From 2001 to 2006, the duration of emergency department visits made by patients presenting with mental health complaints and visits made by all other patients increased at similar rates. However, the longer visits for certain groups of mental health patients suggest that emergency departments incur higher costs in connection with the delivery of services to persons in need of acute stabilization.

The needs and preferences of family members of adults with mental illness are diverse and varied. Consequently, these families may benefit from ongoing provision of information and support tailored to meet the families' individual needs. Continued efforts should be made to understand and address consumer and family needs, potential barriers to participation in family services, and the relationship between stigma and family need.

Veterans with serious mental illness at risk of treatment dropout perceived barriers to mental health care and medical services. Strategies to overcome barriers are needed and should target illness-related factors that may impede service use.

Objectives People dually diagnosed with severe mental illness and substance use disorders are at markedly elevated risk for HIV, hepatitis B and hepatitis C, but generally do not receive basic recommended services. Several barriers impede receipt of services, including lack of programs offered by mental health providers, and client refusal of available services. Clients from ethnic minority groups are even less likely to accept recommended services. The intervention tested was designed to facilitate integrated infectious disease programming in mental health settings, and to increase acceptance of such services among clients. Methods A randomized clinical trial (n=236) compared enhanced treatment as usual (Control) to a brief intervention to deliver best practice services for blood-borne diseases in an urban, largely minority sample of dually diagnosed clients. This intervention included Screening, Testing for HIV and hepatitis, Immunization for hepatitis A and B, Risk-reduction counseling and medical treatment Referral and support (STIRR) at the site of mental health care. Results Clients randomized to STIRR had high levels (over 80%) of participation and acceptance of core services. They were more likely to be tested for HBV and HCV; immunized for hepatitis A and B; increase their hepatitis knowledge and to reduce their substance abuse. However, they showed no reduction in risk behavior, were no more likely to be referred to care (81 vs. 75%) and showed no increase in HIV knowledge. Intervention costs were $541 per client. Conclusions STIRR appears to be efficacious in providing a basic, best-practice package of interventions for dually diagnosed clients.

Despite the elevated crude recorded prevalence of HIV, multivariate analyses suggested that HIV-related risk factors underlie the associations between HIV and the serious mental illness diagnoses. For patients with schizophrenia, this study is the first to demonstrate reduced HIV risk in the absence of a substance use disorder.

The Frontline Reports column features short descriptions of novel approaches to mental health problems or creative applications of established concepts in different settings. Material submitted for the column should be 350 to 750 words long, with a maximum of three authors (one is preferred), and no references, tables, or figures. Send material to Francine Cournos, M.D., at the New York State Psychiatric Institute (fc15@columbia.edu) or to Stephen M. Goldfinger, M.D., at SUNY Downstate Medical Center (steve007ny@aol.com).

al lf f F Fu ul ll l o or r H Ha al lf f E Em mp pt ty y? ?Not long ago, conventional wisdom held that psychiatric hospitals could not be entirely smoke free. Such policies, it was thought, would be impossible to enforce, and attempts to do so would increase the risk of patient violence and fires from clandestine smoking. Now we know that these concerns are unfounded. Wellimplemented smoke-free policies have resulted in care environments that show improved outcomes in smoking-related incidents of restraint and seclusion, and staff resistance has not been insurmountable. In fact, patients and staff alike can and should be significant resources for successful implementation of smoke-free policies. Mental health care settings can create environments that promote a tobacco-free lifestyle to consumers, in the same way that virtually all medical centers and hospitals across the country have already done.