Determining the effect that consultation-liaison psychiatry in primary care has on family physicians' psychiatric knowledge and practice

Evaluation of an electronic consultation service in psychiatry for primary care providers

BACKGROUND

This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked.

METHODS

This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults.

RESULTS

Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4.

CONCLUSIONS

This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

A Guide for Planning and Implementing Successful Mental Health Educational Programs

INTRODUCTION

Considering the global burden of mental disorders, there is a worldwide need to improve the quality of mental health care. In order to address this issue, a change in how health care professionals are trained may be essential. However, the majority of the few reports published on this field's training programs do not discuss the characteristics associated with the success or failure of these strategies. The purpose of this review was to systematically examine the literature about mental health training programs designed for health care professionals in order to identify the relevant factors associated with their effective implementation.

METHODS

The MEDLINE/PubMed, SciELO, and Virtual Health Library databases were used to search for articles published before February 2017 and reviewed by two double-blind reviewers.

RESULTS

We found 77 original papers about mental health educational programs. Many of these studies were conducted in the USA (39%), addressed depression as the main subject (34%), and applied a quasi-experimental design (52%). Effective interventions were associated with the following characteristics: the use of learner-centered and interactive methodological approaches; a curriculum based on challenges in the trainees' daily routines; the involvement of experts in the program's development; the enrollment of experienced participants; interdisciplinary group work; flexible timing; the use of e-learning resources; and optimizing the implementation of knowledge into the participants' routine work practices.

IMPLICATIONS FOR PRACTICE

These results will be helpful for planning and improving the quality of future educational programs in mental health.

Surveying the Knowledge and Practices of Health Professionals in China, India, Iran, and Mexico on Treating Tuberculosis

Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices "often or very often" (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting systematic reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.

Consultation liaison in primary care for people with mental disorders

BACKGROUND

Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder.

OBJECTIVES

To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care.

SEARCH METHODS

We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy.We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data.

MAIN RESULTS

There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people.There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharmacological treatment up to 12 months (four trials, n = 796, NNTB 13, 95% CI 7 to 50). There was also some evidence that consultation liaison may not be as effective as collaborative care in regards to symptoms of mental disorder, disability, general health status, and provision of treatment.The quality of these findings were low for all outcomes however, apart from consumer adherence from three to 12 months, which was of moderate quality. Eight trials were rated a high risk of performance bias because consumer participants were likely to have known whether or not they were allocated to the intervention group and most outcomes were self reported. Bias due to attrition was rated high in eight trials and reporting bias was rated high in six.

AUTHORS' CONCLUSIONS

There is evidence that consultation liaison improves mental health for up to three months; and satisfaction and adherence for up to 12 months in people with mental disorders, particularly those who are depressed. Primary care providers were also more likely to provide adequate treatment and prescribe pharmacological therapy for up to 12 months. There was also some evidence that consultation liaison may not be as effective as collaborative care in terms of mental disorder symptoms, disability, general health status, and provision of treatment. However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.

Establishing a telepsychiatry consultation practice in rural Georgia for primary care physicians: a feasibility report

OBJECTIVE

One approach to solving mental health care disparity issues in rural areas is by establishing a telepsychiatry consultation practice for children, in which a psychiatrist sees a child via videoconferencing for a limited number of sessions and then provides a treatment plan to that child's primary care physician and family.

METHOD

The present study offered a 2-session telepsychiatry consultation clinic, consisting of a psychiatric evaluation session and a recommendation session, with patients located remotely in rural Georgia.

RESULTS

Fifteen consultations with children aged 4 to 18 years (M = 9.73, SD = 3.39) with varying diagnoses were completed. Parental satisfaction with the telepsychiatry consultation model was high, overall mean of 4.58 (SD = 0.63) on a 5-point scale (n = 11).

CONCLUSION

Establishing a child telepsychiatry consultation practice is feasible in rural areas. This report describes the benefits and challenges of our telepsychiatry consultation clinic with rural pediatric patients.

Assessing healthcare providers' knowledge and practices relating to insecticide-treated nets and the prevention of malaria in Ghana, Laos, Senegal and Tanzania

BACKGROUND

Research evidence is not always being disseminated to healthcare providers who need it to inform their clinical practice. This can result in the provision of ineffective services and an inefficient use of resources, the implications of which might be felt particularly acutely in low- and middle-income countries. Malaria prevention is a particularly compelling domain to study evidence/practice gaps given the proven efficacy, cost-effectiveness and disappointing utilization of insecticide-treated nets (ITNs).

METHODS

This study compares what is known about ITNs to the related knowledge and practices of healthcare providers in four low- and middle-income countries. A new questionnaire was developed, pilot tested, translated and administered to 497 healthcare providers in Ghana (140), Laos (136), Senegal (100) and Tanzania (121). Ten questions tested participants' knowledge and clinical practice related to malaria prevention. Additional questions addressed their individual characteristics, working context and research-related activities. Ordinal logistic regressions with knowledge and practices as the dependent variable were conducted in addition to descriptive statistics.

RESULTS

The survey achieved a 75% response rate (372/497) across Ghana (107/140), Laos (136/136), Senegal (51/100) and Tanzania (78/121). Few participating healthcare providers correctly answered all five knowledge questions about ITNs (13%) or self-reported performing all five clinical practices according to established evidence (2%). Statistically significant factors associated with higher knowledge within each country included: 1) training in acquiring systematic reviews through the Cochrane Library (OR 2.48, 95% CI 1.30-4.73); and 2) ability to read and write English well or very well (OR 1.69, 95% CI 1.05-2.70). Statistically significant factors associated with better clinical practices within each country include: 1) reading scientific journals from their own country (OR 1.67, 95% CI 1.10-2.54); 2) working with researchers to improve their clinical practice or quality of working life (OR 1.44, 95% CI 1.04-1.98); 3) training on malaria prevention since their last degree (OR 1.68, 95% CI 1.17-2.39); and 4) easy access to the internet (OR 1.52, 95% CI 1.08-2.14).

CONCLUSIONS

Improving healthcare providers' knowledge and practices is an untapped opportunity for expanding ITN utilization and preventing malaria. This study points to several strategies that may help bridge the gap between what is known from research evidence and the knowledge and practices of healthcare providers. Training on acquiring systematic reviews and facilitating internet access may be particularly helpful.

Taking consultation-liaison psychiatry into primary care

Up to 50% of patients seen in primary care have mental health problems, the severity and duration of their problems often being similar to those of individuals seen in the specialized sector. This article describes the reasons, advantages, and challenges of collaborative or shared care between primary and mental health teams, which are similar to those of consultation-liaison psychiatry. In both settings, clinicians deal with the complex interrelationships between medical and psychiatric disorders. Although initial models emphasized collaboration between family physicians, psychiatrists, and nurses, collaborative care has expanded to involve patients, psychologists, social workers, occupational therapists, pharmacists, and other providers. Several factors are associated with favorable patient outcomes. These include delivery of interventions in primary care settings by providers who have met face-to-face and/or have pre-existing clinical relationships. In the case of depression, good outcomes are particularly associated with approaches that combined collaborative care with treatment guidelines and systematic follow-up, especially for those with more severe illness. Family physicians with access to collaborative care also report greater knowledge, skills, and comfort in managing psychiatric disorders, even after controlling for possible confounders such as demographics and interest in psychiatry. Perceived medico-legal barriers to collaborative care can be addressed by adequate personal professional liability protection on the part of each practitioner, and ensuring that other health care professionals with whom they work collaboratively are similarly covered.

Long term GP opinions and involvement after a consultation-liaison intervention for mental health problems

Background

Shared Mental Health care between Psychiatry and Primary care has been developed to improve the care of common mental health problems but has not hitherto been adequately evaluated. The present study evaluated a consultation-liaison intervention with two objectives: to explore long-term GP opinions (relating to impact on their management and on patient medical outcome) and to determine the secondary referral rate, after a sufficient time lapse following the intervention to reflect a "real-world" primary care setting.

Methods

All the 139 collaborating GPs (response rate: 84.9%) were invited two years after the intervention to complete a retrospective telephone survey for each patient (181 patients; response rate: 69.6%).

Results

91.2% of GPs evaluated effects as positive for primary care management (mainly as support) and 58.9% noted positive effects for patient medical outcome. Two years post-intervention, management was shared care for 79.7% of patients (the GP as the psychiatric care provider) and care by a psychiatrist for 20.3% patients. Secondary referral occurred finally in 44.2% of cases.

Conclusion

The intervention supported GP partners in their management of patients with common mental health problems. Further studies are required on the appropriateness of the care provider.

Impact of shared mental health care in the general population on subjects' perceptions of mental health care and on mental health status

OBJECTIVE

A community survey evaluated whether the development of a shared mental health care intervention had an impact on health care perceptions and mental health status of subjects with common mental health problems (MHP).

METHODS

Adults <70 years old with common MHP (DSM-IV/CIDI-SF major depressive disorder, generalized anxiety or MHI-SF 36 psychic distress diagnoses), were randomly drawn from the general population in the intervention area (IA, n = 349) and in a control area (CA, n = 360), and evaluated twice at an interval of 18 months (percentage of follow-up: IA = 69.3%, CA = 71.9%, P = .44). CA and IA groups did not differ for the criteria of interest at baseline.

RESULTS

At 18 months, compared to CA, IA reported significantly different help-seeking attitudes or behaviours (P = .02 for all subjects and .006 for subjects with current MHP) and greater general satisfaction with care (P = .03 for both). Remission rates and daily life functioning did not differ.

CONCLUSIONS

After 4 years of development of a mental health network based on a consultation-liaison model, Shared Mental Health Care was associated with greater satisfaction and access with care among subjects with common MHP. The association was not found with mental health status, but the study lacked power to adequately address the issues.

Models of telepsychiatric consultation--liaison service to rural primary care

New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary-care setting, particularly in rural areas of the United States. Some models of service delivery have been successful in suburban and urban settings, but they do not always apply to rural settings. "E-health" innovations like videoconferencing, telephone, secure messaging (e-mail), and the Internet are increasingly being used to provide consultation--liaison service to primary care. This article briefly reviews successful models used in primary care, their application to rural sites, new models for rural sites, and suggestions for future e-health research.

Caring for depressed patients in rural communities: general practitioners' attitudes, needs and relationships with mental health services

OBJECTIVE

To examine the needs and practices of rural GPs and their relationships with local acute mental health services, particularly in the provision of care to depressed patients.

DESIGN

Postal survey.

SETTING

Rural general practices.

SUBJECTS

Ninety-nine GPs (63 males, 36 females) from the Hunter Valley region of NSW, Australia.

MAIN OUTCOME MEASURES

GPs' self-reported contact rates, confidence, needs and beliefs.

RESULTS

Depression was the most commonly seen mental disorder, with an average of 1.44 patients per GP per month referred to local acute mental health services, most commonly for suicidality. The preferred form of feedback after the referral of a depressed patient was a follow-up letter, while the most requested type of patient management support was cognitive behavioural therapy (CBT) groups. GPs were most confident in recognising depression, compared to other mental disorders except anxiety, and they were most confident in treating depression, compared to all other mental disorders. The most common barrier to providing care for depressed patients was reported to be 'time constraints' on GPs.

CONCLUSIONS

The challenge for mental health services is to develop ways to collaborate more effectively with GPs in the provision of psychological services for depressed patients in rural communities.

A systematic review of studies of the cost-effectiveness of mental health consultation-liaison interventions in general hospitals

A systematic review of cost-effectiveness analyses of mental health consultation-liaison interventions in general hospitals was conducted. Few studies have evaluated the cost-effectiveness of consultation-liaison interventions, and only two articles met the criteria for inclusion in the review. The comparable variable was length of the hospital stay. It could not be concluded that psychiatric consultation had an effect on the duration of hospital stays. In one of the studies, the group that received psychiatric consultation showed improvement in depressive symptoms. Additional studies would have been relevant to this review if they had replicated clinical practice by using a naturalistic research design.

Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia

Comparison of integrated and consultation-liaison models for providing mental health care in general practice in New South Wales, Australia The characteristics of a new service providing integrated mental health care in general practice are described and comparisons made with an earlier consultation-liaison (C-L) psychiatry service in general practice, including the range and severity of psychiatric problems, levels of general practitioner (GP) and psychiatrist involvement, and patterns of care. Clinical audit checklists were completed by two experienced mental health nurses for the first 100 patients referred to the service, which was conducted in conjunction with 8 general practices in the Port Stephens region of New South Wales, Australia. The mean age of the first 100 referrals was 38.05 years, 63.0% were female, and 55.0% were referred from GPs. Outcome measures included: referral information, patients' demographic and diagnostic characteristics, psychosocial functioning, psychotropic medication, management, and number of contacts with the mental health nurses. Relative to the earlier C-L psychiatry service in general practice, the integrated service treated a broader range of diagnostic groups with higher levels of disability. There were higher rates of mood (48.0%) and psychotic (20.0%) disorders and lower rates of adjustment (2.0%) disorders. One-third of patients were seen by an additional agency, other than the mental health nurses or GPs. Patients averaged 4.95 contacts with the mental health nurses, with marked variations according to diagnostic group. To date, the new service has been well received. It is highly accessible, acceptable to GPs and patients, caters for a broad range of psychopathology, including severe mental illness, and appears to be sufficiently versatile to be adaptable to a variety of treatment settings.

Alexithymia, hypochondriacal beliefs, and psychological distress among frequent attenders in primary health care

Frequent use of health services has been associated with such concepts as alexithymia, hypochondriasis, and psychological distress. The aim of this case-control study was firstly to assess whether alexithymia, hypochondriasis, and psychological distress are associated with frequent attendance and secondly to assess the gender differences of these associations in a primary health care setting. A sample of 304 frequent attenders (eight or more visits during 1 year), including all of the frequent attenders during 1994, and 304 randomly selected age- and sex-matched controls were selected. Half of the sample (every second individual selected in date-of-birth order) was invited for an interview, 113 frequent attenders and 107 controls completed a questionnaire during the interview. Alexithymia was measured with the Toronto Alexithymia Scale-20 (TAS-20), hypochondriasis was screened with the Whiteley Index (WI), and Symptom Checklist-36 (SCL-36) was used to determine psychological distress. We found a distinct gender difference in the associations of these characteristics with frequent attending. Significant associations of alexithymia, hypochondriasis, and psychological distress with frequent attending were found among men, but not among women. Alexithymia, hypochondriasis, and psychological distress should be considered when treating frequent attenders, especially males.

Rates of treatment of schizophrenia by general practitioners. A pilot study

OBJECTIVE

To investigate how many people with schizophrenia are being treated by general practitioners (GPs) and what the associations are between GP characteristics and the number of patients with schizophrenia in their practice.

DESIGN AND SETTING

Pilot study by postal survey of all GPs in the Hunter/Taree region.

PARTICIPANTS

349 of 495 GPs (70.5%) replied to the survey--245 urban GPs and 104 rural GPs from the Hunter/Taree region of New South Wales.

MAIN OUTCOME MEASURES

GP estimates of the number of patients with schizophrenia currently being treated and by whom.

RESULTS

Three-quarters of the GPs in the region were treating patients with schizophrenia, proportionately more in rural areas (87.5%) than in urban areas (70.2%). The typical GP was treating three patients with schizophrenia, two conjointly with specialist services and one without specialist support. It was estimated that the GP-treated prevalence for schizophrenia is 35.5 per 10,000 adults.

CONCLUSION

Although individual GPs treat a small number of patients with schizophrenia, collectively they treat most of the patients with this disorder. Because schizophrenia has such a high burden of illness for the patient and the community, we need to find suitable mechanisms for evaluating and enhancing the treatment of schizophrenia in general practice.

An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice

OBJECTIVE

This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices.

METHOD

Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments.

RESULTS

Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls.

CONCLUSIONS

The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services.