Psychologists in Long-Term Care: Overview of Practice and Public Policy: Introduction to the Special Series

With the overall aging of the population and the concomitant need for the provision of mental health care for older adults, professional psychology in long-term care has come of age. Psychologists are now increasingly practicing in such traditional long-term care settings as nursing homes and in less traditional ones such as rehabilitation units, day centers, partial hospitaliza-tion programs, and hospices. The practice of psychology in long-term care is strongly influenced by public policy issues relating to Medicare, such as conditions of reimbursement, the rise of managed Medicare, and the continued disparity between payment for mental health and medical diagnoses. Ceropsychologists must be flexible in the form of their healthcare delivery to continue to provide quality services. The following articles in this special section on long-term care summarize the research on assessment and interventions for long-term care patients, outline the training opportunities available, and provide a decision-making framework for the common professional ethical/legal issues encountered in long-term care settings.     

Providing Interdisciplinary Geriatric Team Care: What Does It Really Take?

We concur with Speer and Schneider's arguments (2003 ; this issue) that more psychologists should offer mental health services to older adults and that the primary care system is a good focus of such efforts. Three issues deserve more prominence in their review. First, their argument that older adults are averse to mental health services seems incorrect, given research indicating that older adults prefer psychotherapy to medication for treatment of depression. Second, psychologists working in primary care need to be aware of new Current Procedural Terminology (CPT) codes that allow documentation of psychological work in medical settings. Third, Speer and Schneider allude to interdisciplinary team functioning, but provide little information about models of team care or issues in developing a well-functioning interdisciplinary team; this commentary expands on those topics.     

Meeting the Mental Health Needs of Older Adults in Primary Care: How Do We Get the Job Done?

Most elderly persons in the United States with mental health problems such as depression receive no attention or care. Those who receive treatment generally do so in primary care settings, where disorders like depression have a hard time competing with other common and chronic medical problems. Typically, mental illnesses are under-recognized and under-treated in elderly persons attending primary care clinics. The experience of the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study is briefly described, indicating that depression, for example, can be treated successfully in primary care elderly using the type of multidisciplinary collaborative care model advocated by Speer and Schneider (2003 ; this issue). The challenge now facing all of us is to create a consumer- and family-driven demand for good mental health services in geriatric clinics and a political consensus to reimburse such services fairly. Recent improvement in Medicare reimbursement for mental health services to victims of Alzheimer's dementia provides a basis for hope.     

Expressing uncertainty in clinical interactions between physicians and older patients: What matters?

Objective

Uncertainty is one key factor influencing physician and patient behavior. We examined the propensity to express uncertainty on mental health versus biomedical issues by elderly patients (>65 years) and physicians during primary care visits.

Methods

385 videotaped visits were coded according to “topics,” which are issues raised by any participant during the visit. This approach allowed us to examine if uncertainty was expressed in biomedical, mental health or other topics, and the factors associated with expressions of uncertainty.

Results

We found that patients expressed uncertainty in 20.21% of topics compared to physicians expressing uncertainty in 11.73% of topics discussed in all visits. Patients expressed uncertainty in 22% of biomedical and 46.5% (p < 0.01) of mental health topics. Similar statistics were found in physicians’ expression of uncertainty with more uncertainty being expressed with mental health topics (23.9%) than biomedical topics (12.56%, p < 0.05).

Conclusion

Patients expressed more uncertainties than physicians during visits. Patients and physicians both expressed more uncertainties on mental health topics suggesting that patients and primary care physicians felt less knowledgeable or less confident about dealing with mental health issues.

Practice implications

Understanding the inherent uncertainties in medicine can help physicians and patients engage in more productive discussion about both biomedical and mental health topics.     

Depressed mothers coming to primary care: maternal reports of problems with their children

BACKGROUND: Studies of depressed mothers have generally been conducted in psychiatric settings with non-minority, middle-class women. Primary care has an increasing role in early detection and treatment, especially for the poor who have less access to specialized mental health services. Data on the relationship between maternal depression and problems in the offspring in a primary care context could help physicians to more effectively identify children in need of psychiatric help. METHODS: All mothers aged 25 to 55 from a systematic sample of consecutive adults (response rate, 80%) in an urban general medicine practice were screened using the PRIME-MD Patient Health Questionnaire (PHQ). Mothers who screened positive for major depression (n=85); other psychiatric disorders, but not major depression (n=67); or no psychiatric disorders (n=191) were compared on their children's history of emotional problems, unmet need for mental health treatment, parent-child discord, maternal functional status and mental health treatment. RESULTS: Compared to non-psychiatric controls, depressed mothers reported a three-times greater risk of serious emotional problems in their children (95% confidence interval [CI], 1.7-6.1); a four-times greater risk of having their children's problems left untreated (95% CI, 2.3-8.2), and a 10-times greater risk of having poor mother-child relations within the past month (95% CI, 3.9-29.4). Depressed mothers reported more functional disability, more psychiatric treatment and more problems in their offspring than mothers with non-depressive psychiatric disorders. Although a majority of mothers (regardless of psychiatric status) believed that counseling (96%) or medication (84%) should be offered to those with serious emotional problems, only about half (49%) of the depressed mothers had received mental health treatment in the past month. LIMITATIONS: Children were not assessed directly. CONCLUSIONS: The children of low-income depressed women at a general medicine practice were reported to have a greatly increased risk for emotional problems. Many mothers had not received treatment for their own emotional problems. By enquiring about the emotional health of children of adult primary care patients, primary care providers have an opportunity to promote early detection and to facilitate appropriate treatment for both the mothers and their children.     

Psychologists Entering Primary Care: Manhattan Cannot Be Bought for $24 Worth of Beads

Speer and Schneider's review (2003 ; this issue) illustrates a number of problems in psychologists' understanding of elderly primary care (PC) patients and their providers, as well as the context of PC. Claims that elderly patients overutilize health services and do so primarily because of mental health problems are not well founded. Older PC patients also face practical and preference barriers to accepting conventional psychological treatment The evidence that psychological services provide cost offset is questionable, and cost offset is not the best way of evaluating the value of psychological services. Rather than as frontline providers, psychologists' best prospects for an expanded role in PC is in the design, supervision, and evaluation of augmented services in this setting.     

Educating social workers to meet the challenge of an aging urban population: a promising model.

As Americans live longer, they will require more health and social services to address the onset of acute and chronic conditions. The persistent changes in health care delivery and the increasingly diverse older adult population in urban settings, coupled with the high expectation for families to be responsible for home care needs, challenge social workers, who work alongside physicians, nurses, and other health care professionals, to provide services effectively. Because social workers are becoming more essential, social work education must increase the numbers of social workers with the knowledge and skills necessary for practice in the current U.S. health, mental health, and social service systems, particularly in caring for the aging populations in urban settings. A New York Academy of Medicine study identified the need for increased synergy between the two components of graduate social work education: the field experience and classroom instruction. One educational model, the Practicum Partnership Program, which is designed to better integrate field and classroom, is being tested at six sites. Early results from over 300 graduates are encouraging, with evidence that students' knowledge and skills regarding aging adults have increased, their satisfaction with the experience was very high, and those who were trained reflect the diversity of the population of older adults. The early success of this program suggests that innovative educational models that expose graduate social work students to diverse populations across the continuum of care are possible. Such models will be essential for the nation to be successful in producing a social work labor force qualified to meet the challenge of an aging urban population.     

A new paradigm for teaching behavior change: Implications for residency training in family medicine and psychiatry

ABSTRACT: BACKGROUND: Primary care physicians (PCPs) provide ~50 % of all mental health services in the U.S. Given the widening gap between patient mental health needs and resources available to meet those needs, there is an increasing demand for family medicine and psychiatry trainees to master competencies in both behavioral medicine and primary care counseling during residency-if for no other reason than to accommodate the realities of medical practice given the oft present gap between the need for psychiatric services and the availability, quality, and/or affordability of specialized psychiatric care. To begin to address this gap, a skills-based, interactive curriculum based on motivational interviewing (MI) as a teaching method is presented. METHODS: The curriculum described in this paper is a four-week block rotation taught in the second year of residency. Motivational interviewing (MI) is used as a teaching approach toward the goal of clinical behavior change. Residents' strengths, personal choice and autonomy are emphasized. Each week of the rotation, there is a clinical topic and a set of specific skills for mastery. Residents are offered a "menu" of skills, role modeling, role/real play, practice with standardized patients (SP), and direct supervision in clinic. RESULTS: Thirty-nine residents have completed the curriculum. Based on residents' subjective reporting using pre-post scales (i.e., importance and confidence), all participants to date have reported substantial increases in confidence/self-efficacy using primary care counseling skills in their continuity clinic. CONCLUSIONS: This paper presents an innovative, empirically based model for teaching the essential skills necessary for physicians providing care for patients with mental/emotional health needs as well as health-behavior change concerns. Implications for training in the broader context, particularly as it relates to multi-disciplinary and collaborative models of teaching/training are discussed.     

Worries and needs of adults and parents of adults with neurofibromatosis type 1

Neurofibromatosis type 1 (NF1) is a neurocutaneous disorder associated with lifelong tumor growth propensity and neurocognitive impairments. Although follow‐up of adults with NF1 often focuses on tumor growth, follow‐up of cognitive or social problems and other NF1‐related comorbidity is often not a part of standardized care. In order to provide optimal care services for these patients, we explored the care needs of adults with NF1. A qualitative study was performed using semi‐structured group interviews, exploring worries and care needs in medical, psychological, and socioeconomic domains, also focusing on the transition from pediatric to adult care. Four focus groups were conducted, including young adult patients, patients over age 30, and parents of young adult patients. In total, 30 patients and 12 parents participated. Data were transcribed verbatim and analyzed by computerized thematic analysis. Themes were organized using the World Health Organization International classification of functioning, disability, and health (ICF). Results indicated many and diverse worries and care needs both during the transitional period and in adulthood in medical, mental health, and socioeconomic domains. Worries could be categorized into 13 themes. Parents reported high stress levels and difficulties with their parental role. Participants expressed the need for more information, access to NF1 experts, daily living support, care for mental health and socioeconomic participation, and closer communication between health‐care providers. In conclusion, worries and needs of patients and parents underline the importance of multidisciplinary follow‐up and continuity of care during and after the transitional period. Additionally, parental stress requires more attention from care providers.     

汶川地震受灾地区灾后社区、乡镇卫生院工作者精神卫生服务能力评估

目的:了解汶川受灾地区社区、乡镇卫生院工作者的精神卫生知识掌握情况及精神卫生服务能力,为精神卫生培训提供依据,为我国精神卫生服务体系建设提供科学参考。方法:选取灾后社区、乡镇卫生工作者心理卫生服务技能培训班学员353名为研究样本,回收有效问卷313份。使用自编精神卫生知识评估问卷和精神卫生服务调查表进行评估。自编精神卫生知识评估问卷包含抑郁症、酒精依赖、精神分裂症(阳性症状为主)、创伤后应激障碍和躯体形式障碍5种精神障碍。结果:受灾地区乡镇、社区卫生院工作者对于社区5种精神障碍准确诊断率最高的案例为抑郁症(77.0%),药物处理中位数得分最高的为酒依赖;非药物处理中位数得分最高的是酒依赖和创伤后应激障碍。培训前1月内报告未接诊过精神障碍患者的社区、乡镇卫生院工作者占53.4%。不知道任何1所精神卫生服务机构的卫生院工作者占35.1%;不知道精神科专科会诊的占37.7%;不能邀请精神科专科会诊的占39.6%。结论:汶川地震后,受灾地区的乡镇、社区卫生院工作者精神卫生知识和技能掌握较少,精神卫生服务能力相对弱。     

Utilization of mental health care services among older adults with depression

Despite the availability of effective treatments for late life depression, data indicate that only a small minority of adults over the age of 65 years with depression access any kind of care for emotional or mental health problems. Using data from the Canadian Community Health Survey (Cycle 1.1), we compared patterns of mental health service utilization among middle-aged (45-64 years), younger old (65-74 years), and older old (75 years and older) adults with and without depression and identified predictors associated with accessing different services (n=59,302). Compared to middle-aged adults with depression, individuals aged 65 and older with depression were less likely to report any mental health consultation in the past year and especially unlikely to report consulting with professionals other than a family physician. Age remained a significant predictor of mental health service utilization even after accounting for other relevant variables such as gender, marital status, years of education, depression caseness, and number of chronic medical conditions. Although the prevalence of depression is lower in older age groups, the present study provides compelling evidence that mental health services are particularly underutilized by depressed older adults.     

Mistrust in Physicians does not Explain Black-white Disparities in Primary Care and Emergency Department Utilization: The Importance of Socialization During the Jim Crow era

Purpose: Compared to whites, blacks under-utilize primary care (PC) and over-utilize emergency department (ED) services. The aim of this study is to determine whether mistrust in physicians explains these black-white disparities, and the potentially modifying influence of socialization under racially segregated health care (i.e., raised in the U.S. South during the Jim Crow era).Methods: Data come from the nationally representative Americans' Changing Lives Study (n=1,578). Poisson regression techniques are utilized to respectively model PC and ED utilization among a sample of non-Hispanic black and white adults aged forty-years and older.Conclusion: Mistrust in physicians does not explain black-white disparities in PC or ED utilization. Blacks under-utilize PC services compared to whites, net of predisposing, need, and enabling factors, but this is especially apparent among blacks who were raised in the U.S. south during the Jim Crow era and continue to reside in the South. Blacks greatly over-utilize ED services compared to whites, but this is greatest among those raised in the south during the Jim Crow era and/or those currently residing in the South.     

Interest and Use of Mental Health and Specialty Behavioral Medicine Counseling in US Primary Care Patients

Background

Counseling interventions have the potential to improve health and quality of life for primary care patients, but there are few studies describing the interest in and utilization of counseling among this patient population in the USA.

Purpose

The purpose of the study was to evaluate interest in mental health and specialty behavioral medicine counseling and predictors of utilization over 1 year among US primary care patients.

Method

Participants in this two-survey longitudinal study included 658 primary care patients in an urban US academic medical center (461 females, age M?=?51.05, SD?=?15.46 years). Retention rate was 61.2% at survey 2. Patient demographics, depression, anxiety, and interest in counseling services were assessed through a survey mailed 1 week following an outpatient appointment. Respondents to survey 1 were re-contacted 1 year later to assess. Interest and use of the following counseling services were evaluated in the relevant subgroups: mental health (the entire sample and patients with elevated anxiety and/or depression), health/lifestyle (overweight and obese participants), smoking cessation (current and occasional smokers), and pain management (participants with elevated daily pain ratings).

Results

At survey 1, 45.7% of the sample reported interest in mental health counseling, and 58.9% of the sample reported interest in behavioral medicine counseling. Among overweight or obese participants, 59.9% were interested in health/lifestyle counseling. Among smokers, 55.3% were interested in smoking cessation, and among participants with chronic pain, 33.8% were interest in pain management. Rates of utilization of services at survey 2 were 21.3% for mental health, 7.7% for health/lifestyle, 6.7% for smoking cessation, and 6.6% for pain management. Interest in receiving services at survey 1 was the strongest predictor of utilization.

Conclusion

Results demonstrate high interest but low utilization over 1 year among US primary care patients. Identifying patients interested in counseling services and reducing barriers may help facilitate receipt of services for those with interest and need for behavioral treatments.     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study.

BACKGROUND: The Global Mental Health Assessment Tool-Primary Care Version (GMHAT/PC) has been developed to assist health professionals to make a quick and comprehensive standardised mental health assessment. It has proved to be a reliable and valid tool in a previous study involving GPs. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings. AIM: To assess the feasibility of using a computer-assisted diagnostic interview by nurses and to examine the level of agreement between the GMHAT/PC diagnosis and psychiatrists' clinical diagnosis. DESIGN OF STUDY: Cross-sectional validation study. SETTING: Primary care, general healthcare (cardiac rehabilitation clinic), and community mental healthcare settings. METHOD: A total of 215 patients between the ages of 16 and 75 years were assessed by nurses and psychiatrists in various settings: primary care centre (n = 54), cardiac rehabilitation centre (n = 98), and community mental health clinic (n = 63). The time taken for the interview, and feedback from patients and interviewers were indicators of feasibility, and the kappa coefficient (kappa), sensitivity, and specificity of the GMHAT/PC diagnosis were measures of validity. RESULTS: Mean duration of interview was under 15 minutes. The agreement between nurses' GMHAT/PC interview-based diagnosis and psychiatrists' International Classification of Diseases (ICD)-10 criteria-based clinical diagnosis was 80% (kappa = 0.76, sensitivity = 0.84, specificity = 0.92). CONCLUSION: The GMHAT/PC can assist nurses to make accurate mental health assessment and diagnosis in various healthcare settings and it is acceptable to patients.     

Challenging linguistic barriers to health care: students as medical interpreters.

Inadequate medical interpretation services are a barrier to the delivery of optimal health care to persons with limited English proficiency. Even though Title VI of the Civil Rights Act of 1964 requires that interpretation services be available to persons speaking limited English, many health care institutions are struggling to reach full compliance. Communication through untrained interpreters is likely to include mistranslations or omissions of physicians' questions, truncated or slanted patient responses, and inadequate information to facilitate accurate diagnosis and treatment. The Interpreter's Aide Program (IAP) is a service-learning program that was implemented at Brown Medical School in 1997. The IAP is a collaborative effort among Brown students, the Rhode Island Hospital Department of Social Work, and Brown Medical School. This three-way partnership strengthens the IAP and expands interpretation services to Spanish- and Portuguese-speaking patients at Rhode Island Hospital. Bilingual undergraduate and medical students become trained medical interpreters and render community service while developing cross-cultural skills. The authors review the development and implementation of the IAP. There is potential for other academic health centers to develop similar partnerships with local colleges and universities, and to provide service-learning opportunities for future physicians and health care consumers.     

Mental health aspects of emergency medical services for children: summary of a consensus conference.

OBJECTIVE: To address the mental health needs of children involved in emergency medical services (EMS). METHODS: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children. RESULTS: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children's reactions are critically affected by age and developmental level, characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. CONCLUSIONS: Ecological changes in emergency departments, such as linkages to mental health follow-up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care.     

Factors explaining the use of psychiatric services by general practices.

BACKGROUND: Referral rates from general practitioners to hospital services vary up to 25-fold, and several studies have sought reasons for this apparent inconsistency in clinical practice. However, few studies have concentrated on, or indeed included, psychiatric patients or psychiatric referral rates. AIM: To determine the effect of population, general practice, and mental health service factors on use of specialist mental health services by general practices. METHOD: Cross-sectional data from computerized records used in managing clinical care on all patients aged 16 to 64 years who had been in contact with any mental health service staff over a two-year period. Twenty-three practices in Huntingdon Health District were studied, with a list population of 87,643 patients aged 16 to 64 years, served by one inpatient ward and three community mental health teams. The main outcome measures were the relation between age-standardized utilization ratio and markers of morbidity, deprivation, community mental health provision, and practice prescribing. RESULTS: Variation between practices in the use of mental health services was relatively limited, especially compared with the use of other secondary medical and surgical services. Three factors together explained 60.8% of the variance in use between practices: a census-based index of long-term limiting illness in females registered with the practice, use of one of the three community mental health teams, and average quarterly defined daily doses of hypnotics prescribed per practice population. Relatively high prescribing of hypnotics was associated with lower service use. CONCLUSION: Population morbidity and factors in the mental health service explain a substantial part of the variation in the use of mental health services between practices. Further work is needed to replicate these findings and explore why team factors and prescribing patterns influence utilization ratios. This study underlines the importance of examining population, practice, and specialist service factors in explaining variation in the use of secondary care by general practices.