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References and Abstracts
In the year 2001, the status of psychiatry is viewed through the experiences and thoughts of a hypothetical psychiatrist and a hypothetical family physician. Psychiatry is continuing its explosive progress in brain physiology and psychopharmacology, but has backed away from studies and practice in the psychosocial field. As practice patterns change and more outpatient psychiatric care falls into the purview of the family physician, the two physicians see a need for ever more collaboration between their specialties. A greater commitment by family medicine to psychosocial training and research, especially in areas such as physician-patient and physician-family relationships, is urged.
Barber R, Williams AS. Psychiatrists working in primary care: a survey of general practitioners’ attitudes. Aust N Z J Psychiatry 1996;30(2):278-86.
Objectives: To collect information on current working arrangements between general practitioners (GPs) and mental health professionals and to assess GPs’ attitudes towards developing closer working practices with psychiatrists in the primary care setting. Method: Six hundred and three GPs from South Australia were surveyed with questionnaires. Main outcome measures included information about existing primary care links between GPs and mental health professionals, GPs preferred working arrangements with psychiatrists in the primary care setting and their attitude towards developing these practices, including perceived obstacles, advantages and disadvantages. Results: One hundred and eighty-one completed questionnaires were returned. One in 11 GPs returning the questionnaire (RGPs) had established primary care links with a psychiatrist, 1 in 6 with clinical psychologists and 1 in 17 with psychiatric nurses and social workers. RGPs held positive attitudes towards developing closer links at their work settings with psychiatrists when it leads to improved collaboration and access to psychiatrists. Reservations were expressed about the public weakening of the GPs’ primary care role. Conclusions: The joint needs of clinical care and GPs’ further training in psychiatry could be addressed by further development of schemes to attract psychiatrists to work in primary care settings. This is mostly viewed very positively by GPs, although the percentage of GPs responding make these conclusions tentative. It is more likely to occur with changes to current funding of both private psychiatric care and GP remuneration, with a recognition of time spent in liaison.
Bird DC, Lambert D, Hartley D, Beeson PG, Coburn AF. Rural models for integrating primary care and mental health services. Adm Policy Ment Health 1998;25(3):287-308.
This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.
Bloom JD. Psychiatry: three models in search of a future Psychiatr Serv 1996;47(8):874-5.
The author proposes three models for the future of psychiatry. The public health psychiatry model is rooted in psychiatry’s participation in community mental health care for the past 50 years. It emphasizes ideological similarities between community mental health care and managed care. The clinical neuroscience model melds the specialties of neurology and psychiatry to form a clinical brain science, yielding the nonmedical care of mentally ill persons to nonmedical mental health professionals. In the primary care model, more intensive medical training would allow the psychiatrist to function either as a primary care physician or as a “primary care specialist.”
Brown LM, Tower JE. Psychiatrists in primary care: would general practitioners welcome them? Br J Gen Pract 1990;40(338):369-71.
During the spring of 1988 a postal questionnaire was sent to all general practitioners in one health district, enquiring about their present links with psychiatrists and asking for their views on the desirability of psychiatrists visiting their surgeries regularly. At present only a minority of general practitioners have a regular link of this kind but a substantial majority would welcome such an arrangement. The type of link most commonly desired is one in which the general practitioner shares actively in the assessment and treatment of the patient. A degree of ambivalence about the role of other mental health professionals was detected.
Carr VJ, Reid AL. Seeking solutions for mental health problems in general practice. Med J Aust 1996;165(8):435-6.
Mental health counsellors could provide one component of an integrated solution to the structural problems now inherent in the primary care of patients with mental health problems. Further training of general practitioners in interview and counselling skills is also essential.
Creed F, Marks B. Liaison psychiatry in general practice: a comparison of the liaison- attachment scheme and shifted outpatient clinic models. J R Coll Gen Pract 1989;39(329):514-7.
Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.
Engel CC, Kroenke K, Katon WJ. Mental health services in Army primary care: the need for a collaborative health care agenda. Mil Med 1994;159(3):203-9.
Epidemiologic studies have shown that more than half of mentally ill patients in the US receive their psychiatric care exclusively in primary care settings. This fraction may be even higher in the military due to concern over possible occupational repercussions resulting from use of specialty psychiatric care and specialist shortages. Collaboration between generalists and mental health care specialists could potentially improve mental health care delivery and reduce psychiatric disability for a large segment of the Army population who have a psychiatric disorder but may not seek specialty care. Collaborative efforts can reinforce military generalists essential gate-keeping function, thereby decreasing unnecessary medical utilization and health care costs. The authors review the problems associated with mental health care delivery in primary care and provide examples of collaborative models previously studied or currently being explored. A four-part Army Primary Care-Mental Health Services Agenda is proposed, consisting of: (1) coordinated research including primary care-mental health services research and community-based epidemiologic studies; (2) formation of a primary care-mental health services advisory committee for aiding with policy and program development; (3) graduate and continuing medical education in primary care-mental health services emphasizing interdisciplinary collaborative skills; and (4) clinical implementation of feasible collaborative interdisciplinary mental health care models adapted to the range of unique Army primary care settings. The main goal of the Army Primary Care-Mental Health Services Agenda is to improve access to Army mental health care in the most efficacious and cost-effective way and to help minimize the organizational impact of disability related to psychosocial distress.
Falloon IR, Shanahan W, Laporta M, Krekorian HA. Integrated family, general practice and mental health care in the management of schizophrenia. J R Soc Med 1990;83(4):225-8.
Ferguson BG, Varnam MA. The relationship between primary care and psychiatry: an opportunity for change. Br J Gen Pract 1994;44(388):527-30.
The past two decades have seen the development of a symbiotic relationship between primary care and psychiatric services. The changes which have taken place, however, have been piecemeal and variable in their extent. With some exceptions, they have followed an empirical route, and have come about largely because individual practi- tioners intuitively felt that they yielded positive results or attractive patterns of working. For the most part, they have not followed the elaboration of a specific theory and although a great deal of subsequent research has been carried out in order to analyse their benefits and limitations, routine practice has been slow to change. The recent reorganization of the health service has yet to exert an appreciable effect on the relationship between the two disciplines. Owing to the newly developing structures and patterns of care, future change is inevitable and brings with it both opportunities and dangers. This paper sets out some of the arguments in favour of a new contract between psychiatry and primary care based on an equal partnership.
Fink PJ. Psychiatry and the primary care physician. Hosp Community Psychiatry 1985;36(8):870-5.
The author discusses problems that have hindered active collaboration between psychiatrists and primary care physicians, presents models for clinical interaction between them, and describes the role of psychiatrists in the education of primary care physicians. He identifies the differing models of psychiatric and physical medicine as the source of the poor communication that has existed between the two specialties and advocates adherence to a biopsychosocial model as a means of fostering collaboration. He concludes that the psychiatrist can best serve as a teacher and consultant to the primary care physician and as a specialist dealing with serious mental and emotional problems that are beyond the skill of the primary care physician.
Gask L, McGrath G. Psychotherapy and general practice. Br J Psychiatry 1989;154:445-53.
The authors review the development of liaison psychotherapy in general practice, and argue that a skill-sharing approach, where the general practitioner retains the treatment role, is a more efficient model than a consultation approach. Skill-sharing models are reviewed, and the need for psychiatrists and psychotherapists to be more directly involved in teaching basic psychotherapeutic skills to general practitioners is emphasized.
Gask L, Sibbald B, Creed F. Evaluating models of working at the interface between mental health services and primary care Br J Psychiatry 1997;170:6-11.
Background: This paper examines the feasibility of evaluating innovative models of working at the interface between primary care and secondary mental health services. Method: Methodological problems relevant to evaluation of innovative models of working at the interface are discussed. Results: Although there is some evidence that neurotic disorders can be more cost-effectively treated in primary care, many general practitioners (GPs), and possibly some patients, prefer referral to community mental health teams and community psychiatric nurses, which are provided by the secondary health care services. Since the latter are provided with the intention of improving serious mental illness their involvement in the care of neurotic illness can lead to tensions between GPs, local health authorities and service providers. There is little evidence to suggest that psychiatrists working in health centres using the shifted out-patient model have eased this problem. By contrast the consultation-liaison (C-L) model has a number of theoretical advantages; referrals to secondary care should be limited to those most in need of this level of expertise and GP management skills should improve, so leading to better quality of care for patients who are not referred. Conclusion: Studies comparing the different models of service delivery are required to address the tensions that have arisen following changes in government policy. Further work is also needed to develop the necessary research tools.
Goldberg D, Mann A, Pilgrim D, and others. Developing a strategy for a primary care focus for the mental health services. London, England.: Institute of Psychiatry and the Department of General Practice UMDS., 1993:
Goldberg D, Jackson G. Interface between primary care and specialist mental health care [editorial] Br J Gen Pract 1992;42(360):267-9.
Goldberg D, Jackson G, Gater R, Campbell M, Jennett N. The treatment of common mental disorders by a community team based in primary care: a cost-effectiveness study. Psychol Med 1996;26(3):487-92.
Thirty patients suffering from new episodes of depression or anxiety disorders seen by a hospital-based psychiatric service were matched for severity of illness with 30 patients seen by a community mental health team based upon primary care. These patients were drawn from a total of 108 such patients seen in the community and 57 seen by the hospital service. Clinical and social outcomes were similar in both groups, and neither was clearly superior in terms of quality of clinical information recorded. However, patients treated in the community were seen more quickly, had more continuity of care and were more satisfied with the service. Health ser-vices costs were less for those patients treated in the community, because patients were less likely to be admitted. With one atypical patient excluded, treatment by the community team is more cost effective. The greater number of patients seen by the primary-care-based service means that there is no overall cost saving to the NHS.
Goldberg RJ. Psychiatry and the practice of medicine: the need to integrate psychiatry into comprehensive medical care. South Med J 1995;88(3):260-7.
Psychiatric problems are common in general medical practice and strongly influence medical utilization. A number of studies have shown the positive effects of psychiatric interventions for both medical inpatients and outpatients. Unfortunately, historic and economic forces have tended to keep the medical and mental health components of care separated. This paper presents information supporting the need to reintegrate psychiatry into medical practice. Such reintegration will require a shift in the location of mental health clinicians into the primary care setting, a change in the curriculum of medical residents, and a clearer definition of the role of psychiatry in relation to the other mental health professions.
Goldberg RJ. Financial incentives influencing the integration of mental health care and primary care. Psychiatr Serv 1999;50(8):1071-5.
Psychiatric problems are common in general medical practice and strongly influence utilization of medical care. Although several studies have demonstrated the positive clinical and financial impact of psychiatric interventions for medical patients, historic and economic forces have tended to maintain the separation of the primary health and mental health components of care. The author discusses the financial incentives that influence the success or failure of initiatives to integrate mental health care and primary care. Most models for financing care that use fee-for-service, carve-out, or capitated arrangements have done little to encourage collaborative treatment planning and coordination of care or have created conditions that work against such integration. True financial incentives for integration of psychiatric and primary health care are provided only by a shared-risk model of capitation-a model that has long existed in staff-model health maintenance organizations. This model increases motivation to lower overall utilization of care, improve patients’ overall health status, and search for more effective models of care.
Holland J. psychiatry and primary care: closing the gap. International J Psychiatry in Medicine 1996;26(2):109-111.
Horder J. Working with general practitioners. Br J Psychiatry 1988;153:513-20.
Psychiatrists and general practitioners have found new ways of working together in the last ten years, but there have also been separate activities which could develop into rivalry. These opportunities and dangers are the central theme of this paper. Ways are considered in which the psychiatry of general practice differs from the experience of psychiatrists. Forms of help are suggested which general practitioners need from psychiatrists, whether in clinical practice or education.
Kates N. Psychiatry and family medicine: sharing care [editorial]. Can J Psychiatry 1997;42(9):913-4.
Keks NA, Altson BM, Sacks TL, Hustig HH, Tanaghow A. Collaboration between general practice and community psychiatric services for people with chronic mental illness. Med J Aust 1997;167(5):266-71.
King M, Nazareth I. Community care of patients with schizophrenia: the role of the primary health care team. Br J Gen Pract 1996;46(405):231-7.
Schizophrenia is a severe, chronic mental disorder that usually begins in early adulthood. Recurrent relapse leading to long-term psychological and social disability means that patients may require intensive community support. Despite a recent fall in the overall numbers of patients consulting their general practitioner with mental disorders, presentations by those suffering from severe mental disorders have risen. This review encompasses the role of general practitioner in the management of schizophrenia, considering in turn drug and psychological therapies, family interventions, innovations in care, the effects of community care developments, and the liaison between primary health care and mental health professionals. There is a need for further research in the area of family-practice-based interventions involving general practitioners and the practice team.
King MB. Management of patients with schizophrenia in general practice [editorial]. Br J Gen Pract 1992;42(361):310-1.
Lamberg L. Psychiatry and primary care forge new bonds. JAMA 1996;275(24):1865-6.
Lambert D, Hartley D. Linking primary care and rural psychiatry: where have we been and where are we going? Psychiatr Serv 1998;49(7):965-7.
Linking primary care with psychiatric care has long been promoted as a way to improve access to rural mental health services. The authors describe a national survey that identified 53 successfully linked programs, ranging from small local efforts to sophisticated multicounty networks. Findings indicated that lessons from successful integrations are not easily reduced to a how-to list. Organizations cooperate with each other when it is in their interests to do so. Motivation to integrate cannot be mandated, nor is the availability of funding alone sufficient to provide motivation. The authors discuss ways that managed care may facilitate or hinder the link between rural primary care and rural psychiatry.
Laufer N, Jecsmien P, Hermesh H, Maoz B, Munitz H. Application of models of working at the interface between primary care and mental health services in Israel. Isr J Psychiatry Relat Sci 1998;35(2):120-7.
Psychiatric morbidity is common in primary care, a large proportion being treated without specialist referral. A significant proportion may be undetected or inadequately treated. This article describes current models of mental health services (MHS) working at the interface between primary care and MHS with review of data regarding these models and discussion of the application of these models to the Israeli health system. The shifted out-patient model, primarily provided by psychiatrists independent of the Primary and Secondary Care Teams, would seem to increase access to psychiatric services, increase treated prevalence of the disorders and attract a similar population to hospital out-patient services. The psychiatric community liaison model aims to improve primary care practitioner detection and management skills, might reduce referrals to psychiatrists with similar patient outcome and enables treatment of patients unwilling to see a mental health professional (MHP). The attached MHP Model would allow access to a greater range of psychosocial interventions provided by a primary care team member. The community mental health team, currently a model not in practise in Israel, provides a single point of referral for multidisciplinary care but has shown varying patterns of integration and responsiveness to primary care. Other interfaces of collaboration such as Balint groups and education are also discussed.
Maoz B. Psychiatry and primary medicine. Isr J Psychiatry Relat Sci 1992;29(4):245-50.
Psychiatry and primary medicine are related to one another for theoretical and practical reasons. The development of this relationship in Israel in recent years is described. Many patients with mental problems are seen by the primary physician only. The most serious cases are usually detected and referred. The main problem is that people with modest mental disturbances are often neither detected nor referred and treated. The development of various forms of communication between psychiatry and primary medicine, such as consultation-liaison programs, Balint groups and other methods of training, are described and discussed.
Mechanic D. Treating mental illness: generalist versus specialist. Health Aff (Millwood) 1990;9(4):61-75.
As managed care achieves greater penetration in the marketplace, increasing attention is being devoted to models of integration and coordination of behavioral health with general medical care. In considering strategies and models, attention must be given to the heterogeneity of patient populations and the fact that successful approaches with some patient populations may not be suitable for others. Six approaches are reviewed: mainstreaming, the liaison psychiatry/collaboration model, new practitioner models, independent carveouts, functionally integrated carveouts, and extended care models. Each offers potentials and limitations, but little outcome data are available. Managed care models are diverse and changing rapidly. Much depends on the commitments of managers and professionals to the collaborative process and the extent to which incentives are consistent with clinical goals. Despite the uncertain and changing environment, it is clear that primary care physicians will remain significant providers of mental health services if for no other reason than many patients will resist referral to specialty mental health providers.
Mitchell AR. Psychiatrists in primary health care settings. Br J Psychiatry 1985;147:371-9.
An increasing number of psychiatrists are now working partly in primary care settings. This paper describes how the movement began and how both psychiatrists and other members of the specialist psychiatric treatment team have explored ways of working with family doctors in the diagnosis and management of psychiatric disorders. Various styles of collaborative work, the declared advantages of such attachment schemes, the reservations being expressed about their further extension, and their research and educational potential are explored. If such enterprises, designed to help the family doctor identify psychiatric morbidity in the practice and to extend his skills in managing such patients and their relatives, are to be commanded, they must be carefully monitored so that the cost-benefit balance can be established.
Although there has been much importance attached to the relationship between mental health care and general health care, there have been few attempts to systematically describe the nature of the relationships between these two domains of health care. The author reviews other attempts to develop models of interaction between the two systems, describes the dimensions of a patient-oriented set of models for the linkage between mental health and general health care providers, and suggests how these models fit into the overall context of clinical services research at the interface between these two systems of care.
Sartorius N. Psychiatry in the framework of primary health care: a threat or boost to psychiatry? Am J Psychiatry 1997;154(6 Suppl):67-72.
New research directions should be pursued during the coming years if mental illness is to be properly managed in primary medical care practice. Among needed studies are those pertaining to the validity of diagnostic classifications specific to psychiatric morbidity in ambulatory medical settings; the nature of clinical decision-making by primary care physicians; how diagnostic formulations influence treatment choices; and the effectiveness of treatments transferred from the specialist to generalist settings.
Shepherd M. Primary care of patients with mental disorder in the community. BMJ 1989;299(6700):666-9.
Shepherd M. Primary care psychiatry: the case for action. Br J Gen Pract 1991;41(347):252-5.
Since the introduction of the National Health Service a number of epidemiological enquiries have established the importance of mental disorders in the field of primary care. Examples are provided from the work of the General Practice Research Unit at the Institute of Psychiatry in London. The results furnish a rational basis for collaborative action between research workers, general practitioners and policy makers.
Shore JH. Psychiatry at a crossroad: our role in primary care. Am J Psychiatry 1996;153(11):1398-403.
Objective: The shortage of primary care physicians is seen as an urgent health systems priority and is supported by a national consensus. Psychiatry is at a crossroad and must reevaluate the profession’s role in primary care. This article supports the position that psychiatrists need to be able to medically evaluate and to provide basic primary medical care for seriously mentally ill patients who do not have adequate access to general health care. Many of the seriously mentally ill are difficult to treat when they contact a medical care provider. Because of their psychiatric symptoms, they often are unlikely to receive adequate medical care. Psychiatrists frequently are the only physicians with whom they have consistent contact. Method: This article contains a proposal for a new initiative to broaden the role of public psychiatrists to include a primary care role. In addition, new opportunities for dual or triple board certification are reviewed. Results: A new curricular model for primary care training in general psychiatry programs is outlined. The new curriculum would include training for diagnostic and primary care skills to prepare psychiatrists to provide basic primary medical services for the chronically mentally ill. Conclusions: The new curricular proposal would create an elective psychiatry primary care track. This is possible within current accreditation requirements. Psychiatric residents could receive primary care training throughout their residency.
Silberman EK. Should we train psychiatrists as primary care providers? Psychosomatics 1999;40(2):126-9
The author discusses the proposition that psychiatrists would be appropriate primary physicians for specific types of patients. The author reviews the arguments for and against psychiatrists as primary care providers, proposes questions that must be addressed in training for such a role, and describes current models of primary care education and practice for psychiatrists. The author believes that primary care may be an appropriate career track within psychiatry and suggests that the development of family medicine may provide useful guidance in incorporating primary care functions into psychiatry.
Stansfeld SA, Leek CA, Travers W, Turner T. Attitudes to community psychiatry among urban and rural general practitioners. Br J Gen Pract 1992;42(361):322-5.
General practitioners’ requirements for community psychiatric services may differ according to the area in which they practise. A questionnaire survey of general practitioners’ attitudes to community psychiatric services is reported from three contrasting areas: an inner city urban area, a new town and a rural area. General practitioners in all areas wanted more consultation with psychiatrists, and 53-68% wanted regular psychiatric outpatient clinics in their surgeries. There was enthusiasm for community psychiatric nurses and for help with psychotherapy. In the rural area general practitioners favoured surgery based psychiatric outpatient clinics and arranging emergency hospital admissions themselves; in urban areas domiciliary visits from psychiatrists to help with emergencies were favoured. These results appear to reflect the greater geographical distance between primary and hospital based secondary care in rural as opposed to urban areas. Overall, general practitioners wanted more support from community psychiatric services in carrying out their primary therapeutic role especially in rural areas far from hospital-based psychiatric services.
Three models of interaction between primary care and psychiatry in the British National Health Service are presented. Although the first two are traditional and well recognized, the third, the liaison-attachment model, is an innovation of the last decade. Two studies are described that outline the extent and nature of this form of working collaboration between specialists and generalists. Clinical, service, and educational implications are discussed in the context of the British primary care structure.
Strathdee G. The GP, the community and shared psychiatric care. Practitioner 1994;238(1544):751-4.
Ungar TE, Hoffman BF. Two solitudes: psychiatry and primary care family medicine—a growing relationship. Health Law Can 1998;19(2):33-7.
Velamoor R. The interface between family medicine and psychiatry. Canadian J of CME 1999(2):47-66.
Wright AF. A blueprint for shared psychiatric care in the community [editorial]. Br J Gen Pract 1993;43(371):227-8.
Wulsin LR. An agenda for primary care psychiatry. Psychosomatics 1996;37(2):93-9.
With the advent of managed care and the primary care gatekeeper, psychiatry’s relationship to primary care is shifting. Four recent surveys suggest that, in general, departments of psychiatry have done little to restructure their relationships with primary care. This article proposes an agenda for developing primary care psychiatry programs in departments of psychiatry. The rationale for shifting resources toward primary care psychiatry is followed by a discussion of the goals of primary care psychiatry programs. The agenda presents specific high-priority pro-jects in the areas of research, education, and clinical care, citing examples of existing initiatives and discussing the resources needed for funding primary care psychiatry programs.
In rural areas, it is important to clarify our understanding of how primary care and specialty mental health professionals organize care for those with mental disorders, and the role that linkages between specialty mental health and primary health care providers can play in the effectiveness of such care. Although these are issues that must be generally addressed, in rural areas fewer institutional and individual providers per capita accentuate problems of health care organization and delivery. This paper reports findings from an exploratory study of service use in two primary care sites in a rural, group-model HMO (Site A enrollment = 2,625; Site B = 6,019). We found that patients in the primary care site who had weaker mental health consultative linkages, higher rurality, and less availability of mental health specialty care used more mental health services by primary care providers (RR = 5.19 (3.78,6.61)), received more ambulatory care from joint mental health/ primary care providers (RR = 1.68 (1.02,2.78)), and had more mental health hospital utilization (adjusted OR = 1.84 (0.54,6.23)). These findings point to the need for further study of primary care providers and their linkage relationships in rural areas, in this large and currently often underserved population.
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