Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center

OBJECTIVES

The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital.

DESIGN

We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals.

SETTING

An urban safety-net hospital ICU.

PATIENTS

All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories.

CONCLUSIONS

Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

A cascade of care for alcohol use disorder: Using 2015-2019 National Survey on Drug Use and Health data to identify gaps in past 12-month care

BACKGROUND

Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care for persons with AUD.

METHODS

Using 2015-2019 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: (1) adult prevalence of AUD; (2) proportion of adults with AUD who utilized health care in the past 12 months; (3) proportion with AUD screened about their alcohol use; (4) proportion with AUD who received a brief intervention about their alcohol misuse; (5) proportion with AUD who received information about treatment for alcohol misuse; and (6) proportion with AUD who received treatment. Analyses were stratified by AUD severity.

RESULTS

Of the 214,505 persons included in the sample, the weighted prevalence of AUD was 7.8% (95% CI 7.6-8.0%). Cascades of care showed the majority of individuals with AUD utilized health care in the past 12 months [81.4% (95% CI 80.7-82.1%)] and were screened about alcohol use [69.9% (95% CI 68.9-70.8%)]. However, only a minority of individuals received subsequent steps of care, including 11.6% (95% CI 11.0-12.2%) who reported receiving a brief intervention, 5.1% (95% CI 4.6-5.6%) who were referred to treatment, and 5.8% (95% CI 5.4-6.3%) who received treatment. Similar patterns were observed when cascades of care were stratified by AUD severity.

CONCLUSIONS

Persons with AUD commonly utilize health care and are often screened about alcohol use, but few receive treatment. Healthcare settings-particularly primary care settings-represent a prime opportunity to implement AUD treatment to improve outcomes in this high-risk population.

[The COVID-19 psychological helpline of the Spanish Ministry of Health and Spanish Psychological Association: characteristics and demand.]

Between March and May 2020, the Spanish Ministry of Health and the Spanish Psychological Association created the Psychological First Care Service (Servicio de Primera Ayuda Psicológica-SPAP), a national helpline designed to provide early psychological intervention to those people affected by COVID-19. This service attended more than 15,000 calls and carried out more than 11,000 interventions and 9,500 follow-ups with the general population, healthcare and other essential professionals and the patients and relatives of the sick or deceased. Results show that the majority of calls (45.7%) came from the Autonomous Community of Madrid, that women significantly used this service in a higher proportion than men (73.5%) and that the commonest age range among users was 40-59. 75.9% of consultations were related to psychological problems linked to anxiety and depressive symptoms. However, grief symptoms also stood out among the patients or relatives of the sick and deceased and, to a lesser extent, stress symptoms were prevalent in the group of professionals. These data show the usefulness of this early psychological care service and the need for similar resources to be implemented in coordination with or within the National Health System.

Mobile crisis team in the Brussels region: facts and figures

BACKGROUND

A reformation of psychiatry was set up in Belgium with the establishment of mobile crisis teams.

SUBJECTS AND METHODS

We performed a retrospective analysis of the patients referred to the mobile team "Pharos" in the period between December 2013 and December 2018.

RESULTS

The number of patients is growing over the years and the most common referral reasons are suicidal thoughts and depressive mood. We have a high percentage of inclusions, maybe because the main referrers are GPs. Alcohol withdrawal at home is feasable and safe.

CONCLUSION

Many psychiatric crisis situations can be managed at home with support of mobile teams, but further research is needed to provide evidence on outcome and cost effectiveness.

Crisis support-seeking behavior and temperature in the United States: Is there an association in young adults and adolescents?

BACKGROUND

Mounting evidence demonstrates the relationship between high temperatures and adverse mental health outcomes. Yet, no study has examined the influence of temperature on crisis support-seeking behavior among youth in large urban areas.

METHODS

Crisis Text Line (CTL) is a text messaging service that provides crisis interventions for support-seeking individuals for a range of mental-health outcomes in the United States. We applied a distributed lag non-linear modeling technique to assess the short-term impacts of daily maximum and minimum temperature on crisis-related events in four metropolitan locations in the USA.

RESULTS

There were multiple positive associations in three of the four study locations that demonstrate crisis help-seeking behavior increased during anomalously warm conditions.

CONCLUSIONS

This study suggests that there is a significant association between high minimum or maximum temperatures and crisis help-seeking behaviors in young adults and adolescents in urban areas in the United States.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel

BACKGROUND

Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events.

METHODS

Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques.

RESULTS

212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts.

CONCLUSIONS

The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

The Need for New Emphasis on Batterers Intervention Programs

Although Batterers' Intervention Programs (BIPs) remain a crucial part of victim safety and coordinated community responses, they have received less support and less attention by scholars than other parts of the domestic violence system. Research on BIPs also suggests that they have not been particularly effective at preventing recidivism, are prone to attrition, and increasingly lack the support and confidence of the courts. Nevertheless, BIPs remain one of the few viable alternatives to incarceration for perpetrators of domestic violence. This article examines the historical and empirical reasons for the apparent lack of effectiveness of BIPs. New research suggests avenues for improvement. This begins with incorporating existing research findings, consistency in implementation of best practice models, better diagnosis of personality characteristics of perpetrators and of types of violence that characterize their relationships as well as better funding and support for research. In addition, differentiated treatment approaches tailored to the abuser and their particular types of violence may hold promise-and require increased support by the research and practice communities.

[Suicide in France, a situational analysis]

The fall in the number of suicides in France in no way diminishes the urgent need to act and reinforce the efforts, initiatives and resources to fight against this human tragedy. Public policies are starting to show results. The action of the French national suicide watch, associations, health professionals as well as the perspectives of the French national mental health council should amplify this movement.

The experiences of frequent users of crisis helplines: A qualitative interview study

OBJECTIVE

To understand why some users call crisis helplines frequently.

METHODS

Nineteen semi-structured telephone interviews were conducted with callers to Lifeline Australia who reported calling 20 times or more in the past month and provided informed consent. Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was used to generate common themes. Approval was granted by The University of Melbourne Human Research Ethics Committee.

RESULTS

Three overarching themes emerged from the data and included reasons for calling, service response and calling behaviours. Respondents called seeking someone to talk to, help with their mental health issues and assistance with negative life events. When they called, they found short-term benefits in the unrestricted support offered by the helpline. Over time they called about similar issues and described reactive, support-seeking and dependent calling behaviours.

CONCLUSION

Frequent users of crisis helplines call about ongoing issues. They have developed distinctive calling behaviours which appear to occur through an interaction between their reasons for calling and the response they receive from the helpline.

PRACTICE IMPLICATIONS

The ongoing nature of the issues prompting frequent users to call suggests that a service model that includes a continuity of care component may be more efficient in meeting their needs.

[Do individuals with substance use disorders find information for crisis intervention and suicide prevention resources on the Internet?]

BACKGROUND AND OBJECTIVE

Suicidality is an important issue for substance-dependent people. The few studies about Internet searches have provided ambiguous results regarding help and support using suicide-related terms.

MATERIAL AND METHODS

Five popular search engines and several substance use- and suicide-related German search terms were used; the search results were classified as being pro-suicide, anti-suicide, suicide-neutral, websites not associated with suicide or "page could not be loaded".

RESULTS

The majority of identified websites was not associated with suicide at all, whereas websites offering help and support were less frequent. Using suicide-associated search terms (such as "Selbsttötung") almost half of all web pages were help sites. Websites with instructions for committing suicide were very rarely found.

CONCLUSIONS

In view of the difficulties for substance abusers to get immediate and adequate information about help and support in a suicidal crisis via the Internet, it is urgently necessary to extend fast available help sites on the Internet.

Examining the nexus between domestic violence and animal abuse in a national sample of service providers

Companion animals play a complex role in families impacted by violence. An outlet of emotional support for victims, the family pet often becomes a target for physical abuse. Results from a comprehensive e-survey of domestic violence shelters nationwide (N = 767) highlight both improvements and existing gaps in service provision for domestic violence victims and their pets. Quantitative and qualitative data noted frequently encountered obstacles to successful shelter seeking by abuse victims with companion animals including a lack of availability, funding, space, and reliable programming. Although results indicate an overall improvement in organizational awareness, fewer than half of surveyed shelters include intake questions about animals. Continued awareness and an expansion of services is needed to create viable safety planning strategies and reliable alternatives for women with companion animals in order to improve the likelihood that abuse victims will seek escape and refuge for themselves, their children, and their pets.

Awareness and utilization of peer support programs in Singapore public general hospitals

To address the effects of acute, chronic and cumulative stress in the healthcare environment in Singapore, the Ministry of Health provided funding to develop a comprehensive crisis response management system (peer support programs/PSPs) that increases mental health awareness, provides emotional support to affected staff during work-related critical incidents and assists hospital management to better understand the emotional needs of the employees. This paper reports the awareness and utilization of PSPs in Singapore public general hospitals about one year after they were set up.

Alternative work and world. Chronicity of emergencies and the work in crisis unit

We describe the legal framework within which we carry out consultations, otherwise called expertises, with view to considering involuntary admissions to hospital for the treatment of mental illness (here called confinements). We note that in our area only 40% of consultations lead to involuntary admissions to hospital, and we believe that this number is related to our consideration of alternative methods of care in the community. We suggest a multi-centric study to evaluate what specific skills are required to properly carry out these assessments and to establish the extent to which the increased workload of assessments is influencing the rate of involuntary admissions.

Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001

OBJECTIVE

To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001.

METHOD

Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center.

RESULTS

In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications.

CONCLUSIONS

In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.

Mobile crisis team intervention to enhance linkage of discharged suicidal emergency department patients to outpatient psychiatric services: a randomized controlled trial

OBJECTIVES

Many suicidal patients treated and released from emergency departments (ED) fail to follow through with subsequent outpatient psychiatric appointments, often presenting back for repeat ED services. Thus, the authors sought to determine whether a mobile crisis team (MCT) intervention would be more effective than standard referral to a hospital-based clinic as a means of establishing near-term clinical contact after ED discharge. This objective was based on the premise that increased attendance at the first outpatient mental health appointment would initiate an ongoing treatment course, with subsequent differential improvements in psychiatric symptoms and functioning for patients successfully linked to care.

METHODS

In a rater-blinded, randomized controlled trial, 120 participants who were evaluated for suicidal thoughts, plans, or behaviors, and who were subsequently discharged from an urban ED, were randomized to follow-up either in the community via a MCT or at an outpatient mental health clinic (OPC). Both MCTs and OPCs offered the same structured array of clinical services and referral options.

RESULTS

Successful first clinical contact after ED discharge (here described as "linkage" to care) occurred in 39 of 56 (69.6%) participants randomized to the MCT versus 19 of 64 (29.6%) to the OPC (relative risk = 2.35, 95% CI = 1.55-3.56, p < 0.001). However, we detected no significant differences between groups using intention-to-treat analyses in symptom or functional outcome measures, at either 2 weeks or 3 months after enrollment. We also found no significant differences in outcomes between participants who did attend their first prescribed appointment via MCT or OPC versus those who did not. However divided (MCT vs. OPC, present at first appointment vs. no show), groups showed significant improvements but maintained clinically significant levels of dysfunction and continued to rely on ED services at a similar rate in the 6 months after study enrollment.

CONCLUSIONS

Community-based mobile outreach was a highly effective method of contacting suicidal patients who were discharged from the ED. However, establishing initial postdischarge contact in the community versus the clinic did not prove more effective at enhancing symptomatic or functional outcomes, nor did successful linkage with outpatient psychiatric care. Overall, participants showed some improvement shortly after ED discharge regardless of outpatient clinical contact, but nonetheless remained significantly symptomatic and at risk for repeated ED presentations.

[Community-based crisis home programme. Cost-efficient alternative to psychiatric hospitalization]

BACKGROUND

Over recent decades, institutional psychiatric care has shifted its focus from traditional inpatient treatment to a variety of more advanced outpatient services. Within this context, a new "crisis home" programme (CHP) was launched in Zurich on 1 January 2005. With this programme, mentally ill patients can avoid hospitalization by living with a host family for a certain time period while receiving standard outpatient care. In this study we addressed the question of whether the quite substantial financial advantages of the Zurich CHP over traditional inpatient care are achieved at the expense of a reduced quality of care.

SAMPLE AND METHODS

Between 1 January 2005 and 30 June 2007, a total of 33 patients enrolled in the Zurich CHP with an average stay of 19 days at host families. The vast majority of the patients (85%) were moderately to severely ill at study entry. Of these patients data were collected in a standardized way on the basis of five rating instruments. The statistical data analysis included cross-comparisons with corresponding inpatient data.

RESULTS

Results showed that (1) the CHP works well in a routine setting and provides cost-efficient interventions for patients in acute crises; (2) the financial advantages of the Zurich host family programme over traditional inpatient care do not lead to a reduced quality in patient care; (3) patients suffering from severe mental illnesses clearly benefit from this programme, thus avoiding hospitalization.

CONCLUSIONS

The Zurich CHP is a cost-efficient alternative to traditional inpatient treatment. Specifically, our results suggest that this type of acute crisis intervention should be established as a standard psychiatric care service.

[Couples and families emergency/crisis consultation: emergency patterns and treatment assessment]

Since the opening in 2003 of the Couple & Family Consultation Unit (UCCF) at Prangins Hospital, we have met urgent demands and observed that the suffering systems (i.e., couples and families) couldn't face any waiting period. So in 2007 an Emergency/Crisis Facility was created, based on the hypothesis that there is no contra-indication to systemic emergency care, if one understands and structures both crisis and treatment. We studied the suffering population in demand and the emergency/crisis issues and assessed therapy efficiency. Then we observed that treating suffering systems in emergency does produce therapeutic gain in terms of crisis resolution and patients' satisfaction. Those treatments refer to public health issues, as considered the human, social and financial cost of couples/families dysfunctions.

[Psychological support for road accident participants: the program implementation outcome]

Road accident belongs to one of the categories of traumatic events, and can cause posttraumatic stress disorder (PTSD). The most common psychological consequences of road traffic accidents are the emotional disorders, cognitive deficits (disorders concentration of attention and memory function), impaired social relationships, troubles with performing work duties and physical symp-toms of stress. The article discusses the program of psychological support given to the participants of road accidents, conducted in Wroclaw, its theoretical assumptions and the mode of its implementation. Basic theoretical assumptions of the program are inter alia based on the theories of H. Selye and R. Lazarus. The authors of this article also refer to the so-called therapeutic process of education designed by Everly and Rosenfeld, who recommend that the process of developing self-responsibility be used for therapeutic purposes. This requires clarifying the exact nature of the problem, and then looking for possible remedies. The program is open to all road accident participants (victims, perpetrators, witnesses) and their families. Classes are designed to combine theory (lectures) and practice (exercises). Anxiety and cognitive processes, as well as relaxation training, interpersonal training (eg, assertiveness) and kinesiology are the major areas of activities. Psychological support provided for road accident participants is of intervention--and preventive nature; intervention, as it relates to the consequences ofa specific stressogenic event, namely a road accident; preventive, as it serves the overriding purpose--the improvement of road safety. This article presents the main findings of the program, the results of the survey evaluation, and proposals to develop psychological operations aimed at the road accidents participants.

[Time-limits on collaboration between the emergency mental health services and the police: a practice-based evaluation in the City of Utrecht, the Netherlands]

National and regional agreements have been reached with regard to time-limits on collaboration between the emergency mental health services and the police. On the basis of 69 emergency cases attended by both the crisis-team and the police in Utrecht, we investigated whether the time-limits had been observed in that city. Of the cases 85% were dealt with adequately within 6 hours (in accordance with the national guideline and 20% within 2 hours (regional norm). The average time needed to reach an emergency case was 1 hour 35 minutes, but was longer when the emergency resulted from substance abuse. The average time required for case-assessment was 1 hour 25 minutes and was longer in cases requiring compulsory detention and in cases involving manic behaviour.

[Changes in crisis intervention and emergency psychiatry, Amsterdam emergency consultations in 1983 and 2005]

BACKGROUND

Since 1992 The Netherlands has seen a striking increase in the number of compulsory admissions. There is a danger that coercion will become the dominant form of treatment in the Amsterdam clinics.

AIM

To build up a picture of the changes in emergency psychiatry which have contributed to the increase in the number of acute compulsory admissions.

METHOD

A cohort (n = 460) of consultations conducted by the city crisis service in 1983 was compared with a similar cohort (n = 436) of consultations conducted in 2004-2005 based on the following variables: crisis-service procedures, patient characteristics, diagnosis and consultation outcomes.

RESULTS

In 2003-2004 more services were involved with psychiatric patients in acute situations in the public domain than were involved in 1983. The number of patients referred by the police almost doubled, rising from 29.3 to 62.7%. In 1983 all consultations took place where the patients were located; in 2004-2005 60% took place at the premises of the crisis service. The number of psychotic patients in the cohort rose from 52 to 63.3%. There was a rise in the number of compulsory admissions (from 16.7 to 20%) and a sharp decline in voluntary admissions (from 25.7 to 7.6%). The total number of admissions following a consultation decreased from 42 to 28%.

CONCLUSIONS

The front-line outreach service of 1983 has been transformed into a specialist psychiatric emergency department with only a modest outreach component. Voluntary admissions via the consultation service have almost ceased. Further research is needed into the characteristics of the consultations and into the variables that play a role in the use of compulsion in emergency psychiatry.

The domestic violence home-visit intervention: impact on police-reported incidents of repeat violence over 12 months

The domestic violence home-visit intervention (DVHVI) provides home visits by police-advocate teams within 72-hours of domestic incident to provide safety, psychoeducation, mental health, legal, or additional police assistance. Clinical and police record data were collected for 512 cases, and repeat calls to the police were tracked for 12 months. Analyses revealed that women who engaged with the DVHVI were more likely to contact the police for subsequent events than those who received no or minimal DVHVI contact. Hispanic women served by Spanish-speaking advocate-officer teams were the most likely to utilize services and call the police for subsequent incidents.

Community emergency psychiatric service in Israel: a one-year experience

BACKGROUND

In 2005 the Forensic Psychiatry Department of Mental Health Services at the Ministry of Health launched a pilot project: the Community Emergency Psychiatric Service (CEPS). The purpose was to offer community-based emergency response to acute psychiatric conditions during after-hours periods, including Saturdays and holidays. The project was implemented in the Tel Aviv, Central and Southern districts.

METHOD

Advertisements were posted in mass circulating newspapers announcing the launching of the new program for the general public in the participating districts. The public was invited to call the hotline of the medical emergency service, Magen David Adom (MDA), in the event of psychiatric distress or emergency. MDA personnel were instructed to give the callers a telephone number of an on-call psychiatrist. The Ministry of Health engaged a pool of seven licensed psychiatrists to be available on-call one per shift. The psychiatrists offered crisis intervention over the phone or house visits when necessary.

RESULTS

Data were obtained from the Tel Aviv, Central and Southern Districts. The results show that there were 1,472 calls between May 2005 and June 2006. In 198 cases (13.5%) clients were referred for treatment and follow-up to local outpatient clinics, while in 116 of the cases (7.8%) a home visit by the on-call psychiatrist was carried out, resulting in 50 voluntary and 16 involuntary hospitalizations. An examination of records of calls received by the on-call psychiatrists (N=97) during August 2006 suggests that most callers fit the following profile: female, ranging in age 19-35, unmarried, with diagnosis of schizophrenia, with no previous psychiatric hospitalizations, and presenting no danger to herself or others.

CONCLUSIONS

A limited response team, comprised of one on-call psychiatrist per shift, can provide a viable service for psychiatric emergencies in a population center of approximately 2.7 million. The findings also suggest that such a service may increase the number of referrals to outpatient clinics in the community as well as the number of voluntary and involuntary hospitalizations after working hours. The potential contribution of such a project to improving accessibility to outpatient psychiatric care and to reinforcing continuity of care among in- and out-patient facilities needs further investigation as is the important question of cost-effectiveness.

[Efficacy of the emergency unit's filter function in patients with psychiatric symptoms]

The fundamental functions of the recently established emergency units/departments include the initial assessment, triage, commencement of treatment and referral for admission to the hospital.

AIM

The aim of the study was to analyze psychiatric cases assessed at the department of emergency with particular reference to misdiagnoses and the reasons why emergency physicians failed to reach correct diagnoses.

METHOD

This is a chart review of patients with psychiatric diagnoses evaluated at the Department of Emergency, Mohács City Hospital during 2006. These patients were followed through the electronic database of the hospital and their socio-demographic and clinical characteristics were analyzed.

RESULTS

Of the 596 patients who were considered primarily psychiatric cases during 2006, 289 (49%) were admitted to the psychiatric ward, 182 (30%) were referred to outpatient treatment, and 125 (21%) were misdiagnosed and proved to be non-psychiatric emergencies and eventually ended up in other wards (75 patients in internal medicine, 20 in neurology, 12 in intensive care, and 18 in other units).

CONCLUSION

Overall, the diagnostic and triage functions of the department of emergency were satisfactory in psychiatric cases. Medical emergencies that were frequently mistaken for psychiatric cases (e.g. atypical pneumonia, sensory aphasia) deserve particular attention. The authors emphasize the importance of the close collaboration of different medical areas involved in emergency assessment and treatment.

Ambulatory care provision versus first admission to psychiatric hospital: 5 years follow up

OBJECTIVE

Ambulatory care for subjects with severe mental problems has been clearly shown to be a valid alternative to hospitalisation. However, very few studies have considered the fate of patients over several years. Ambulatory care services are often experimental set-ups, for small groups, and their impact on subsequent treatment has only been assessed over the first few months of treatment. The value of developing this practice therefore remains unclear. We investigated the possible consequences of generalising ambulatory care services by a mobile crisis intervention team (ERIC) to all requests for the first hospitalisation in a psychiatric department. The principal aim was to determine whether systemic intervention by the crisis intervention team could provide a true alternative to hospitalisation. We also investigated whether problem-resolving approaches and ambulatory care led, in the long term, to fewer prolonged or repeated periods of hospitalisation than practices in which hospitalisation was considered as an ordinary solution.

METHODS

We carried out a prospective, comparative, cohort study over a 5-year period beginning with the creation of ERIC by one of the hospital departments. All patients arriving at this department for the first time were offered immediate ambulatory care by this team for 1 month. Their hospitalisation record (duration of hospital stay, number of days in hospital) was compared with that of subjects hospitalised in the same conditions but in other departments of the hospital.

RESULTS

This study included most of the subjects referred for the first time to the psychiatric hospital, in our department. Regardless of their diagnosis, intensive follow-up at home, based on systemic crisis intervention work, was found to be an effective and well-accepted alternative to hospitalisation. Indeed, a highly significant immediate decrease in both the number of admissions and the duration of hospital stay was observed for the experimental group, with no subsequent increase in the number of days of hospitalisation. From the second year onwards, the use of hospitalisation did not seem to be influenced by the type of care initially given to the patient. Rehospitalisation was rare in both groups. One third of the patients in the experimental group benefited from another intervention of the ambulatory emergency team from the second year onwards, highlighting the value placed on this type of care by the patients and their families.

CONCLUSION

Our results support the development of ambulatory crisis intervention services, including those from psychiatric hospitals. Clinical studies following the treatment paths of patients in a more exhaustive manner would almost certainly distinguish more precisely between the "natural" course of the disease and the impact of the care provided. In any case, the prevention of hospitalisation must be based as much on a possible alternative at the time of the crisis as on subsequent access to ambulatory care.

Post-trauma support in the workplace: the current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK

Employers' duties of care under both common and statute law include the need to take reasonable care of the health and safety of the workforce. This includes both the moral and legal duties to consider the psychological needs of personnel following exposure to traumatic events related to the workplace. While this has been recognized within many high-risk occupations such the police, fire and rescue services and the military, there is also evidence that post-trauma support in the workplace is increasingly commonly provided not only among health and social services agencies, but within many private sector organizations. Over the past decade, however, there has been considerable controversy over the provision of early psychological support to personnel in the form of critical incident stress management (CISM) processes. In particular, one aspect of CISM, the use of psychological debriefing (PD) has come under scrutiny and criticism as two studies indicated that PD was ineffective and had the potential to do harm. Inevitably, this has provoked much uncertainty and confusion among some organizations as what should be the most appropriate support. It has also led to misconceptions and misunderstandings as to the aims and purpose of PD, together with inaccuracies of terminology, for example describing PD as 'counselling'. Despite the controversy, both CISM and PD continue to be provided on a widespread basis, often utilizing a framework of voluntary peer group support. This paper intends to (i) present a review of the current status of CISM practices, including the use of PD within various organizations in the UK and (ii) provide a clear framework and understanding of the main issues and to clarify conceptual misunderstandings. The history, principles and background of the use of post-trauma support in the workplace, charting trends over the past two decades, previous research, problems with the evidence base and current thinking and practice in the field are reviewed. The relevance and implications of the National Institute for Clinical Excellence Guidelines on the Assessment and Management of Post Traumatic Stress Disorder, which make recommendations for early interventions for post-traumatic stress disorder are discussed. Reference is made to the use of CISM and PD within both statutory and voluntary organizations in an international context.

Management of mental health patients attending Victorian emergency departments

OBJECTIVE

To evaluate the management of mental health presentations to Victorian emergency departments.

METHOD

An observational study in five Victorian emergency departments (four metropolitan and one regional). All patients with an ICD-10 discharge diagnosis for a predetermined mental health disorder were included. Data were collected on patient demographics, presentation, clinical management (emergency and mental health) and disposition.

RESULTS

There were 3702 patients enrolled (96.0% of all mental health presentations). At presentation 39.1% were intoxicated and 39.9% arrived by ambulance, 17.6% with the police. There was a significant variation (p <0.001) between sites for: the median time to be seen by a clinician (14 vs 43 min), the time between referral to and review by mental health services (15 vs 50 min), the median time in the emergency department (208 min vs 380 min), the proportion who spent >24 h in the emergency department (0.0% vs 11.6%) and disposition (proportion discharged home from ED 49.8% vs 63.5%).

CONCLUSION

Important variations were identified in the management of patients with mental health presentations to Victorian emergency departments. This variation is most likely due to differing access to resources. All levels of administration must work with carers and patients to ensure that optimal patient care is provided at every site.

Assertive community treatment in the Netherlands: a randomized controlled trial

OBJECTIVE

Assertive community treatment is rapidly implemented by many European mental health services, but recently the evidence base has been questioned. Positive results of randomized trials in the USA were not replicated in the UK. The question is whether the UK findings are representative for other European countries with modern mental health services.

METHOD

Open randomized controlled trial of long-term severely mentally ill patients [Health of the Nation Outcome Scales (HoNOS) total score >or=15], assigned to assertive community treatment (n = 59) or to standard community mental health care (n = 59).

PRIMARY OUTCOME

sustained contact; housing stability and admission days. This trial is registered as an International Standard Randomized Clinical Trial, number ISRCTN 11281756.

RESULTS

Assertive community treatment was significantly better in sustaining contact with patients, but not in reducing admission days. No differences in housing stability, psychopathology, social functioning or quality of life were found.

CONCLUSION

The results are in agreement with UK studies. However, the sustained contact potential of assertive community treatment is important, as too many patients are lost in standard care.

Differential characteristics of intimate partner, acquaintance, and stranger rape survivors examined by a Sexual Assault Nurse Examiner (SANE)

Relatively little is known about characteristics of sexual assault survivors who present to the emergency room. Examination of differences in survivor, assault, and exam characteristics by type of offender (intimate partner, acquaintance, acquaintance-just-met, and stranger) was conducted using intake data collected from 331 women who presented to an emergency room and were examined by a Sexual Assault Nurse Examiner between 2001 and 2004. First, the data suggest there is a difference in injury patterns depending on the survivor-offender relationship. Second, there was a high rate of women assaulted by a known offender presenting to the emergency room. Third, there are important differences in survivor substance use among women assaulted by different offenders. Implications for research and practice are discussed.

Impact of support initiatives on retaining rural general practitioners

OBJECTIVE

This study aimed to evaluate the impact of the Dr DOC program, a rural doctor workforce support program, which consists of social and psychological support and practical interventions, on the well-being and retention of rural GPs.

DESIGN

Rural GPs were assessed on different aspects of well-being and their intentions to leave rural general practice, and these were compared with similar data collected two years prior.

SETTING

Rural general practices in South Australia.

PARTICIPANTS

Two hundred and twenty-one rural GPs (55% of South Australian rural GP workforce).

MAIN OUTCOME MEASURES

GPs completed a questionnaire assessing their levels of support, intention to leave rural practice, use of the dr doc program, and psychological health.

RESULTS

Improvements were found in the support networks and in the physical and emotional health of rural GPs from time 1 to time 2. There was also a reduction in the number of GPs wanting to leave rural general practice in the short to medium term (from 30% to 25%).

CONCLUSIONS

The initial study in this series suggested that improving psychological well-being might influence rural GPs' intentions to leave rural practice. The current study confirms these suggestions by demonstrating that programs targeted at psychological and physical well-being do indeed impact on rural GPs' intentions to leave. The results of this study highlight the role of psychological well-being in retaining rural GPs and emphasise the value of developing psychologically based programs to not only boost the physical and mental health of GPs, but also to reduce departure from rural areas.

Overriding psychiatric advance directives: factors associated with psychiatrists' decisions to preempt patients' advance refusal of hospitalization and medication

Psychiatric advance directives (PADs) are intended to support patients' treatment decisions during a crisis. However, PAD statutes give clinicians broad discretion over whether to carry out patients' advance instructions. This study uses data from a survey of psychiatrists (N=164) to examine reasons for overriding PADs. In response to a hypothetical vignette, 47% of psychiatrists indicated that they would override a valid, competently-executed PAD that refused hospitalization and medication. PAD override was more likely among psychiatrists who worked in hospital emergency departments; those who were concerned about patients' violence risk and lack of insight; and those who were legally defensive. PAD override was less likely among participants who believed that involuntary treatment is largely unnecessary in a high-quality mental health system.

Female victims of domestic violence: which victims do police refer to crisis intervention?

Factors associated with activation of a volunteer-based crisis intervention services program for victims of police-reported intimate partner violence (IPV) were examined to determine if those for whom services were activated were representative of the overall eligible population. The study population comprised 2,092 adult female victims of male-perpetrated police-reported IPV. Crisis intervention services were requested by responding patrol officers in 415 (19.8%) of these incidents. Activation of crisis intervention services was more likely for victims who were married to their abusive partner, pregnant, or of Latina or Asian race/ethnicity and among IPV incidents involving physical abuse, visible victim injuries, and arrest of the abusive partner. Additionally, one of the city's five police precincts was less likely than the remaining four to utilize these services. Activation of crisis intervention services was associated with factors related to need and feasibility of service delivery, but differential activation at the precinct level was also found to be influential.

Mental health, health, and substance abuse service needs for the Native American Rehabilitation Association Northwest (NARA NW) in the Portland, Oregon metropolitan area

Consistent with results of previous needs assessments for urban American Indian and Alaska Native populations, a needs assessment in the Portland,Oregon metropolitan area for the Native American Rehabilitation Association Northwest revealed high levels of co-occurring conditions for American Indian and Alaska Native clients, often combining chronic health problems, substance abuse histories, and mental health diagnoses. Focus group results suggest the need for crisis care as well as specific needs of children and families, veterans, elders, and adults.

Crisis resolution/home treatment teams and psychiatric admission rates in England

BACKGROUND

Introduction of crisis resolution/home treatment teams has been associated with a reduction in hospital admissions in trials. Between 2001 and 2004 there was a rapid expansion in the numbers of these teams in England.

AIMS

To examine whether national implementation of these teams was associated with comparable reductions in admissions.

METHOD

Observational study using routine data covering working age adult patients in 229 of the 303 local health areas in England from 1998/9 to 2003/4.

RESULTS

Admissions fell generally throughout the period, particularly for younger working age adults. Introduction of crisis resolution teams was associated with greater reductions for older working age women (35-64 years); teams always on call were associated with additional reductions for older men and younger women. By the end of the study admissions had fallen by 10% more in the 34 areas with crisis resolution teams in place since 2001, and by 23% more in the 12 of these on call around the clock than in the 130 areas without such teams by 2003/4. Reductions in bed use were smaller. Introduction of assertive outreach teams was not associated with overall reductions in admissions.

CONCLUSIONS

Introduction of crisis resolution teams has been associated with reductions in admissions.

Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001

OBJECTIVE

The authors surveyed a sample of Project Liberty crisis counseling recipients approximately 1.5 years after the terrorist attacks on September 11, 2001, to determine the proportion of respondents who screened positive for complicated grief, a recently identified condition marked by symptoms of continuing separation distress and accompanying bereavement-related traumatic distress.

METHODS

A total of 149 service recipients drawn from eight high-volume providers responded to a telephone survey that included questions to screen for complicated grief.

RESULTS

Approximately half of the recipients knew someone who had been killed in the attacks. Of those recipients, 44 percent screened positive for complicated grief. Individuals who lost a family member were more likely than those who lost an acquaintance to screen positive for complicated grief. Positive screens were associated with functional impairment independent of the presence of symptoms consistent with full or subthreshold major depression or posttraumatic stress disorder (PTSD). Thirty-two percent of those who screened positive for complicated grief did not meet even subthreshold criteria for major depression or PTSD.

CONCLUSIONS

Results affirmed the importance of complicated grief as a unique condition and indicated the need to attend to the psychological consequences of bereavement in disaster-related mental health services.

A mental health program for ground zero rescue and recovery workers: cases and observations

Clinical vignettes from the World Trade Center Worker and Volunteer Mental Health Monitoring and Treatment Program at the Mount Sinai Medical Center in New York City are presented. The hospital-based program pairs mental health screenings with federally funded occupational medical screenings to identify persons with mental health problems related to their rescue and recovery roles. The program also provides on-site mental health treatment. The cases illustrate the diverse mental health needs of the rescue and recovery workers, some of whom initially sought treatment years after September 11, 2001. The cases show that in addition to symptoms of posttraumatic stress disorder, workers experienced survivor guilt, distressing memories of childhood trauma, shame associated with intense feelings, substance abuse relapse, psychosis, and problems with family relationships.

Demographic characteristics of individuals who received Project Liberty crisis counseling services

OBJECTIVES

This article describes demographic characteristics of service recipients and their patterns of use of crisis counseling services provided under Project Liberty during the 27 months after the September 11, 2001, attacks on the World Trade Center. It also examines the extent to which service recipients reflected the demographic characteristics of their home communities.

METHODS

A total of 753,015 service encounter logs submitted by 177 providers were analyzed to determine rates of use by different demographic groups and to evaluate patterns of use over time with goodness-of-fit and logistic regression models.

RESULTS

A total of 687,848 individual crisis counseling sessions were provided to an estimated 465,428 individuals, including large numbers of persons from racial or ethnic minority groups and non-English-speaking individuals. Most of these services were provided to residents of the five New York City boroughs, with a small percentage of services to residents from the ten surrounding counties. Most services were provided in community settings rather than provider offices. African-American and Hispanic individuals showed the greatest increase in rates of accessing services over time. Follow-up visits were significantly more likely to be by Caucasians than by non-Caucasians, and children were more likely than adults to receive follow-up visits. Demographic characteristics of individuals using Project Liberty crisis counseling services generally were representative of the five boroughs and ten other counties constituting the greater metropolitan region and representative of estimated need.

CONCLUSIONS

Project Liberty provided services that were accessible to individuals of diverse racial and ethnic backgrounds.

Use of Project Liberty counseling services over time by individuals in various risk categories

OBJECTIVE

The authors examined temporal changes in the rates at which people sought access to Project Liberty services after the attacks of September 11, 2001, according to risk category (family of missing or deceased, persons directly affected, uniformed personnel, other rescue or recovery workers, schoolchildren, displaced employed and unemployed workers, persons with disabilities, and the general population).

METHODS

First visits to individual counseling services, as determined from logs of 465,428 service encounters, were proportioned among risk categories and plotted across 27 months.

RESULTS

Individuals who lost family members accounted for 40 percent of visits in the first month but dropped to 5 percent or fewer visits by five months. Uniformed personnel used disproportionately larger percentages of services after the first year. Occupationally displaced and unemployed workers sought counseling at relatively steady rates.

CONCLUSIONS

Postdisaster counseling should be made available for extended periods, with shifting emphases to meet the changing needs of high-risk groups.

Clusters of event reactions among recipients of Project Liberty mental health counseling

OBJECTIVE

This study aimed to determine a pattern in the frequency with which individuals who manifested distress reactions resembling diagnostic syndromes of posttraumatic stress disorder (PTSD) and major depressive disorder accessed services provided by Project Liberty.

METHODS

Hierarchical cluster analysis was applied to 31 reactions to stress (event reactions) shown by 465,428 recipients of Project Liberty counseling, to determine how well event reactions mapped onto traditional diagnostic criteria. Service recipients were tracked when they first sought Project Liberty counseling during the 27 months after the attacks. Those who reported three or more reactions associated with these clusters were characterized as having possible diagnosable conditions.

RESULTS

Strong consistent clusters corresponding to traumatic stress and depressive symptoms emerged, with 26 percent, 16 percent, and 8 percent of service recipients rated as having possible PTSD, major depressive disorder, or both, respectively. Taken together, this group constituted over 40 percent of service recipients served by Project Liberty almost every month throughout the 27 months of its existence.

CONCLUSIONS

Event reactions, as reported by Project Liberty crisis counselors, many of whom were nonclinicians, mapped coherently onto diagnostic syndromes, suggesting that a checklist of such reactions may be useful to disaster counselors as a cost-effective screening and planning instrument. The steady entry over time into Project Liberty counseling by a substantial number of individuals experiencing high levels of distress underscores the need for providing long-term access to mental health services postdisaster.

Impact of a media campaign for disaster mental health counseling in post-September 11 New York

OBJECTIVE

After the September 11, 2001, terrorist attacks on the World Trade Center, the New York State Office of Mental Health (NYOMH) initiated a three-phase multifaceted, multilingual media campaign that advertised the availability of counseling services. This study evaluated the association between patterns of spending within this campaign and the volume of calls received and referred to a counseling program.

METHODS

Spending on television, radio, print, and other advertising was examined, as was the corresponding volume of calls to the NetLife hotline seeking referrals to counseling services.

RESULTS

From September 2001 to December 2002, $9.38 million was spent on Project Liberty media campaigns. Call volumes increased during months when total monthly expenditures peaked. Initially, flyers, billboards, and other material items accounted for most monthly expenses. Over time, spending for television and radio advertisements increased, whereas other advertising declined. Temporal patterns show that in periods after an increase in media spending, call volumes increased independently of other sentinel events such as the one-year anniversary of the attacks.

CONCLUSIONS

Sustained advertising through multiple media outlets appeared to be effective in encouraging individuals to seek mental health services.

Did Project Liberty displace community-based medicaid services in New York?

OBJECTIVE

This study analyzed how the introduction of Project Liberty services after the September 11, 2001, terrorist attacks affected agencies' provision of community-based Medicaid mental health services in the New York metropolitan area.

METHODS

Provision of Medicaid mental health services was tracked between January 2000 and June 2003 for provider agencies participating in Project Liberty (N=164) and for a comparison group of mental health provider agencies that did not participate in this program (N=94).

RESULTS

Overall, participation in Project Liberty did not significantly affect the volume of Medicaid services provided. However, for agencies with one site, a statistically significant difference was seen; compared with agencies in the comparison group, agencies that participated in Project Liberty claimed a mean+/-SE decrease of $4.66+/-3.57 less in Medicaid services per month per Project Liberty visit.

CONCLUSIONS

Project Liberty permitted rapid expansion of the total volume of services provided by community-based organizations without interfering with the provision of traditional services, although a modest effect was seen for smaller agencies. Although the results do not imply that "supply side" planning for disaster needs would not improve system response, they do imply that implementation of flexible "demand side" financing can call forth a large volume of new services rapidly and without interfering with other community services.

Service utilization and event reaction patterns among children who received Project Liberty counseling services

OBJECTIVES

This study examined service utilization and event reaction patterns among children who used crisis counseling services provided under Project Liberty for 27 months after the September 11, 2001, terrorist attacks on the World Trade Center.

METHODS

The authors analyzed logs of 681,318 service encounters submitted by Project Liberty counselors, paying particular attention to demographic characteristics and reported event reactions.

RESULTS

Nine percent of service recipients reached by community-based Project Liberty providers were children, whereas census data for the 15 counties and boroughs served by Project Liberty indicated that children constituted 25 percent of the population. Service use as a function of race or ethnicity and of gender was consistent with census data. Similar to findings for adults, the most common emotional event reactions reported for children were experiencing sadness and tearfulness, being anxious and fearful, having difficulty concentrating, experiencing irritability and anger, having intrusive thoughts or images, and having difficulty sleeping. Behavioral event reactions listed on service logs suggested that older children (12 to 17 years) were more likely to use drugs whereas elementary school-age children were more likely to display signs of anxiety, isolation and withdrawal, and difficulties with concentration and memory.

CONCLUSIONS

Sensitivity to differences in the event reaction patterns shown by younger and older children may be useful in refining treatments to help reduce the psychological impact of children's trauma after terrorist incidents.

Who visits the psychiatric emergency room for the first time?

OBJECTIVE

To examine patient and system characteristics of first-time ("incident") vs. recurrent ("recurrent") use of a psychiatric emergency room (PER).

METHODS

Data on demographic and clinical characteristics and health service utilization were collected for incident and recurrent users (n=3,719) who visited the PER of the university hospital in Leuven, Belgium, between March 2000 and March 2002.

RESULTS

About 64% (n=2,368) were incident and 36% (n=1,351) were recurrent users. The PER was the first treatment setting ever for 50% of the incident users. Incident users were most likely over 69 years (OR=2.84, P<0.001), employed (OR=2.21, P<0.001), or referred by a health care professional (OR=1.72, P<0.001). They were less likely to have a personality disorder (OR=0.40, P<0.001) or to have used inpatient or outpatient services in the past (OR's 0.11 and 0.65, respectively, P<0.001). About 44% were admitted, 38% referred for outpatient treatment, 9% referred to the outpatient crisis-intervention program, and 9% refused any follow-up.

CONCLUSIONS

The PER was a first treatment setting ever for 1 in 3 patients. Incident and recurrent users differed in sociodemographic characteristics, pathways to care, service use, and the presence of a personality disorder. They did not differ in axis 1 disorders, comorbid mental disorders, or pathways after care.

A propensity score analysis of brief worksite crisis interventions after the World Trade Center disaster: implications for intervention and research

BACKGROUND

Postdisaster crisis interventions have been viewed by some as appropriate to enhance the mental health status of persons affected by large-scale traumatic events. However, studies and systematic reviews have challenged the effectiveness of these efforts.

OBJECTIVES

The focus of this study was to examine the impact of brief mental health interventions received by employees at the worksite after the World Trade Center disaster (WTCD) among workers in New York City (NYC).

RESEARCH DESIGN

The data for the present study come from a prospective cohort study of 1121 employed adults interviewed by telephone in a household survey 1 year and 2 years after the WTCD. All study participants were living in NYC at the time of the attacks. For the current study, we used propensity scores to match intervention cases (n = 150) to nonintervention controls (n = 971) using a 1:5 matching ratio based on a bias-corrected nearest-neighbor algorithm.

RESULTS

Approximately 7% of NYC adults (approximately 425,000 persons) reported receiving employer-sponsored, worksite crisis interventions related to the WTCD provided by mental health professionals. In addition, analyses indicated that attending 1 to 3 brief worksite sessions was associated with positive outcomes up to 2 years after the WTCD across a spectrum of results, including reduced alcohol dependence, binge drinking, depression, PTSD severity, and reduced anxiety symptoms.

CONCLUSIONS

Although our study had limitations, it is one of the few to suggest that brief postdisaster crisis interventions may be effective for employees after mass exposure to psychologically traumatic events. The reasons for the effectiveness of these interventions are unclear at this time and warrant further investigation.

Assessing intervention effects in a community-based trial to reduce self-harm: A methodological case study

This paper considers the assessment of the impact of a community-based randomized controlled trial to reduce repeat deliberate self-harm. It considers the drawbacks in simplistic applications of conventional significance testing procedures, as well as possible failures regarding the statistical assumptions underlying such tests. Instead, the paper considers how relevant prior information might be incorporated within a fully Bayesian-model-based assessment procedure. The model includes a latent trait approach to patient morbidity; controlling for morbidity and other patient characteristics enhances the impact of the intervention (measured by a hazard rate ratio). If allowance is made for external information (e.g. ethical approval of the treatment), the weight of evidence shifts towards a positive intervention effect.

The role of psychological well-being in retaining rural general practitioners

OBJECTIVE

Retention of rural GPs is an increasing area of concern and is receiving considerable attention from the government, medical authorities and the media. This study aimed to examine the potential for psychological interventions to assist in the retention of rural GPs through targeting their psychological well-being.

DESIGN

GPs completed a questionnaire, including questions about their level of support in rural practice, psychological health (work-related morale and distress, distress related specifically to working in rural general practice, quality of work life) and intentions to leave rural practice.

SETTING

Rural general practices in South Australia.

PARTICIPANTS

One hundred and eighty-seven rural GPs.

RESULTS

Results indicated that rural GPs who were seriously considering leaving rural practice had higher work-related distress, higher distress related specifically to working in a rural general practice and lower quality of work life. GPs who considered leaving rural practice also reported having fewer colleagues with whom to discuss professional issues.

CONCLUSION

Results indicated that psychological interventions (such as cognitive behavioural training), assistance with stress reduction and coping mechanisms (such as more interaction with colleagues) may be of benefit to GPs who are considering leaving rural practice. Such training may increase the number of GPs who ultimately stay in rural practice.