A health services perspective on delivery of psychiatric services in primary care including internal medicine

Provision of psychopharmacological services in nursing homes

We examined the psychopharmacological services provided within 3 months of nursing home (NH) admission to a whole population of newly admitted Florida NH residents 65 years and older (N = 947) for a 1-year period via secondary analyses of selected variables from Medicaid and the Online Survey and Certification and Reporting System. Within 3 months of admission, 12% received nonpsychopharmacological mental health care. However, 71% of new residents received at least one psychoactive medication, and more than 15% were taking four or more psychoactive medications. Most of those being treated with psychoactive medication had not received psychopharmacological treatment 6 months prior to admission (64%) and had not received a psychiatric diagnosis 6 months preceding admission (71%). Blacks were less likely to receive medications than non-Hispanic Whites. Results expand on past research by identifying an increase in the amount of psychoactive medications prescribed to NH residents, a lack of prior psychiatric treatment and diagnoses for those currently receiving psychoactive medications, only limited provision of nonpsychopharmacological mental health care, and racial or ethnic differences in the use of medications by NHs.

Integrating Mental Health and Primary Care

Mental health and primary care delivery systems have evolved to operate differently. For example, attention to multiple medical issues, health maintenance, and structured diagnostic procedures are standard elements of primary care rarely incorporated into mental health care. A multidisciplinary treatment approach, group care, and case management are common features of mental health treatment settings only rarely used in primary care practices. Advances in treatments for mental health disorders and increased knowledge of the integral link between mental health and physical health encourage mental health disorder treatment in primary care settings, which reach the most patients. Effective integration of mental health care into primary care requires systematic and pragmatic change that builds on the strengths of both mental health and primary care.

Early psychosis in rural areas

Early psychosis (EP), in which the terms first-episode psychosis or first-break psychosis are also considered, is an area of developing research intensity. Although it is apparent that considerable progress has been made in establishing best practice criteria and protocols for EP in general, the particular issues pertaining to rural areas have not received the same attention. The purpose of the present study was to conduct a systematic review of the literature of early psychosis programmes, initiatives and research in rural areas in order to help establish the best available evidence. The authors conducted a systematic search of major electronic databases, based on the NHMRC hierarchy of evidence, an established scale, for identified early psychosis cross-referenced with multiple rural terms, between the years 1995 and 2005. A total of 637 articles met the initial search criteria; 206 were identified as having primary significance; three dealt specifically with rural areas. There is a paucity of research findings or published literature concerning the specific needs or characteristics of early psychosis practice or service delivery in rural areas. A number of inferences and suggestions for further research, investigations and policy directions are put forward for consideration.

Screening for mental illness in primary care clinics

OBJECTIVES

To assess the prevalence of mental disorders in inner city outpatient clinics and to improve the diagnosis of mental illness in primary care.

METHODS

The Problem Oriented Patient Report (POPR), a patient self-report checklist, was administered to 362 outpatients at two inner-city Buffalo primary care clinics. Patients' completed POPR checklists were evaluated to identify those with potential mental illness diagnoses and were available for the physicians' review during the patients' visits. After the visit, clinical charts were reviewed to determine the frequency of new mental illness diagnoses among continuing and new patients.

RESULTS

The screening checklist (POPR) revealed potential mental illnesses in 148/362 outpatients, of which 98% had not been identified by the physicians who had reviewed the patients' completed POPR forms. Only five new diagnoses of mental illnesses were independently made by clinics' physicians-all in follow-up (continuing) patients.

CONCLUSIONS

The physicians in the two clinics did not diagnose mental illnesses in their patients, even when written checklists of self-reports were available to them. Differences in staff attitudes may influence the data collection process, and patients' as well as physicians' responses. A weakness of this study is that the POPR might generate false positive results. Even if this were the case, the rate of previous diagnoses was still extremely low.

Psychiatric symptoms of adolescents with physical complaints admitted to an adolescence unit

The aim of this study was to evaluate the psychiatric symptoms among adolescents who were seen in the outpatient clinic for their physical complaints. Two hundred and ninety adolescent outpatients (154 males and 136 females) between 13 and 17 years of age (mean 14.3+/-1.2) are included in this study. Patients with known psychiatric disorders, mental retardation, organic brain diseases, or chronic organic problems were excluded. The Brief Symptom Inventory, which measures the psychiatric symptoms under the categories of anxiety, depression, negative self, somatization, and hostility, was given to all subjects. Symptoms of urinary and cardiovascular systems were related to hostility. Patients with obesity, hirsutism, problems of external genitalia, enuresis nocturna, abdominal pain, chest pain, and lack of weight gain showed psychiatric symptoms at pathological levels. Hostility symptom was found to be high in all groups.

The development of outpatient Clinical Glidepaths

For clinicians who are struggling with the complexities of medical decision-making, practice guidelines and evidence-based medicine (EBM) have become increasingly popular and have potential to positively influence the practice of medicine. Nevertheless, they have their limitations. Guidelines are often rigid, based solely on age, and usually do not take into account a patient's comorbidities, life expectancy, and nonmedical preferences. EBM studies may not always include particular patient populations commonly seen by the geriatric clinician (e.g., studies on lipid-lowering agents or antihypertensive drug usually exclude the very old or patients who are frail, demented, or at the end of life). These limitations have made it difficult for geriatric clinicians to use these guidelines because of the need to individualize evaluation and treatment approaches and take into account the varied preferences of their older patients. The purpose of this paper is to present an alternative model of care for geriatric clinicians called The Clinical Glidepaths. The Clinical Glidepaths are outpatient tools intended to assist geriatric clinicians in their decision-making process. They are based on the following principles. (1) Clinicians need guidance concerning many different types of patients, not rigid guidelines based solely on age. (2) EBM should be used but has some limitations of which to be aware. (3) Clinical experience, which emphasizes individual outcomes instead of populations, is an important component of medical decisions. (4) There needs to be room for patient preferences in medical decision-making. (5) An approach to patients based on probable life expectancy and function, instead of age, will be more applicable and useful. (6) Making a useful tool will focus on common problems seen in every day geriatric practices.