Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied?

Barriers to Mental Health care in Canada Identified by Healthcare Providers: A Scoping Review

The mental health treatment gap remains wide across the world despite mental illness being a significant cause of disability globally. Both end-user and healthcare provider perspectives are critical to understanding barriers to mental healthcare and developing interventions. However, the views of providers are relatively understudied. In this review, we synthesized findings from current literature regarding providers' perspectives on barriers to mental healthcare in Canada. We searched Medline, PsycINFO, Embase, and CINAHL for eligible Canadian studies published since 2000. Analysis and quality assessment were conducted on the included studies. Of 4,773 reports screened, 29 moderate-high quality studies were reviewed. Five themes of barriers emerged: health systems availability and complexity (reported in 72% of the studies), work conditions (55%), training/education (52%), patient accessibility (41%), and identity-based sensitivity (17%). Common barriers included lack of resources, fragmented services, and gaps in continuing education. Interestingly, clinicians often cited confusion in determining the ideal service for patients due to an overwhelming number of potential services without clear descriptions. These five domains of barriers present a synthesized review of areas of improvement for mental healthcare spanning both patients and clinicians. Canadian mental health systems face a need to improve capacity, clinician training, and in particular service navigability and collaboration.

Filling a gap in OBGYN education: a pilot lecture series on perinatal mental health

Perinatal mood and anxiety disorders (PMADs) are one of the most common complications in the peripartum period. The Council for Resident Education in Obstetrics and Gynecology (CREOG) includes diagnosis and management of PMADs as educational objectives, but no formal curriculum for trainees exists. Consequently, providers often struggle to identify and treat these disorders. We aimed to assess the effects of a pilot lecture series on obstetrics and gynecology (OBGYN) residents' knowledge and comfort in the diagnosis and management of PMADs. As part of an educational cross-sectional study, a Qualtrics survey was distributed to OBGYN residents at a single center in New York City. Residents were exposed to a 10-h virtual lecture series on perinatal mental health, and a follow-up survey was distributed. Initially, few residents were familiar with screening tools (45%), and few felt comfortable providing resources (5-45%), diagnosing (0-55%), and managing (0-30%) patients with the PMADs presented. After the pilot, improvement was seen in residents' familiarity with screening tools (86%), and their comfort in providing resources (11-67%) and diagnosing (11-78%) PMADs. However, comfort in management did not improve (0-22%). The majority of trainees (75%) found the virtual setting appropriate. There is a deficit in OBGYN residents' knowledge and comfort regarding diagnosis and discussion of PMADs that can be improved with a focused lecture series, though a greater emphasis on treatment is needed. The majority of OBGYN learners found the virtual setting conducive to learning this material. Their preferences should guide the development of a formal, national curriculum.

"Not doing it justice": Perspectives of Recent Family Medicine Graduates on Mental Health and Addictions Training in Residency

OBJECTIVES

Family physicians report feeling inadequately prepared to meet the evolving mental health care needs of the population. Little scholarship exists evaluating the effectiveness of curricula designed to teach mental health and addiction (MH&A) care to family medicine (FM) residents. As such, the purpose of this study was to explore the experiences of recent FM residency graduates in providing mental health care, and their perceptions of mental health training gaps during their residencies.

METHODS

A qualitative descriptive study design was conducted by 8 recent graduates of the University of Toronto's FM residency program, who participated in semi-structured video interviews. A thematic analysis approach was used to collect and analyze the data.

RESULTS

Through thematic analysis, 3 overarching themes were developed: (1) barriers in providing mental health and addiction care, (2) curriculum renewal, and (3) the role of FPs and professional identity. Consistent with the literature, the majority of recent FM graduates expressed discomfort when managing patients with mental health and addiction concerns. Additionally, participants perceived residency program time constraints, rotational site differences, and limited exposure to marginalized populations all impacted learning and mastery of skills.

CONCLUSION

The findings of this study underscore current gaps within the FM residency curriculum and highlight the need to address current curricular deficits.

Antidepressant Prescription Behavior Among Primary Care Clinician Providers After an Interprofessional Primary Care Psychiatric Training Program

Primary care providers (PCPs) are increasingly called upon to screen for and treat depression. However, PCPs often lack the training to diagnose and treat depression. We designed an innovative 12-month evidence and mentorship-based primary care psychiatric training program entitled the University of California, Irvine (UCI) School of Medicine Train New Trainers Primary Care Psychiatry (TNT PCP) Fellowship and examined whether this training impacted clinician prescription rates for antidepressants. We retrieved information on 18,844 patients and 192 PCPs from a publicly insured health program in Southern California receiving care between 2017 and 2021. Of the 192 PCPs, 42 received TNT training and 150 did not. We considered a patient as exposed to the provider's TNT treatment if they received care from a provider after the provider completed the 1-year fellowship. We utilized the number of antidepressant prescriptions per patient, per quarter-year as the dependent variable. Linear regression models controlled for provider characteristics and time trends. Robustness checks included clustering patients by provider identification. After PCPs completed TNT training, "exposed" patients received 0.154 more antidepressant prescriptions per quarter-year relative to expected levels (p < 0.01). Clustering of standard errors by provider characteristics reduced precision of the estimate (p < 0.10) but the direction and magnitude of the results were unchanged. Early results from the UCI TNT PCP Fellowship demonstrate enhanced antidepressant prescription behavior in PCPs who have undergone TNT training. A novel, and relatively low-cost, clinician training program holds the potential to empower PCPs to optimally deliver depression treatment.

Mental health training in family medicine residencies: International curriculum overview

Integration of mental health into primary care has become a global trend, and many countries have developed mental health training in primary care. However, systematic mental health training for family physicians is insufficient in Japan. The newly established Japan Primary Care Association Mental Health Committee surveyed the current status of mental health training curricula in family medicine residency internationally. Participants were individuals involved in family medicine residency programs who were from Australia, Brazil, Hong Kong, the Philippines, Taiwan, the United Kingdom, and the United States. The results revealed that many academic societies have created competency lists and curriculum guidelines for mental health training; however, the implementation varied. This study is novel as it examined and compared different countries' curriculum; the findings of which can be used as a reference to develop future mental health training curriculum in Japan.

Psychiatric consultation in general practitioners' daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland

BACKGROUND

Mental disorders are frequent in primary care settings, which is challenging for primary care physicians. In Neuchâtel (Switzerland), a Consultation-Liaison psychiatrist integrated three primary care group practices, proposing both clinical interventions and supervisions/psychiatric training. Primary care physicians' experience regarding this collaboration was investigated.

METHODS

A qualitative study was conducted. Three focus groups were organized in each primary care group practice involved in the project (10 primary care physicians participated in focus groups). Data were analysed with thematic content analysis.

RESULTS

Six major themes emerged from our analysis, describing primary care physicians' collaboration with psychiatrists: 1) Impact on a difficult to reach and "reluctant to consult" population; 2) Fluidity of the intraprofessional collaboration; 3) Influence on the doctor-patient relationship; 4) Positive emotional experiences; 5) Psychiatric counselling and training; 6) Long-term prospects for the project.

CONCLUSIONS

Consultation-Liaison psychiatrist's presence came as a relief for participating primary care physicians, facilitating accessibility to mental healthcare, introducing a common culture of care, and offering "in-situ" psychiatric training. Primary care physicians felt that their relationships with patients benefited from such interventions, being better able to deal with complex emotional experiences and found patients more confident regarding proposed care. Models of psychiatric intervention provided in primary care must establish settings of collaboration that reinforce relationships between primary care physicians, psychiatrists, and patients.

Train New Trainers Primary Care Psychiatry Fellowship-Optimizing Delivery of Behavioral Health Care Through Training for Primary Care Providers

OBJECTIVE

To expand and optimize the behavioral health workforce, it is necessary to improve primary care providers' (PCPs) overall knowledge and clinical skills in primary care-based psychiatry. Studies on the effects of postgraduate psychiatric education programs for PCPs on psychiatric knowledge are limited.

METHODS

A total of 251 PCPs completed a 1-year fellowship. Data from program development and evaluation were analyzed for 4 fellowship years (2016-2019). Fellows were surveyed at baseline, midpoint, and postfellowship about mental health stigma, perceived competency, attitudes about psychiatry, satisfaction with current psychiatric knowledge, confidence and comfort to treat psychiatric illnesses, and program satisfaction. Psychiatric knowledge was evaluated at baseline, midpoint, and postfellowship.

RESULTS

Large effects were noted on perceived competency/self-efficacy and confidence in the treatment of common psychiatric disorders encountered in primary care settings. Positive effects were observed on attitudes of mental health stigma, and even more robust effects were found with improvement in psychiatry clinical knowledge. Knowledge improved by 12% at postfellowship (P < .0001). Correlations of the degree of change in attitude with improved psychiatric literacy demonstrated significant relationships with reduction of stigma total score (r = -0.2133, P = .0043), increased willingness (r = 0.1941, P = .0096), and increased positive attitudes (r = 0.1894, P = .0111).

CONCLUSION

Innovative initiatives to improve and expand psychiatric knowledge and clinical skills among those who provide the most behavioral health care (PCPs) can have marked impacts on attitudes toward mental health care delivery, stigma, and competency/self-efficacy. Future studies are necessary to consider the impact of this program on clinical practice pattern outcomes on a larger scale.

Cultivating mental health education in obstetrics and gynecology: a call to action

Mental health disorders are common and have a significantly negative impact on the health and well-being of women. For example, perinatal mental health disorders such as anxiety and depression are widely understood to be the most common complications of pregnancy and childbirth. Untreated mental health disorders are associated with significant obstetrical and psychiatric sequelae and have a long-lasting impact on neonatal and childhood outcomes. As front-line providers for women during times of elevated risk of psychiatric morbidity, such as pregnancy and postpartum, obstetricians and gynecologists are compelled to have familiarity with such disorders. Yet, a wide gap exists between the level of education in mental health disorders that obstetrician and gynecologist providers receive and the clinical need thereof. The objectives of this commentary are to describe the urgent need for mental health education for obstetricians and gynecologists providers and to introduce our vision for a concise, evidence-based and accessible set of digital educational materials designed to convey core concepts in women's reproductive mental health.

Education Research: A Qualitative Study on Student Perceptions of Neurology and Psychiatry Clerkship Integration

OBJECTIVE

To explore student perceptions of the feasibility of neurology and psychiatry clerkship integration, including clinical education and competency evaluation, as there has been a call to improve undergraduate medical education integration of the disciplines to better develop physicians that can address nervous system disorders.

METHOD

Via a constructivist grounded theory approach, we carried out 5 focus groups in 2016-2017 with 28 medical students who completed both independent clerkships. Investigator triangulation was used with iterative interpretation comparisons, and themes were identified using constant comparative analysis.

RESULTS

Three major themes arose: (1) combining the clerkships was not favorable as students need sufficient time to delve deeper into each discipline; (2) students did not observe an integrated clinical approach by faculty; (3) there is positive value to making links between neurology and psychiatry for effective patient care.

CONCLUSIONS

Students emphasized the importance of making stronger links between the 2 disciplines for their learning and to improve patient care; however, they did not observe this clinical approach in the workplace. Students perceived that integration of neurology and psychiatry clerkships should occur via increased affinity of the complementary discipline by trainees and faculty in each specialty.

Teaching residents mental health care

OBJECTIVE

We tested the hypothesis that trained medical faculty can train residents effectively in a mental health care model.

METHODS

After the authors trained medical faculty intensively for 15 months in primary care mental health, the newly trained faculty taught medical residents intensively. Residents were evaluated pre- and post-residency and compared to non-equivalent control residents in another city. Using ANOVA, the primary endpoint was residents' use of a mental health care model with simulated patients. Secondary endpoints were residents' skills using models for patient-centered interviewing and for informing and motivating patients.

RESULTS

For the mental health care model, there was a significant interaction between study site and time (F = 33.51, p < .001, Eta² = .34); mean pre-test and post-test control group scores were 8.15 and 8.79, respectively, compared to 7.44 and 15.0 for the intervention group. Findings were similarly positive for models of patient-centered interviewing and informing and motivating.

CONCLUSIONS

Training medical faculty to teach residents a mental health care model offers a new educational approach to the widespread problem of poor mental health care.

PRACTICE IMPLICATIONS

While the models tested here can provide guidance in conducting mental health care, further evaluation of the train-the-trainer program for preparing residents is needed.

A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care

Supplemental Digital Content is available in the text.

Background:

Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care.

Methods:

We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area.

Results:

Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing.

Conclusions:

The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.

Behavioral Health Training in Pediatric Residency Programs: A National Survey of Training Directors

OBJECTIVE

To identify perceptions of behavioral health (BH) training in pediatric residency programs, the degree of involvement from behavioral health providers (BHPs), and opportunities for and barriers to innovation in training.

METHOD

A tailored design methodology was used to target all pediatric residency program directors in the United States (N = 214). Participants were identified from the Electronic Residency Application Service website of the Association of American Medical Colleges and were asked to complete a 22-item item survey on BH training.

RESULTS

A 69.2% usable response rate (N = 148) was obtained. A total of 62.8% of directors described training in the developmental-behavioral pediatrics (DBP) rotation as optimal; 36% described BH training in the residency program as a whole (i.e., outside the DBP rotation) as optimal. Only 20.3% described "common factors" training as optimal, and the quality of training in this area was positively and significantly related to the quality of BH training in the residency program as a whole (χ = 35.05, p < 0.001). The quality of common factors training was significantly higher in programs that had embedded BHPs (i.e., psychologists and social workers) in the continuity clinic than programs that did not (χ = 7.65, p = 0.04). Barriers to quality training included instructional content, instructional methods, stakeholder support, and resources.

CONCLUSION

Despite substantial improvement in residency training in BH over the last decade, additional improvement is needed. Barriers to continued improvement include training content, training methods, support from faculty and administrator stakeholders, and resource issues. Strategies derived from implementation science have the potential to address these barriers.

A research coding method to evaluate medical clinicians conduct of behavioral health care in patients with unexplained symptoms

OBJECTIVE

Develop a reliable coding method of a Behavioral Health Treatment Model for patients with Medically Unexplained Symptoms (BHTM-MUS).

METHODS

Two undergraduates trained for 30h coded videotaped interviews from 161 resident-simulated patient (SP) interactions. Trained on 45 videotapes, coders coded 33 (20%) of 161 study set tapes for the BHTM-MUS. Guetzkow's U, Cohen's Kappa, and percent of agreement were used to measure coders' reliability in unitizing and coding residents' skills for eliciting: education and informing (4 yes/no items), motivating (2), treatment statements (5), commitment and goals (2), negotiates plan (8), non-emotion patient-centered skills (4), and patient-centered emotional skills (8).

RESULTS

60 items were dichotomized a priori from analysis of the BHTM-MUS and were reduced to 33 during training. Guetzkow's U ranged from .00 to .082. Kappa ranged from 0.76 to 0.97 for the 7 variables and 33 individual items. The overall kappa was 0.87, and percent of agreement was 95.7%. Percent of agreement by item ranged from 85 to 100%.

CONCLUSIONS

A highly reliable coding method is recommended to evaluate medical clinicians' behavioral care skills in patients with unexplained symptoms.

PRACTICE IMPLICATIONS

A way to rate behavioral care in patients with unexplained symptoms.

The primary care physician/psychiatrist joint consultation: A paradigm shift in caring for patients with mental health problems?

OBJECTIVE

Thirty to forty percent of patients seen in primary care medicine suffer from mental health problems, but primary care physicians (PCPs) often feel unprepared to deal with their patients' mental health problems. Joint consultations conducted with a liaison psychiatrist can help. The purpose of this study was to evaluate the experience of joint consultations in a primary care service in Geneva, Switzerland.

METHODS

We retrospectively analyzed reports of psychiatric evaluations conducted between October 2010 and August 2012 (n=182), in the Primary Care Service of the Geneva University Hospitals. We also carried out 4 focus groups with 23 physicians-in-training to explore their experiences and perceptions of the joint consultations.

RESULTS

Seventy two percent of the evaluations resulted in a psychiatric diagnosis. Psychiatric follow-up was not considered necessary in 61% of cases. Focus groups revealed that prior to experiencing joint consultations, PCPs considered mental health problems to be the domain of psychiatrists and outside their own area of competence. Joint consultations helped to demystify the role of psychiatrists, reduce their anxiety and increase PCPs' confidence in dealing with patients' mental health problems.

CONCLUSION

Joint consultations enabled PCPs to shift away from a dichotomous view of somatic versus mental health problems and their management, and towards a more integrated view.

IMPLICATIONS FOR PRACTICE

Joint consultations provide a useful strategy for training primary care physicians in the management of mental health problems. Integrated management of somatic and mental health problems can lead to a better understanding of the patient and improve the therapeutic relationship.

Teaching child psychiatric assessment skills: Using pediatric mental health screening tools

This article describes the workshop "Teaching Child Psychiatric Assessment Skills: Using Mental Health Screening Instruments," presented at the 35th Forum for Behavioral Sciences in Family Medicine on 20 September 2014. The goals of the presentation were (1) to teach family medicine behavioral health educators to use both general and problem-specific mental health screening tools (MHSTs) in their work with trainees to help satisfy the Accreditation Council for Graduate Medical Education (ACGME) mandate for behavioral and mental health experience during family medicine residency, (2) to reflect on how MHSTs might be integrated into the flow of family medicine teaching practices, and (3) to exemplify how evidence-based methods of adult education might be used in teaching such content. One general MHST, the Pediatric Symptom Checklist-17 and one problem-specific MHST for each of the four commonest pediatric mental health issues: for attention-deficit hyperactivity disorder, the Vanderbilt; for Anxiety, the Screen for Childhood Anxiety-Related Emotional Disorders; for Depression, the Patient Health Questionnaire-9 for teens; and for Aggression, the Retrospective-Modified Overt Aggression Scale, were practiced at least twice in the context of a clinical vignette. All of the selected MHSTs are free in the public domain and available for download from the website: www.CAPPCNY.org. Participants were asked to reflect on their own office practice characteristics and consider how MHSTs might be integrated into their systems of care. This workshop could be replicated by others wishing to teach the use of MHSTs in primary care settings or teaching programs.

Use of a specialty clinic to teach a standardized approach to mood disorders in a family medicine residency

The Mood Disorder Clinic was started at the Cone Family Medicine Residency in 2004 with the threefold purpose of providing a patient care service to a largely uninsured or underinsured population; teaching Family Medicine resident physicians how to more accurately identify, diagnose, and treat mood disorders in their patients; and modeling a team-based approach to addressing mental stress, distress, and dysfunction in the primary care setting. The authors present the logistics of the clinic and the standard approach to mood issues that is taught to resident physicians. Formal feedback suggests that the resident physicians find the experience useful in developing psychiatric knowledge and skills.

The current and ideal state of mental health training: pediatric resident perspectives

PHENOMENON: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier.

APPROACH

The purpose of this study is to describe pediatric residents' experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach.

FINDINGS

Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees' MH knowledge and skills to provide optimal MH care for children.

A systematic review of self-management health care models for individuals with serious mental illnesses

OBJECTIVE

The general medical health of individuals with serious mental illnesses is compromised relative to those without serious mental illnesses. To address this health disparity, numerous integrated care strategies are being employed from the system level to the level of individual patients. However, self-management of health care, a strategy considered an integral aspect of typical care, has been infrequently included in interventions for this population. Despite reservations about the capacity of those with serious mental illnesses to self-manage health care, a subset of new interventions focused on general medical health in this population has tested whether models including self-management strategies have empirical support. To understand whether these models are supported, the authors reviewed the evidence for self-management models.

METHODS

This systematic review examined collaborative and integrated care models that include self-management components for individuals with serious mental illnesses.

RESULTS

Across the 14 studies identified in this review, promising evidence was found that individuals with serious mental health issues can collaborate with health professionals or be trained to self-manage their health and health care. The evidence supports the use of mental health peers or professional staff to implement health care interventions. However, the substantial heterogeneity in study design, types of training, and examined outcomes limited conclusions about the comparative effectiveness of existing studies.

CONCLUSIONS

This review found preliminary support that self-management interventions targeting the general medical health of those with serious mental illnesses are efficacious, but future work is needed to determine what elements of training or skills lead to the most salient changes.

Mental health care professionals' experiences with the discharge planning process and transitioning patients attending outpatient clinics into community care

BACKGROUND

Health care reform promotes delivery of mental health care in the community. Outpatient mental healthcare professionals (HCPs) are pressured to discharge patients. This study's purpose: to understand the experience and perceptions of mental HCPs with discharge planning and transitioning patients into community care.

METHODS

Twelve HCPs participated in semi-structured qualitative interviews.

FINDINGS

Three main categories: engaging in the discharge planning process, making the transition smooth, and guiding values emerged. A conceptual framework was created to explain the phenomenon.

CONCLUSION

HCPs valued strengthening partnerships and building relationships to ensure smooth transition. Sufficient resources and trust imperative for safe patient discharge.

Addressing mental health issues in primary care: an initial curriculum for medical residents

OBJECTIVE

Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems.

METHOD

We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base.

RESULTS

We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care.

CONCLUSION

Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve.

PRACTICE IMPLICATIONS

Training residents in mental health will lead to improved care for this very prevalent primary care population.

An evidence-based patient-centered method makes the biopsychosocial model scientific

OBJECTIVE

To review the scientific status of the biopsychosocial (BPS) model and to propose a way to improve it.

DISCUSSION

Engel's BPS model added patients' psychological and social health concerns to the highly successful biomedical model. He proposed that the BPS model could make medicine more scientific, but its use in education, clinical care, and, especially, research remains minimal. Many aver correctly that the present model cannot be defined in a consistent way for the individual patient, making it untestable and non-scientific. This stems from not obtaining relevant BPS data systematically, where one interviewer obtains the same information another would. Recent research by two of the authors has produced similar patient-centered interviewing methods that are repeatable and elicit just the relevant patient information needed to define the model at each visit. We propose that the field adopt these evidence-based methods as the standard for identifying the BPS model.

CONCLUSION

Identifying a scientific BPS model in each patient with an agreed-upon, evidence-based patient-centered interviewing method can produce a quantum leap ahead in both research and teaching.

PRACTICE IMPLICATIONS

A scientific BPS model can give us more confidence in being humanistic. In research, we can conduct more rigorous studies to inform better practices.

Evaluation of Saudi family medicine training program: the application of CIPP evaluation format

The Saudi Diploma in Family Medicine (SDFM) was enacted in 2007 to fulfill the needs of qualified Primary Health Care providers in Saudi Arabia. Evaluation is not only an integral process for designing educational training programs, but an effective evaluation strategy that helps achieve program objectives and enhances the quality of learning objectives: (1) Construct a self-administered questionnaire based on Context, input, process and product (CIPP) format to seek trainees' perceptions about the SDFM program; (2) identify the strengths and weaknesses of the SDFM program in relation to the learning outcomes; and (3) define the main obstacles to achieve the outcomes. A self-administered questionnaire was designed based on the CIPP evaluation format after. its validity and reliability were tested through piloting. Then, all the SDFM program trainees were included. The study response rate was 91.2%. More than 77% of the trainees stated that they had achieved the program objectives; a significant difference was found among Saudis and non-Saudis (p = 0.002). The training period was reported by 84% as a main barrier to achieve the program objectives, particularly the hospital rotation period. Results indicate an overall satisfaction with the training objectives and the teaching methods used. These findings can be useful for the policy makers to implement the suggested recommendations and deal with obstacles to improve the SDFM program in order to provide effective and efficient primary care services.

Proportion of antidepressants prescribed without a psychiatric diagnosis is growing

Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis. Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. These results do not clearly indicate a rise in inappropriate antidepressant use, but they highlight the need to gain a deeper understanding of the factors driving this national trend and to develop effective policy responses. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers' prescribing practices, revamp drug formularies, or vigorously pursue implementation of broad reforms of the health care system that will increase communication between primary care providers and mental health specialists.

Postpartum mental health screening and diagnosis by obstetrician-gynecologists

Postpartum depression (PPD) and postpartum psychosis (PPP) can impact mother, infant, and family. Obstetrician-gynecologists (ob-gyns) are often the most frequent medical contact for postpartum women, and so are in a position to identify women needing psychological care. This study assessed ob-gyns' knowledge, attitudes, and practices regarding diagnosing PPD/PPP. A survey was sent to 400 members of the American College of Obstetricians and Gynecologists who have volunteered to participate in research. Response rate was 56%. Routine screening for PPD and PPP is conducted by 72% and 30% of respondents, respectively. Personal experience (through friend, family, or self) was associated with increased screening. Perceived PPP screening barriers are similar to those found in the PPD literature: time constraints, lack of training, and lack of knowledge of diagnostic criteria. In responding to standardised vignettes, physicians were more likely to over-diagnose, than under diagnose PPD/PPP. This study is the first to provide exploratory data of ob-gyns' knowledge, attitudes, and practice regarding PPD and PPP. Ob-gyns are screening for PPD/PPP, though not universally so. Future research should identify ways to mitigate screening barriers.

Relational barriers to depression help-seeking in primary care

OBJECTIVE

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

METHODS

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

RESULTS

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

CONCLUSION

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests.

PRACTICE IMPLICATIONS

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

Psychiatrists for medically complex patients: bringing value at the physical health and mental health/substance-use disorder interface

BACKGROUND

In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use.

METHOD

The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties.

CONCLUSION

Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.