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6 | Pg 7 References and Abstracts Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice BMJ 1994;308(6936):1083-6. Objectives: To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists’ and general practitioners’ views on outreach clinics. Design:Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. Setting: 50 hospitals in England and Wales. Subjects: 50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. Main Outcome Measures: Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. Results: 28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. Conclusions: Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists. Balestrieri M, Williams P, Wilkinson G. Specialist mental health treatment in general practice: a meta-analysis. Psychol Med 1988;18(3):711-7. A meta-analysis of studies was carried out to compare treatment by specialist mental health professionals in the general practice setting and usual GP treatment. Overall, treatment by specialist mental health professionals had a 10% greater success rate. Biderman A, Yeheskel A, Tandeter H, Umansky R. Advantages of the psychiatric liaison-attachment scheme in a family medicine clinic. Isr J Psychiatry Relat Sci 1999;36(2):115-21. Background: The study presents the advantages of the psychiatric liaison-attachment scheme, by analyzing the psychiatric consultations of a 12 months period (1995), in an urban family medicine clinic in Israel. Method: Family physicians filled a questionnaire about all patients who had been seen at the consultation. Results: The consulting psychiatrist saw 46 patients. The reasons for consultation were mostly to confirm a diagnosis and to decide upon medications. Medical diagnoses most often made were depression and personality disorder. The psychiatrist referred 35% of patients for further therapy in the psychiatric clinic. The family physicians would have referred 45% of patients to psychiatric clinics, if they had no psychiatric consultation available. All patients referred complied with the recommended referral. Family physicians saw accessibility as the main advantage of this consultation strategy. Limitations: This study was done in a unique setting, a teaching family medicine clinic, with nine specialized family physicians working in the psychiatric liaison-attachment scheme for as long as 10 years and more. Therefore the results of this study may not be generalized to other clinics. Conclusions: We conclude that the advantages of the psychiatric liaison-consultation method were for the patients, the family physicians and the psychiatric consultant. The main advantages for the family physicians, as stated by them, were the accessibility, the non-stigmatic availability of a psychiatrist in the clinic, and the good compliance with referral to psychiatric therapy. For the consulting psychiatrist, the advantages were the valuable information from the family physicians and the social worker, the better follow-up of patients and the team work with the family practice team. Bower P, Sibbald B. Do consultation-liaison services change the behavior of primary care providers? A review. Gen Hosp Psychiatry 2000;22(2):84-96. Browning SM, Ford MF, Goddard CA, Brown AC. A psychiatric clinic in general practice—a description and comparison with an outpatient clinic. Bull R Coll Psychiatrists 1987;11:114-117. Burbach FR, Harding S. GP referral letters to a community mental health team: an analysis of the quality and quantity of information. Int J Health Care Qual Assur Inc Leadersh Health Serv 1997;10(2-3):67-72. Presents the results of a study which investigated whether the quality of information provided by GP referral letters to a community mental health team (CMHT) was sufficient to determine an appropriate response and the allocation of professional resources. A random sample of GP referral letters received over a six month period was analysed. The presenting problem, diagnosis and the indication of severity of symptoms were rated. Perusal of the CMHT members replies to the GPs allowed a rough analysis of the extent of agreement with the GPs’ diagnoses, description of presenting problems and severity of symptoms. Discusses the results of the study with regard to the implications of GP fundholding and the employment of GP-based counsellors. Carr VJ, Donovan P. Psychiatry in general practice. A pilot scheme using the liaison-attachment model. Med J Aust 1992;156(6):379-82. Objective: To improve the quality and accessibility of psychiatric service in the primary care setting. Design: Under the liaison-attachment model, a senior psychiatry trainee provided psychiatric consultations part-time in general practice over an 18-month period. Patients regarded by the participating doctors as having significant psychiatric problems were referred to the trainee for consultation. Setting: Four group general practices, involving 18 doctors, took part in the scheme. Participants: During the study 172 patients with a wide spectrum of diagnoses were assessed. Near the end of the 18-month period the participating general practitioners provided their evaluations of the scheme. Intervention: In almost all cases standard treatment was provided in the primary care setting and administered by either a general practitioner, the trainee or both working collaboratively together. Outcome Measures: The general practitioners evaluated the results of the consultations and the effect of the service on their referral patterns. They also rated the overall impact of the scheme on their own knowledge and skills, the quality of care, and its accessibility. Results: The quality of outcome, if known, was regarded as satisfactory in 88% of cases. The reported frequency of referrals to psychiatrists in private practice dropped significantly. The participating doctors perceived improvements in their own abilities to deal with psychiatric problems and regarded the quality and accessibility of psychiatric care to be enhanced by the scheme. Conclusions: The psychiatric liaison-attachment model, developed in Britain, is applicable and effective in the Australian primary care setting. Carr VJ, Faehrmann C, Lewin TJ, Walton JM, Reid AA. Determining the effect that consultation-liaison psychiatry in primary care has on family physicians psychiatric knowledge and practice. Psychosomatics 1997;38(3):217-29. The impact of a community-based consultation-liaison (C-L) psychiatry service on family physicians’ levels of psychiatric knowledge, diagnostic and treatment confidence, and patterns of referral to mental health care agencies was evaluated over a 12-month period. The physicians with long-term access to the C-L service had higher levels of psychiatric knowledge than those with short-term or no access. However, there was no evidence that the C-L service produced changes in the physicians levels of clinical confidence, referral likelihood, or psychiatric knowledge during the evaluation period. Significant predictors of psychiatric knowledge were age (younger) and gender (women). The participating physicians were highly satisfied with the service and preferred it over other possible referral agencies. However, community C-L services in family practice appear to have a limited role in the provision of psychiatric care and are not an efficient way for improving family physicians’ levels of psychiatric knowledge or altering their practices. The appropriate role of community C-L psychiatry may be as one component of a comprehensive service-delivery strategy integrated within ongoing, formal family-physician educational programs. Carr VJ, Lewin TJ, Reid AL, Walton JM, Faehrmann C. An evaluation of the effectiveness of a consultation-liaison psychiatry service in general practice. Aust N Z J Psychiatry 1997;31(5):714-25; discussion 726-7. Objective: This study evaluated the 6-month outcome of patients referred by their general practitioner (GP) to a consultation-liaison (C-L) psychiatry service provided to eight group general practices. Method: Over a 12-month period, there were 307 referrals to the C-L psychiatry service of whom 86 consented to take part in an outcome study. Two different control groups were examined comprising patients seen by the same GPs but not referred to the C-L service, who were matched with the C-L referrals on the basis of either demographic characteristics (n = 86) or initial symptomatology (n = 59). Clinical interviews were conducted at recruitment to the outcome study using the Composite International Diagnostic Interview (CIDI), while postal questionnaires were used at both the initial and 6-month assessments. Results: Data reported include DSM-III-R clinical audit and CIDI diagnoses, changes in current symptomatology (SCL-90-R) and changes in global ratings of physical health, emotional health, social relationships and ability to perform everyday duties. Consultation-liaison referrals without symptom-matched controls (n = 27), being patients with higher levels of symptoms initially, were more likely to be referred to other psychiatric services for treatment. They also showed more marked improvement over time on the selected outcome measures. However, there were no significant differences in the patterns of change over time between symptom-matched C-L referrals and their non-referred controls. Conclusions: The findings from the 6-month outcome study raise doubts about the overall benefit of the current C-L service relative to usual GP care. Improving the quality of psychiatric care in general practice is likely to require a range of interrelated strategies, including C-L psychiatry services, GP education and well-functioning links with public mental health services. Carr VJ, Lewin TJ, Walton JM, Faehrmann C, Reid AL. Consultation-liaison psychiatry in general practice. Aust N Z J Psychiatry 1997;31(1):85-94. Objective: This paper describes the characteristics of 303 consecutive referrals, over a 12-month period, to a consultation-liaison (C-L) psychiatry service provided to eight group general practices in Newcastle, Australia. Method: A purpose designed service audit form was used throughout the evaluation period to collect information about demographic characteristics, reasons for referral, service contacts, psychiatric diagnoses and clinical management. In addition, patients were invited to participate in a separate, prospective outcome evaluation study, which involved structured interviews and questionnaires. Results: The most common reasons for referral were: depression (33%); anxiety (12%); diagnostic assessment (9%); and impaired relationships (8%). The most common psychiatric diagnoses were: mood disorders (29%); mild, transient conditions (29%); anxiety (14%); and substance abuse disorders (12%). Following the psychiatric consultation(s), GPs were actively involved in patients’ treatment in 53% of cases. However, there was a higher than expected rate of referral (44%) to another mental health agency. Selected comparisons are also reported between patients referred to the C-L service (n = 303) and a sample of non-referred GP attenders (n = 535). Conclusions: As expected, the diagnostic profiles of patients attending the C-L service differed in several respects from those using similar services in general hospitals. There were comparatively low rates of organic brain syndromes, suicide risk evaluations, and problems of differential diagnosis of somatic symptoms. Greater emphasis needs to be placed on more formal psychiatric education for GPs, on ways of screening out from the referral process those patients with mild, transient conditions who do not require specialist expertise, and on the development of strategies to help GPs manage such conditions Corney RH. Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding. Br J Gen Pract 1996;46(405):221-4. Background: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. Aim: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. Methods: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. Results: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. Conclusion: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.
Daniels ML, Linn LS. Psychiatric consultation in a medical
clinic: what do medical providers want? Gen Hosp Psychiatry 1984;6(3):196-202. A participant observation needs assessment of the use of a psychiatrist in a primary care medical setting was undertaken to quantify details of the interaction between a psychiatrist and primary care providers. Two hundred seventeen encounters involving 63 providers were recorded over a five and one-half month period. Utilization of the psychiatrist was widespread but skewed, with only 17% of the sample using 50% of the services. The mean number of encounters for all providers was 3.44. Consultation occurred mainly in a private area of the clinic, usually in an unplanned fashion. Only 21% of encounters involved seeing a patient. The range and content of these interactions was broad. Initial reasons for consultation were often redefined as the consultation ensued. The kinds of help most frequently requested involved discussing non psychopharmacologic treatments (35%), assisting providers with evaluations (31%), and exploring unresolved feelings about patients or patient care issues (29%). Slightly more than 50% of encounters required some type of follow-up. The findings suggest that psychiatrists who wish to work in primary care settings must have expertise in a multitude of areas and must be flexible in adapting themselves to the setting in which the primary care providers work. Darling C, Tyrer P. Brief encounters in general practice: liaison in general practice psychiatry clinics. Psychiatric Bulletin 1990;14:592-594. Davies JW, Ward WK, Groom GL, Wild AJ, Wild S. The case-conferencing project: a first step towards shared care between general practitioners and a mental health service. Aust N Z J Psychiatry 1997;31(5):751-5. Objectives: The objectives of this study were: (i) to improve general practitioners knowledge of the mental disorders they commonly treat, and to increase their confidence in managing people with these disorders; and (ii) to increase general practitioners’ familiarity with the Logan-Beaudesert Mental Health Service. Method: Eleven general practitioners met with psychiatrists from the Logan-Beaudesert Mental Health Service in six 2-hour sessions held at monthly intervals. Each session comprised a teaching component, a consumer interview and a case-conference. Outcomes were measured using an objective test of general practitioners’ knowledge, a subjective test of their confidence in dealing with mental health problems, and satisfaction surveys for participating consumers, general practitioners and psychiatrists. Results: On the objective test, the scores of 10 out of the 11 general practitioners improved (P < 0.05). On the subjective test, the ranked scores improved in nine out of the 11 cases (P < 0.05). Consumers, general practitioners and psychiatrists expressed their satisfaction with the format and content of the course. Conclusions: Having improved the knowledge of a group of general practitioners who are familiar with the functioning of the Logan-Beaudesert Mental Health Service, the stage is now set to proceed to the next step: the shared-care project. Ferguson B, Cooper S, Brothwell J, Markantonakis A, Tyrer P. The clinical evaluation of a new community psychiatric service based on general practice psychiatric clinics. Br J Psychiatry 1992;160:493-7. A new community psychiatric service in Nottingham based on general practice clinics was compared with a conventional hospital-orientated model. Despite providing treatment for an inner-city population of significantly greater social disadvantage, the community service was associated with similar levels of symptom morbidity as assessed by the CRPS and the SFS. It also involved greater use of day-hospital facilities, more extensive multidisciplinary care, and a commitment to longer-term follow-up of chronically ill patients. Such a model is offered as a basis for future developments of urban community psychiatric services. 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, 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 services 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. Hansen V. Psychiatric service within primary care. Mode of organization and influence on admission-rates to a mental hospital. Acta Psychiatr Scand 1987;76(2):121-8. The organization of a psychiatric specialist service integrated in primary care is described. One of the aims was to replace admissions to the mental hospital with consultation and treatment within primary care. An 18% reduction of admissions was achieved over a 2-year period. The staff at the local mental hospital to a large extent controlled the number of admissions. Lack of cooperation from part of the staff made a greater reduction of admissions difficult. It is argued that in order to achieve a true shift from institutional to community psychiatry, the use of the hospital beds should be monitored from the community level. Jackson G, Gater R, Goldberg D, Tantam D, Loftus L, Taylor H. A new community mental health team based in primary care. A description of the service and its effect on service use in the first year. Br J Psychiatry 1993;162:375-84. A new community multidisciplinary team based in primary care is described and the experience of the first year discussed. The effect the team has had on the use of psychiatric services in its first year was studied. There was a threefold increase in the rate of inception to care, leading to a doubling in the prevalence of treated psychiatric disorder. There has been a reduction in the demands made on the hospital out-patient services, but no change in the use of in-patient resources or emergency contacts.
Kates N. Psychiatric consultation in the family physician’s
office. Advantages and hidden benefits. Gen Hosp Psychiatry 1988;10(6):431-7. Family physicians spend up to 40% of their time dealing with emotional and psychiatric problems and may be the only caretaker for 60% of all episodes of psychiatric illness. One way of strengthening the role of the family physician in managing psychiatric problems in their practices is by involving them in an initial psychiatric assessment, which may entail the patient being seen in the primary care setting. This intervention, offered by a community mental health center (CMHC) in Ontario, Canada, was evaluated by examining all cases referred by family physicians over a 3-year period and comparing those seen in consultation in family physicians’ offices with those seen in consultation in the CMHC. While the office consultation appears to be a cost-effective intervention, the main factor that determined whether it took place appeared to be the attitude of the referring physician rather than the nature of presenting problem. Other benefits arising from such a liaison-consultation relationship are also discussed.
Kates N, Craven M, Crustolo AM, Nikolaou L, Allen C. Integrating
mental health services within primary care. A Canadian program. Gen
Hosp Psychiatry 1997;19(5):324-32. The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists into the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the program’s operation (13 practices and 45 family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered new opportunities for continuing education, and led to a reduced and more efficient use of other mental health services. The components of the program can be adapted to most communities. Kates N, Craven M, Webb S, Low J, Perry K. Case reviews in the family physician’s office. Can J Psychiatry 1992;37(1):2-6. The majority of patients with emotional or psychiatric disorders are treated in the primary care setting without psychiatric input. Psychiatrists need to find ways of helping family physicians manage these patients without necessarily taking over their care. One way of achieving this is for a psychiatric consultant to visit the family physician’s office on a regular basis to discuss the physician’s problem cases. This paper describes such a pilot project, outlines the kinds of problems family physicians discussed and recommendations that were made, and discusses the benefits of this collaborative approach. Kates N, Craven MA, Crustolo AM, Nikolaou L, Allen C, Farrar S. Sharing care: the psychiatrist in the family physician’s office. Can J Psychiatry 1997;42(9):960-5. Objective: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. Method: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. Results: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. Conclusions: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists. Kates N, Crustolo AM, Nikolaou L, Craven MA, Farrar S. Providing psychiatric backup to family physicians by telephone. Can J Psychiatry 1997;42(9):955-9. Objective: To examine whether links between psychiatric services and family physicians can be strengthened and additional support provided for family physicians if a psychiatrist is available by phone to respond to clinical calls from family physicians. Method: A psychiatrist, who visited 18 family physicians in 5 practices on a regular basis to provide clinical consultations, was available to provide telephone backup concerning mental health problems the family physicians encountered. All calls received by the psychiatrist were documented and analysed at the end of a 12-month period. Results: Over the course of one year, 128 calls were received from the 5 practices. Fifty were considered urgent, while 78 involved more routine management or medication issues. Telephone advice enabled the family physicians to handle these cases more effectively, often reducing utilization of other mental health services and providing support that was not otherwise available. The average time spent per call was 8 minutes, which meant the psychiatrist was only spending 20 minutes per week on the phone responding to family physicians requests. Conclusion: Providing telephone backup to family physicians is a time-efficient and effective method of supporting family physicians and reducing utilization of mental health services. It is applicable to psychiatrists working in any clinical setting. Kates N, Craven M, Crustolo AM, Nikoloau L. Mental health services in the family physician’s office: a Canadian experiment. Isr J Psychiatry Relat Sci 1998;35(2):104-13. This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician’s office and the way in which these teams are coordinated and discusses how this “shared care” approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients’ providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities. Katon W, Gonzales J. A review of randomised trials of psychiatric consultation-liaison studies in primary care. Psychosomatics 1994;35(3):268-78. The field of consultation-liaison (C-L) psychiatry has developed a variety of research interventions to try to improve the recognition and treatment of mental disorders in primary care. The authors review the results of three generations of randomised trials of mental health interventions developed by C-L psychiatrists. In general, these trials have been more successful in improving detection of mental illness and increasing the application of mental health treatments by primary care physicians than in changing patient outcomes. The results of these randomised trials are interpreted by using models developed in the health services field. Katon W, Von Korff M, Lin E, and others. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273(13):1026-31. Objective: To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of “usual care” by the primary care physician. Design: A randomised controlled trial among primary care patients with major depression or minor depression. Patients: Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomised, with 91 patients meeting criteria for major depression and 126 for minor depression. Interventions: Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials. Main Outcome Measures: Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms. Results: In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P < 0.01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < 0.03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < 0.01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < 0.01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < 0.004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < 0.001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P < 0.02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time. Conclusion: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression. Katon W, Robinson P, Von Korff M, and others. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53(10):924-32. Background: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. Methods: One hundred fifty-three primary care patients with current depression were entered into a randomised controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received “usual” care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. Results: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. Conclusion: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression. Klinkman MS, Okkes I. Mental health problems in primary care. A research agenda J Fam Pract 1998;47(5):379-84. Background: The North American Primary Care Research Group (NAPCRG) Task Force on Mental Health Problems was commissioned to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action by NAPCRG. This paper presents the key findings and recommendations of the task force. Methods: As co-chairpersons of the task force, we performed a comprehensive review of the primary care mental health literature using MEDLINE searches with manual follow-up and personal communications with many active researchers in the field. Task force members participated in the editing and refinement of this paper through electronic mail and a series of face-to-face meetings. Conclusions: Rapid changes in the US health care environment threaten to undo the integration of mental and physical health that is at the heart of primary care. It will be necessary for the primary care leaders in the mental health field to step forward to guide policymakers, purchasers, and the public as primary care is reengineered for the next generation. Efforts to use episode of care and comorbidity recording within electronic medical record systems, particularly in cooperation with managed care corporations or primary care research networks, may represent the most effective strategy for promoting the integration of mental health services into primary care. The most promising area for original research may be the exploration of common mental health problems in the context of routine primary care practice. Low CB, Pullen I. Psychiatric clinics in different settings. A case register study. Br J Psychiatry 1988;153(8):243-5. Out-patient referrals to the Edinburgh adult psychiatric service between 1981 and 1985 were studied using the Edinburgh Psychiatric Case Register. The hypotheses that primary-care clinics have more patients with less severe illnesses and fewer patients with psychotic illnesses were confirmed. Meadows GN. Establishing a collaborative service model for primary mental health care. Med J Aust 1998;168(4):162-5. A collaborative project between general practitioners and mental health services, which links a consultation-liaison model with shared care, was piloted with success. This article provides a broad overview of the service model and the stages in its development. Midgley S, Burns T, Garland C. What do general practitioners and community mental health teams talk about? Descriptive analysis of liaison meetings in general practice. Br J Gen Pract 1996;46(403):69-71. Background: Liaison meetings between psychiatrists and general practitioners are now well established. Much has been written about their purpose and structure but little about their content. Aim: A study aimed to describe the clinical focus of meetings between a community mental health team and general practitioners and the nature of the professionals’ interactions. Method: Audiotapes of six consecutive monthly meetings between a community mental health team and general practitioners in two general practices were analysed. Results: Attendance rates among professionals were over 70%. Over 90% of discussion time was focused on patient-centred clinical matters. Almost two thirds of interactions were focused on patients receiving ongoing joint care; few interactions were devoted to new referrals or to patients who had not been assessed. Psychotic patients, although accounting for 15% of referrals, occupied 54% of patient-centred discussion time. Most interactions consisted of reciprocal information exchange between members of the community mental health team and general practitioners. Conclusion: The high attendance rates indicate that both general practitioners and community mental health team members considered these meetings as high priority. The steady move towards management of severely ill psychiatric patients in the community rather than in hospital requires close collaboration between primary and secondary care teams. The meetings described in this paper appear to be a simple, manageable and sustainable response to this need. Nickels MW, McIntyre JS. A model for psychiatric services in primary care settings. Psychiatr Serv 1996;47(5):522-6. The integration of mental health care and primary medical care enhances the quality of patient care and may improve the overall cost- effectiveness of a health care system. The authors describe implementation of a program that provides mental health care at 12 locations in a network of primary care sites associated with a university-affiliated community hospital in Rochester, New York. A project of the hospital’s department of psychiatry, the program has as its goals improved recognition, diagnosis, and treatment of mental health problems and education of primary care providers in these areas. Each of the program’s three primary therapists provide short-term, symptom-focused individual, marital, family, and group therapies and case consultation at several primary care sites. The program director, a psychiatrist, makes diagnostic assessments and provides medication consultation to both the primary therapists and the primary care physicians. The authors discuss the advantages and disadvantages of the program model and plans for its future development. Pullen IM, Yellowlees AJ. Scottish psychiatrists in primary health-care settings. A silent majority. Br J Psychiatry 1988;153:663-6. There has been a growing number of reports of psychiatrists moving out into primary-care settings. We report a survey of consultant psychiatrists to assess the extent of this practice in Scotland. Some time spent in the primary-care setting was reported by 56%, the figures being highest in rural areas. An equal number of non-consultant medical staff were involved. Most schemes were initiated by psychiatrists, over half of whom had had some postgraduate general-practice experience. A similar survey in England and Wales showed that only 19% of consultant psychiatrists spent time in primary-care settings, a smaller proportion of non-consultant staff being involved. The value of working in primary-care settings has yet to be assessed.
Schulberg HC. Mental disorders in the primary care setting.
Research priorities for the 1990s. Gen Hosp Psychiatry 1991;13(3):156-64. 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. Shah A. Cost comparison of psychiatric outpatient clinics based in hospitals and in primary care (general practice health center). Acta Psychiatr Scand 1995;92(1):30-4. The first study to compare the costs of hospital-based and primary care (general practice health center)-based psychiatric outpatient clinics is reported. The operating costs of both clinic settings were estimated to be similar. There are many advantages of primary care-based clinics compared with hospital-based clinics. However, as there are no evaluative studies of the comparative efficacy of either clinic setting, before policy decisions to encourage primary care clinics are made such evaluative studies should take place. Strathdee G. Psychiatrists in primary care: the general practitioner viewpoint. Fam Pract 1988;5(2):111-5. Within the past few decades, a growing number of psychiatrists in the UK have moved their outpatient clinics out of their hospital bases and have established liaison-attachment clinics in primary care settings within their catchment areas. This study reports the views of the senior general practitioners who have access to such clinics in their practices. The majority described a significant alteration in the nature of their relationships with the specialists. This, together with the opportunity for general practitioners to become involved in integrated management approaches, is believed to significantly improve continuity of patient care. Strathdee G, Brown RM, Doig RJ. Psychiatric clinics in primary care. The effect on general practitioner referral patterns. Soc Psychiatry Psychiatr Epidemiol 1990; 25:95-100. A consecutive series of 176 referrals from family doctors to psychiatrists conducting their outpatient clinics in primary care was studied. The presence of psychological symptoms was the stated reason for referral in only half of the patients, although chronic illnesses and the psychotic disorders were well represented. Female sex, attending the GP with physical ill-health and the absence of personality disorder were influential but unacknowledged factors in the referral process. The implications of these findings for the development of community psychiatric services and the relationship between primary and secondary care is discussed. Subotsky F, Brown RM. Working alongside the general practitioner: a child psychiatric clinic in the general practice setting. Child Care Health Dev 1990;16(3):189-96. A monthly child psychiatric clinic was established in a primary health care centre in order to offer a more accessible service to patients, and to improve liaison with primary health care professionals. Compared with the base child guidance unit, at the health centre there was a better first attendance rate, a much higher proportion of referrals from health professionals especially general practitioners, and an increased proportion of younger children referred. If further follow-up was necessary at the child guidance unit the attendance rate was very good. The service provided, although not reducing the need for a main multidisciplinary base, offered an acceptable and accessible opportunity for children with psychological problems to be assessed and treated, and for the referring professionals to have easy communication with the child psychiatrist. Turner T, de Sorkin A. Sharing psychiatric care with primary care physicians: the Toronto Doctors Hospital experience (1991-1995). Can J Psychiatry 1997;42(9):950-4. Objectives: To investigate the shared mental health care experience of the psychiatry department of a small urban general hospital, which serves an ethnoculturally diverse population. Methods: A chart survey was undertaken of all patients referred by community physicians to a new shared care program between January 1991 and December 1995. Selected demographic and diagnostic characteristics were collected and analyzed. Results: Seven hundred and thirteen patients were assessed. They were principally female, ethnoculturally varied, and highly comorbid. The most striking association involved mood and substance-related disorders. Conclusion: The Doctors Hospital experience shows that the shared care approach can reach large numbers of patients through a multiplier effect. Additionally, this approach has the potential to enhance access for ethnoculturally varied and diagnostically complex groups. Tyrer P, Ferguson B, Wadsworth J. Liaison psychiatry in general practice: the comprehensive collaborative model. Acta Psychiatr Scand 1990;81(4):359-63. A model of liaison psychiatry in general practice is described and its impact assessed using data from the Nottingham psychiatric case register. The model incorporates a comprehensive network of general practice psychiatric clinics for both psychiatrists and other mental health professionals, associated with mainly informal liaison with general practitioners and others in the primary care team, and a reduction in psychiatric outpatient clinics. Following the introduction of this model, the proportion of new and referred patients seen in primary care settings rose from 1% to 18% in Nottingham over an 8-year period. Over this period admission rates significantly fell in Nottingham compared with the rest of England and evidence is given that the growth of primary care psychiatry contributed significantly to this reduction. Tyrer P, Turner R, Johnson AL. Integrated hospital and community psychiatric services and use of inpatient beds. BMJ 1989;299(6694):298-300. The impact of introducing a divisional psychiatric service based in the community in Nottingham in 1981 on adult psychiatric admissions (patients aged 15-65) was examined with data from the Nottingham case register. During 1980-5 the number of psychiatric admissions fell significantly (4.5% a year) compared with the national figures (0.46% a year). Admissions were reduced most for the diagnoses of affective psychosis and neurotic and personality disorders. The average duration of admission fell by 3.6% a year, and use of inpatient beds fell by 37.5%. Integrating hospital and community psychiatric services by creating sectors is a viable and economically feasible way of improving psychiatric services. Von Korff M, Katon W, Bush T, and others. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60(2):143-9. Objective: The report estimates the treatment costs, cost-offset effects, and cost-effectiveness of Collaborative Care of depressive illness in primary care. Study Design: Treatment costs, cost-offset effects, and cost-effectiveness were assessed in two randomised, controlled trials. In the first randomised trial (N = 217), consulting psychiatrists provide enhanced management of pharmacotherapy and brief psychoeducational interventions to enhance adherence. In the second randomised trial (N = 153). Collaborative Care was implemented through brief cognitive-behavioral therapy and enhanced patient education. Consulting psychologist provided brief psychotherapy supplemented by educational materials and enhanced pharmacotherapy management. Results: Collaborative Care increased the costs of treating depression largely because of the extra visits required to provide the interventions. There was a modest cost offset due to reduced use of specialty mental health services among Collaborative Care patients, but costs of ambulatory medical care services did not differ significantly between the intervention and control groups. Among patients with major depression there was a modest increase in cost-effectiveness. The cost per patient successfully treated was lower for Collaborative Care than for Usual Care patients. For patients with minor depression, Collaborative Care was more costly and not more cost-effective than Usual Care. Conclusions: Collaborative Care increased depression treatment costs and improved the cost-effectiveness of treatment for patients with major depression. A cost offset in specialty mental health costs, but not medical care costs, was observed. Collaborative Care may provide a means of increasing the value of treatment services for major depression. Warner RW, Gater R, Jackson MG, Goldberg DP. Effects of a community mental health service on the practice and attitudes of general practitioners. Br J Gen Pract 1993;43(377):507-11. Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners’ ability to detect or manage psychiatric illness. Wilkinson G, Piccinelli M, Falloon I, Krekorian H, McLees S. An evaluation of community-based psychiatric care for people with treated long-term mental illness. Br J Psychiatry 1995;167(1):26-37; discussion 38-40. Background: We evaluated integrated, multidisciplinary, community-based care for a cohort of people with treated long-term mental illness over two years in a field trial set in a semi-rural setting. The aim was to organize local psychiatric services on an extramural basis with general practitioner teams as the key element. Method: Trained research workers used a structured interview to collect standardized base-line and three-monthly socio-demographic, clinical, social, family adjustment and burden, and treatment measures from patients, informants, and key-workers. Analysis included descriptive statistics and, for longitudinal data, analysis of best-fitted straight lines. Results: We studied 34 patients (14 with schizophrenia, 11 with major affective disorders, and 9 with minor (non-major) affective disorders and anxiety disorders) who had a mean of 12 years continuous illness. At baseline, they were mainly characterized by research workers as mildly ill with fair social adaptive functioning, and by lay informants as having moderate target symptom severity and disturbance of social performance. Over two years, there were statistically significant, slight improvements in clinical global impressions ratings by research workers, and in informants’ ratings of target symptoms and social performance. Most patients continued to receive prescriptions for psychotropic drugs throughout follow-up, and they had a mean of 47 therapeutic contacts, mainly from nurses. Two patients were admitted to psychiatric hospital. There were few differences between patients in different diagnostic groups. Conclusions: Integrated, multidisciplinary, community-based psychiatric care for people with treated long-term mental illness is feasible in a semi-rural setting: patients receiving pharmacotherapy and regular psychosocial treatments remained relatively stable on clinical and social measures over two years. The unique way in which the service was monitored, by making regular, systematic assessments of patients and carers, serves as an example for other services. Williams P, Balestrieri M. Psychiatric clinics in general practice. Do they reduce admissions? Br J Psychiatry 1989;154:67-71. General-practice-based psychiatric clinics have increased substantially in recent years. We investigated the influence on psychiatric admissions of this style of practice in England over an 18-year period. We utilized data from a previous survey concerned with this type of work (Strathdee and Williams, 1984) and compared them with figures on psychiatric admissions. Parts of the country in which there has been greater development of general-practice-based psychiatric clinics were also those in which there has been a steeper decrease in psychiatric admissions. Further analysis showed this to be due primarily to an effect on admission of non-psychotic patients.
Yuen EJ, Gerdes JL, Gonzales JJ. Patterns of rural mental
health care. An exploratory study Gen Hosp Psychiatry 1996;18(1):14-21. 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. |
