The Internet's impact on the practice of psychiatry.

OBJECTIVE: In the past decade, the Internet has rapidly evolved into a mainstream communication and information resource. During this period, health care resources and databases have been developed. This paper reviews the literature on e-mail communication and on-line health care information resources to determine the impact on psychiatry. METHOD: The Medline electronic database and the search engines Altavista and Google were used to review the literature discussing on-line guidelines, clinical trials, and continuing medical education (CME) resources, as well as the literature on Internet usage, e-journals, and e-mail communication. CONCLUSIONS: The Internet has accelerated psychiatrists' access to new research findings and other information pertinent to clinical practice. It has eliminated distance barriers and offered psychiatrists and the general public equal access to scientific articles, clinical trials, and guidelines. The literature shows that the general public is using the Internet to obtain information and, to a lesser extent, to communicate with health care professionals. In terms of health outcomes, the effectiveness of patient on-line access to information is still uncertain, and further research is necessary. Although physicians have embraced on-line journals, further work is required before they embrace on-line CME. The Internet has developed to a point where it is important for psychiatrists to understand the issues and pitfalls in its use, to be able to access the resources available, and to be in a position to mentor patients who want to research their condition further.     

The private practice study group as phase-IV research tool

Research in the routine field of psychiatry must include psychiatrists in private practice. A majority of psychiatric patients is treated as outpatients and many of these are only seen by private psychiatrists. Setting or patient variables pose restrictions on the therapy which leads to the development of specific treatment strategies. Because these are empirically based, it can be expected that the knowledge of practitioners can make a major contribution to the development of optimal treatment recommendations. Research in private practice requires special organisational efforts. One way to get access to this field are collaborative study groups which bring together scientists and their research facilities with practitioners and their surgeries. Such an instrument may allow: access to patients, which may never show up in any other research institution; monitoring of patient characteristics and treatment modalities under routine conditions; elaboration of special skills, insights and treatment strategies developed by the practitioner. These study groups can vary with regard to type of practice, type of collaboration and type of research. Studies can rely on information from patient self-reports, observations by the practitioners themselves or their office assistants and on data gathered by scientific staff working occasionally or continuously in the practice.     

Collaboration of the general practitioner and the psychiatrist with the psychiatric hospital. A literature review

Co-operation of physicians in private practice with psychiatric hospitals was investigated in Germany scarcely until now, although evaluation of consumer satisfaction is of great importance to quality assurance in psychiatry. In this paper, findings from previous studies are presented together with data from interviews with general practitioners and psychiatrists, evaluating their expectations regarding psychiatric hospitals. Substantial problem area in collaboration is referral to the psychiatric hospital. Apart from sociodemographic and disease-related variables, referral practice depends on referring physician's attitudes and competence in psychiatry, and provider influences like delay of admission, communication with referring physician, and competence of the hospital. As conclusion, constructive collaboration must be developed at the interface of outpatient and inpatient care. On account of increasing diversification of psychiatric services, functional network should be an ongoing goal to improve treatment continuity of patients with mental disorders.     

综合医院医学心理门诊医师对抑郁症的识别

目的 了解综合性医院精神科门诊中专科和非专科医师对抑郁症的识别情况及对抑郁症的治疗模式和临床疗效,并对其相关影响因素进行分析,为制定综合医院精神卫生服务政策提供相关依据。方法 收集来自上海市9所综合性医院精神科门诊中的抑郁症患者47例,分为专科医师组20例和非专科医师组27例,在入组时、治疗第2周、第4周、第8周、第12周时,进行汉密顿抑郁量表24项（HAMD^24）、汉密顿焦虑量表（HAMA）、健康状况调查问卷（SF-36）、修订社会功能缺陷筛选量表（SDSS）、自编的药物依从性评估等量表的评定。结果 （1）综合性医院精神科门诊中专科医师对抑郁症的识别显著高于非专科医师组（χ^2=12．68,P〈0．01）。（2）专科医师组对抑郁症的治疗疗效优于非专科医师组（χ^2=7．16,P〈0．01）,两者在治疗后第8周及第12周HAMD、HAMA总分减分率上有显著性差异。（3）两组在治疗第12周时SF-36各因子分均较入组时有显著提高。结论 综合性医院精神科门诊中专科医师在对抑郁症的识别、治疗疗效上优于非专科医师;非专科医师对抑郁症的识别及诊治能力有待进一步提高．相关的卫生管理体系作用需要进一步加强。     

Psychiatrists disciplined by a state medical board

OBJECTIVE: This study determined the risk of discipline by a medical board for psychiatrists relative to other physicians and assessed the contributions to such risk. METHOD: Physicians disciplined by the California Medical Board in a 30-month period were compared with matched groups of nondisciplined physicians. RESULTS: Among 584 disciplined physicians, there were 75 (12.8%) psychiatrists, nearly twice the number of psychiatrists among nondisciplined physicians. Female psychiatrists were underrepresented in the disciplined group. Psychiatrists were significantly more likely than nonpsychiatrist physicians to be disciplined for sexual relationships with patients and about as likely to be charged with negligence or incompetence. The disciplined and nondisciplined psychiatrists did not differ significantly from a group of 75 nondisciplined psychiatrists on years since medical school graduation, international medical graduate status, or board certification. The disciplined group included significantly more psychiatrists who claimed child psychiatry as their first or second specialty and significantly fewer psychoanalysts. CONCLUSIONS: Organized psychiatry has an obligation to address sexual contact with patients and other causes for medical board discipline. This obligation may be addressable through enhanced residency training, recertification exams, and other means of education.     

Continuing medical education in psychiatry

The increasing importance of continuing medical education (CME) in psychiatry is discussed. The need to take account of the principles of adult education (AE) and also of the diversity of current psychiatric practice and individual differences when developing CME programmes is emphasised. The relevance of mandatory CME to the assessment of practitioner performance is also discussed.     

Use of general practitioners versus mental health professionals in six European countries: the decisive role of the organization of mental health-care systems

Objective

To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems.

Methods

Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP? for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands).

Results

Among respondents consulting GPs and/or MHPs in the past year (n = 1,019), respondents from the MHP? group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders.

Conclusions

Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.     

The future of Australasian psychiatrists: online or out of touch?

OBJECTIVE: The aim of this paper is to examine the delivery of mental health care which will be enabled by the various communications technologies over the next 5 to 10 years. METHOD: A literature review, reviews of multiple Internet websites and the author's personal experience and opinions are combined to provide a commentary on the group of new technologies for communication available within health, and how they will affect the practice of psychiatry and psychiatrists over the next decade. The driving forces for these changes are the rise of consumerism, technological change and financial necessity, and it is evident that patients will have in future much greater choice of access to their therapists than at present. The health-care environment of the future will be different to today, as will the roles of psychiatrists, who will increasingly have to work as members of teams in an expert capacity rather than in traditional one-to-one practice. CONCLUSIONS: It is concluded that it is essential for psychiatrists to become involved in online health care, and in particular to join their patients on the Internet, and that there are major opportunities for Australasian psychiatrists to provide high quality psychiatric care across national boundaries, particularly into the Asia-Pacific region.     

The future of psychiatry: psychiatrists of the future

OBJECTIVE: The authors' goal was to examine the changing demographic trends in psychiatry manpower. These changes have important implications for the practice of the profession in the future. METHOD: Each year, the APA Office of Membership, in collaboration with the American Association of Directors of Psychiatric Residency Training, conducts a census of all residents in psychiatry. A survey instrument is sent to the director of residency training in each U.S. program accredited by the Accreditation Council for Graduate Medical Education. Using data from this survey and from the American Medical Association, the authors conducted a study of the changes in the number of psychiatric residents over the last decade, particularly the increases in the number and percentage of women in medicine and psychiatry. RESULTS: They found that the number of psychiatric residents has grown from 4,674 in academic year 1978-1979 to 5,829 in 1987-1988, an increase of 25%. The percentage of women has increased from 32% of all psychiatric residents in 1978-1979 to 41% in 1987-1988. The largest proportions of female physicians and psychiatrists were found in the age groups younger than 35. CONCLUSIONS: Previously documented gender differences that affect practice patterns and career opportunities may very well change as a function of the increasing representation of women in the profession of psychiatry, and these changes need to be taken into account in planning for future patient care and research needs.     

Collaboration between general practitioners and mental health care professionals: a qualitative study

Background

Collaboration between general practice and mental health care has been recognised as necessary to provide good quality healthcare services to people with mental health problems. Several studies indicate that collaboration often is poor, with the result that patient' needs for coordinated services are not sufficiently met, and that resources are inefficiently used. An increasing number of mental health care workers should improve mental health services, but may complicate collaboration and coordination between mental health workers and other professionals in the treatment chain. The aim of this qualitative study is to investigate strengths and weaknesses in today's collaboration, and to suggest improvements in the interaction between General Practitioners (GPs) and specialised mental health service.

Methods

This paper presents a qualitative focus group study with data drawn from six groups and eight group sessions with 28 health professionals (10 GPs, 12 nurses, and 6 physicians doing post-doctoral training in psychiatry), all working in the same region and assumed to make professional contact with each other.

Results

GPs and mental health professionals shared each others expressions of strengths, weaknesses and suggestions for improvement in today's collaboration. Strengths in today's collaboration were related to common consultations between GPs and mental health professionals, and when GPs were able to receive advice about diagnostic treatment dilemmas. Weaknesses were related to the GPs' possibility to meet mental health professionals, and lack of mutual knowledge in mental health services. The results describe experiences and importance of interpersonal knowledge, mutual accessibility and familiarity with existing systems and resources. There is an agreement between GPs and mental health professionals that services will improve with shared knowledge about patients through systematic collaborative services, direct cell-phone lines to mental health professionals and allocated times for telephone consultation.

Conclusions

GPs and mental health professionals experience collaboration as important. GPs are the gate-keepers to specialised health care, and lack of collaboration seems to create problems for GPs, mental health professionals, and for the patients. Suggestions for improvement included identification of situations that could increase mutual knowledge, and make it easier for GPs to reach the right mental health care professional when needed.     

The Impact of Managed Care on Psychiatry

It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude and impact on job satisfaction and labor market responses are unknown. Surveys of general physicians in MCOs have provided a framework for understanding some of the difficulties and opportunities faced by managed care psychiatrists, but have failed to shed much light on many aspects of medical practice specific to the provision of mental health care within the boundaries of managed care. Future research in this area would help fill this gap, and assist in shaping the roles of psychiatrists in managed mental health care organizations.     

Coalescence of psychiatry, neurology, and neuropsychology: from theory to practice

In a climate of renewed interest in the synergy between neurology and psychiatry, practitioners are increasingly recognizing the importance of exchange and collaboration between these two disciplines. However, there are few working models of interdisciplinary teams that freely share expertise in real time, while providing clinical and academic training to future physicians who specialize in the central nervous system. Over the past 11 years, the McLean Hospital Neuropsychiatry and Behavioral Neurology service has provided proof-of-principle for such collaboration, demonstrating that a team comprising psychiatrists, neurologists, and neuropsychologists can function effectively as a unit while maintaining the autonomy of these three disciplines and also synthesizing their combined knowledge. In addition to delivering enhanced patient care and promoting medical research, this clinical service has provided enriched cross-specialty training for fellows, residents, and medical students. The practical functioning of the team is described, and case vignettes are presented to illustrate the team's collaborative synergism in practice.     

Putting "rural" into psychiatry residency training programs.

OBJECTIVE: Evidence indicates disparities in the number of psychiatrists practicing in rural America compared to urban areas suggesting the need for a greater emphasis on rural psychiatry in residency training programs. The authors offer suggestions for integrating a rural focus in psychiatry residency training to foster greater competency and interest in rural psychiatry. METHODS: The authors surveyed the limited rural psychiatry training and the more extensive family medicine rural residency literature to review efforts to develop rural focused training curricula. RESULTS: Many factors in the rural environment influence mental health care, including overlapping professional-patient relationships, caregiver isolation and stress, limited availability and access to mental health resources, disease stigma, and economic and health status. To enhance both an interest in and the quality of the training for a rural practice, the authors suggest three levels of training for integrating rural factors into psychiatry programs from a basic didactic understanding of the contextual issues affecting rural psychiatry, to creating rural clinical experiences and preceptors, to developing a rural psychiatry fellowship. CONCLUSIONS: Providing trainees with an understanding of the rural mental health issues and experiences might contribute to trainees' selecting rural practices and enhance the rural competency of psychiatrists.     

Discrepancy between opinion and attitude on the practice of ECT by psychiatrists specializing in old age in the Netherlands

BACKGROUND: Current guidelines consider electroconvulsive therapy (ECT) in the Netherlands a treatment of choice for a depressive disorder with psychotic features, severe suicidal behavior, severe physical exhaustion, or resistance to treatment with antidepressants (consecutively SSRIs, TCAs, lithium, MAO inhibitors). It is advised to use ECT early on in the treatment of depressed elderly patients. In practice, ECT is applied to only a minority of depressed elderly patients in the Netherlands. This situation dates back to the 1970s, in which strong aversive opinions toward ECT grew in the Netherlands, largely as a reaction to the malpractice of ECT in that time and influenced by social-cultural opinions toward psychiatry. Negative attitudes among professionals and lack of knowledge may contribute to the under use in depressed elderly patients. METHODS: A postal questionnaire was sent to 152 psychiatrists who specialize in old age to assess their opinions and attitudes toward ECT. RESULTS: Only a small minority thought ECT was a treatment of choice in a depressive disorder with psychotic features (4%), severe suicidal risk (2%), or physical exhaustion (5%). The majority of the psychiatrists had strongly reserved opinions in considering ECT as a treatment of first, second or third choice in depressed elderly patients, even in treatment-resistant depressive disorders. CONCLUSIONS: Many psychiatrists who specialize in old age in the Netherlands divert from the current guidelines and are reluctant toward using ECT as a treatment of choice in a number of specific, clinical situations. This might be a major contributing factor to the present and past underuse of ECT in depressed elderly patients in the Netherlands.     

Academic performance of psychiatrists compared to other specialists before, during, and after medical school

OBJECTIVE: This study was designed to compare psychiatrists with other physicians on measures of academic performance before, during, and after medical school. METHOD: More than three decades of data for graduates of Jefferson Medical College (N=5,701) were analyzed. Those who pursued psychiatry were compared to physicians in seven other specialties on 18 performance measures. Analysis of covariance was used to control for gender effect. RESULTS: Compared to other physicians, psychiatrists scored higher on measures of verbal ability and general information before medical school and on evaluations of knowledge and skills in behavioral sciences during medical school, but they scored lower on United States Medical Licensing Examinations step 3. CONCLUSIONS: The results generally confirmed the authors' expectations about psychiatrists' academic performance. More attention should be paid to the general medical education of psychiatrists.     

The ethics of forensic psychiatry

PURPOSE OF REVIEW: Forensic psychiatrists find themselves at the crossroads of disparate ethical demands stemming from their basic identification as physicians versus obligations of their professional activities that often involve working for third parties and upholding the principles of law. Ethical demands in law may collide with those of the ethics of medicine. RECENT FINDINGS: This review focuses on theoretical articles in which the two ethical paradigms impacting the forensic practice are discussed. In addition, this review includes some articles that bring new insights into old problems such as coercion and articles dealing with an emerging controversy, the use of medical information or medical personnel in interrogations. SUMMARY: The controversy on the two paradigms under which forensic psychiatrists operate has not been exhausted; no definite position has been advanced about the virtues of one over the other or how best to reconcile the two. Old issues such as coercion remain topics of concern and new areas of debate such as intelligence interrogations, which eventually will have an impact on forensic psychiatry, are now starting to permeate the ethical discourse.     

Training general psychiatry residents in child and adolescent psychiatry

The authors describe the nature of current social and economic forces impacting on the education and future practice of general psychiatry residents in child and adolescent psychiatry. They review theoretical and practical reasons for training in child and adolescent psychiatry, analyze the form and content of what is currently taught based on a national survey of general training programs, and suggest guidelines for the training and postgraduate practice of general psychiatrists in evaluating and treating children and adolescents. The authors conclude that while social and economic changes necessitate general psychiatrists' clinical involvement with children and adolescents, insufficient general training may necessitate postgraduate education and supervision. They pose ethical and professional dilemmas for the field in meeting the national shortage of child and adolescent psychiatrists and propose strategies to enhance recruitment into child and adolescent residency training.     

Defining neuropsychiatry: professional activities and opinions of psychiatrist-neurologists with dual certification

A computer-based search was conducted to locate physicians jointly certified by the American Board of Psychiatry and Neurology in both adult psychiatry and adult neurology since 1960. Eighty-six such physicians were found, and a survey concerning their practice patterns and opinions was conducted. From this survey, it appears that a number of "supraspecialized" neuropsychiatrists are involved in clinical activities that overlap the traditional limits of neurology and psychiatry.     

Measuring the stigma of psychiatry and psychiatrists: development of a questionnaire

The stigma of mental illness is a severe burden for people suffering from mental illness both in private and public life, also affecting their relatives, their close social network, and the mental health care system in terms of disciplines, providers, and institutions. Interventions against the stigma of mental illness employ complementary strategies (e.g., protest, education, and contact) and address different target groups (e.g., school children and teachers, journalists, stakeholders). Within this framework, the World Psychiatric Association has adopted an Action Plan with the goal to improve the image of psychiatry and to reduce potential stigmatizing attitudes toward psychiatry and psychiatrists. To evaluate such interventions, a questionnaire has been developed that assesses opinions and attitudes toward psychiatrists and psychiatry in different samples of medical specialists (psychiatrists and general practitioners). The questionnaire comprises scales about perceived stigma in terms of the perception of societal stereotypes, self-stigma in terms of stereotype agreement, perceived stigma in terms of structural discriminations, discrimination experiences, stigma outcomes, and attitudes toward a second medical discipline. It is available in several languages (Arab, English, German, Japanese, Polish, and Spanish) and can easily be adapted for utilization in other medical specialties.