Untreated Psychiatric Disorders Research Articles

Perspectives on mental health services for medical students at a Ugandan medical school

BackgroundUniversity-based mental health services for medical students remain a challenge, particularly in low-income countries, due to poor service availability. Prior studies have explored the availability of mental health services in high-income countries but little is known about mental health services in countries in sub-Saharan Africa, such as Uganda. Medical students are at a higher risk of developing mental health challenges during their course of study as compared with other students. Thus, there is a need for well-structured mental health services for this group of students. The aim of this study was to explore perspectives on mental health services for medical students at a public University in Uganda.MethodsThis was a qualitative study where key informant interviews were conducted among purposively selected university administrators (n = 4), student leaders (n = 4), and mental health employees of the university (n = 3), three groups responsible for the mental well-being of medical students at a public university in Uganda. Interviews were audio-recorded, transcribed, and thematically analyzed to identify relevant themes.ResultsThe working experience of university administrators and mental health providers was between eight months to 20 years, while student leaders had studied at the university for over four years. We identified five broad themes: (1) Burden of medical school: A curriculum of trauma, (2) Negative coping mechanisms and the problem of blame, (3) The promise of services: Mixed Messages, (4) A broken mental health system for students, and (5) Barriers to mental health services.ConclusionDistinguishing between psychological distress that is anticipated because of the subject matter in learning medicine and identifying those students that are suffering from untreated psychiatric disorders is an important conceptual task for universities. This can be done through offering education about mental health and well-being for administrators, giving arm’s length support for students, and a proactive, not reactive, approach to mental health. There is also a need to redesign the medical curriculum to change the medical education culture through pedagogical considerations of how trauma informs the learning and the mental health of students.

Psychiatric Comorbidity Among Sexual and Gender Minority Youth and Young Adults at Risk for Suicide

Abstract Background Compared with peers, young sexual and gender minorities (SGM) are at a four to seven-fold increased risk of attempting suicide. Prior epidemiological studies, mainly focusing on monomorbid inequalities and without conducting diagnostic clinical interviews, have been unable to report robust data on psychiatric comorbidities among those who attempted suicide. The purpose of this presentation is to describe the presence of current psychiatric comorbidities among SGM youth and young adults at elevated risk for repeat suicide attempts. Methods A diverse convenience sample of SGM youth and young adults with a lifetime history of suicide attempts and current suicidal ideation was recruited for an open-phase suicide prevention trial in San Diego, CA. At baseline, participants underwent a 15-module DIAMOND interview for adults or computerized K-SADS for minors, and a battery of self-report questionnaires. Results Among the 31 participants (Mage = 22 years [Range: 16, 29]; 100% sexual, 52% gender, and 61% racial/ethnic minority), 27 (87%) participants met criteria for any mood disorder, 24 (77%) for any anxiety disorder, 16 (52%) for any trauma or stress disorder, and 2 (6%) for any psychotic disorder. One (3%) participant did not meet criteria for any psychiatric diagnoses, while five (16%) met criteria for a single and 25 (81%) for multiple diagnoses. The average number of diagnoses was 3.2 (Range: 0, 7). Additionally, 20 (65%) participants met the cut-off for likely ADHD, 20 (65%) for possible borderline personality disorder, and 21 (68%) for likely body dysmorphic disorder, with 11 (35%) within the 90th percentile for reference eating disorder severity. Conclusions The degree of psychiatric comorbidities in the sample of SGM youth and young adults at elevated risk for suicide was high. Beside direct suicide risk mitigation efforts, suicide prevention programs that target young SGM with a history of attempts should screen for untreated psychiatric disorders. Key messages • LGBTQ+ youth and young adults at elevated risk for repeat suicide attempts experience a high degree of psychiatric comorbity. • Beyond suicide risk mitigation, LGBTQ+ youth suicide prevention programs should focus on untreated psychiatric comorbidities.

Resultados Gestacionales asociados al tratamiento antipsicótico durante el embarazo: Una revisión narrativa

Antipsychotics are increasingly prescribed for various disorders including bipolar disorder, schizophrenia, other psychotic disorders and to a lesser extent for depression, anxiety, insomnia and even nausea during pregnancy. The full knowledge about its possible effects due to exposure during pregnancy is still limited, although some studies refer to some degree of relationship with the appearance of effects such as gestational diabetes, premature birth, congenital malformations, our review did not find a sufficiently clear relationship with them. In addition to the safety profile, another aspect to consider is the assessment that untreated psychiatric disorders could also represent a risk factor for poor pregnancy outcomes. Therefore, due to the lack of highly significant data on these aspects during pregnancy, more studies are needed to provide more detail on the risks and benefits of these drugs at this stage.

Plastic Surgery: Review on Screening of Psychiatric Disorder

Recently the popularity of plastic surgical procedure has been increased. Many people surgically alter their physical appearance with the intent of boosting their social and psychological well-being; however, the long-term effectiveness of aesthetic surgery on improving well-being is unconfirmed. To have successful cosmetic plastic surgery result, it is imperative to assess candidates for predictors of poor outcomes. These include the following factor: psychiatric disorder, demographic factors (male and younger age), relationship issues, unrealistic expectations, previous dissatisfied surgery, and minimal deformity. For psychiatric patients, despite having technically satisfactory cosmetic surgery, poor emotional adjustment and social functioning were seen post procedure. Proper screening and evaluation of these patients could save money and resources. In this brief review we discuss about psychiatric disorder screen on plastic surgery to prevent unwanted outcome. A literature review was conducted in the electronic database PubMed using keyword “Psychiatric Disorder”, “Plastic surgery”, “Prevention” and “Screening”. All type of studies were included for this study, such as controlled trials, systematic reviews, literature reviews, and pilot studies published between 2011 and 2021. Articles which not written in English were excluded from the study. This search resulted in 18 papers. Some patient who undergo cosmetic surgery suffer from underdiagnosed or untreated psychiatric disorder. To avoid unnecessary expense and resource it is advisable that all patient who seek cosmetic procedure undergo psychiatric screen such as PHQ-9, GAD-7, BDDQ and other test to avoid un-necessary expense and resource.

Plastic Surgery: Review on Screening of Psychiatric Disorder

Recently the popularity of plastic surgical procedure has been increased. Many people surgically alter their physical appearance with the intent of boosting their social and psychological well-being; however, the long-term effectiveness of aesthetic surgery on improving well-being is unconfirmed. To have successful cosmetic plastic surgery result, it is imperative to assess candidates for predictors of poor outcomes. These include the following factor : psychiatric disorder, demographic factors (male and younger age), relationship issues, unrealistic expectations, previous dissatisfied surgery, and minimal deformity. For psychiatric patients, despite having technically satisfactory cosmetic surgery, poor emotional adjustment and social functioning were seen post procedure. Proper screening and evaluation of these patients could save money and resources. In this brief review we discuss about psychiatric disorder screen on plastic surgery to prevent unwanted outcome. A literature review was conducted in the electronic database PubMed using keyword “Psychiatric Disorder”, “Plastic surgery”, “Prevention” and “Screening”. All type of studies were included for this study, such as controlled trials, systematic reviews, literature reviews, and pilot studies published between 2011 and 2021. Articles which not written in English were excluded from the study. This search resulted in 18 papers. Some patient who undergo cosmetic surgery suffer from underdiagnosed or untreated psychiatric disorder. To avoid unnecessary expense and resource it is advisable that all patient who seek cosmetic procedure undergo psychiatric screen such as PHQ-9, GAD-7, BDDQ and other test to avoid un-necessary expense and resource.

Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness.

Given the relative lack of psychiatric information and data on the perpetrators of US mass shootings, the aim of our study was to understand who these "mass shooters" were and whether they had a psychiatric illness. If so, were they competently diagnosed, and if so, were they treated with appropriate medication for their diagnoses before the violence? Because a prospective study of diagnosis and treatment could not, for obvious reasons, be carried out, we designed a retrospective, observational study of mass shooters, defined as those who killed 4 or more people with firearms between 1982 and 2012 or who killed 3 or more people with firearms between 2013 and 2019 in the United States. We used the Mother Jones database-a database of 115 persons identified as committing a mass shooting in the United States between January 1982 and September 2019. In the vast majority of the incidents identified in the database, the perpetrator died either during or shortly after the crime, leaving little reliable information about their history-especially psychiatric history. We focused on the 35 mass shooters who survived and for which legal proceedings were instituted because these cases presented the most reliable psychiatric information. For each of these 35 mass shootings, we interviewed forensic psychiatrists and forensic psychologists who examined the perpetrator after the crime and/or collected the testimony and reports by psychiatrist(s) at trial or in the postconviction proceedings contained in the court record. In addition, we reviewed available information from the court proceedings, public records, a videotaped interview of assailant by law enforcement, social media postings of the assailant, and writings of the assailant. After collecting the clinical information from multiple sources on each case to make a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis, we also completed a Sheehan Diagnostic Scale. After this, 20 additional cases where the assailant died at the crime were randomly selected form the remaining 80, to determine whether there were differences in psychiatric diagnoses and treatment between such assailants and those who survived. Twenty-eight of 35 cases in which the assailant survived had a psychiatric diagnosis-18 with schizophrenia, 3 with bipolar I disorders, 2 with delusional disorders, persecutory type, 2 with personality disorders (1 paranoid and 1 borderline), 2 with substance-related disorders without other psychiatric diagnoses, and 1 with posttraumatic stress disorder. Four had no psychiatric diagnosis, and in 3, we did not have enough information to make a diagnosis.Of 15 of 20 cases in which the assailant died, 8 had schizophrenia. None of those diagnosed with psychiatric illnesses were treated with medication. A significant proportion of mass shooters experienced unmedicated and untreated psychiatric disorder.

Anxiety Linked to Hypertensive Disorders in Pregnancy

Back to table of contents Previous article Next article Clinical & ResearchFull AccessAnxiety Linked to Hypertensive Disorders in PregnancyTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:12 Jan 2021https://doi.org/10.1176/appi.pn.2021.12a11AbstractRates of comorbid anxiety and preeclampsia increased nearly sixfold over 10 years.Pregnant women who have anxiety may be at increased risk for hypertensive disorders of pregnancy such as gestational hypertension, preeclampsia, and eclampsia, suggests a study in the Journal of Affective Disorders.Women should be screened for mental disorders in the first trimester of pregnancy, says Tuong-Vi Nguyen, M.D., M.Sc.McGill University“Mental health screening should be considered in the first trimester of the pregnancy if it is to be used prospectively to prevent hypertensive disorders of pregnancy and mental health disorders in the postpartum period,” study researcher Tuong-Vi Nguyen, M.D., M.Sc., told Psychiatric News. She is an assistant professor and a reproductive psychiatrist at McGill University in Montreal.The researchers analyzed data from a population-based retrospective study involving nearly 9.1 million pregnant women using Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) data from 2004 through 2014. This database samples 20% of all discharges from community hospitals in the United States except for long-term care and rehabilitation facilities. For their analysis, the researchers used ICD-9 codes for gestational hypertension, preeclampsia, and eclampsia and categorized mental disorders as bipolar disorder, depression, mood disorder, and anxiety disorder as well as mental disorders of mother, antepartum condition, or complication.The rapid increase in rates of comorbid mental health disorders and hypertensive disorders in pregnancy are a call to action for health care professionals, says Eva Suarthana, M.D., Ph.D.McGill UniversityPregnant women who had anxiety had a 32% greater risk of gestational hypertension, a 52% greater risk of preeclampsia, and an 81% greater risk of eclampsia compared with pregnant women who did not have anxiety. The rate of pregnant women with anxiety disorder and gestational hypertension increased from 1.75 per 10,000 women in 2004 to 12.99 per 10,000 women by 2014. At the same time, the rate of pregnant women with anxiety and preeclampsia increased from 2.21 to 12.85 per 10,000 women.“In the past decade people have become more aware of and open about mental health problems, so I personally expected to see an increasing trend,” said senior author Eva Suarthana, M.D., Ph.D., an adjunct professor in the Obstetrics and Gynecology Department at McGill University and a researcher at McGill University Health Center in Montreal. “Nevertheless, I was still surprised to see such a remarkable increase and thought that health care professionals need to do something about this concerning trend.”The researchers found that having depression did not consistently increase the risk of hypertensive disorders in pregnancy. Pregnant women with depression had a 15.6% greater risk of gestational hypertension and a 25.5% greater risk of preeclampsia than those who did not have depression, but they did not appear to have an increased risk of eclampsia.The medical literature supports actively treating pregnant women with psychiatric disorders to wellness, says Jennifer Payne, M.D.Rouse Photography Group LLCJennifer Payne, M.D., an associate professor of psychiatry and behavioral sciences and the director of the Women’s Mood Disorders Center at Johns Hopkins Medicine, said there is no harm in psychiatrists screening their pregnant patients who have anxiety for hypertension.“Technically, the patients’ OB-GYNs are screening them regularly, [but] it never hurts to have more screening, particularly if a psychiatrist is prescribing a medication that can raise blood pressure,” said Payne, who was not involved in the research.Payne emphasized the importance of psychiatric treatment in this population.“In general the literature currently supports actively treating pregnant women with psychiatric disorders, including anxiety, to wellness. Untreated psychiatric disorders are not benign in pregnancy,” Payne said.This study was supported in part by the Academic Enrichment Fund of the Department of Obstetrics and Gynecology at McGill University. ■“Pregnancy Hypertension and Its Association With Maternal Anxiety and Mood Disorders: A Population-Based Study of 9 Million Pregnancies”. ISSUES NewArchived

Psychological aspects of aesthetic and cosmetic surgery: Clinical and therapeutic implications.

Recently there is a surge in cosmetic and aesthetic surgery procedures. Several patient seeking various cosmetics procedures present to aesthetic surgery clinics and demanding procedures which are out of proportion. Several of these patients have under-recognized or untreated psychiatric disorders. Proper screening and evaluation of these patients could save money and resources. This brief review focuses on current trends, clinical and psychological assessment and expectations on the part of patients and recommendations regarding management of these patients.

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Women With Mental Illness Seeking Assisted Reproduction Considerations in Ethical Candidate Selection.

This review aims to provide guidance to clinicians facing requests for assisted reproduction from women with mental illness. The paper explores the clinical and safety aspects of initiating fertility treatment in this context, including the use of psychotropic medication and the risk of untreated psychiatric mood or psychotic disorders. It also presents the ethical considerations involved in candidate selection, including treating similar cases equitably to avoid biased decisions based solely on "gut-feelings," respect for women's reproductive autonomy, and an effort to protect patients and prospective fetuses/children from harm by employing optimal strategies regarding medication and psychosocial support. Clinicians ought to be informed regarding recent evidence related to the safety and efficacy of psychopharmacologic treatment of women during pregnancy and the post-partum. They should also carry out a thoughtful ethical analysis to ensure minimal violation of women's reproductive autonomy.

Modifying mental health help-seeking stigma among undergraduates with untreated psychiatric disorders: A pilot randomized trial of a novel cognitive bias modification intervention

Help-seeking stigma is a potent barrier to the utilization of mental health services. This study aimed to determine if, compared to a psychoeducation condition, individuals randomized to a novel cognitive bias modification intervention for help-seeking stigma (CBM-HS) demonstrate greater reductions in help-seeking stigma, as well as increases in readiness to change and help-seeking behaviors. Participants included 32 undergraduates with a DSM-5 psychiatric disorder who denied past-year mental health treatment. Post-randomization, three intervention sessions were delivered in one-week intervals (45 min total). Participants were assessed at baseline, mid-intervention, one-week post-intervention, and two-month follow-up. RM-ANOVAs were utilized among the intent-to-treat sample. There were no significant differences across time points between the intervention groups for help-seeking stigma and readiness to change. At two-month follow-up, 25% of participants initiated mental health treatment (29.4% CBM-HS, 20.0% psychoeducation). Strikingly, across groups, there was a statistically significant reduction in help-seeking self-stigma (F[2.214,66.418] = 5.057, p = 0.007, ηp2 = 0.144) and perceived public stigma (F[3,90] = 6.614, p < 0.001, ηp2 = 0.181) from baseline to two-month follow-up, indicating large effects; 18.8% achieved clinically significant change, among whom two-thirds were in the CBM-HS condition. Two brief, scalable interventions appear to reduce help-seeking stigma among undergraduates with untreated psychiatric disorders. Studies are needed to evaluate these interventions against an inactive control.

Pharmacological treatment for dual diagnosis: a literature update and a proposal of intervention

It has long been appreciated that alcohol use disorder (AUD) is associated with increased risk of psychiatric disorder. As well, people with history of mental disorder are more likely to develop lifetime AUD. Nevertheless, the treatment of dual diagnosis (DD) in alcohol addiction still remains a challenge. The efficacy of pharmacological treatment for these patients has been widely investigated with controversial results. Patients with untreated psychiatric disorder are at higher risk to return to drinking and tend to do so more quickly. The aim of this review was to collect clinical data for developing guidelines for the pharmacological treatment of psychiatric diseases in a population with AUD. A literature review was conducted using the following databases: PubMed-NCBI, Cochrane database, Embase Web of Science, and Scopus, including studies published between 1980 and 2015. Search terms were: “guideline”, “treatment”, “comorbidity”, “substance abuse”, “alcohol”, “dual-diagnosis”, “antidepressant”, “antipsychotic”, “mood-stabilizer”. Out of 1521 titles, 84 studies were included for their relevance on pharmacological treatment of psychiatric disorders in people with AUD. Different drugs were collected in major pharmacological classes (antidepressant, mood-stabilizer, antipsychotic), in order to identify their proved efficacy for treating specific psychiatric disorder in the AUD population. Data were selected and verified for publications from randomized clinical trials, open-label trials and case reports. DD in alcohol dependence is a complex clinical entity, and its high prevalence is supported by epidemiological data. Pharmacological management of psychiatric disorders in patients with AUD remains partially anecdotal. Based on reviewed articles, we propose a classification of psychiatric medications for treatment of mental disorders comorbid with AUD, listed with evidence-based recommendations. More research is needed to obtain and collect clinical data, in order to organize and share evidence-based guidelines.

Risk Factors for Opioid-Use Disorder and Overdose.

Opioid analgesics are recognized as a legitimate medical therapy for selected patients with severe chronic pain that does not respond to other therapies. However, opioids are associated with risks for patients and society that include misuse, abuse, diversion, addiction, and overdose deaths. Therapeutic success depends on proper candidate selection, assessment before administering opioid therapy, and close monitoring throughout the course of treatment. Risk assessment and prevention include knowledge of patient factors that may contribute to misuse, abuse, addiction, suicide, and respiratory depression. Risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. Suicides are probably undercounted or frequently misclassified in reports of opioid-related poisoning deaths. Greater understanding and better assessment are needed of the risk associated with suicide risk in patients with pain. Clinical tools and an evolving evidence base are available to assist clinicians with identifying patients whose risk factors put them at risk for adverse outcomes with opioids.

Evidence-Based Psychotherapy in Primary Care.

The functional and financial effects of untreated psychiatric disorders within primary care have led to the development of novel service delivery models to improve access to high-quality, evidence-based mental health treatments. Cognitive-behavioral therapy (CBT) is an efficacious and effective psychotherapeutic approach for treating a broad range of mental health conditions. CBT is a practical, skill-building approach that emphasizes self-efficacy and self-management of symptoms while working toward defined and measurable treatment goals. Although significant barriers to the full dissemination of CBT remain, collaborative care and integrated behavioral health programs embedded within primary care clinics can enhance treatment outcomes by using CBT. Identifying core CBT principles used in the treatment of anxiety (e.g., exposure), depression (e.g., behavioral activation), and insomnia (e.g., stimulus control) is an important step toward improving the quality of care for these conditions. High-impact, low-intensity CBT programs hold promise in improving access to this evidence-based treatment across a broader population.

Duration and Relevance of Untreated Psychiatric Disorders, 2: Nonpsychotic Psychiatric Disorders and Substance Use Disorders.

Duration and Relevance of Untreated Psychiatric Disorders, 2: Nonpsychotic Psychiatric Disorders and Substance Use Disorders.

Duration and Relevance of Untreated Psychiatric Disorders, 1: Psychotic Disorders.

Duration and Relevance of Untreated Psychiatric Disorders, 1: Psychotic Disorders.

Managing Your Own Mood Lability: Use of Mood Stabilizers and Antipsychotics in Pregnancy.

The management of psychiatric disorders during the perinatal period can be difficult; psychiatric decompensation during pregnancy can affect not only the mother but also the fetus and neonate. It is imperative that psychiatric providers proactively discuss pregnancy planning, and be able to thoughtfully weigh the risks of untreated psychiatric illness and psychotropic medications in pregnancy and breast-feeding. With the exception of valproate and carbamazepine, several mood stabilizers and antipsychotics can be utilized during pregnancy with minimal risk to the fetus and neonate in terms of major malformations; there is a growing body of evidence regarding the risk profile of use of these medications in pregnancy. Key Points Preconception planning is very helpful when it can be done; consider discussion and documentation of risks at time of administration of psychotropic medications for any reproductive-aged women, regardless of plans for conception. Continued psychiatric stability through the perinatal period is imperative; the risks of an untreated psychiatric disorder are just as important, if not more so important, than the risks of psychotropic medication exposure. Exposure to one psychotropic medication is safer than exposure to multiple medications. Utilize lowest effective dose of medication; most risks are not dose dependent, therefore would typically prefer higher dose of medication, rather than emergence of psychiatric symptoms, in order to avoid exposure of the fetus to both psychotropic medications and psychiatric symptoms. General recommendations are to avoid valproate and carbamazepine in reproductive-aged women. With close monitoring, lithium can be safely utilized in pregnancy. Preliminary data regarding use of atypical antipsychotics is reassuring in regards to major malformations; however, larger numbers of participants are needed to provide more complete reproductive safety data with this class. Clearly document risks of an untreated psychiatric illness as well as risks of psychotropic medication management to the mother and developing fetus/neonate.

Increase in untreated cases of psychiatric disorders during the transition to adulthood.

During the transition to adulthood, youths face challenges that may limit their likelihood of obtaining services for psychiatric problems. The goal of this analysis was to estimate changes in rates of service use and untreated psychiatric disorders during the transition from adolescence to adulthood. In a prospective, population-based study, participants were assessed up to four times in adolescence (ages 13-16; 3,983 observations of 1,297 participants, 1993-2000) and three times in young adulthood (ages 19, 21, and 24-26; 3,215 observations of 1,273 participants, 1999-2010). Structured diagnostic interviews were used to assess service need (participants meeting DSM-IV diagnostic criteria for a psychiatric disorder) and use of behavioral services in 21 service settings in the past three months. During young adulthood, 28.9% of cases of psychiatric disorders were associated with some treatment, compared with a rate of 50.9% for the same participants during adolescence. This decrease included a near-complete drop in use of educational and vocational services as well as declines in use of specialty behavioral services. Young adults most frequently accessed services in specialty behavioral or general medical settings. Males, African Americans, participants with substance dependence, and participants living independently were least likely to get treatment. For cases of psychiatric disorders among young adults, insurance and poverty status were unrelated to likelihood of service use. Young adults were much less likely to receive treatment for psychiatric problems than they were as adolescents. Public policy must address gaps in service use during the transition to adulthood.

The role of the right inferior frontal gyrus in the pathogenesis of post-stroke psychosis

Psychotic symptoms have previously been reported following right hemisphere brain injury. We sought to identify the specific neuroanatomical basis of delusions following stroke by studying a series of patients with post-stroke psychosis. Lesion overlap analysis was conducted on three individuals with delusions following right hemisphere stroke. These cases were compared with a control group of patients with similar anatomical damage. The main outcome measures were presence of delusions and presence of behavioural susceptibility. The right inferior frontal gyrus and underlying white matter, including the superior longitudinal fasciculus and anterior corona radiata, were involved in all three cases. All three had a preexisting untreated psychiatric disorder. In contrast, only one of nine control cases with equivalent lesions had evidence of previous psychiatric disorder (p = 0.0182, Fisher’s exact test), and this was being treated at the time of stroke. We provide clinical evidence from patients with structural brain lesions implicating damage to the right inferior frontal lobe in the generation of persistent psychosis following stroke. We suggest that preexisting psychiatric disease provided a behavioural susceptibility to develop delusions in these individuals.Electronic supplementary materialThe online version of this article (doi:10.1007/s00415-014-7242-x) contains supplementary material, which is available to authorized users.

Primary Care Physician Describes Health Care ‘Hot Spotting’

Primary Care Physician Describes Health Care ‘Hot Spotting’