The Treatment of Anxiety Disorders in a Primary Care HMO Setting

Anxiety disorders are common, yet under diagnosed, in primary care settings. Many patients with anxiety and other psychiatric disorders do not seek care in mental health care settings. An integrated primary care/mental health model offers one approach to improving outcomes for patients with anxiety disorders. This model has been researched for the treatment of depression with positive results but has not been well studied for the treatment of anxiety disorders. We describe the results of care for a cohort of adult patients with Generalized Anxiety Disorder (GAD) and clinically significant anxiety secondary to Major Depressive Disorder (MDD) treated in an integrated model. Compared to a matched cohort of adults treated in a primary care setting with usual care, the intervention cohort experienced significantly improved reduction in symptoms of anxiety at 6 months. The intervention cohort also was significantly more satisfied with care.     

Sleepiness Versus Sleeplessness: Shift Work and Sleep Disorders in the Primary Care Setting

This Academic Highlights section of The Primary Care Companion to The Journal of Clinical Psychiatry presents the highlights of the teleconference series "Differential Diagnosis and Management of Excessive Sleepiness," held April 5, 7, and 22, 2004. The teleconference and this ACADEMIC HIGHLIGHTS were supported by an unrestricted educational grant from Cephalon, Inc. This report was prepared by Physicians Postgraduate Press, Inc.     

Parent and Pediatrician Perspectives Regarding the Primary Care of Children with Autism Spectrum Disorders

Parents of children with autism spectrum disorders (ASD) (n = 144) and primary care providers (PCPs) (n = 144) completed similar surveys assessing the ability of the PCP to address ASD-specific needs. Parents also rated their PCP’s ability to deliver family-centered care. A majority of parents rated their PCP’s ability as “not good” in addressing 14 of 17 ASD-specific needs, while a majority of PCPs rated themselves as “good” in addressing 10 of 17 areas. On 7 of 17 items, parents rated their PCPs lower than PCPs rated themselves. Parents who reported receiving family-centered care were more likely to rate the PCP’s ability to meet ASD specific needs as “good”. Both parents and PCPs identified areas for improvement in caring for children with ASD.     

Challenges of Implementing Depression Care Management in the Primary Care Setting

Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.     

Physician Perspectives on Providing Primary Medical Care to Adults with Autism Spectrum Disorders (ASD)

Journal of Autism and Developmental Disorders - We conducted in-depth case studies of 10 health care professionals who actively provide primary medical care to adults with autism spectrum...     

Clinically Significant Psychotropic Drug-Drug Interactions in the Primary Care Setting

In recent years, the growing numbers of patients seeking care for a wide range of psychiatric illnesses in the primary care setting has resulted in an increase in the number of psychotropic medications prescribed. Along with the increased utilization of psychotropic medications, considerable variability is noted in the prescribing patterns of primary care providers and psychiatrists. Because psychiatric patients also suffer from a number of additional medical comorbidities, the increased utilization of psychotropic medications presents an elevated risk of clinically significant drug interactions in these patients. While life-threatening drug interactions are rare, clinically significant drug interactions impacting drug response or appearance of serious adverse drug reactions have been documented and can impact long-term outcomes. Additionally, the impact of genetic variability on the psychotropic drug's pharmacodynamics and/or pharmacokinetics may further complicate drug therapy. Increased awareness of clinically relevant psychotropic drug interactions can aid clinicians to achieve optimal therapeutic outcomes in patients in the primary care setting.     

Enhancement of Treatment Response in Depression in the Primary Care Setting

This Academic Highlights section of The Primary Care Companion to The Journal of Clinical Psychiatry presents the highlights of the teleconference "Enhancement of Treatment Response in Depression" held May 18, 2004, and supported by an unrestricted educational grant from Cephalon, Inc. This meeting report was prepared by Physicians Postgraduate Press, Inc.     

Emerging Collaborative Care Models for Dementia Care in the Primary Care Setting: A Narrative Review

The rapidly increasing population living with dementia presents a unique economic and public health challenge. However, primary care physicians, despite their position as first-line providers, often lack the time, support, and training to systematically screen for, diagnose, and treat dementia, as well as provide adequate psychosocial support to unpaid caregivers. Models of collaborative care, which have found success in reducing symptom severity and increasing quality of life for other chronic illnesses, have been studied for feasibility, efficacy, and cost effectiveness in treating individuals with dementia and supporting caregivers. A review of initial data from several models suggests that enrollment in a collaborative care program for dementia is associated with benefits such as reduction in behavioral symptoms of dementia, improved functioning and quality of life, less frequent utilization of acute medical services, and decrease in caregiver burden. These evidence-based models, if implemented widely, stand to facilitate delivery of highly effective dementia care while reducing associated total medical expense. In this narrative review, we examine the key components of collaborative care teams, summarize outcomes of prior studies and discuss barriers and opportunities for wider dissemination of collaborative care models that are partnered with and/or based within primary care settings.     

Screening Young Children for Autism Spectrum Disorders in Primary Practice

The increasing prevalence of autism spectrum disorders as well as emerging evidence of the efficacy of early intervention has focused attention on the need for early identification of young children suspected of having an ASSD. Several studies have suggested that while parents report concerns early in development, it may be months before children can be evaluated and services provided, and these delays may be even more marked in under-served populations. The American Academy of Pediatrics recently recommended universal screening for autism spectrum disorders at the 18- and 24-month well-child pediatric visit. The authors review several early screening tools currently in use and offer recommendations for integrating autism specific screening into primary care practice.     

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.     

Measures to Assess the Noncognitive Symptoms of Dementia in the Primary Care Setting

Noncognitive symptoms associated with Alzheimer's disease and related dementias include psychosis, mood disturbances, personality changes, agitation, aggression, pacing, wandering, altered sexual behavior, changed sleep patterns, and appetite disturbances. These noncognitive symptoms of dementia are common, disabling to both the patient and the caregiver, and costly. Primary care physicians will often play a major role in diagnosing and treating dementia and related disorders in the community. Accurate recognition and treatment of noncognitive symptoms is vital. A brief, user-friendly assessment tool would aid in the clinical management of noncognitive symptoms of dementia. Accordingly, we reviewed the available measures for their relevance in a primary care setting. Among these instruments, the Neuropsychiatric Inventory-Questionnaire seems most appropriate for use in primary care and worthy of further investigation.     

Investigating Gaze Behaviour of Children Diagnosed with Autism Spectrum Disorders in a Classroom Setting

Journal of Autism and Developmental Disorders - A defining feature of ASD is atypical gaze behaviour, however, eye-tracking studies in ‘real-world’ settings are limited, and the...