A call for improved prevention and reduction of obesity among persons with serious mental illness.

The primary purpose of this Open Forum is to alert the psychiatric community to a recently published policy paper by the National Association of State Mental Health Program Directors (NASMHPD), Obesity Reduction and Prevention Strategies for Individuals With Serious Mental Illness. The report was developed through a comprehensive review of materials and extensive discussions in an expert panel meeting held August 9-10, 2007. The report indicates that psychiatrists who disregard the physical health of their patients and focus only on treating the patient's psychiatric condition are not only neglectful but are also contributing to the epidemic of obesity among people with serious mental illness. The NASMHPD Medical Directors Council has concluded that psychiatrists in the public mental health system are doing far too little to prevent and reduce obesity among patients the system serves.

Principles of antipsychotic prescribing for policy makers, circa 2008. Translating knowledge to promote individualized treatment.

Findings from 2 pivotal government-funded studies of comparative antipsychotic effectiveness undermine assumptions about the marked superiority of the more expensive second-generation "atypical" medications in comparison to the less expensive first-generation "typical" drugs. Because this assumption was the basis for the almost universal recommendation that these newer antipsychotics be used preferentially resulting in a 10-fold increase in state governmental expenditures on this class of medications over the past decade, a reassessment of policy is called for. To address the issue, the Medical Directors Council of the National Association of State Mental Health Program Directors critically reviewed findings of these studies in the context of other data and considered policy implications in the light of the obligations of state government to make available best possible and individually optimized treatment that is cost-effective. The Medical Directors Council unanimously adopted a set of recommendations to promote appropriate access, efficient utilization, and best practice use. We present our policy statement, in which we provide a succinct background, articulate general principles, and describe a set of 4 broad recommendations. We then summarize our understanding of the current state of knowledge about comparative antipsychotic effectiveness, best antipsychotic practice, and considerations for state policy that represent the basis of our position statement.

Impact of the CATIE findings on state mental health policy.

The authors, who are medical directors of three state mental health agencies and members of the Medical Directors' Council of the National Association of State Mental Health Program Directors (NASMHPD), describe the impact on public mental health policy of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Before publication of the CATIE results, the preponderance of information indicated substantial and broad-ranging advantages of second-generation antipsychotics over first-generation agents. State mental health authorities focused on improving access to and increasing utilization of the newer agents. In many states, expenditures for these agents accounted for 10% of the total pharmacy budget of the Medicaid program. After CATIE, state policy makers have had to take a more critical look at the data and formulate more nuanced approaches. The authors summarize policy recommendations of the NASMHPD Medical Directors' Council, which reviewed efficacy studies of antipsychotics and formulated a position statement. The recommendations cover three broad areas of policy. First, neither complete open access for all patients at all times nor a uniform fail-first trial of a first-generation antipsychotic is an optimal approach. A more nuanced middle ground is necessary. Second, excessive emphasis on the cost of second-generation antipsychotics has led to a lack of focus on optimizing use of all antipsychotic medication in usual practice. More research and management attention must be focused on improving how these medications are prescribed for individual patients. Third, more resources should be invested in clinical trials that more clearly and accurately reflect current practice.