The challenge to meet the mental health and biopsychosocial needs of the poor: expanded roles for hospital social workers in a changing healthcare environment

Despite the absence of coordinated federal health care reform, social workers in hospital settings have opportunities to identify, develop, advocate for, and facilitate access to innovative health care services, resulting in improved capacity to meet the mental health and biopsychosocial needs of the poor and, potentially, reduced hospital costs over time. There are opportunities for expanded roles for social workers in forging better linkages between hospital services and the community, developing an integrated biopsychosocial healthcare delivery system within hospitals and primary care settings, utilizing information systems as tools in an integrated system, and advocating for a client-centered approach to mental health services.     

Comorbidity of Chronic Pain and Mental Health Disorders: The Biopsychosocial Perspective.

An exciting period in mental and physical health research is beginning, resulting from a paradigm shift from an outdated biomedical reductionism approach to a more comprehensive biopsychosocial model, which emphasizes the unique interactions among biological, psychological, and social factors required to better understand health and illness. This biopsychosocial perspective is important in evaluating the comorbidity of mental and physical health problems. Psychiatric and medical pathologies interface prominently in pain disorders. Important topics in the biopsychosocial approach to comorbid chronic mental and physical health disorders, focusing primarily on pain, are presented. Though this biopsychosocial model has produced dramatic advances in health psychology over the past 2 decades, important challenges to moving the field forward still remain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A preventive health paradigm for health care psychologists.

Developed a preventive health paradigm for health care psychologists by building on public health and preventive mental health models of primary, secondary, and tertiary prevention. Adoption of a "biopsychosocial" perspective on health and illness is basic to the preventive health paradigm. Examples of preventive health programs are considered along with a wide range of preventive health activities by psychologists in health care settings. (31 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Angiocardiographic digital still images compressed via irreversible methods: concepts and experiments

OBJECTIVE: Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment. METHOD: The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?" RESULTS: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors. CONCLUSIONS: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.     

The biopsychosocial approach to chronic pain: Scientific advances and future directions.

The prevalence and cost of chronic pain is a major physical and mental health care problem in the United States today. As a result, there has been a recent explosion of research on chronic pain, with significant advances in better understanding its etiology, assessment, and treatment. The purpose of the present article is to provide a review of the most noteworthy developments in the field. The biopsychosocial model is now widely accepted as the most heuristic approach to chronic pain. With this model in mind, a review of the basic neuroscience processes of pain (the bio part of biopsychosocial), as well as the psychosocial factors, is presented. This spans research on how psychological and social factors can interact with brain processes to influence health and illness as well as on the development of new technologies, such as brain imaging, that provide new insights into brain-pain mechanisms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Provision of mental health services in women's health centers

Women's health centers are often associated with a comprehensive model of health care that treats the "whole woman." Using data from a nationwide study of 467 women's health centers, we explored how the ideal of comprehensive care was implemented with respect to mental health services. Specifically, we examined the rates of screening and treatment for a subset of mental health and behavioral and social problems in women's health centers and the structural, staffing, philosophical, and patient factors associated with the provision of services. Across 12 services, the overall rates of provision ranged from 7.7% for screening for dementing disorders to 27.6% for smoking cessation counseling and treatment. In a series of logistic regressions, center type (primary care) and having a mental health staff person were consistently associated with service provision; other important variables were having a high percentage of women using the center as their usual source of care and having a belief in women-centered care. Findings indicate that the majority of women using women's health centers do not receive services in a comprehensive care environment that includes key mental health services.     

Examining the content of mental health intake assessments from a biopsychosocial perspective.

Psychotherapists' approach to intake assessment has a major impact on mental health case conceptualization and treatment. Despite the importance of this issue, very little is known about the actual intake assessment practices of therapists providing mental health care in the community. This appears to be the first study that has investigated which aspects of biological, psychological, and sociocultural functioning are documented by therapists in their client intake assessments, how thoroughly these issues are assessed, and how well the information collected is then integrated into the assessment findings and case conceptualization. The examination of 163 client files from 3 mental health clinics found that therapists were regularly collecting client information regarding a wide range of biopsychosocial issues, though not in a detailed or comprehensive manner. There was also little evidence that the information was being integrated in a manner designed to maximize treatment effectiveness. These findings have major implications for training and practice in mental health assessment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines

The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.     

Basal expression, subcellular distribution, and up-regulation of the proto-oncogene c-JUN in the rat dentate gyrus after unilateral entorhinal cortex lesion

OBJECTIVE: To compare perceived current mental health and disablement between primary care and end-stage renal disease (ESRD) patients, and to study social support and stress and severity of illness as possible determinants of mental health and disablement. METHOD: Observational cross-sectional analysis of 414 primary care patients in a rural community health center and 125 ESRD patients requiring hemodialysis in two community dialysis units. The Duke Health Profile (DUKE) anxiety-depression scale was used to assess mental health; the DUKE disability scale, to indicate disablement; the Duke Social Support and Stress Scale, to measure support and stress; and the Duke Severity of Illness Scale, to rate severity of illness. RESULTS: Perceived current mental health in terms of anxiety and depression symptoms was worse for primary care than for ESRD patients, and perceived current disablement was no different for the two groups. Patients' perception of their health status and of stress from family members were more closely associated with their level of anxiety and depression symptoms than were their diagnostic profiles or overall severity of illness. In turn, their level of anxiety and depression symptoms was the principal correlate of their disablement. CONCLUSIONS: The demonstration of strong relationships among anxiety and depression symptoms, disablement, and family stress in these two very different patient populations should stimulate further research and motivate clinicians to evaluate all three parameters as part of routine patient care.     

Primary care in psychiatry residency training

The author summarizes patient perspectives and government initiatives that have fostered closer medicine-psychiatry cooperation and more comprehensive treatment of patients. Despite the growing numbers of people requiring more formal mental health care, most patients are being treated by primary health care providers. This trend will continue as long as there is a decline in the number of medical students entering psychiatry. The author summarizes several general principles that psychiatry residency program directors should consider in designing primary care experiences for their residents and for medical students rotating on their services: longitudinal primary care experiences in organized medical care settings, training in basic medical principles and techniques, and instruction in the biopsychosocial model of disease. The author also recommends there specific training experiences for psychiatry residents that would enhance their ability to provide more effective mental health services to primary care physicians and their patients: consultation psychiatry, primary mental health care, and general psychiatry. The author concludes that medical students, through their contact with primary care-oriented psychiatry residency programs, would be more attracted to psychiatry as a specialty choice and that residents, upon completion of training, would be more inclined to practice in primary care settings.     

Health status and satisfaction with health care: Results from the medical outcomes study.

Relations between self-assessed health status and satisfaction with health care were examined using 2 waves of data obtained from participants in the Medical Outcomes Study. Using a multisample covariance modeling framework, separate models were examined for patients with significant symptoms of depression (n?=?417 ) and patients with chronic physical health conditions (n?=?535 ). The pattern of findings was essentially identical for both patient subgroups. General satisfaction with care was cross-sectionally associated with mental?but not physical--health status. In addition, significant cross-lagged effects were found linking baseline satisfaction with care to subsequent mental health and baseline mental health to subsequent satisfaction with care. By contrast, no crosslagged directional effects linking satisfaction with care and physical health status were identified. Finally, no evidence was found that satisfaction with specific aspects of health care contributed independently to either mental or physical health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrating mental health services into primary medical care

Primary care clinicians occupy a strategic position in relation to the emotional problems of their patients. Integrating mental health and primary medical services promotes available, coordinated, accessible, and less stigmatizing treatment by recognizing an indivisibility of the total person in illness and in health. Federal efforts to encourage Health Maintenance Organization (HMO) development as part of a national health program prompts serious attention to organizational arrangements for developing such an integrated program for medical-mental health care. We have found a team collaborative model in which mental health providers are members of a primary care team to be useful and promising. Supportive services are provided on a continuing basis through patterned relationships. Shared responsibility for patient care between physicians, nurse practitioners, physician assistants, and mental health workers provides built-in peer review and encourages intrateam consultation.     

Canadian perspectives on research in depression.

Depression is a serious mental health problem that will affect a large segment of the Canadian population either directly as a sufferer, or indirectly as a family member, friend or employer of a person who experiences depression. This special issue of the Canadian Journal of Behavioural Science highlights the significant contribution that Canadian psychologists are making to advance our understanding of the psychological basis of depression. Contributors deal with a number of issues such as the status of schema-based research on depression, comorbidity of depressive symptoms in adolescents, perfectionism and the persistence of depressive symptoms, gender differences in self-regulation and their relation to dysphoric mood, and personality influences on the "depressive realism" phenomena. In this introductory article, a brief summary of the main findings reported by each contributor to the special issue are discussed, and some conclusions are drawn about the status of psychological research on depression in Canada. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Symptom profiles of depression among general medical service users compared with specialty mental health service users

BACKGROUND: Since depressive disorders are now eminently treatable and early detection and treatment could bring substantial benefits, it is critical to address alternative presentations of depression in the general medical setting. Concern regarding under-diagnosis of depression in general medical settings has given rise to the question of whether the clinical disorder of depression differs qualitatively or only quantitatively across care settings. METHODS: Symptom profiles of depression were compared across care sectors to investigate how the presentation of depression among general medical service users might differ qualitatively from specialty mental health service users. Data on depression symptoms within 6 months of interview gathered in three community surveys that were part of the NIMH Epidemiologic Catchment Area Program were analysed using methods developed to assess item bias. The subjects were 4931 and 363 persons who reported a visit to the general medical sector or to specialty mental health respectively, within 6 months of interview. RESULTS: Compared with specialty mental health service users, general medical service users were less likely to present dysphoria (adjusted Odds Ratio, aOR = 0.57; 95% Confidence Interval, CI = 0.38-0.84) and feeling worthless, sinful, or guilty (aOR = 0.63; 95% CI = 0.40-0.98), but were more likely to present fatigue (aOR = 1.71; 95% CI = 1.09-2.69), even after holding constant other characteristics that might influence reporting of symptoms as well as level of depression. CONCLUSIONS: These results suggest that there are qualitative differences in depression presenting in general medical care compared with specialty mental health care and call for a re-conceptualization of depression in the general medical setting.     

The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans.

Growing evidence suggests that posttraumatic stress disorder (PTSD) is associated with poorer health status (e.g., more medical disease, physical symptoms, and sick visits to health care professionals) among veterans who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. We investigated whether PTSD, depression, and substance use disorders independently predicted health status over time among OEF/OIF veterans. Information regarding psychiatric and medical conditions and health care utilization was culled for 4,463 OEF/OIF veterans enrolled in Veterans Administration primary care for a period of 6 years. Data were analyzed using multilevel modeling and generalized estimating equations. Results suggest that PTSD, depression, and substance use disorders are independently associated with increased medical disease burden and mental health care utilization but not increased medical health care utilization. The association between PTSD and medical disease burden strengthened over time. These data suggest that OEF/OIF veterans with PTSD may be at risk for increasingly poorer physical health in terms of medical disease burden over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The discursive construction of dementia care: implications for mental health nursing

This paper sets out a new approach to dementia that may be used to underpin mental health nursing practice. The paper begins by examining the development of community care. Various models of service provision to people with dementia are then critically examined. As an alternative to these approaches a new model of dementia is developed which highlights the position of various family members in the provision of dementia care including the person with dementia and also the importance of linguistic devices such as narrative and discourse. Finally the implications of this approach upon the mental health nursing practice are examined together with various suggestions for the development of research.     

The role of physical health functioning, mental health, and sociodemographic factors in determining the intensity of mental health care use among primary care medical patients.

The present study examined sociodemographic and attitudinal predisposing factors (gender, age, marital status, health insurance, household income, attitudes about mental health care), and need/illness variables (depression severity, physical and mental health functional status) as predictors of past-year mental health care use intensity (i.e., visit counts) and use/nonuse. The sample included 283 adult primary care patients from the Midwestern United States in a cross-sectional study. Nonlinear regression models demonstrated that past-year treatment use intensity was significantly associated with both married status and poorer physical health functioning, while the use (vs. nonuse) of treatment was associated with depression severity. A sociodemographic and attitudinal multivariate predictor model only explained 5% of the variance in treatment use intensity, but a need/illness model significantly contributed an additional 23% variance. Poorer physical health functioning was significant in predicting treatment use intensity, while depression severity was significant in predicting the use (vs. nonuse) of treatment. Results demonstrate the particular importance of physical health problems in determining the intensity of mental health care use, and depression severity in determining the use/nonuse of treatment, notwithstanding the restricted sociodemographic contour of the sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Congruence between culturally competent treatment and cultural needs of older Latinos.

This study investigated a new 2-factor construct, termed cultural congruence, which is related to cultural competence in the delivery of mental health services to ethnic minority clients. Cultural congruence was defined as the distance between the cultural competence characteristics of the health care organization and the clients’ perception of those elements according to their cultural needs. The measure evidenced both reliability and validity in predicting criterion-related indicators. Older Hispanic/Latino clients (N = 272) receiving mental health services either through integrated primary care or referral to specialized mental health care were assessed for depression and anxiety symptomatology and health status at baseline, 3-, and 6-month follow-up treatment. Results indicated that cultural congruence predicted treatment outcomes (reduction of symptomatology) independent of treatment and evidenced moderator effects with respect to depression, suicidality, anxiety, and physical health criteria. Cultural congruence was more effective under the condition of the enhanced specialty referral model than under the integrated primary care model. Results are discussed in terms of how the new construct of cultural congruence extends knowledge of culturally competent mental health practice among the older Hispanic/Latino population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of prior and current alcohol use on use of services by patients with depression and chronic medical illnesses

OBJECTIVE: Alcohol use often co-occurs with other major chronic conditions, but its effect on health care utilization in this context is not understood. This study examines the impact of alcohol consumption on health care use by patients with chronic medical conditions or depression, or both. DATA SOURCES/STUDY SETTING: Data came from the Medical Outcomes Study, an observational study of patients from the offices of general medical providers and mental health specialists in three U.S. cities. STUDY DESIGN: Longitudinal data spanning four years for outpatient general medical visits and outpatient mental health visits were analyzed using a two-part model to assess the impact of alcohol use disorder, problem drinking, and current and past alcohol consumption on health care use by patients, controlling for patient demographics and health status. DATA COLLECTION/EXTRACTION METHODS: Data were collected from 2,546 adult patients with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), and/or current major depression or subthreshold depression using periodic, self-report surveys detailing health care utilization and health status information. PRINCIPAL FINDINGS: Current alcohol consumption increases outpatient doctor visits, and problems related to current drinking decrease outpatient mental health visits. CONCLUSIONS: Patterns of alcohol consumption have an impact on both mental health and overall health care use by patients with chronic medical conditions or depression.     

Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial.

The literature is replete with evidence that the stress inherent in health care negatively impacts health care professionals, leading to increased depression, decreased job satisfaction, and psychological distress. In an attempt to address this, the current study examined the effects of a short-term stress management program, mindfulness-based stress reduction (MBSR), on health care professionals. Results from this prospective randomized controlled pilot study suggest that an 8-week MBSR intervention may be effective for reducing stress and increasing quality of life and self-compassion in health care professionals. Implications for future research and practice are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)