Satisfaction with mental health services in older primary care patients.

OBJECTIVE: This study examines whether older adult primary care patients are satisfied with two intervention models designed to ameliorate their behavioral health problems. METHODS: A total of 1,052 primary care patients aged 65 and older with depression, anxiety, or at-risk drinking were randomly assigned to and participated in either integrated care (IC) or enhanced specialty referral (ESR) model and completed the Client Satisfaction Questionnaire (CSQ) administered at three-month follow-up assessment. RESULTS: Older adult patients' satisfaction with IC (mean: 3.4, standard deviation [SD]: 0.60) was significantly higher than that with ESR (mean: 3.2, SD: 0.78), but the absolute difference was modest. Regression results showed that patients who used the IC model, attended the treatment service twice or more, or showed clinical improvement were more likely to express greater satisfaction. Stigma toward mental illness was negatively associated with satisfaction with mental health services. CONCLUSIONS: Older adults are more likely to have greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

How do general practitioners manage subjects with early schizophrenia and collaborate with mental health professionals?

Objective This study was conducted to explore how general practitioners (GPs) manage subjects with early psychosis and collaborate with psychiatrists in the care of such patients. Methods Survey questionnaires exploring practice in patients with early psychosis were mailed to all GPs in South-Western France (n=3,829). Results The response rate was 23.6%. Half of GPs responding to the survey had actually diagnosed a possible case of schizophrenia during the previous year. In such cases, the most frequent decision was to refer the patient to a psychiatrist, despite the difficulties of convincing the patient and obtaining a rapid referral. According to GPs' answers, the relationships between primary care and the mental health team were characterised by a lack of communication: less than one out of three GPs had regular contact with a mental health team, and a large majority reported that they never or rarely had information about the diagnosis and treatment of subjects referred for early schizophrenia. Having regular contacts with mental health services had a major impact on GPs' management of subjects with early schizophrenia, in particular on reducing delays to obtain a psychiatric consultation and on level of information on diagnosis and treatment after referral. Conclusion Promotion of networking between primary care and mental health services is required to reduce delayed access to care in subjects with early schizophrenia.     

Integrating psychiatry and primary care improves acceptability to mental health services among Chinese Americans

The objective of this study was to investigate whether integrating psychiatry and primary healthcare improves referral to and treatment acceptability of mental health services among Chinese Americans. The "Bridge Project," a program to enhance collaboration between primary care and mental health services for low-income Chinese immigrants was implemented at South Cove Community Health Center in Boston. The project consisted of conducting training seminars to primary care physicians to enhance recognition of common mental disorders, using a primary care nurse as the "bridge" to facilitate referrals to the Behavioral Health Department of the same facility, and co-locating a psychiatrist in the primary care clinic to provide onsite evaluation and treatment. The rate of mental health service referrals and successful treatment engagement before and during the project were compared. During the 12-month period of the Bridge Project, primary care physicians referred 64 (1.05% of all clinic patients) patients to mental health services, a 60% increase (chi(2)=4.97, P<.05) in the percentage of clinic patients referred in the previous 12 months. Eighty-eight percent of patients referred during the project showed up for psychiatric evaluation, compared to 53% (chi(2)=15.3, P<.001) in the previous 12 months. Integrating psychiatry and primary care is effective in improving access to mental health services and in increasing treatment engagement among low-income immigrant Chinese Americans.     

Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use

OBJECTIVE: The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients. METHOD: This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023). RESULTS: Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care. CONCLUSIONS: Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.     

Prediction of Mental Health Services Use One Year After Regular Referral to Specialized Care Versus Referral to Stepped Collaborative Care

Referral to collaborative mental health care within the primary care setting is a service concept that has shown to be as effective as direct referral to specialized mental health care for patients with common mental disorders. Additionally it is more efficient in terms of lower mental health services use. This post-hoc analysis examines if treatment intensity during 1-year of follow-up can be predicted prospectively by baseline characteristics. With multilevel multivariate regression analyses baseline characteristics were examined as potential predictors of visit counts. Results showed that only the enabling factors service concept and referral delay for treatment had a significant association with mental health visit counts, when outcome was dichotomized in five or more visits. Inclusion of the outcome variable as a count variable confirmed the predictive value of service concept and referral delay, but added marital status as a significant predictor. Overall, enabling factors (service concept and referral delay) seem to be important and dominant predictors of mental health services use.     

Mental health services received by depressed persons who visited general practitioners and family doctors

OBJECTIVES: This study estimated the rates of mental health service provision and of specialist referral in primary care in Canada and investigated factors associated with receiving mental health services and with referral to mental health specialists among persons who reported major depressive episodes. METHOD:S: Data from the 1998-1999 Canadian National Population Health Survey were used. The 608 respondents who reported having major depressive episodes in the 12 months preceding the survey and who reported contacting a general practitioner or family doctor during that time were included in the study. The rates of provision of mental health services by general practitioners and family doctors and of referral to mental health specialists were calculated. Demographic, socioeconomic, and clinical characteristics associated with receiving mental health services and with referral to specialists were investigated. RESULTS: Among the 608 respondents who had contacted general practitioners or family doctors for any reason, 153 had contacted them for emotional or mental problems. Of this subgroup of 153, 64.5 percent received mental health services either from these practitioners or by referral to specialists, and 26 percent were referred to mental health specialists. Depressed respondents who reported having talked to a general practitioner or family doctor about mental health problems, who reported impairment, and whose depressive symptoms had lasted eight or more weeks were more likely to have received mental health services. Respondents aged 12 to 24 years were more likely to be referred to mental health specialists. CONCLUSION:S: Impairment associated with depression and chronicity of depressive symptoms appear to be the primary determinants of the decisions made by general practitioners and family doctors about providing mental health services. Patients' willingness to consult with general practitioners or family doctors for mental health problems may also be a key factor, both for effective management of depression in primary care settings and for referral to mental health specialists.     

Exploring Primary Care Activities in ACT Teams

People with serious mental illness often receive inadequate primary and preventive care services. Federal healthcare reform endorses team-based care that provides high quality primary and preventive care to at risk populations. Assertive community treatment (ACT) teams offer a proven, standardized treatment approach effective in improving mental health outcomes for the seriously mentally ill. Much is known about the effectiveness of ACT teams in improving mental health outcomes, but the degree to which medical care needs are addressed is not established. The purpose of this study was to explore the extent to which ACT teams address the physical health of the population they serve. ACT team leaders were invited to complete an anonymous, web-based survey to explore attitudes and activities involving the primary care needs of their clients. Information was collected regarding the use of health screening tools, physical health assessments, provision of medical care and collaboration with primary care systems. Data was analyzed from 127 team leaders across the country, of which 55 completed the entire survey. Nearly every ACT team leader believed ACT teams have a role in identifying and managing the medical co-morbidities of their clientele. ACT teams report participation in many primary care activities. ACT teams are providing a substantial amount of primary and preventive services to their population. The survey suggests standardization of physical health identification, management or referral processes within ACT teams may result in improved quality of medical care. ACT teams are in a unique position to improve physical health care by virtue of having medically trained staff and frequent, close contact with their clients.     

Management of Mental Disorders in VA Primary Care Practices

The association between facility-level organizational features and management of mental health services was assessed based on a survey of directors from 219 VA primary care facilities. Overall, 26.4% of VA primary care facilities referred patients with depression, while 72.6% and 46.1% referred patients with serious mental illness and substance use disorders, respectively Staffing mix (i.e., physician extenders such as nurse practitioners) was associated with a lesser likelihood of mental health referral. Managed care (preauthorization requirement) was associated with a greater likelihood of referral for depression. VA primary care programs, while tending to refer for more serious mental illnesses, may also be using mental health specialists and physician extenders to provide mental health care within general medical settings.     

Profiles of and practices in crisis resolution and home treatment teams in Norway: a longitudinal survey study

Background

Crisis resolution and home treatment (CRHT) is one of the more recent modes of delivering acute mental health care in the community. The objective of the study was to describe the standardizations and variations in the CRHT teams in Norway in order to gain knowledge regarding the structures and processes of CRHT teams.

Methods

A longitudinal survey of five CRHT teams in Norway was carried out for a period of 18 months with two sets of questionnaires-one for CRHT team profiles for a bi-yearly survey and the other for services and practices of CRHT teams for a monthly survey.

Results

The five CRHT teams were configured by a set of common basic characteristics in their operations, while at the same time were variant in several areas of the teams' structures and processes. Significant differences among the teams were evident in terms of the structural aspects such as service locality, staffing and team make-up, caseload, service hours, and travel time, and the process aspects such as the number of referrals received, referral source, admission, service duration, and discharge destination. These variations are reflected upon the perspectives regarding the nature of mental health crisis, the conflicting policies in mental health services, and the nature of home-based mental health care.

Conclusions

The diversity in the way CRHT teams are established and operate needs to be examined further in order to understand the reasons for such variations and their impact on the quality of services to service users and in relation to the total mental health service system in a community.     

Can Assertive Community Treatment Remedy Patients Dropping Out of Treatment Due to Fragmented Services?

Previously, many patients with severe mental illness had difficulties to engage with fragmented mental health services, thus not receiving care. In a Dutch city, Assertive Community Treatment (ACT) was introduced to cater specifically for this group of patients. In a pre–post comparison, changes in mental health care consumption were examined. All mental health care contacts, ACT and non-ACT, of patients in the newly started ACT-teams were extracted from the regional Psychiatric Case Register. Analyses of mental health care usage were performed comparing the period before ACT introduction with the period thereafter. After the introduction of ACT, mental health care use increased in this group of patients, although not all patients remained under the care of ACT teams. ACT may succeed in delivering more mental health care to patients with severe mental illness and treatment needs who previously had difficulties engaging with fragmented mental health care services.     

Benefits of an Outpatient Psychiatric TeleConsultation Unit: Results of a 1-Year Pilot

BACKGROUND: A Psychiatric TeleConsultation Unit (PTCU) was created at the Massachusetts General Hospital (MGH) in response to critical changes in the health care delivery system. The PTCU's design was based on an understanding of the needs of primary care physicians (PCPs) at MGH, as derived from PCPs' responses to a survey and at focus groups. The PTCU was designed to supply psychiatric expertise to PCPs on a "1 phone call away" basis and to assist the MGH in supporting an increasingly large network of PCPs by expanding access to the MGH's psychiatric staff and services. METHOD: Open Monday through Friday, 9 a.m. to 5 p.m., the PTCU provided PCPs with immediate telephone access to a staff psychiatrist who answered diagnostic- and treatment-related questions, often while the patient was still in the PCP's office. If a referral for mental health services was required, the PTCU facilitated this using an electronic mail (e-mail)-based referral system. Data were gathered from April 1996 to April 1997. RESULTS: During its first year of operation, the PTCU served 107 PCPs and their 46,377 patients; its projected capacity was 470,000 patients. It provided 595 teleconsultations; half were primarily directed toward making a referral, one fourth were primarily directed toward diagnosis or treatment, and one fourth were for both referral- and diagnosis- or treatment-related reasons. 361 patients were referred via e-mail distribution lists to a network of 92 clinicians. In 72 teleconsultations (12%), referral for mental health services was prevented. The estimated savings from these prevented services far exceeded the PTCU's costs of providing all 595 teleconsultations. Projected yearly savings for the PTCU at full capacity were projected at $379,080, from prevented referrals for mental health services. Follow-up semistructured interviews of the first 81 PCP callers revealed that 71% were "extremely satisfied," 18% were "very satisfied," and only 2% were "not at all satisfied" with the PTCU. PCPs reported that the PTCU saved them time in 85% of teleconsultations. Teleconsultations related to diagnosis or treatment changed the PCP's diagnosis 20% of the time and changed the PCP's treatment plan in nearly two thirds of cases. Twenty percent of the teleconsultations were done while the patient was in the PCP's office. Ninety-four percent of the PCPs enthusiastically said they would use the PTCU again. CONCLUSION: Our PTCU increased the efficiency and efficacy of care provided by PCPs. Cost savings associated with a reduced frequency of unnecessary referrals were more than the costs of the PTCU in a capitated health care system.     

Child and adolescent psychiatry in general practice.

OBJECTIVE: This review discusses the role of general practitioners and primary care health staff in the assessment, treatment and prevention of child and adolescent psychiatric disorders and to consider implications for service delivery. METHOD: Literature review. Papers were selected as having an empirical evidence base or as describing and documenting new initiatives in general practice. RESULTS: A small proportion of about 3% of children present to general practice with behavioural or emotional problems, but psychiatric disorders in the context of somatic presentations are considerably more common. They are probably higher than in the general population reflecting an increased tendency by children with disorders to consult. Recognition by general practitioners is limited and few children with disorders are referred to specialist clinics. However, referrals are mostly appropriate: the more severely affected children in difficult psychosocial circumstances. A number of pilot studies have shown the feasibility and potential usefulness of setting up shifted specialist clinics in primary care and of training primary care doctors and other staff in the recognition or management of child mental heath problems. CONCLUSION: Primary care is an appropriate resource to help increase attention to child and adolescent mental health problems. Its potential requires further development and rigorous evaluation. Areas lending themselves to development include: improved medical undergraduate teaching and postgraduate training; suitable information and advice-giving on child mental health problems by the primary care team; the development of specific child and adolescent psychiatric interventions for use in the primary care setting; careful and discriminating development of shifted outpatient clinics for selected child psychiatric disorders; the development of focused protocols for referral to specialist services; further development of mental health promotion clinics in primary care.     

Prison Mental Health In-reach: The Effect of Open Referral Pathways

In England and Wales, mental health in-reach teams manage high levels of mental disorder in prisons, but problems with reception screening and referral triage have been identified. As one potential solution, we examined the effect of an open referral pathway upon one in-reach team by evaluating its referrals and caseload across two time periods (in 2008 and 2011). There was a doubling of team referrals (from 101 to 203) with significantly improved identification of people with no mental health history. There was further evidence for a lowering of thresholds for referral and assessment, an approach that can be seen as helpful within a system that is known to under-identify mental health problems. Despite limitations, this evaluation offers some evidence for the effectiveness of open referral systems. It also raises questions about the potential effects of liaison and diversion services that are presently being piloted for national introduction.     

PRISM-E: comparison of integrated care and enhanced specialty referral models in depression outcomes

OBJECTIVE: This study, entitled Primary Care Research in Substance Abuse and Mental Health for the Elderly, examined six-month outcomes for older primary care patients with depression who received different models of treatment. METHODS: Clinical outcomes were compared for patients who were randomly assigned to integrated care or enhanced specialty referral. Integrated care consisted of mental health services co-located in primary care in collaboration with primary care physicians. Enhanced specialty referral consisted of referral to physically separate, clearly identified mental health or substance abuse clinics. RESULTS: A total of 1,531 patients were included; their mean age was 73.9 years. Remission rates and symptom reduction for all depressive disorders were similar for the two models at the three- and six-month follow-ups. For the subgroup with major depression, the enhanced specialty referral model was associated with a greater reduction in depression severity than integrated care, but rates of remission and change in function did not differ across models of care for major depression. CONCLUSIONS: Six-month outcomes were comparable for the two models. For the subgroup with major depression, reduction in symptom severity was superior for those randomly assigned to the enhanced specialty referral group.     

Community mental health care: clients' perceptions of services and an evaluation of a voluntary agency support scheme

A questionnaire assessment of mental health and of perceptions of formal care was conducted with a sample of clients before they received a voluntary agency mental health intervention in addition to normal community psychiatric and social services. The assessment was repeated three months later. A matched control group who received only the normal services were also assessed twice over a period of three months. Both groups improved significantly on the mental health measure over the three months and there was little difference between the treatment and control group. Clients in the voluntary agency group were less satisfied with community psychiatric services and may have chosen the voluntary agency as an alternative source of help. Women in both groups showed less improvement in measured mental health than men. Community Psychiatric Nurses (CPNs) were seen more frequently than social workers, psychologists and psychiatrists. Contacts with CPNs and social workers were rate most favourably.     

Preliminary outcomes from an integrated mental health primary care team

The effects of establishing a multidisciplinary mental health primary care team in a Veterans Affairs internal medicine primary care clinic were evaluated. The multidisciplinary team worked in collaboration with primary care providers to evaluate and treat their patients, who had a wide variety of psychiatric disorders, in the primary care clinic. In the first year of operation preliminary outcomes indicated that the rate of referrals to specialty mental health care dropped from 38 percent to 14 percent. The mean number of appointments with the team for evaluation and stabilization was 2.5. These outcomes suggest that a multidisciplinary mental health primary care team can rapidly evaluate and stabilize patients with a wide range of psychiatric disorders, reduce the number of referrals to specialty mental health care, and improve collaborative care.     

Collaboration Between Mental Health Services and Primary Care: The Bologna Project

OVERVIEW: Management of anxiety and depressive disorders within the community necessitates collaboration between mental health services and primary care. While cooperative projects do exist in many countries, Italy's National Health System does not have a program designed to address this issue. In Bologna, a cooperative project arose as a spontaneous undertaking between mental health professionals and primary care physicians. A model of collaboration was designed specifically for the Italian National Health System, consisting of a network of primary care liaison services (PCLSs) instituted within the community mental health services. PCLSs are managed by a staff of specially trained mental health care professionals and are designed to facilitate communication between physicians, and they provide continual and multifaceted support consisting of diagnostic assessment and focused clinical intervention. PCLSs also provide formal consultation-liaison meetings and a telephone consultation service designed to promote communication and enrich diagnostic assessment and treatment. DISCUSSION: PCLSs are innovative, not only because they represent one of the first collaborative efforts in Italy to date, but also because of their innovative design, which is specific for the Italian National Health System. Overall, the project yielded a good result. Primary care physicians utilized the service extensively, and together with psychiatric personnel were satisfied with the outcome. These results, when compared with the traditional separation between the 2 services, are encouraging. Our model could be adapted for most communities in Italy, but must be preceded by shared recognition of local need.     

Multidisciplinary Treatment for Adults with Autism Spectrum Disorder and Co-Occurring Mental Health Disorders: Adapting Clinical Research Tools to Everyday Clinical Practice

ABSTRACT

In California, individuals with autism and co-occurring mental disorders, and their families, face two serious barriers when attempting to access the mental health services they need. The first is that the State Mental Health Specialty Service guidelines specifically exclude autism as a qualifying primary diagnosis for eligibility for mental health treatment and funding. The second is the lack of understanding and awareness regarding the challenges faced by individuals with classic autism and co-occurring mental disorders and their families. These two barriers, combined with the absence of a clear protocol for referral and assessment, have made access to services for clients and their families difficult. The Adult Autism Spectrum Disorder and Co-Occurring Mental Health Disorders project was an opportunity to study potential assessment tools and referral guidelines. We evaluated the use in a clinical setting of the Schedule for the Assessment of Psychiatric Problems Associated with Autism—a research instrument designed specifically for the psychiatric evaluation of patients with autism—to assist in diagnosing co-occurring mental health disorders. The experience gained in this study helped identify effective treatment options as well. After the assessment, clients were offered choices among several possible treatments fitting their specific needs. Our experience indicates that while adapting a research tool to everyday clinical service may encourage a more rigorous standardized approach to clinical assessment and evaluation, it may be difficult to employ such a tool in a clinical setting because of service needs and managed care constraints of serving a large and diverse population.