General Medical Providers Research Articles

Prevalence, Treatment Data Raise Troubling Questions

Prevalence, Treatment Data Raise Troubling Questions

Folgeerkrankungen nach Organtransplantation

Transplant medicine has significantly changed the prognosis of diseases leading to terminal organ failure. It has evolved from an experimental procedure to standard therapy for liver, kidney and cardio-vascular diseases. Transplant medicine combines operative organ replacement with the management of severely ill patients before transplantation, as well as life-long follow-up of organ graft recipients. Ten year survival rates of 65% to over 90% have led to a steady increase of transplanted patients seen by general medical care providers which represents a challenge for practicing internists. Apart from organ-specific conditions, infectious, immunosuppressant-associated and metabolic consequences determine long-term survival. These include virus reactivation, graft rejection, anastomotic problems but more importantly general mortality determining factors such as diabetes, renal insufficiency and hypertension, which are often a consequence of immunosuppressant administration. They directly impact long-term survival. The awareness and treatment of these secondary conditions of organ transplantation in routine medical practice contributes significantly to secure the long term success of transplant medicine.

Transforming Mental Health Care at the Interface With General Medicine: Report for the Presidents Commission

This paper is based on a report commissioned by the Subcommittee on Mental Health Interface With General Medicine of the Presidents New Freedom Commission on Mental Health. Although mental and medical conditions are highly interconnected, medical and mental health care systems are separated in many ways that inhibit effective care. Treatable mental or medical illnesses are often not detected or diagnosed properly, and effective services are often not provided. Improved mental health care at the interface of general medicine and mental health requires educated consumers and providers; effective detection, diagnosis, and monitoring of common mental disorders; valid performance criteria for care at the interface of general medicine and mental health; care management protocols that match treatment intensity to clinical outcomes; effective specialty mental health support for general medical providers; and financing mechanisms for evidence-based models of care. Successful models exist for improving the collaboration between medical and mental health providers. Recommendations are presented for achieving high-quality care for common mental disorders at the interface of general medicine and mental health and for overcoming barriers and facilitating use of evidence-based quality improvement models.

Psychiatry Resident Graduate Comfort With General Medical Issues: Impact of an Integrated Psychiatry-Primary Medical Care Training Track

To determine if a psychiatry-primary medical care (PPMC) training track impacts comfort and behaviors related to addressing general medical issues after residency. Thirty five psychiatry resident graduates completed mailed surveys; nine of them had completed the PPMC track. Compared to non-PPMC participants, PPMC participants felt better prepared to address medical issues and tended to perform more consultations and feel more comfortable referring patients to general medical providers. They were not more likely to perform routine health screenings. Integrated training tracks may impact resident preparedness and career choice but may be insufficient to influence practice behaviors related to delivering general medical care.

Epidemiology of psychiatric and alcohol disorders in Ukraine

This study presents the lifetime, 12-month, and 1-month prevalence estimates of nine psychiatric and alcohol disorders in Ukraine assessed as part of the World Health Organization (WHO) World Mental Health (WMH) research program. The Ukraine WMH survey is the first psychiatric epidemiologic study in a former Soviet Union country to administer a structured psychiatric interview to a nationally representative sample. In 2002, a national probability sample of 4,725 respondents ages 18 and older were interviewed with the WMH version of the Composite International Diagnostic Interview (WMH-CIDI). Prevalence estimates, age-of-onset curves, comorbidity, demographic and geographic risk factors, and treatment seeking were examined. Close to one third of the population experienced at least one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder in their lifetime, 17.6% experienced an episode in the past year, and 10.6% had a current disorder. There was no gender difference in the overall prevalence rates. In men, the most common diagnoses were alcohol disorders (26.5% lifetime) and mood disorders (9.7% lifetime); in women, they were mood disorders (20.8% lifetime) and anxiety disorders (7.9% lifetime). The odds ratios for most pairs of disorders were highly significant. Age of onset was primarily in the teens and early 20s. Age, education, and living in the Eastern region of Ukraine were significant risk factors across disorders, with respondents older than 50 years having the highest prevalence of mood disorder and the lowest prevalence of alcoholism and intermittent explosive disorder. Only a minority of respondents talked to a professional about their symptoms. Prevalence estimates of alcoholism among men and recent depression among women were higher in Ukraine than in comparable European surveys. The results argue for the need to develop and implement educational programs focused on the recognition and treatment of mental and alcohol disorders for the general population, psychiatrists, and general medical providers, who are the main source of mental health care.

Twelve-Month Use of Mental Health Services in the United States

Dramatic changes have occurred in mental health treatments during the past decade. Data on recent treatment patterns are needed to estimate the unmet need for services. To provide data on patterns and predictors of 12-month mental health treatment in the United States from the recently completed National Comorbidity Survey Replication. Nationally representative face-to-face household survey using a fully structured diagnostic interview, the World Health Organization's World Mental Health Survey Initiative version of the Composite International Diagnostic Interview, carried out between February 5, 2001, and April 7, 2003. A total of 9282 English-speaking respondents 18 years and older. Proportions of respondents with 12-month DSM-IV anxiety, mood, impulse control, and substance disorders who received treatment in the 12 months before the interview in any of 4 service sectors (specialty mental health, general medical, human services, and complementary and alternative medicine). Number of visits and proportion of patients who received minimally adequate treatment were also assessed. Of 12-month cases, 41.1% received some treatment in the past 12 months, including 12.3% treated by a psychiatrist, 16.0% treated by a non-psychiatrist mental health specialist, 22.8% treated by a general medical provider, 8.1% treated by a human services provider, and 6.8% treated by a complementary and alternative medical provider (treatment could be received by >1 source). Overall, cases treated in the mental health specialty sector received more visits (median, 7.4) than those treated in the general medical sector (median, 1.7). More patients in specialty than general medical treatment also received treatment that exceeded a minimal threshold of adequacy (48.3% vs 12.7%). Unmet need for treatment is greatest in traditionally underserved groups, including elderly persons, racial-ethnic minorities, those with low incomes, those without insurance, and residents of rural areas. Most people with mental disorders in the United States remain either untreated or poorly treated. Interventions are needed to enhance treatment initiation and quality.

Identification of and Guidance for Problem Drinking by General Medical Providers

Heavy alcohol use is associated with health costs and medical problems. There has been a growing consensus that primary care patients should be screened for alcohol problems. We examined rates at which patients were asked about alcohol or drug use and problems, extending research in this area by using a standardized problem drinking instrument with a large national sample, examining community level variables, and assessing the extent to which patients who were identified received follow-up. A subsample of 7371 persons from the 1998 Healthcare for Communities survey who reported visiting a general medical provider (GMP) in the past year. Participants completed questionnaires on demographics, mental and physical health, alcohol, drug use and problems, enrollment in a managed health care plan, whether their medical provider asked about alcohol or drug use, and whether they received advice, counseling, or referral. Being asked about alcohol and drug use was associated with being male, young, highly educated, more health problems, mental health diagnosis, and being classified as a problem drinker. Only 48% of problem drinkers received any follow-up, with most being told to "stop drinking" by their GMP. Few people are queried about alcohol or drug use when they visit a GMP. When problem use is identified, most patients do not receive appropriate follow-up and aftercare. The quality of primary care could improve if GMPs were educated about providing brief advice/counseling and were given information concerning resources in their community to make appropriate referrals for patients.

Fighting the Psychological War on Terrorism

The article by Stein and associates (Stein et al. 2004) documents the psychological consequences of the September 2001 terrorist attacks on the World Trade Center. A significant number of the 16% surveyed adults with persistent distress reported ongoing impairment in vocational and social functioning as well as alcohol/medical/drug misuse. We are particularly concerned that so few informants either received counseling or were provided with pertinent information about posttraumatic distress from general medical providers or other sources. Life in the United States has changed since September 11, 2001. National fears of bioterrorism have fueled the establishment of the Department of Homeland Security, military actions in Afghanistan and Iraq, and increased security at airports, schools, and landmarks deemed potential terrorist targets. But terrorism is primarily psychological warfare. The impact of terrorism extends far beyond the immediate victims of such attacks. Its primary goal is to produce widespread social disruption through creation of a credible threat affecting cognitive, emotional, and behavioral stability and function. Indeed, the major changes in public policy and government expenditures since September 11, 2001, are clear evidence that the attacks on the World Trade Center and Pentagon have continued to exert a profound psychological impact on American society as a whole. There is no question about the urgent need for prevention and protection against attacks with chemical, biological, nuclear, or even conventional weapons. We are concerned, however, that there has been insufficient attention to the major weapons wielded by terrorists. Those weapons are fear and anxiety. They are highly toxic, infectious agents that can bring a nation or society to its knees. Contagion by fear or anxiety can be immediate. It can infect large areas of the Psychiatry 67(2) Summer 2004 123

A National Longitudinal Study of the Psychological Consequences of the September 11, 2001 Terrorist Attacks: Reactions, Impairment, and Help-Seeking

This article examines the evolution of psychological and behavioral reactions following the September 2001 terrorist attacks in a nationally representative sample, and describes where people turned for support, information, and counseling. From November 9 to November 28, 2001, we resurveyed 395 (71%) of the original 560 adults 19 years or older within the United States who participated in our national random-digit-dialing telephone survey conducted on September 14 to September 16, 2001, about their terrorism-related psychological distress and behavior. Sixteen percent of adults had persistent distress, reporting one or more substantial distress symptoms in both September and November. Adults with persistent distress reported accomplishing less at work (65%); avoiding public gathering places (24%); and using alcohol, medications, or other drugs to relax, sleep, or feel better because of worries about terrorism (38%). Seventy-five percent talked with family and friends; however, 43% reported sometimes feeling unable to share their terrorism-related thoughts and feelings with others because it made others uncomfortable. Few reported receiving counseling or information about psychological distress from general medical providers (11%). These findings suggest that a significant number of adults across the country were continuing to experience terrorism-related distress and disruption of their daily lives approximately 2 months after September 11; many turned to family and friends for support, but at times many felt uncomfortable doing so, and few used clinicians as a source of information or support. Clinicians and policymakers should consider how the healthcare system and other community organizations might provide a coordinated community-wide response for individuals needing information and counseling following terrorist events.

Training Psychology Interns in Primary Behavioral Health Care.

This article describes a training program for primary behavioral health care (PBHC) for clinical psychology interns. The authors discuss the rationale for integrating mental health into primary care and the need for additional training programs at the predoctoral internship level. A review of relevant literature suggests that effective functioning in primary care requires competence in (a) generalist psychology, (b) health psychology, (c) interdisciplinary team functioning, and (d) skills specific to primary care. The authors advocate for a relatively intensive training program to address these areas. Common intern training difficulties observed during 3 years of program implementation are discussed. Practical, lessons-learned recommendations that address these problem areas provide guidance for others seeking to develop a PBHC training program. A growing body of literature recognizes the potential value of integrating behavioral health services into the primary care arena. Researchers have found that approximately 60% of primary care visits involve some behavioral health need (Cummings, Cummings, & Johnson, 1997). Furthermore, epidemiological research suggests that although 28% of Americans in any given year meet diagnostic criteria for a mental disorder, half of these individuals do not receive any form of treatment. Of those who are treated, approximately half receive specialized mental health treatment, whereas the remaining half receive services solely through their general medical providers (Narrow, Regier, Rae, Manderscheid, & Locke, 1993; Regier et al., 1993). Thus, the existing mental health system provides specialized, intensive services to a minority of individuals with behavioral health problems. The rest receive treatment solely from their physician or receive no behavioral health services whatsoever. Traditional models of mental health care cannot adequately provide services to the large numbers of individuals presenting to primary care clinics with a host of biopsychosocial problems. Consequently, innovative service delivery models capable of providing more comprehensive behavioral health interventions to primary care populations have been developed (Blount, 1998;

Delivering a different kind of primary care? Nurses working in personal medical service pilots.

This article examines the roles and responsibilities of primary care nurses in England. The study was commissioned by the Department of Health to consider how nurses were working in Personal Medical Service (PMS) pilots--a new initiative launched in April 1998. All nurses in the study reported that they had extended their clinical role--in varying degrees. Nurses were running new clinics and services, and general practitioner time was freed up. Some of the nurses used PMS to deliver a different kind of primary care, one that was more community and patient focused than other General Medical Service providers. Many of the nurses in the study are successfully breaking down traditional demarcations between primary and secondary care, between medicine and nursing, and between professionals and patients.

Addressing depression in obstetrics/gynecology practice

Efforts to improve the care of depression in primary care patients have largely ignored the potential of obstetrics/gynecology (OB/GYN) practices. We describe feasibility studies of a depression screening and care management intervention in three diverse OB/GYN practices. Patients were screened using the Patient Health Questionnaire. A depression care manager offered education and referral assistance to women who screened positive for depression. The prevalence of depression was higher in the hospital clinic (20.2%, 47/233) than the suburban clinic (10.7%, 8/75) or the office practice (8.2%, 48/583). Seventy-two women participated in the care management intervention. Patient satisfaction with the intervention was high and at 1-month follow-up, 31.9% of patients had kept or scheduled a new mental health appointment. Depression interventions developed in primary care can be successfully adapted for use with patients in OB/GYN practices. Additional modifications, particularly efforts to improve coordination of care with both general medical and mental health providers, are needed.

Help seeking for mental health problems among Mexican Americans.

This study uses data from a household survey (Mexican American Prevalence and Services Study; MAPSS) of 3,000 respondents in Fresno County, California, to 1) contrast use across multiple sectors of care among immigrant and U.S. born Mexican Americans with recent psychiatric disorders, 2) contrast multiple provider utilization patterns, and 3) identify specific factors associated with the use of mental health specialty and general medical sectors. Immigrants and U.S. born disproportionately used the general medical sector for treating mental health problems. The U.S. born were more likely to use family physicians and counselors than were immigrants, and neither relied heavily upon informal network providers to treat psychiatric disorders. A comparison of patterns showed that most people with a recent disorder used a combination of providers. The logistic regression analyses showed that knowing where to find a provider increased the likelihood of specialty mental health use by an odds ratio (O.R.) of 4.68. Private insurance increased use of mental health providers, O.R. = 3.76. Public insurance availability did not increase mental health provider use, suggesting that other factors were linked to use of mental health specialty care. Public insurance did increase medical sector care for psychiatric problems, O.R. = 2.57. Poor self-rated mental health status was primarily associated with use of physicians by U.S. born (O.R. = 5.39). Severe mental health impairment increased use of both general medical (O.R. = 5.54) and specialty mental health (O.R. = 5.1) providers. These results point out that eligibility for public insurance is a necessary but not sufficient status to increase mental health sector care among immigrants, and education and more effective referral from other sectors are needed to encourage use of these services.

Measuring costs of guideline-driven mental health care: the Texas Medication Algorithm Project.

BACKGROUND: Algorithms describe clinical choices to treat a specific disorder. To many, algorithms serve as important tools helping practitioners make informed choices about how best to treat patients, achieving better outcomes more quickly and at a lower cost. Appearing as flow charts and decision trees, algorithms are developed during consensus conferences by leading experts who explore the latest scientific evidence to describe optimal treatment for each disorder. Despite a focus on "optimal" care, there has been little discussion in the literature concerning how costs should be defined and measured in the context of algorithm-based practices. AIMS OF THE STUDY: This paper describes the strategy to measure costs for the Texas Medication Algorithm project, or TMAP. Launched by the Texas Department of Mental Health and Mental Retardation and the University of Texas Southwestern Medical Center at Dallas, this multi-site study investigates outcomes and costs of medication algorithms for bipolar disorder, schizophrenia and depression. METHODS: To balance costs with outcomes, we turned to cost-effectiveness analyses as a framework to define and measure costs. Alternative strategies (cost-benefit, cost-utility, cost-of-illness) were inappropriate since algorithms are not intended to guide resource allocation across different diseases or between health- and non-health-related commodities. "Costs" are operationalized consistent with the framework presented by the United States Public Health Service Panel on Cost Effectiveness in Medicine. Patient specific costs are calculated by multiplying patient units of use by a unit cost, and summing over all service categories. Outpatient services are counted by procedures. Inpatient services are counted by days classified into diagnosis groups. Utilization information is derived from patient self-reports, medical charts and administrative file sources. Unit costs are computed by payer source. Finally, hierarchical modeling is used to describe how costs and effectiveness differ between algorithm-based and treatment-as-usual practices. DISCUSSION: Cost estimates of algorithm-based practices should (i) measure opportunity costs, (ii) employ structured data collection methods, (iii) profile patient use of both mental health and general medical providers and (iv) reflect costs by payer status in different economic environments. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Algorithms may help guide clinicians, their patients and third party payers to rely on the latest scientific evidence to make treatment choices that balance costs with outcomes. IMPLICATION FOR HEALTH POLICIES: Planners should consider consumer wants and economic costs when developing and testing new clinical algorithms. IMPLICATIONS FOR FURTHER RESEARCH: Future studies may wish to consider similar methods to estimate costs in evaluating algorithm-based practices.

Earnings changes for depressed individuals treated by mental health specialists.

It is unclear whether the additional benefits of receiving depression treatment from mental health specialists in routine care pays for the additional costs, compared with treatment delivered by general medical providers. This study examines the difference in lost earnings and the difference in treatment costs experienced by depressed individuals treated in these two sectors. Representative community residents with depression were recruited and interviewed at baseline and at 6-month and 12-month follow-ups. Lost earnings were measured by lost workdays multiplied by subjects' wage rates. Treatment costs were approximated by charges abstracted from provider and insurance records. After controlling for sociodemographic variables, baseline severity, and baseline comorbidity, the authors found a net mean annual economic savings of $877 associated with depression treatment delivered in the mental health sector compared with the general medical sector. Sensitivity analyses in alternative scenarios indicated similar savings. Although it is the trend for primary care providers to provide mental health services, these analyses indicate a net economic savings if depression treatment is provided by mental health specialists, probably as a result of patients' greater functional improvement. As gatekeepers, especially in managed care, primary care providers have a unique responsibility to identify and detect patients with mental health problems. In the current structure, however, they may lack the necessary time to provide effective mental health services. Therefore, mental health specialists play a crucial role, with primary care providers' cooperation (i.e., detection, consultation, and referral), in providing the most cost-effective mental health services.

Mental disorders and access to medical care in the United States.

The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.

Use of formal and informal sources of mental health care among older African-American public-housing residents.

Elderly residents of public housing have high rates of psychiatric disorders, but most of those in need of care do not use any mental health service. This study examines the use of formal and alternative informal sources of mental health care in a sample of elderly African-American public-housing residents. Data from an epidemiological survey of six Baltimore public-housing developments for the elderly (weighted N = 818) were analysed to examine the utilization of mental health services by older African-American residents. Logistic regression analyses were used to determine correlates of using formal and informal sources by those needing mental health care. Thirty-five per cent of subjects needed mental health care. Less than half (47%) of those in need received any mental health care in the previous 6 months. Residents in need were more likely to use formal (38.5%) than informal sources (18.6%) for care. The strongest correlates of using formal providers were substance use disorder (OR = 15.62), Medicare insurance (OR = 10.31) and psychological distress (OR = 10.27). The strongest correlates of using informal sources were perceiving little or no support from religious/spiritual beliefs (OR = 21.65), cognitive disorder (OR = 19.71) and having a confidant (OR = 15.07). Contrary to elderly African-Americans in general, those in public housing rely more on formal than informal sources for mental health problems. Nevertheless, both sources fail to fill the gap between need and met need. Interventions to increase identification, referral and treatment of elderly public-housing residents in need should target general medical providers and clergy and include assertive outreach by mental health specialists.

Rural‐Urban Differences in Service Use and Course of Illness in Bipolar Disorder

Abstract: Policy analysts have long been concerned that the reduced availability of mental health professionals in rural areas prohibits rural individuals from getting the care they need for serious psychiatric conditions like bipolar disorder. Through a community‐based telephone survey, the researchers recruited 54 subjects with bipolar disorder who were currently experiencing depressive episodes. Forty‐six (85.1%) of them were reinterviewed one year after the first survey. Multivariate models indicate that while rural subjects were just as likely to receive nonacute services for mental health problems as their urban counterparts, the rural residents had 22.1 times the odds (95% confidence interval 2.5 to 198.3, P=0.006) of receiving such services exclusively from a general medical provider. Rural subjects had 5.8 times the odds (95% confidence interval 0.8 to 40.7, P=0.07) of using hospital or emergency room services and 4 times the odds (95% confidence interval 0.8 to 20.5, P=0.10) of experiencing a manic episode during the year following baseline. While rural individuals with bipolar disorder have a comparable likelihood of receiving care for their mental health problems, they utilize more acute services and experience worse outcomes. Further research is warranted to deter‐mine what causes these differences before developing cost‐effective ways to improve the care delivered to individuals with this serious illness.

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy.

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.

Comorbid anxiety disorder and the functioning and well-being of chronically ill patients of general medical providers.

The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and policy interest, in part owing to the evidence that anxiety disorders themselves are associated with morbidity. However, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples. A 2-year observational study of 875 adult patients with hypertension, diabetes, heart disease, and current depressive disorder or subthreshold depression receiving care from general medical providers was conducted. The unique effect of any comorbid anxiety disorder on functioning and well-being (determined with the use of the 36-Item Short-Form Health Survey [SF-36]) was estimated, as well as the differential impact at baseline, 2-year follow-up, and change over time, of any comorbid anxiety disorder for patients with chronic medical conditions or depression. Patients with comorbid anxiety who received general medical care had lower levels of functioning and well-being than those without comorbid anxiety. These differences were most pronounced in mental health-related quality-of-life measures and when anxiety was comorbid with chronic medical conditions rather than with depression. Hypertensive and diabetic patients with comorbid anxiety were as debilitated as patients with depression or heart disease, and this low health-related quality of life persisted over time. Comorbid anxiety had less of an effect on patients with heart disease who already had a low health-related quality of life. The finding of substantial differences in the quality of life between hypertensive and diabetic patients with and without comorbid anxiety disorder highlights the clinical and societal importance of identifying comorbid anxiety in these patients.