Rural Models for Integrating Primary Care and Mental Health Services

This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models—diversification, linkage, referral and enhancement—which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.     

Mental Health in Primary Health Care

Children and families across the world face a multitude of ever-changing challenges that affect their sense of emotional well-being. Dilemmas for children in the first world include competition, consumerism, individualism, narcissism, family breakdown contributing to children as consumers, the erosion of collective (social) responsibility, dislocation, alienation, inequality, relative poverty, and crime. Dilemmas for children in the third world include regional wars and conflict, ecological catastrophe (man-made and natural) contributing to material poverty, lack of state resources (e.g., medical), migration, fragmentation of communities, disease, malnutrition, and crime. Each society has its own mechanisms to promote the natural resilience of children and families in the face of each individual, family, and society's unique challenges. The era of globalization has resulted in the global exchange of not only goods but also ideas and values, resulting in new challenges. Aggressive free market global economic systems contribute to the creation of new dangers. Child psychiatry has unwittingly contributed to reifying children's mental health, helping to obscure the real-life situations that create mental distress. The development of universalized therapeutic approaches has inadvertently replicated colonial dynamics by imposing Western notions of self, childhood, and family onto non-Western populations. Globalization also brings new opportunities for new identities, fusions, and creative solutions. The implications of this perspective for theory, research, and clinical practice in child and adolescent mental health are explored.     

Commentary: Hispanic Access to Health/Mental Health Services

Currently, the Hispanic population of the United States is growing very rapidly. Despite the significance of this growth and the fact that it is expected that Hispanics will be soon the largest ethnic minority group in this country, the access to health/mental health care for the Hispanic population is rather limited. Many factors are currently affecting the Hispanics' access to health/mental health care services. Among them, cultural and language barriers, insufficient numbers of Hispanic manpower in the health care professions, low educational and socioeconomic levels, the high number of uninsured Hispanics, and ethnic and racial prejudices and discrimination. In this commentary, I address the factors that interfere with the Hispanics' access to health/mental health care, and advance recommendations geared to alleviate and/or resolve this critical problem.     

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.     

Mental Health and Primary Care in Africa

This is the first literature review of studies on mental health in Bangladesh with a special focus on depression. We searched seven databases for search terms related to Bangladesh and mental health. The 61 papers we found had exceptionally high heterogeneity. They reported depression prevalence from 6.6 percent to 97 percent in various populations, plus a high prevalence of sleep disorders and anxiety. Two studies found that poverty and torture appear to have roughly the same capacity to cause poor mental well-being. Additional studies document violence as linked to poor mental health. Health care availability is low. Relevant cultural factors include a novel national concept of self-esteem and low emotional expressivity. It was concluded that poverty reduction in Bangladesh may reduce mental health needs, but increasing access to care is a pressing concern nonetheless. Culturally competent perspectives, trauma-informed care, and emphasis on care for depression are important. Exceptionally large research gaps exist.     

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.     

Providing Health Services for Hispanic Americans

Hispanics—consisting of Mexican-Americans, Puerto Ricans, Cubans, and Central and South Americans—are among the fastest growing population segments in the U.S. today. In order to provide effective health services, physicians must become familiar with demographic, epidemiologic, and cultural differences that affect Hispanics. Although recent literature suggests that Hispanics may have a lower adjusted mortality rate for all causes of death than non-Hispanic whites, certain conditions have particular importance. These include diabetes mellitus, cirrhosis, and homicide. Cultural issues in working with Hispanics are reviewed, as are guidelines for the use of interpreters in clinical practice. Twelve recommendations are made to assist psychiatrists and other health professionals who treat Hispanic patients.     

Measuring Community Preferences for Public Mental Health Services: Pilot Test of a Mail Survey Method

This study tested the feasibility of a simple mail survey approach to measuring community preferences for mental health services. A 38 item survey detected statistically significant differences in preferences for four central goals, finding that community members most value Focus on the Severely Mentally Ill, followed by Community Safety and Environment, Service Quality and Original Community Mental Health Goals. Some procedural problems were encountered that reduced the response rates, however, the study yielded information that suggests improved procedures for future surveys. Simple mail surveys appear to offer a potentially affordable, efficient way to assess community service priorities.     

Mental Health Collaborative Care and its Role in Primary Care Settings

Bipolar depression is considered the most difficult-to-treat phase of bipolar disorder, in relation to its pervasiveness and efficacy and/or tolerability limitations of available treatments. Indeed, most mood stabilizers and atypical antipsychotics are not as effective in ameliorating depressive compared with manic symptoms, and entail substantial tolerability limitations. However, the use of antidepressants is highly controversial, as their efficacy appears less robust in bipolar compared with unipolar depression. In addition, antidepressants, in spite of generally having adequate somatic tolerability, in BD may be associated with a higher risk of manic/hypomanic switch, suicidality and rapid cycling. Among alternative pharmacological strategies, compounds with stimulant and pro-dopaminergic effects, such as methylphenidate, modafinil, armodafinil and pramipexole, have showed potential antidepressant activity, even though their use in clinical practice has been limited by the paucity of controlled evidence. This article seeks to review available evidence about the use of the aforementioned compounds in the treatment of bipolar depression. Findings from reviewed studies suggested that pro-dopaminergic compounds, such as pramipexole and stimulants/stimulant-like agents, deserve consideration as adjunctive therapies in bipolar depressed patients, at least in some subgroups of patients. Nevertheless, caution regarding their use is recommended as further clinical trials with larger samples and longer follow-up periods are necessary to clarify the roles of these medications in bipolar depression.     

A Conceptual Model for Behavioral Health and Primary Care Integration: Emerging Challenges and Strategies for Improving International Mental Health Services

In many countries, there is a growing concern about the lack of coordination and integration of primary care with services for mental and substance-use conditions: Care is all too often fragmented across the spectrum of general medical and specialty behavioral health systems. This fragmentation tends to perpetuate systems of care that are not sensitive to the needs of individuals, provide poor quality of care, and produce inconsistent health outcomes. General health care functions across a continuum of care that includes prevention, primary care, and chronic care management. The articulation of the common elements in general and behavioral health care along that continuum has the potential to foster a framework for enhanced coordination of care for individuals in the context of improved systems of care that better supports recovery and favorable health outcomes.     

Mental Health Services Expenditures among Children Placed in Out-of-Home Care

This study examined Florida Medicaid mental health expenditures for children in out-of-home care. Child welfare and Medicaid administrative databases were analyzed using two-part models to identify characteristics associated with expenditures. Mental health expenditures were higher for older children, boys, children who were abused or lost their caregivers, or with a longer length of stay in out-of-home care. In contrast, African American children were less likely to have positive expenditures than White children, but among youth with positive expenditures, African Americans had higher expenditures. In addition, among youth with positive expenditures, substance use and affective disorders were associated with higher expenditures.     

Telepsychiatry and e-Mental Health Services: Potential for Improving Access to Mental Health Care

Reforming mental health care is a focus of many ongoing initiatives in the United States, both at the national and state levels. Access to adequate mental health care services is one of the identified problems. Telepsychiatry and e-mental health services could improve access to mental health care in rural, remote and underserved areas. The authors discuss the required technology, common applications and barriers associated with the implementation of telepsychiatry and e-mental health services.     

Mental Health Factors in the Utilization of Pediatric Primary Care

The relationship of mental health factors to use of pediatric medical care in a 12-month period is examined using cross-sectional and prospective data from a community-based cohort of children (aged 4–8 years at baseline) and their families. Results from this study demonstrate that mother's self-reported mental health is statistically significantly related to the number of pediatric visits. In the cross-sectional analysis, the effect of mothers's mental health on children with 5 or more pediatric visits is moderated by poverty and mothers with depressive symptoms are much more likely than those without such symptoms to have children who are very high service users (10 visits or more). In the longitudinal analysis, an inconsistent pattern of mothers' mental health problems over a 24-month period increases the likelihood of high use in the third year and the persistence of maternal mental health problems increases the likelihood of very high use.     

Addressing the Population Burden of Child and Adolescent Mental Health Problems: A Primary Care Model

A model for primary care child and adolescent mental health (CAMH) services is presented, the overall goal of which is to reduce population burden of CAMH problems. The theoretical orientation of the model is based on ecological systems theories. Features of the model include: local population outcome measures; small area service focus; primary-care-based CAMH specialists; a locally comprehensive service framework based in primary care (schools and general practices); and an explicit process of community engagement. The model is illustrated by reference to a primary care CAMH service (currently the subject of a controlled trial) in Flintshire, North Wales.     

Developing Quality Indicators for Family Support Services in Community Team-Based Mental Health Care

Quality indicators for programs integrating parent-delivered family support services for children’s mental health have not been systematically developed. Increasing emphasis on accountability under the Affordable Care Act highlights the importance of quality-benchmarking efforts. Using a modified Delphi approach, quality indicators were developed for both program level and family support specialist level practices. These indicators were pilot tested with 21 community-based mental health programs. Psychometric properties of these indicators are reported; variations in program and family support specialist performance suggest the utility of these indicators as tools to guide policies and practices in organizations that integrate parent-delivered family support service components.