Consulting psychiatry within an integrated primary care model

Understanding the journey of patients with depression in Brazil: A systematic review

Despite having an organized mental health law and policy, a majority of patients with depression remain underreported and undertreated in Brazil. The study aimed to quantitatively map and identify the deficiencies in patient journey touchpoints in terms of awareness, screening, diagnosis, treatment, adherence, and control for depression in Brazil using a semi-systematic approach highlighting the knowledge gaps in the existing literature. A structured search of Embase, MEDLINE, and BIOSIS databases was conducted to identify the relevant studies published in English, Portuguese, and Spanish from 2006 to 2021. An unstructured search was also conducted on Google or government websites with no restrictions. To address the data gaps, anecdotal data were also considered. Weighted or simple means were calculated for the pooled data. Of 3175 articles retrieved, 10 articles met the inclusion criteria. Synthesized evidence indicates that the pooled prevalence of depression in Brazil ranged from 4.1% to 21.8%; 42.4% of patients had awareness of depression, 37.5% underwent screening, 18.7% had a diagnosis, and 54.4% received treatment. No data on adherence and control were available. The study findings highlight the need for more research to accurately estimate the common patient journey touchpoints for depression to achieve better clinical outcomes in Brazil.

Meta-Analysis of Positive Psychology Interventions on the Treatment of Depression

This meta-analysis examined the efficacy of positive psychology interventions (PPIs) in treating depression in 11 articles. PubMed, Web of Science, and Clinical Key were used to identify papers published from 2010 to 2020 that utilized PPIs. Key terms were “positive psychology” and “treatment of depression.” Studies on adults with (a) depressive symptoms or (b) diagnosed clinical depression were included. A random-effects model was used to compare PPIs and control groups on post- vs. pre-intervention differences in depression scores. Data analysis examined Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), and Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) scores. Findings show PPIs are effective in treating depressive symptoms, with significant improvements in depression scores when compared to control groups in all but one study. This was true for both post- vs. pre-intervention (pooled Cohen’s d = −0.44 (−0.77, −0.11)) and follow-up- vs. pre-intervention analyses (pooled Cohen’s d = −0.46 (−1.02, 0.09)). PPIs can improve the accessibility and affordability of depression treatments.

Coordinating Systems of Care for HIV and Opioid Use Disorder: A Systematic Review of Enablers and Barriers to Integrated Service Access, and Systems and Tools Required for Implementation

Individuals who have HIV who also use drugs experience increased age-matched morbidity and mortality in comparison with those with HIV who do not use drugs. A systematic review was conducted to describe models of integrated HIV and opioid use disorder (OUD) services, enablers of and barriers to integrated service access, and the coordinated systems and tools at the state and service delivery levels required for implementation. Database searches yielded 235 candidate articles, of which 22 studies met the inclusion criteria. Analysis found that integrated programs operated with minimal coordinated policy and systems guidance at the state level. Service delivery systems and tools used for integration, including use of integrated protocols, risk assessment tools, case management tools, and referral systems, were similar across integration models. Concerted efforts to coordinate state-level systems and develop supportive policies, guidelines, and standardized tools may facilitate integration at the service delivery level.

Pediatric Mental Health and the Power of Primary Care: Practical Approaches and Validating Challenges

INTRODUCTION

With over 300 school shootings in the past 5 years, the unprecedented use of online social media, and the growing demands of academia, mental illness is quickly becoming one of the top causes of morbidity and mortality in the pediatric population. In the past year, 90% of children in the U.S. visited their pediatric primary care provider (PCP), giving PCPs a unique opportunity to address the mental health needs of their patients.

METHODS

The author conducted a comprehensive review of the literature.

RESULTS

This clinical paper seeks to validate the mental health competency of pediatric PCPs, identifies current challenges, and outlines practical approaches to care.

DISCUSSION

The consequences of untreated pediatric mental illness are indisputable. Pediatric PCPs have an obligation to address the growing pediatric mental health crisis directly. By utilizing standardized screening tools, referring to established clinical guidelines, seeking continuing education, and developing a comprehensive list of available resources, pediatric PCPs can incorporate mental health care into primary care.

Integrated Care: Should It Count as Community Psychiatry Training for Psychiatry Residents?

Psychiatry residents are required to be exposed to community psychiatry. Historically, this occurred in public hospitals or assertive community treatment (ACT) teams. A new model of psychiatric care delivery, integrated care, has become prevalent. While integrated care shares some features with traditional community psychiatry rotations, no research exists to demonstrate if integrated care rotations can accomplish the aims of traditional rotations. This pilot study compared learning outcomes in ACT team rotations versus integrated care rotations. Pre- and post-rotation surveys were disseminated to third-year psychiatry residents (N = 8) who were randomized to complete a rotation with an ACT team or an integrated care team. By rotation end, many in both settings changed how conservative they were in treatment philosophies, but this did not result in a difference between groups. Residents in both groups were satisfied with their rotations. Training in integrated care may be a reasonable alternative to traditional community psychiatry rotations.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population

OBJECTIVE

In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity.

METHODS

We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language.

RESULTS

Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits.

CONCLUSIONS

Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

Primary care consultation liaison and the rate of psychiatric hospitalizations: a countrywide study in Chile

Objectives

To assess the quality of consultation liaison across all primary health care centers in Chile, and its potential relationship with the psychiatric hospitalization rate.

Methods

We carried out a countrywide ecological cross-sectional study on 502 primary health centers in 275 municipalities (87.3% of total primary health centers in Chile) during 2009. We characterized the presence of consultation liaison using four criteria: availability, frequency, continuity of participants, and continuity across care levels. We also created a dichotomous variable called “optimal consultation liaison” for when all four criteria were met. A quasi-Poisson regression model was used to estimate the rate of hospitalization due to different psychiatric disorders, adjusting by population attributes.

Results

Of the primary health centers, 28.3% of them had had optimal consultation liaison during the preceding year, concentrated in the poorest and richest municipalities. Continuity of care was the criterion that was met least often (38.3%). The presence of optimal consultation liaison at the municipal level was associated with fewer psychiatric discharges, with the following incidence rate ratios and 95% confidence intervals (CIs): schizophrenia, 0.65 (95% CI: 0.49–0.85); other psychoses, 0.68 (95% CI: 0.52–0.89); and personality disorders, 0.66 (95% CI: 0. 49–0.89). Municipalities with optimal consultation liaison showed 2.44 fewer total psychiatric discharges per 10 000 inhabitants, although without reaching statistical significance (-0.85 to 5.70).

Conclusions

Using a nationally representative sample, we found that consultation liaison in primary care was associated with having fewer psychiatric hospitalizations. More studies are required to understand the role of each component of consultation liaison.

Better care through an optimized mental health services continuum (Eastern Townships, Québec, Canada): A systematic and multisource literature review

INTRODUCTION

In 2014, the health authorities of the Eastern Townships (Québec, Canada) commissioned an evaluation of the mental health admission system for adults (GASMA) to identify the best GASMA organizational or structural elements and optimize the mental health services continuum.

METHODS

To develop better services, seven indicators (ie, accessibility to services, integration of levels of services, user satisfaction, guidance and management time, evaluation tools, professional composition, and interprofessional collaboration) were examined through four evaluation questions. A three-step systematic and multisource evaluation was realized. A systematic review of the scientific and gray literature was performed. This evaluation also included key informant opinions to contextualize results from this review.

RESULTS

Results from 91 scientific articles, 40 gray literature documents, and 10 interviews highlighted determinants and barriers associated with the examined indicators. From these results, 24 preliminary recommendations were formulated and discussed in a steering committee. These recommendations were then weighted and validated. This served to formulate three final recommendations.

CONCLUSION

To optimize the regional mental health services continuum, stakeholders should (1) implement a single-window access for adults with mental health needs, (2) develop alternative services based on users' needs, and (3) test the effectiveness of new methods, initiatives, and tools.

Cupping therapy in Saudi Arabia: from control to integration

Cupping therapy or Hijamah is a leading traditional practice after spiritual healings and herbal medicine in Saudi Arabia. Wet cupping is by far the most common type of cupping therapy. Hijamah in Saudi Arabia and other Muslim countries is a model of religious influences, interconnectivity, and cross-cultural influences between different civilizations. Accordingly, differentiating the cupping practiced in Saudi Arabia, and other Muslims societies from that practiced in other countries like China, by Korea only by the technique or cupping sites is an underestimation of the differences. In Saudi Arabia, the profile or characteristics of cupping therapy user is distinct from the profile of other traditional medicine users by being more educated, with higher job rank and not affected by nationality or gender. After an era of unregulated practice, cupping therapy is currently regulated and monitored by the National Center for Complementary and Alternative Medicine in the Ministry of Health (NCCAM/MOH) of Saudi Arabia. Regulations and licensing include practitioners, practice place, and cupping equipment. After regulation, cupping is mainly offered by the private sector and paid directly by the client as insurance does not cover it. In the private sector, licensed cupping service is usually provided as a parallel and not an integrated service. However, there are few models of integrated cupping clinic in universities, academic institutions, and governmental hospitals. Further health system research is needed to develop more models of integrated cupping service pending for the healthcare transformation which is going on in Saudi Arabia.

Meeting the Mental Health Needs of the Homebound: A Psychiatric Consult Service Within a Home-Based Primary Care Program

The growing population of homebound adults increasingly receives home-based primary care (HBPC) services. These patients are predominantly frail older adults who are homebound because of multiple medical comorbidities, yet they often also have psychiatric diagnoses requiring mental health care. Unfortunately, in-home psychiatric services are rarely available to homebound patients. To address unmet psychiatric need among the homebound patients enrolled in our large academic HBPC program, we piloted a psychiatric in-home consultation service. During our 16-month pilot, 10% of all enrolled HBPC patients were referred for and received psychiatric consultation. Depression and anxiety were among the most common reasons for referral. To better meet patients' medical and psychiatric needs, HBPC programs need to consider strategies to incorporate psychiatric services into their routine care plans.

GPs' and child and adolescent psychiatry specialists' experiences of joint consultations in the GP's office: a qualitative study

Background

The study is an exploration of a joint consultation model, a collaboration between general practitioners (GPs) and specialists from child and adolescent mental health services (CAMHS) in Lillehammer, Norway.

Methods

A qualitative study based on two focus group interviews, one with participating GPs and one with participating specialists from the local CAMHS. Participants were five GPs, with work experience varying from 6 months to 20 years (four of them specialists in general medicine) and two CAMHS specialists—a psychiatrist and a psychologist—both with more than 20 years of experience.

Results

The focus group discussions revealed that both GPs and CAMHS specialists saw the joint consultations as a good teaching method for improving GPs’ skills in child and adolescent psychiatry. Both groups believed that this low-threshold service benefits the patients and that the joint consultation is especially suited to sort problems and determine the level of help required.

Conclusions

The GPs and CAMHS specialists shared the impression that the collaboration model is beneficial for both patients and health care providers. Close collaboration with primary health care is recommended in the guidelines for child and adolescent psychiatry outpatient clinics. We suggest that the joint consultation model could be a good way for GPs and CAMHS specialists to collaborate.

Managing common mental health problems: contrasting views of primary care physicians and psychiatrists

BACKGROUND

Recent studies have reported a lack of collaboration and consensus between primary care physicians (PCPs) and psychiatrists.

OBJECTIVE

To compare the views of PCPs and psychiatrists on managing common mental health problems in primary care.

METHODS

Four focus group interviews were conducted to explore the in-depth opinions of PCPs and psychiatrists in Hong Kong. The acceptance towards the proposed collaborative strategies from the focus groups were investigated in a questionnaire survey with data from 516 PCPs and 83 psychiatrists working in public and private sectors.

RESULTS

In the focus groups, the PCPs explained that several follow-up sessions to build up trust and enable the patients to accept their mental health problems were often needed before making referrals. Although some PCPs felt capable of managing common mental health problems, they had limited choices of psychiatric drugs to prescribe. Some public PCPs experienced the benefits of collaborative care, but most private PCPs perceived limited support from psychiatrists. The survey showed that around 90% of PCPs and public psychiatrists supported setting up an agreed protocol of care, management of common mental health problems by PCPs, and discharging stabilized patients to primary care. However, only around 54-67% of private psychiatrists supported different components of these strategies. Besides, less than half of the psychiatrists agreed with setting up a support hotline for the PCPs to consult them.

CONCLUSIONS

The majority of PCPs and psychiatrists support management of common mental health problems in primary care, but there is significantly less support from the private psychiatrists.