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Abstract
SummaryMental health service delivery in the general health care sector is restricted with regard to understanding the magnitude and impact of mental illness in the medically ill (co-morbidity), as well as the significance of current mental health service delivery. A new model in development in the framework of a Biomed2 grant is presented. It consists of case-finding through complexity of hospital care prediction (COMPRI) followed by an integral health service needs assessment (INTERMED). It might serve to develop a more structural relation with the general health care sector for the management of mentally co-morbid high utilizing patients.
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2
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Lee KKS, Silim UA. Implementation of the CLiP database. Int J Health Care Qual Assur 2019; ahead-of-print. [PMID: 31886638 DOI: 10.1108/ijhcqa-08-2018-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to review the findings from an audit of the implementation of a consultation-liaison psychiatry (CLiP) database in all inpatients referred to a CLiP service at the largest hospital in Malaysia with the aim of improving the quality CLiP services. DESIGN/METHODOLOGY/APPROACH All inpatient referrals to the CLiP team were recorded over a three-month period and compared to previous audit data from 2017. Four audit standards were assessed: the reporting of referrals, timeliness of response indication of reason for referral and presence of a management plan. FINDINGS The compliance of reporting using the CLiP form was 70.1 per cent compared to 28 per cent in the audit data from 2017 after interventions were conducted. Analysis of the completed CLiP form reveals that 89 per cent of referrals were seen within the same working day. All referrals included the reason for referral. The most common reason for referral was for depressive disorders, but post-assessment, delirium was the most common diagnosis. In total, 87.8 per cent satisfied the audit criteria for a completed written care plan. ORIGINALITY/VALUE Specialised CLiP services are relatively new in Malaysia and this is the first paper to examine the quality of such services in the country. Interventions were effective in improving the compliance of reporting using the CLiP database. The findings suggest that the CLiP services are on par with international audit standards. Furthermore, data from this clinical audit can serve as a benchmark for the development of national operating policies in similar settings.
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Affiliation(s)
| | - Umi Adzlin Silim
- Department of Consultation-Liaison Psychiatry Unit, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
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Butler DJ, Fons D, Fisher T, Sanders J, Bodenhamer S, Owen JR, Gunderson M. A review of the benefits and limitations of a primary care-embedded psychiatric consultation service in a medically underserved setting. Int J Psychiatry Med 2018; 53:415-426. [PMID: 30132357 DOI: 10.1177/0091217418791456] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.
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Affiliation(s)
- Dennis J Butler
- 1 Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,2 Columbia St. Mary's Family Medicine Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Dominique Fons
- 3 Department of Family and Community Medicine, University of Illinois Medical School, Urbana, IL, USA.,4 Family Medicine Residency Program, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Travis Fisher
- 5 Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,6 Community Division Psychiatry, Froedtert Hospital, Milwaukee, WI, USA
| | - James Sanders
- 1 Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,2 Columbia St. Mary's Family Medicine Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Julie R Owen
- 8 Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Marc Gunderson
- 9 Saint Louis Behavioral Medicine Institute, Saint Louis, MO, USA
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4
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Bogen DL, Fisher SD, Wisner KL. Identifying Depression in Neonatal Intensive Care Unit Parents: Then What? J Pediatr 2016; 179:13-15. [PMID: 27697325 DOI: 10.1016/j.jpeds.2016.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Debra L Bogen
- Department of Pediatrics University of Pittsburgh School of Medicine Division of General Academic Pediatrics Children's Hospital of Pittsburgh; Department of Psychiatry Western Psychiatric Institute and Clinic University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania.
| | - Sheehan D Fisher
- Department of Psychiatry Northwestern University Feinberg School of Medicine
| | - Katherine L Wisner
- Department of Psychiatry Northwestern University Feinberg School of Medicine; Department of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine Chicago, Illinois
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Katon WJ, Ludman EJ. Improving Services for Women with Depression in Primary Care Settings. PSYCHOLOGY OF WOMEN QUARTERLY 2016. [DOI: 10.1111/1471-6402.00091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Women have a higher prevalence of depressive disorders compared to men. The current system of care for women with depressive disorders provides significant financial barriers for patients with lower incomes to access mental health services. Primary care systems are used extensively by women and have the potential to diagnose patients at early stages of mental illness and to provide evidence-based treatments, but this potential is largely unfulfilled because of significant system-level barriers inherent in primary care. Recent effectiveness research provides an excellent framework for cost-effectively improving care of depression using stepped care principles and strategies effective for improving care of other chronic conditions. Psychologists have the potential to help implement stepped care models by providing training, consultation and ongoing quality assurance, as well as by delivering collaborative care models of acute-phase treatment and relapse prevention interventions.
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Affiliation(s)
- Wayne J. Katon
- Dept. of Psychiatry and Behavioral Sciences, Box 356560, University of Washington Medical School, 1959 NE Pacific, Seattle, WA 98195
| | - Evette J. Ludman
- Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1600, Seattle, WA 98101
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Fortney JC, Pyne JM, Turner EE, Farris KM, Normoyle TM, Avery MD, Hilty DM, Unützer J. Telepsychiatry integration of mental health services into rural primary care settings. Int Rev Psychiatry 2016; 27:525-39. [PMID: 26634618 DOI: 10.3109/09540261.2015.1085838] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
From a population health perspective, the mental health care system in the USA faces two fundamental challenges: (1) a lack of capacity and (2) an inequitable geographic distribution of services. Telepsychiatry can help address the equity problem, and if applied thoughtfully, can also help address the capacity problem. In this paper we describe how telepsychiatry can be used to address the capacity and equity challenges related to the delivery of mental health services in rural areas. Five models of telepsychiatry are described, including (1) the traditional telepsychiatry referral model, (2) The telepsychiatry collaborative care model, (3) the telepsychiatry behavioural health consultant model, (4) the telepsychiatry consultation-liaison model, and (5) the telepsychiatry curbside consultation model. The strong empirical evidence for the telepsychiatry collaborative care model is presented along with two case studies of telepsychiatry consultation in the context of the telepsychiatry collaborative care model. By placing telepsychiatrists and tele-therapists in consultation roles, telepsychiatry collaborative care has the potential to leverage scarce specialist mental health resources to reach more patients, thereby allowing these providers to have a greater population level impact compared to traditional referral models of care. Comparative effectiveness trials are needed to identify which models of telepsychiatry are the most appropriate for patients with complex psychiatric disorders.
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Affiliation(s)
- John C Fortney
- a Department of Psychiatry, School of Medicine , University of Washington , Seattle , Washington.,b Department of Veterans Affairs, Health Services Research and Development , Center of Innovation for Veteran-Centered and Value-Driven Care , Seattle , Washington
| | - Jeffrey M Pyne
- c Department of Psychiatry, College of Medicine , University of Arkansas for Medical Sciences , Little Rock Arkansas.,d Department of Veterans Affairs, Health Services Research and Development , Center for Mental Healthcare and Outcomes Research , Little Rock Arkansas
| | - Eric E Turner
- a Department of Psychiatry, School of Medicine , University of Washington , Seattle , Washington.,e Seattle Children's Research Institute , Seattle , Washington
| | | | | | - Marc D Avery
- a Department of Psychiatry, School of Medicine , University of Washington , Seattle , Washington
| | - Donald M Hilty
- h Department of Psychiatry and Behavioral Sciences, Keck School of Medicine , University of Southern California , Los Angeles , CA , USA
| | - Jürgen Unützer
- a Department of Psychiatry, School of Medicine , University of Washington , Seattle , Washington
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Cowley D, Dunaway K, Forstein M, Frosch E, Han J, Joseph R, McCarron RM, Ratzliff A, Solomon B, Unutzer J. Teaching psychiatry residents to work at the interface of mental health and primary care. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2014; 38:398-404. [PMID: 24733538 DOI: 10.1007/s40596-014-0081-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Accepted: 08/29/2013] [Indexed: 06/03/2023]
Abstract
The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.
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McAllister M, Matarasso B. Mental health community liaison in aged care: a service of value to all. Int J Older People Nurs 2013; 2:148-54. [PMID: 20925792 DOI: 10.1111/j.1748-3743.2007.00064.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Aim. This paper describes an effective community nursing role in which mental health care is brought to long-term care in a way that restores and promotes mental health wellbeing in the older person, builds understanding between clinicians, and develops staff confidence in attending to the whole needs of residents of nursing homes. Background. Mental health is a significant issue in the ageing population and there is much that mental health nurses as well as staff in long-term care can do to promote early detection of problems, facilitate effective treatment and build coping in the older person and family so that they recover from grief or depression issues and go on to make this stage of life satisfying and rewarding. Conclusions. The mental health nurse liaison role is a useful contribution to comprehensive aged care in the community. The role provides support to clinicians enabling them to develop skills and expand their area of practice, whilst creating an environment in which the needs of the client may also be better understood and thereby met.
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Affiliation(s)
- Margaret McAllister
- Associate Professor, Research Centre for Practice Innovation, Griffith University, Nathan, QLD, AustraliaClinical Nurse Consultant, Annerley Mental Health, Princess Alexandra Health Service District, Woolloongabba, QLD, Australia
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Agyapong VIO, Jabbar F, Conway C. Shared care between specialised psychiatric services and primary care: the experiences and expectations of General Practitioners in Ireland. Int J Psychiatry Clin Pract 2012; 16:293-9. [PMID: 22509780 DOI: 10.3109/13651501.2012.667115] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective. The study aims to explore the views of General Practitioners in Ireland on shared care between specialised psychiatric services and primary care. Method. A self-administered questionnaire was designed and posted to 400 randomly selected General Practitioners working in Ireland. Results. Of the respondents, 189 (94%) reported that they would support a general policy on shared care between primary care and specialised psychiatric services for patients who are stable on their treatment. However, 124 (61.4%) reported that they foresaw difficulties for patients in implementing such a policy including: a concern that primary care is not adequately resourced with allied health professionals to support provision of psychiatric care (113, 53.2%); a concern this would result in increased financial burden on some patients (89, 48.8%); a lack of adequate cooperation between primary care and specialised mental health services (84, 41.8%); a concern that some patients may lack confidence in GP care (55, 27.4%); and that primary care providers are not adequately trained to provide psychiatric care (29, 14.4% ). Conclusion. The majority of GPs in Ireland would support a policy of shared care of psychiatric patients; however they raise significant concerns regarding practical implications of such a policy in Ireland.
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Agyapong VIO, Conway C, Guerandel A. Shared care between specialized psychiatric services and primary care: the experiences and expectations of consultant psychiatrists in Ireland. Int J Psychiatry Med 2012; 42:295-313. [PMID: 22439298 DOI: 10.2190/pm.42.3.e] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Internationally, there has been a growing interest in the pursuit of collaborative forms of care for patients with enduring mental health difficulties. OBJECTIVE The study aims to explore the views of consultant psychiatrists in Ireland on shared care between specialized psychiatric services and primary care for patients with mental health difficulties. METHOD A self-administered questionnaire was designed and posted to 470 consultant psychiatrists who are members of the College of Psychiatry of Ireland. Stamped self-addressed envelopes were included for the return of completed questionnaires. RESULTS Overall, 213 questionnaires were returned, giving a response rate of 45%. Of the respondents, 194 (91%) reported that they would support a general policy on shared care between primary care and specialized psychiatric services for patients who are stable on their treatment. However, 181 (85%) reported that they foresaw difficulties for patients in implementing such a policy including: increased financial burden on some patients (141, 66%); some patients may lack confidence in GP care (100, 47%); primary care is not adequately resourced with allied health professionals to support provision of psychiatric care (128, 60%); primary care providers are not adequately trained to provide psychiatric care (111, 52%); and lack of adequate cooperation between primary care and specialized mental health services (96, 45%). CONCLUSION The Irish government and the Colleges of General Practitioners and Psychiatrists in Ireland need to work together to remove the bottlenecks that hinder the active involvement of primary care in the management of patients with enduring mental health difficulties. Also, the health care systems need to be organized along a shared care model to facilitate effective collaboration between primary and specialized psychiatric services.
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Affiliation(s)
- Vincent I O Agyapong
- University of Dublin Trinity College and St. Patrick's University Hospital, Dublin, Ireland.
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Reilly S, Planner C, Gask L, Hann M, Knowles S, Druss B, Lester H. Collaborative care approaches for people with severe mental illness. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009531] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cruz M. Mental Health Services Research and Community Psychiatry. HANDBOOK OF COMMUNITY PSYCHIATRY 2012:561-573. [DOI: 10.1007/978-1-4614-3149-7_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
OBJECTIVES Primary care teams have the potential to deliver much of the care currently provided by specialist services. The aim of this review was to determine from patients' clinical records and multidisciplinary team discussions, those that may be suitable for discharge back into primary care. METHODS A retrospective review of the clinical notes of all patients attending a psychiatric outpatient clinic was carried out by all members of the multidisciplinary team to determine the appropriateness of continuing to provide psychiatric services in a specialised psychiatric clinic rather than in a primary care setting, taking into account the patients demographic and clinical variables. RESULTS It was recommended that 60% of all the patients needed to continue attending the local mental health service, 35.2% could be discharged back into primary care for continuing management whilst the remaining 4.8% could be managed jointly between primary care and the community mental health service. The bulk of the patients recommended for discharge into primary care had a diagnosis of anxiety disorder or depression and all of them had been stable on their treatment for more than six months. CONCLUSION Regular multidisciplinary team review has a potential to identify patients who could be discharged back into primary care.
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Zatzick D, Rivara F, Jurkovich G, Russo J, Trusz SG, Wang J, Wagner A, Stephens K, Dunn C, Uehara E, Petrie M, Engel C, Davydow D, Katon W. Enhancing the population impact of collaborative care interventions: mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma. Gen Hosp Psychiatry 2011; 33:123-34. [PMID: 21596205 PMCID: PMC3099037 DOI: 10.1016/j.genhosppsych.2011.01.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 12/30/2010] [Accepted: 01/03/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of the study was to develop and implement a stepped collaborative care intervention targeting posttraumatic stress disorder (PTSD) and related comorbidities to enhance the population impact of early trauma-focused interventions. METHOD We describe the design and implementation of the Trauma Survivors Outcomes and Support study. An interdisciplinary treatment development team was composed of trauma surgical, clinical psychiatric and mental health services "change agents" who spanned the boundaries between frontline trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. RESULTS Two hundred seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by frontline acute care masters in social work and nurse practioner providers. CONCLUSIONS Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other nonspecialty posttraumatic contexts.
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Affiliation(s)
- Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA 98104, USA.
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Physician Staffing for the Practice of Psychosomatic Medicine in General Hospitals: A Pilot Study. PSYCHOSOMATICS 2010. [DOI: 10.1016/s0033-3182(10)70746-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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What is the role of consultation-liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis. Gen Hosp Psychiatry 2010; 32:246-54. [PMID: 20430227 DOI: 10.1016/j.genhosppsych.2010.02.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 02/01/2010] [Accepted: 02/03/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression. METHODS Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed. RESULTS Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26). CONCLUSIONS Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.
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Bauer AM, Fielke K, Brayley J, Araya M, Alem A, Frankel BL, Fricchione GL. Tackling the Global Mental Health Challenge: A Psychosomatic Medicine/Consultation–Liaison Psychiatry Perspective. PSYCHOSOMATICS 2010. [DOI: 10.1016/s0033-3182(10)70684-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry 2010; 32:456-64. [PMID: 20851265 PMCID: PMC3810032 DOI: 10.1016/j.genhosppsych.2010.04.001] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 04/05/2010] [Accepted: 04/06/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the history and evolution of the collaborative depression care model and new research aimed at enhancing dissemination. METHOD Four keynote speakers from the 2009 NIMH Annual Mental Health Services Meeting collaborated in this article in order to describe the history and evolution of collaborative depression care, adaptation of collaborative care to new populations and medical settings, and optimal ways to enhance dissemination of this model. RESULTS Extensive evidence across 37 randomized trials has shown the effectiveness of collaborative care vs. usual primary care in enhancing quality of depression care and in improving depressive outcomes for up to 2 to 5 years. Collaborative care is currently being disseminated in large health care organizations such as the Veterans Administration and Kaiser Permanente, as well as in fee-for-services systems and federally funded clinic systems of care in multiple states. New adaptations of collaborative care are being tested in pediatric and ob-gyn populations as well as in populations of patients with multiple comorbid medical illnesses. New NIMH-funded research is also testing community-based participatory research approaches to collaborative care to attempt to decrease disparities of care in underserved minority populations. CONCLUSION Collaborative depression care has extensive research supporting the effectiveness of this model. New research and demonstration projects have focused on adapting this model to new populations and medical settings and on studying ways to optimally disseminate this approach to care, including developing financial models to incentivize dissemination and partnerships with community populations to enhance sustainability and to decrease disparities in quality of mental health care.
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Affiliation(s)
- Wayne Katon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Kenneth Wells
- Department of Psychiatry and Biobehavioral Sciences, UCLA Medical School, Los Angeles, CA 90095, USA
| | - Loretta Jones
- Charles R. Drew University of Medicine and Science, Los Angeles, CA 98059, USA
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Wisner KL, Scholle SH, Stein B. Perinatal disorders: advancing public health opportunities. J Clin Psychiatry 2008; 69:1602-5. [PMID: 19192443 PMCID: PMC7077030 DOI: 10.4088/jcp.v69n1010] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Katherine L. Wisner
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Bradley Stein
- University of Pittsburgh School of Medicine, Community Care Behavioral Health, RAND Corporation, Pittsburgh, Pennsylvania
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Parker AG, Hetrick SE, Purcell R, Gillies D. Consultation liaison in primary practice for mental health problems. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd007193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Wani ZA, Khan AW, Baba AA, Khan HA, Wani QUA, Taploo R. Cotard's syndrome and delayed diagnosis in Kashmir, India. Int J Ment Health Syst 2008; 2:1. [PMID: 18271948 PMCID: PMC2248558 DOI: 10.1186/1752-4458-2-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2007] [Accepted: 01/11/2008] [Indexed: 11/10/2022] Open
Abstract
Cotard's syndrome is a rare syndrome, characterized by the presence of nihilistic delusions. The syndrome is typically related to depression and is mostly found in middle-aged or older people. A few cases have been reported in young people with 90% of these being females. We present a case of a young pregnant woman suffering from Cotard's syndrome. This is the first report of this syndrome in a pregnant woman. The case was diagnosed late, due to lack of awareness of psychiatric problems in primary care physicians resulting in undue suffering, loss of precious time and resources for the patient. Besides highlighting the rare combination of pregnancy and Cotard's syndrome this report delineates the difficulties faced by patients with such symptoms in a low resource setting.
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Affiliation(s)
- Zaid A Wani
- Department of Psychiatry, SKIMS Medical College, Srinagar, Jammu and Kashmir, India.
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Vannoy S, Powers D, Unützer J. Models of care for treating late-life depression in primary care. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/1745509x.3.1.67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The aim of this review is to highlight the need for treating late-life depression in primary care settings, review obstacles to doing so and introduce evidence-based models of depression care for older primary care patients. While interventions focusing on depression screening, provider education and referral to mental health specialists have had only limited success, several recent trials have demonstrated that programs in which primary care providers and mental health professionals effectively collaborate to treat depression using evidence-based treatment algorithms are more effective than usual care. Future research should address the problem of persistent depression, which has been identified in recent collaborative care studies, and focus on how to translate evidence-based approaches for late-life depression treatment into real world practice.
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Affiliation(s)
- Steven Vannoy
- University of Washington, School of Medicine, Department of Psychiatry and Behavioral Sciences, 1959 NE Pacific St, BOX 356560, Seattle, WA 98195–6560, USA
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Robiner WN. The mental health professions: workforce supply and demand, issues, and challenges. Clin Psychol Rev 2006; 26:600-25. [PMID: 16820252 DOI: 10.1016/j.cpr.2006.05.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2005] [Revised: 04/13/2006] [Accepted: 05/16/2006] [Indexed: 11/23/2022]
Abstract
The U.S. mental health (MH) workforce is comprised of core disciplines: psychology, psychiatry, social work, psychiatric nursing, and marriage and family therapy. A broader group of practitioners also deserves recognition. Diverse professions provide significant services in a variety of settings, extending the de facto mental health workforce. A tally of key disciplines estimates there are 537,857 MH professionals, or 182 per 100,000 U.S. population. This article provides an overview of the need and demand for mental health services and summarizes the MH professions (e.g., training, educational credentials, workforce estimates). It also discusses a range of challenges confronting MH professionals and the need for greater understanding of the workforce and integration of services. Methodological factors that confound estimates of the magnitude of the MH workforce are reviewed.
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Affiliation(s)
- William N Robiner
- Health Psychology, Department of Medicine, University of Minnesota Medical School, Mayo Mail Code 295, 420 Delaware Street, Southeast, Minneapolis, MN 55455-0392, USA.
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25
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Abstract
The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.
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Affiliation(s)
- Roger Kathol
- Cartesian Solutions, Inc., 3004 Foxpoint Road, Burnsville, MN 55337, USA.
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Chen H, Coakley EH, Cheal K, Maxwell J, Costantino G, Krahn DD, Malgady RG, Durai UNB, Quijano LM, Zaman S, Miller CJ, Ware JH, Chung H, Aoyama C, Van Stone WW, Levkoff SE. Satisfaction with mental health services in older primary care patients. Am J Geriatr Psychiatry 2006; 14:371-9. [PMID: 16582046 DOI: 10.1097/01.jgp.0000196632.65375.b9] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems. METHODS A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment. RESULTS Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services. CONCLUSIONS Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.
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Affiliation(s)
- Hongtu Chen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
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Zatzick DF, Simon GE, Wagner AW. Developing and Implementing Randomized Effectiveness Trials in General Medical Settings. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1468-2850.2006.00006.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Barry CL, Frank RG. Commentary: an Economic Perspective on Implementing Evidence-based Depression Care. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2005; 33:21-5. [PMID: 16215663 DOI: 10.1007/s10488-005-4234-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite the development of cost-effective evidence-based models for treating depression in primary care, economic and organizational barriers often impede sustainability in routine clinical practice. Under the Depression in Primary Care: Linking Clinical and System Strategies program, the Robert Wood Johnson Foundation (RWJF) funded eight demonstration grants to implement clinical changes in depression care alongside changes in contractual relationships, payment methods and other economic arrangements. The preceding articles summarize the specific economic and organizational changes implemented under four of these demonstration projects. This commentary highlights certain elements that appear critical to successfully re-align system incentives to support evidence-based depression care based in part on the experiences of these four sites.
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Affiliation(s)
- Colleen L Barry
- Department of Epidemiology and Public Health, Yale University School of Medicine, 60 College Street, CT, New Haven 06520, USA.
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Ballester DA, Filippon AP, Braga C, Andreoli SB. The general practitioner and mental health problems: challenges and strategies for medical education. SAO PAULO MED J 2005; 123:72-6. [PMID: 15947834 PMCID: PMC11052419 DOI: 10.1590/s1516-31802005000200008] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Within the context of primary health care and mental disorders, our aim was to study the opinions of general practitioners regarding attendance of people with mental health problems. DESIGN AND SETTING Qualitative focal group study among primary care services in the cities of Porto Alegre and Parobé, State of Rio Grande do Sul. METHODS A deliberately selected sample of 41 general practitioners who were working in basic health services met in focal groups. Two videos were presented, which simulated consultations for patients with depression and psychoses. The discussions about the identification and handling of mental health problems were recorded and assessed via content analysis. RESULTS The opinions related to the difficulties of diagnosing and treating mental problems, the involvement of relatives in caring for patients, the difficulty of compliance with the treatment, the uncertainty experienced by physicians and the difficulty of referring patients to specialized services. CONCLUSIONS The general practitioners indicated that they perceived the mental health problems among their clientele, but the diagnosis and treatment of these problems are still seen as a task for specialists. The challenge of continuing education on mental health requires methods of interactive and critical teaching, such as the problem-based approach.
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de Cruppé W, Hennch C, Buchholz C, Müller A, Eich W, Herzog W. Communication between psychosomatic C-L consultants and general practitioners in a German health care system. Gen Hosp Psychiatry 2005; 27:63-72. [PMID: 15694220 DOI: 10.1016/j.genhosppsych.2004.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2003] [Accepted: 08/16/2004] [Indexed: 11/27/2022]
Abstract
A randomized and prospective study examined the effects of intensive communication between treatment providers on physician behavior and patient care using a representative sample of patients referred to a German psychosomatic consultation-liaison (C-L) service (1998-1999). Sixty-seven patients were grouped (ICD-10) and randomized into intervention (n=33) and control groups (n=34). In the control group (CG), only the inpatient referring physicians were informed of consultation findings, as is standard practice in Germany. In the IG, the consultant directly reported the consultation findings to the general practitioner (GP). Patients were examined at 6-month (T2) and 3.5-year (T3) follow-up. Physician feedback and requests regarding the nature of communication were also assessed at T2. A significant reduction in symptoms was revealed at both follow-ups for the IG and CG. No significant group differences were found for acceptance of psychotherapy (59.1% IG and 42.3% CG at T3). The utilization of medical services remained stable across time. Patients who began psychotherapy were shown to have greater baseline symptom levels and "openness for new experiences" (NEO Five-Factor Inventory, NEO-FFi). Regular GP integration of psychosocial aspects into primary care differed between IG (44.0%) and CG (25.0%). Ninety-one percent of the GPs requested the option for a telephone conversation with the consultant or a case conference involving the patient at either their practice (37.7%) or the clinic (24.5%). We conclude that GPs are interested in a differentiated and more intensive cooperation concerning the integration of psychosocial aspects in their outpatient treatment. The patient's acceptance to follow a recommendation for psychotherapy, however, is related to the level of symptom severity and openness for new experiences.
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Affiliation(s)
- Werner de Cruppé
- Department of General Internal and Psychosomatic Medicine, University of Heidelberg, Medical Hospital, D-69120 Heidelberg, Germany.
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Fuller J, Edwards J, Martinez L, Edwards B, Reid K. Collaboration and local networks for rural and remote primary mental healthcare in South Australia. HEALTH & SOCIAL CARE IN THE COMMUNITY 2004; 12:75-84. [PMID: 14675367 DOI: 10.1111/j.1365-2524.2004.00470.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This paper draws on a consultation with 200 stakeholders about a mental health plan in the most remote region of South Australia to discuss primary mental healthcare improvement strategies. In rural and remote environments, a lack of services means that it is more difficult to deal with a mental illness or provide assistance for circumstantial life problems. The authors' consultations revealed difficulties with service access, acceptability and teamwork. They also found that the availability of local human service workers leads to their use as first-level mental health contacts, but these workers are neither skilled nor supported for this. These difficulties will require attention to the boundaries between different service providers which can otherwise create inflexibility and service gaps. The regional mental health plan that is being rolled out will develop collaboration through regional interagency task groups, networking groups for local human service workers and the position of a regional mental health coordinator in order to overcome these difficulties and to operationalise service partnerships.
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Affiliation(s)
- Jeffrey Fuller
- Department of Public Health, University of Adelaide, Adelaide, South Australia.
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Swindle RW, Rao JK, Helmy A, Plue L, Zhou XH, Eckert GJ, Weinberger M. Integrating clinical nurse specialists into the treatment of primary care patients with depression. Int J Psychiatry Med 2003; 33:17-37. [PMID: 12906341 DOI: 10.2190/qry5-b61v-qe4r-8141] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the effectiveness of integrating generalist and specialist care for veterans with depression. METHOD We conducted a randomized trial of patients screening positive for depression at two Veterans Affairs Medical Center general medicine clinic firms. Control firm physicians were notified prior to the encounter when eligible patients had PRIME-MD depression diagnoses. In the intervention firm, a mental health clinical nurse specialist (CNS) was to: design a treatment plan; implement that plan with the primary care physician; and monitor patients via telephone or visits at two weeks, one month and two months. Primary outcomes (depressive symptoms, patient satisfaction with health care) were collected at 3 and 12 months. RESULTS Of 268 randomized patients, 246 (92%) and 222 (83%) completed 3- and 12-month follow-up interviews. There were no between-group differences in depressive symptoms or satisfaction at 3 or 12 months. The intervention group had greater chart documentation of depression at baseline (63% versus 33%, p = 0.003) and a higher referral rate to mental health services at 3 months (27% versus 9%, p = 0.019). There was no difference in the rate of new prescriptions for, or adequate dosing of, anti-depressant medications. In 40% of patients, CNSs disagreed with the PRIME-MD depression diagnosis, and their rates of watchful waiting were correspondingly high. CONCLUSIONS Implementing an integrated care model did not occur as intended. Experienced CNSs often did not see the need for treatment in many primary care patients identified by the PRIME-MD. Integrating integrated care models in actual practice may prove challenging.
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Lucena RJM, Lesage A, Elie R, Lamontagne Y, Corbière M. Strategies of collaboration between general practitioners and psychiatrists: a survey of practitioners' opinions and characteristics. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2002; 47:750-8. [PMID: 12420653 DOI: 10.1177/070674370204700806] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The description of collaboration models and the key underlying principles provide important information for designing services. However, to apply this broad corpus of information to clinical services and policymaking, we need to know which key principles (or strategies) of collaboration are the most accepted by local physicians. METHOD In this context, we designed a survey that included 2 objectives: 1) to collect the opinions of practising general practitioners (GPs) and psychiatrists in Montreal with respect to strategies for improving collaboration between these 2 groups and 2) to identify demographic and practice characteristics of those physicians associated with the acceptance of such strategies. We designed a questionnaire to specifically elicit physicians' opinions about strategies involving communication, continuing medical education (CME) for GPs in psychiatry, and access to consulting psychiatrists, as well as to identify the profiles of the respondent physicians. We mailed the questionnaire to 203 GPs and 203 psychiatrists who were randomly selected. RESULTS The response rate was 86% for GPs and 87% for psychiatrists. Physicians expressed favourable opinions about most strategies involving 1) the improvement of communication and 2) the organization of CME activities concerning GP practices in the field of psychiatry. On the other hand, they did not indicate acceptance of the strategies involving on-site collaboration between GPs and psychiatrists. Physician age, sex, place of practice, type of practice (such as seeing patients with or without appointments), and responsibility for administrative duties associated significantly with the degree of acceptance of the proposed strategies. CONCLUSION Communication and CME strategies for GPs in psychiatry can be an option to improve collaboration between GPs and psychiatrists. However, strategies of access to consulting psychiatrists require significant alterations to established clinical routines and professional roles.
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Rost K, Fortney J, Fischer E, Smith J. Use, quality, and outcomes of care for mental health: the rural perspective. Med Care Res Rev 2002; 59:231-65; discussion 266-71. [PMID: 12205828 DOI: 10.1177/1077558702059003001] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.
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Abstract
Few long term studies have reported observations of changes over time with Consultation-liaison (C-L) populations. This is a longitudinal observational study of a tertiary care psychiatric C-L-service over a ten-year-period (1988-1997) using a standardized computerized clinical database to examine 4,429 consecutive referrals. Sociodemographic variables, relative consultation rates, reasons for referral and psychiatric diagnoses, apart from a shift from adjustment disorders with depressed mood to major depressive disorders within the depressive syndrome group, did not demonstrate significant changes during the study period. Levels of psychosocial and somatic functioning of referred patients decreased. Changes occurred in the pattern of C-L-psychiatric recommendations, e.g., in the prescription of antidepressants where tricyclic antidepressants were replaced by newer agents such as the selective serotonin reuptake inhibitors. Consulting psychiatrists were more likely to refer to private psychiatrists to follow patients, and more patients were transferred to inpatient psychiatric units. Due to a decrease in length of stay over the ten year observation period, the correlation of lagtime (the time from admission to the hospital until referral to C-L psychiatry) and length of stay decreased from very strong to moderate.
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Affiliation(s)
- Albert Diefenbacher
- Division of Behavioral Medicine and Consultation Psychiatry, The Mount Sinai-New York University Medical Center/Health Service, New York, NY, USA.
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Blankenstein AH, van der Horst HE, Schilte AF, de Vries D, Zaat JOM, André Knottnerus J, van Eijk JTM, de Haan M. Development and feasibility of a modified reattribution model for somatising patients, applied by their own general practitioners. PATIENT EDUCATION AND COUNSELING 2002; 47:229-235. [PMID: 12088601 DOI: 10.1016/s0738-3991(01)00199-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor's speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10-30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification 'dealing with illness worry' showed limited feasibility.
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Affiliation(s)
- Annette H Blankenstein
- Department of General Practice, Faculty of Medicine, EMGO Institute, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
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Bower P, Gask L. The changing nature of consultation-liaison in primary care: bridging the gap between research and practice. Gen Hosp Psychiatry 2002; 24:63-70. [PMID: 11869739 DOI: 10.1016/s0163-8343(01)00183-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Consultation-liaison (C-L) psychiatry is hypothesized to be a model of interface between primary care and specialist mental health services with significant advantages over other models of organizing mental health care. However, there are significant complexities in the definition and evaluation of this model. As well as discussing the definition of C-L in primary care, this paper highlights the gap between models of traditional C-L that are popular in practice and the increasingly complex models (based on chronic disease management) evaluated in research studies. It is hypothesized that traditional C-L approaches and newer models use different mechanisms of change to achieve their goals. The former focus on the relationships between primary care and specialist professionals, while the latter highlight the importance of the development of effective systems of delivering care. Although the latter may be crucial in enhancing the "efficacy" and "effectiveness" of these models in terms of clinician behavior change and patient outcome, the former may be crucial in terms of "dissemination" and "implementation" of these models from research contexts to routine care settings.
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Affiliation(s)
- Peter Bower
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Fischer LR, Wei F, Rolnick SJ, Jackson JM, Rush WA, Garrard JM, Nitz NM, Luepke LJ. Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization. J Am Geriatr Soc 2002; 50:307-12. [PMID: 12028213 DOI: 10.1046/j.1532-5415.2002.50063.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost. SETTING Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota. PARTICIPANTS Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516). DESIGN Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates. MEASUREMENT Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database. RESULTS Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges. CONCLUSION This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.
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Affiliation(s)
- Lucy Rose Fischer
- HealthPartners Research Foundation, University of Minnesota, Minneapolis 55440, USA.
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Oxman TE, Barrett JE, Sengupta A, Katon W, Williams JW, Frank E, Hegel M. Status of minor depression or dysthymia in primary care following a randomized controlled treatment. Gen Hosp Psychiatry 2001; 23:301-10. [PMID: 11738460 DOI: 10.1016/s0163-8343(01)00166-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This report describes the rates of recovery and remission from minor depression or dysthymia in primary care patients three months after completing a randomized controlled treatment trial. The subjects were primary care patients who received > or =4 treatment sessions with Problem-Solving Treatment, paroxetine, or placebo and who completed an independent assessment 3 months after the study (201 with minor depression, 229 with dysthymia). The 17-item Hamilton Rating Scale for Depression (HAMD), semistructured questions about postintervention depression treatments, and baseline medical comorbidity, neuroticism, and social function were the primary measures. For minor depression 76% and for dysthymia 68% of subjects who were in remission at the end of the 11-week treatment trial were recovered (HAMD < or =6) three months after the treatment trial. Of patients who were not in remission at 11 weeks, for minor depression 37% and for dysthymia 31% went on to achieve remission at 25 weeks. The majority of patients chose not to use antidepressants or psychotherapy after the trial. Patients with minor depression that had greater baseline social function and lower neuroticism scores were more likely to be recovered. For patients with minor depression, these findings suggest a need for some matching of continuation and maintenance treatment to patient characteristics rather than uniform, automatic treatment recommendations. Because of the chronic, relapsing nature of dysthymia, practical improvements in encouraging effective continuation and maintenance phases of treatment are indicated.
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Affiliation(s)
- T E Oxman
- Departments of Psychiatry and Community & Family Medicine, Dartmouth Medical School, Lebanon, NH 03756, USA.
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Kishi Y, Robinson RG, Kosier JT. Suicidal ideation among patients during the rehabilitation period after life-threatening physical illness. J Nerv Ment Dis 2001; 189:623-8. [PMID: 11580007 DOI: 10.1097/00005053-200109000-00009] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A total of 496 patients were examined for suicidal ideation during the acute hospital period and at 3, 6, 12, and 24 months' follow-up after suffering either stroke, traumatic brain injury, myocardial infarction, or spinal cord injury. A total of 7.3% of patients had suicidal ideation during the in-hospital evaluation (acute-onset suicidal ideation), and 11.3% developed it during the chronic 3 to 24 month rehabilitation period (delayed-onset suicidal ideation). Compared with delayed-onset suicidal patients, acute-onset suicidal patients had more predisposing risk factors (i.e., personal psychiatric history and alcohol abuse/dependence) and less social support (i.e., lower frequency of being married). Both acute and delayed-onset suicidal ideation, however, were strongly associated with the existence of major depression and impaired social functioning. These findings suggest that the detection and appropriate treatment of depressive disorders and social isolation may be the most important factor in preventing suicide both during the acute and chronic period following life-threatening physical illnesses.
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Affiliation(s)
- Y Kishi
- Department of Psychiatry, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
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Abstract
BACKGROUND Two million older Americans suffer from depression annually. Depression causes more functional impairment than many other common medical conditions and older adults have the highest rate of suicide in the United States. Although many of these patients fail to seek or fail to receive care for depression, the majority will be seen in primary care for the treatment of other conditions. OBJECTIVE To review the health services research on quality improvement for late life depression. METHODS Qualitative literature review. RESULTS During the past 30 years, multiple educational and quality improvement interventions have been designed and tested to improve the recognition and treatment of depression in primary care settings. The findings from this large body of health services research suggest that: (1) the outcome of major depression in the usual care of primary care is typically poor; this is particularly true of late life depression; (2) informational support provided to primary care physicians is necessary but insufficient to improve the outcomes of late life depression in primary care; achieving guideline-level therapy requires the substantial participation of an informed and motivated patient working in concert with a health care team and health care system designed to care for chronic conditions; (3) up to 30% of older primary care patients will fail to respond to excellent guideline-level therapy provided in primary care; and (4) the latest quality improvement efforts focus not only on the clinical skills of primary care physicians, but also on patient's self-care and on innovative strategies to improve the system of care. CONCLUSIONS Late life depression is often a chronic disease and outcomes research demonstrates that quality improvement efforts that focus resources on improving systems of care and the active participation of patients offer the best evidence of improved patient outcomes.
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Affiliation(s)
- C M Callahan
- Indiana University Center for Aging Research, Regenstrief Institute for Health Care, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Anfinson TJ, Bona JR. A health services perspective on delivery of psychiatric services in primary care including internal medicine. Med Clin North Am 2001; 85:597-616. [PMID: 11349475 DOI: 10.1016/s0025-7125(05)70331-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Serious problems persist in the recognition and treatment of psychiatric problems in primary care despite multiple interventions directed at correcting these problems. Improved outcomes depend on improved recognition, and screening instruments need to be streamlined tremendously to be accepted by primary care providers. Publication of guidelines and physician education, although essential for improved care, are probably insufficient to implement guidelines-based care. Improvements in psychiatric outcome appear to depend on the level of intensity of the intervention employed. Continued research is needed to determine the most effective type of educational intervention and more widely applicable quality improvement processes. Broad-based changes in health service delivery focusing on the true integration of mental health services with general medical care are required to bring about meaningful, effective change. Ongoing changes in physician training programs (combined primary care/psychiatry programs) may facilitate implementation of guideline-based psychiatric care in medical settings, but the full impact of these changes is not likely to be felt for several years.
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Affiliation(s)
- T J Anfinson
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
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Schriger DL, Gibbons PS, Langone CA, Lee S, Altshuler LL. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Ann Emerg Med 2001; 37:132-40. [PMID: 11174229 DOI: 10.1067/mem.2001.112255] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Undiagnosed mental illness is highly prevalent and produces needless morbidity. Emergency department patients with vague or longstanding complaints are at risk for occult mental illness, but are seldom diagnosed. We conducted this study to determine whether a previously validated, self-administered, computerized psychiatric interview (Primary Care Evaluation of Mental Disorders [PRIME-MD]) could increase the detection of occult psychiatric illness in the ED. METHODS This was a randomized, controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000. ED house staff and attending physicians participated. Patients were those with nonspecific complaints potentially associated with occult psychiatric illness (eg, long-standing headache, abdominal or back pain). Exclusion criteria were known psychiatric illness, complaint, or medication; and straightforward reason for the ED visit. Consenting subjects completed the PRIME-MD questionnaire in the waiting room, and were randomly assigned to either the "report" (report results given to physician) or "no-report" groups. PRIME-MD results were clipped to the front of the chart of report group patients. There was no other intervention. The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis, consultation, or referral from the emergency physician. RESULTS A total of 339 (5.1%) of all patients were approached; 230 consented to participate in the study, and 218 completed the PRIME-MD session and were randomly assigned to study groups. Ninety-two patients in the report group and 98 cases in the no-report group were analyzed. Patients were omitted for the following reasons: left without being seen (8), mistakenly enrolled (10), or unretrievable medical records (10). Seventy-nine (42%) patients received a psychiatric diagnosis from PRIME-MD and 9 (5%) from the physician. The frequencies of physician psychiatric diagnosis and referral did not differ between groups (diagnosis: report 9%, no report 9%, Delta 0%, 95% confidence interval [CI] -13, 14; referral: report 9%, no report 7%, Delta 2%, 95% CI -11, 16). CONCLUSION ED patients willingly completed the PRIME-MD questionnaire (in a median time of 7 minutes), which frequently diagnosed psychiatric conditions. Despite this, physicians rarely diagnosed or treated these conditions regardless of whether they were provided with the PRIME-MD diagnoses.
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Affiliation(s)
- D L Schriger
- University of California-Los Angeles Emergency Medical Center, Department of Psychiatry, and School of Medicine, Los Angeles, CA, USA.
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Swindle R, Heller K, Pescosolido B, Kikuzawa S. Responses to nervous breakdowns in America over a 40-year period. Mental health policy implications. AMERICAN PSYCHOLOGIST 2000; 55:740-9. [PMID: 10916863 DOI: 10.1037/0003-066x.55.7.740] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The 1957 and 1976 Americans View Their Mental Health surveys from the Institute of Social Research were partially replicated in the 1996 General Social Survey (GSS) to examine the policy implications of people's responses to feeling an impending nervous breakdown. Questions about problems in modern living were added to the GSS to provide a profile of the public's view of mental health problems. Results were compared for 1957, 1976, and 1996. In 1957, 19% of respondents had experienced an impending nervous breakdown; in 1996, 26% had had this experience. Between 1957 and 1996, participants increased their use of informal social supports, decreased their use of physicians, and increased their use of nonmedical mental health professionals. These findings support policies that strengthen informal support seeking and access to effective psychosocial treatments rather than current mental health reimbursement practices, which emphasize the role of primary care physicians.
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Affiliation(s)
- R Swindle
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA.
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Jørgensen CK, Fink P, Olesen F. Psychological distress among patients with musculoskeletal illness in general practice. PSYCHOSOMATICS 2000; 41:321-9. [PMID: 10906354 DOI: 10.1176/appi.psy.41.4.321] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors investigated the importance of psychological distress and somatization among patients with musculoskeletal illness in general practice. The authors used the Hopkins Symptom Check List (SCL-8) and the Whiteley Index to rate 1,720 patients with musculoskeletal illness referred to physiotherapy from general practice. General practitioners (GPs), patients, and physiotherapists often noted stress or psychological distress to be a possible cause of the patient's musculoskeletal illness, but agreement between them was low. If the GP included the patient's own view on psychological distress, the result of the SCL-8 did not add much to the detection of distress. The results emphasize the importance of discussing psychological distress when dealing with patients with musculoskeletal illness.
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Affiliation(s)
- C K Jørgensen
- Department of General Practice, University of Aarhus, Denmark.
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Abstract
BACKGROUND Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs). OBJECTIVES To assess the effects of on-site MHWs in primary care on the clinical behaviour of primary care providers (PCPs). SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (18-22 June 1998), the Cochrane Controlled Trials Register (18-22 June 1998), MEDLINE (1966 to 1998), EMBASE (1980 to 1998), PsychInfo (1984 to 1998), CounselLit (18-22 June 1998), NPCRDC skill-mix in primary care bibliography, and reference lists of articles. SELECTION CRITERIA Randomised trials, controlled before and after studies and interrupted time series analyses of MHWs either replacing PCPs as providers of mental health care ('replacement' models) or providing collaborative care/support to PCPs in managing patients' mental health problems ('consultation-liaison' models). The participants were primary care providers. The outcomes included objective PCP behaviours such as diagnosis, prescribing and referral. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Thirty-eight studies were included involving more than 460 PCPs and more than 3880 patients. There was some evidence that 'replacement' model MHWs achieved significant short-term reductions in PCP psychotropic prescribing and mental health referral, but the effects were not reliable. Consultation rates were also reduced, but with even less evidence of a consistent effect. There were no indirect effects in prescribing behaviour on the wider population and no consistent pattern to the impact on referrals. 'Indirect' effects on PCP consultation rates were not assessed. There was some evidence that 'consultation-liaison' model MHWs had a direct effect on PCP prescribing behaviour when used as part of complex, multifaceted interventions. Few studies examined the 'indirect' effects of such interventions, and those that did failed to provide evidence that 'direct' effects were generalisable to the wider population or endured once the 'consultation-liaison' intervention was removed. REVIEWER'S CONCLUSIONS This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.
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Affiliation(s)
- P Bower
- National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester, UK, M13 9PL.
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Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature. PSYCHOSOMATICS 2000; 41:39-52. [PMID: 10665267 DOI: 10.1016/s0033-3182(00)71172-8] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.
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Affiliation(s)
- K Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.
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Abstract
Anxiety disorders are common, yet under diagnosed, in primary care settings. Many patients with anxiety and other psychiatric disorders do not seek care in mental health care settings. An integrated primary care/mental health model offers one approach to improving outcomes for patients with anxiety disorders. This model has been researched for the treatment of depression with positive results but has not been well studied for the treatment of anxiety disorders. We describe the results of care for a cohort of adult patients with Generalized Anxiety Disorder (GAD) and clinically significant anxiety secondary to Major Depressive Disorder (MDD) treated in an integrated model. Compared to a matched cohort of adults treated in a primary care setting with usual care, the intervention cohort experienced significantly improved reduction in symptoms of anxiety at 6 months. The intervention cohort also was significantly more satisfied with care.
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Affiliation(s)
- D Price
- Colorado Permanente Medical Group, USA
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Walker Z, McKinnon M, Townsend J. Shared care for high-dependency patients: mental illness, neurological disorders and terminal care--a review. Health Serv Manage Res 1999; 12:205-11. [PMID: 10622798 DOI: 10.1177/095148489901200401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Changes in the structure of health services in the UK have increased the need to identify and formalize shared responsibilities between primary and secondary care for patients with chronic conditions. There are well-established schemes for the management of patients with some chronic diseases but very little for other high-dependency groups. This review examines the extent of systematic and shared care for some of the less well served groups: these are mental illness, neurological disorders and terminal care. Examples of good practice are highlighted.
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Affiliation(s)
- Z Walker
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
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Abstract
OBJECTIVES To review recent findings on the epidemiology, burden, diagnosis, comorbidity, and treatment of depression, particularly in general medical settings; to delineate barriers to the recognition, diagnosis, and optimal management of depression in general medical settings; and to summarize efforts under way to reduce some of these barriers. DESIGN MEDLINE searches were conducted to identify scientific articles published during the previous 10 years addressing depression in general medical settings and epidemiology, co-occurring conditions, diagnosis, costs, outcomes, and treatment. Articles relevant to the objective were selected and summarized. CONCLUSIONS Depression occurs commonly, causing suffering, functional impairment, increased risk of suicide, added health care costs, and productivity losses. Effective treatments are available both when depression occurs alone and when it co-occurs with general medical illnesses. Many cases of depression seen in general medical settings are suitable for treatment within those settings. About half of all cases of depression in primary care settings are recognized, although subsequent treatments often fall short of existing practice guidelines. When treatments of documented efficacy are used, short-term patient outcomes are generally good. Barriers to diagnosing and treating depression include stigma; patient somatization and denial; physician knowledge and skill deficits; limited time; lack of availability of providers and treatments; limitations of third-party coverage; and restrictions on specialist, drug, and psychotherapeutic care. Public and professional education efforts, destigmatization, and improvement in access to mental health care are all needed to reduce these barriers.
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Affiliation(s)
- L S Goldman
- Council on Scientific Affairs, American Medical Association, Chicago, IL 60610, USA
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