms for care management that are not currently available.” Inanother randomizedcontrolled trial in this issue,Piacentini et al report the results of a behavioral treatment intervention called habit reversal training for Tourette disorder and chronic tic disorder. This study is notable not only for calling attention to an evidence-based nonpharmacologic intervention for these neuropsychiatric disorders, but also because it useda timeandattentioncontrol treatmentof supportivepsychotherapy and education as a “placebo” comparator, an improvement over many studies of psychotherapeutic interventions that use only no treatment or waiting list controls and thus do not control for the nonspecific effects of time and attention. Significantly more children receiving the behavioral treatment (53%) were rated as very much or much improved comparedwithchildrenreceiving thecontrol treatment(19%) after 10 weeks, with 87% of available responders to behavior therapy showing continued benefit 6 months after treatment. Concernsabout injuredsoldiers inIraqandAfghanistanhave recently focusedattentiononpersonswithtraumaticbrain injuries and their needs for rehabilitation. In addition to physical and cognitive impairment, psychological impairments associated with traumatic brain injuries are of concern. The occurrence of major depressive disorder (MDD) in individuals with traumatic brain injuries is one such concern. Bombardier et al report that in a cohort of 559 consecutively hospitalized adults with traumatic brain injuries (most commonly due to motor vehicle crashes), 53% met criteria for MDD at least once during the first year after their injury, with an increased risk for MDD associated with MDD at the time of injury, history ofMDDpriorto injury,youngerage,andlifetimealcoholdependence. Clearly, identification of and treatment for MDD are important issues for further research, clinical care, and rehabilitation of persons with traumatic brain injuries. In an article about the occurrence and effect of major depression in the course of another medical disorder, Hedayati et al report that the presence of a major depressive episode was associated with an increased risk of hospitalization and initiation of dialysis in patients with chronic kidney disease. Previous studies have found that depression is an independent risk factor for hospitalization and death in maintenance dialysis patients, but the new report shows that depression is associated with worse outcomes in chronic kidney disease patients not yet undergoing dialysis. Research on the efficacy and safety of treatments for depression in this patient population is clearly needed. In an analysis of an intriguing natural experiment, Costello et al report longer-term follow-up results from their 2003 JAMA report on the effects of an income supplement provided to Cherokee Indian families when a casino was opened on their reservation in 1996. The earlier report