Early tracheostomy in trauma patients

The purpose of this study was to determine the current level of psychiatric training in internal medicine residencies, satisfaction with this training, and perceived need, if any, for more training. Surveys were mailed to all training directors of accredited primary care (N = 178) and categorical (N = 410) internal medicine residencies in the United States; 110 primary care (62%) and 238 categorical (58%) training directors returned the surveys. Seventy-five percent of categorical and 66% of primary care training directors thought their program should spend more time on psychiatric disorders. For all categories of psychiatric disorder, training intensity was greater and satisfaction with training higher in the primary care programs, but less than half of the directors were satisfied with their current level of training, e.g., 33% of categorical and 47% of primary care directors were satisfied with their residents training concerning depression. Training in somatoform disorders, psychotropic drugs, and office psychotherapy were most frequently identified as deficient. The most favored additions to the curriculum were psychiatric consultants in medical clinics and on medical wards. Although most outpatient care for psychiatric disorders is given by primary care physicians, internal medicine training directors perceive current levels of training in their residencies as inadequate. Innovative collaborations between medicine and psychiatry departments will be necessary if treatment of psychiatric disorders in primary care is to be improved.     

The impact of national health insurance on the tasks and practice of psychiatry

Psychiatry, like all professions, is strongly affected by changes in societal expectations and economic forces. Changes in professional priorities and patterns of patient care will undoubtedly be brought about by national health insurance. Two major types of national health insurance have been proposed: comprehensive health insurance and catastrophic insurance. We do not anticipate major impact on psychiatric tasks from some form of catastrophic insurance. Comprehensive health insurance would shape and change psychiatric practice. An examination of psychiatric tasks provides a framework for anticipating alterations in practice. We identify four major task areas in psychiatry: (1) medical tasks, (2) reparative tasks, (3) social control tasks, and (4) humanistic tasks. These tasks would be differentially influenced. Psychiatry's medical tasks will be stressed, while funding for many reparative tasks may be limited. The care of the severely ill patient may be fragmented because of problems in integrating medical and rehabilitative services.     

Psychiatry in crisis

Psychiatry today faces sociopolitical, economic, and philosophical pressures that threaten its existence as a valued medical specialty. Recent legislation that decreases the numbers of foreign medical graduates eligible to practice in the United States, increases the numbers of community mental health centers and types of services they offer, and limits federal support of psychiatric education will affect the future of psychiatry as a profession and discipline. Forthcoming legislation and federal health policies will be related to the ability of the profession to demonstrate its unique role in the provision of mental health and health services. The authors offer suggestions for the education of the American public regarding the important role of psychiatry in America's health and mental health care system.     

The early case for caring for the insane in general hospitals

The early argument for caring for the insane in general hospitals arose in the late 1800s in the context of criticisms of the asylum made by neurologists and some psychiatrists. The movement in support of general hospital psychiatry gained ground within psychiatry as the modernization of the general hospital made it a more attractive work site for physicians. By the second decade of this century, a newly independent discipline of hospital administration was providing an audience for psychiatrists who wanted to make the medical and financial case for the value of psychiatric care in the general hospital. Although in the 1930s only a fraction of general hospitals included a "department for mental patients," general hospital psychiatric treatment had ceased to be only a rhetorical or experimental concept and was fast becoming a practical program of treatment.     

Aspects of perinatal psychiatric illness

BACKGROUND: In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness. METHOD: A systematic review was undertaken of relevant articles on MEDLINE, ClinPsych and Excerpta Medica Psychiatry. RESULTS: Sixty-eight articles were used in the review. CONCLUSIONS: Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child, as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.     

Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients

The aims of this study were to determine whether detection of major depression in primary care was associated with improved outcome, and to compare the 4.5 month outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. Primary care patients with major depression were recruited from the practices of 50 family physicians in Southeastern Michigan using a two-stage selection procedure employing the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Structured Clinical Interview for DSM-III-R (SCID); clinician detection of depression was ascertained by response to a direct query on a rating form. Depressed patients seeking treatment in an outpatient psychiatric setting also received the CES-D and the SCID. Data on patient demographics and clinical characteristics were obtained for both primary care and psychiatric patients. Initial and 4.5 month scores on the Hamilton Depression Rating Scale (HAM-D) were obtained for 34 undetected and 25 detected depressed primary care and 55 depressed psychiatric patients. Improvement in depression over time was assessed by the change in HAM-D scores over the 4.5 months. The three groups did not differ in initial severity. Both psychiatric and undetected primary care patients showed significant improvement at 4.5 months, whereas detected primary care patients did not improve. At 4.5 months there were no differences in mean HAM-D scores between undetected, depressed primary care patients and depressed psychiatric outpatients. This result did not change after controlling for age and severity of depression at initial presentation, nor did it change after exclusion of cases of mild depression to control for a possible "floor effect." However, differences among groups in the stage of depressive episodes may have affected this comparison. These findings suggest that an exclusive focus on increasing detection of depression in primary care patients is unlikely to improve outcomes, and that undetected depression among primary care patients does not necessarily represent poor quality of care. Although depressed psychiatric patients in this study had better outcomes than detected depressed primary care patients, the presence of unmeasured differences among groups in the stage of the depressive episode makes it impossible to determine whether treatment of depression by psychiatrists is superior to that provided by primary care physicians. These findings should stimulate efforts to examine a more comprehensive model for detection and treatment of depression in primary care.     

Using DSM-IV primary care version: a guide to psychiatric diagnosis in primary care

The prevalence of patients with psychiatric disorders in primary care settings indicates that family physicians have a need for a diagnostic manual suited to the realities of their practice. This article reviews the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., primary care version (DSM-IV-PC) and highlights the ways it accommodates the clinical needs of family physicians. DSM-IV-PC emphasizes the use of nine diagnostic algorithms for the most prevalent psychiatric disorders in primary care. The authors review the conceptual similarities between DSM-IV and DSM-IV-PC and the diagnostic features that are unique to DSM-IV-PC, and offer an illustrative case that incorporates a DSM-IV-PC approach to diagnosis. The authors also outline clinical and technical issues that remain unresolved in DSM-IV-PC.     

The relevance of ethology for psychiatry

Darwin's evolutionary theory was the starting point for ethology, associated with an impact on scientific psychiatry. Psychiatry and ethology have common scientific and methodological prerequisites: inductive and deductive methods and "gestalt theory" as a basis for observing and describing behaviour patterns with subsequent causal analysis. There have been early endeavours to anchor ethological thinking in psychiatry but this tendency did not prevail for the following reasons: on the one hand, the methodology of ethology was immature or not applicable to man, whereas on the other hand the dominating experiential phenomenological school of Karl Jaspers and Kurt Schneider stressed the privileged position of human thinking, perception, and feeling. These fundamental categories of human existence did not appear amenable to any causal ethological analysis. Psychiatry and evolutionary biology were linked in an atrocious manner during the Nazi regime, both being abused for propaganda purposes and genocide. More recently, there is a "reconciliation" of both disciplines. In psychiatric nosology, operational, behaviour-oriented diagnostic systems have been introduced; ethology has opened up for theories of learning; new subsections like human ethology and sociobiology have evolved. The seeming incompatibility of (behavioural) biological psychiatry and experiential phenomenological psychopathology may be overcome on the basis of Konrad Lorenz' evolutionary epistemology. The functional analysis of human feeling and behaviour in psychotic disorders on the basis of Jackson's theory of the evolution and dissolution of the nervous system may serve as an example. The significance of an "ethological psychiatry" for diagnostic and therapeutical processes of psychiatric disorders derive from prognostic possibilities and the analysis of non-verbal communication in therapist-patient-interactions, but have not yet been systematically investigated.     

Impact of strain heterogeneity on Lyme disease serology in Europe: comparison of enzyme-linked immunosorbent assays using different species of Borrelia burgdorferi sensu lato

BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.     

Military health care providers' views on prescribing privileges for psychologists.

Selected military psychologists have been trained and privileged to independently prescribe psychotropic medications. To explore the attitudes of health care professionals toward prescribing authority, a survey of 395 military psychiatrists, psychologists, primary care physicians, and social workers was conducted. Psychologists, physicians, and social workers supported prescribing privileges and continuation of the training programs. Results suggested that support by physicians and social workers is based on improving access to comprehensive mental health care for their patients. Psychologists advocating prescribing privileges at the state level need to pursue the training and licensing authority to prescribe independently. The opposition of organized psychiatry seems assured. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

Linking primary care and rural psychiatry: where have we been and where are we going?

Linking primary care with psychiatric care has long been promoted as a way to improve access to rural mental health services. The authors describe a national survey that identified 53 successfully linked programs, ranging from small local efforts to sophisticated multicounty networks. Findings indicated that lessons from successful integrations are not easily reduced to a how-to list. Organizations cooperate with each other when it is in their interests to do so. Motivation to integrate cannot be mandated, nor is the availability of funding alone sufficient to provide motivation. The authors discuss ways that managed care may facilitate or hinder the link between rural primary care and rural psychiatry.     

Inhibitory influence of sympathetic nerves on afferent nerve-induced extravasation in the rat incisor pulp upon direct electrical stimulation of the tooth

Clinical practice guidelines for primary care providers that address the detection, diagnosis, and treatment of depression may have an impact on psychiatric practice as well as on general medical education and the research agenda. This commentary highlights the conceptual and scientific issues that surrounded the development of these guidelines and speculates on their potential practical impact, particularly on psychiatry.     

A study of replanted permanent teeth in different age groups

In the inpatient treatment of acute psychiatric episodes in children and adolescents, the psychiatrist must set up an initial treatment plan incorporating one or more psychotherapeutic modalities and adapt this plan to the patient's clinical course. This article summarises the clinical experience of a model unit at the University of Heidelberg, the result of a collaboration between the Department of General Psychiatry and the Department of Child and Adolescent Psychiatry at the Clinic of Psychiatry. A series of 116 adolescent admissions was reviewed for clinical diagnosis, the nature and frequency of psychotherapeutic modalities, and the role of family involvement in patient care. Differential and adaptative approaches to the selection of treatment modalities in the context of an acute care setting are emphasised.     

Sharing care: the psychiatrist in the family physician's office

OBJECTIVE: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. METHOD: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. RESULTS: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. CONCLUSIONS: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.     

Major stress protein Hsp70 interacts with NF-kB regulatory complex in human T-lymphoma cells

Utilization of psychiatric in-patient care among 537 new patients was studied in the Department of Psychiatry in Oulu, Finland, during a 3-year follow-up period. Hospitalization during the second and third years of the follow-up was predicted by hospitalization and number of emergency out-patient contacts during the first year of the study, diagnosis of functional psychosis or personality disorder, and previous in-patient care. In total, 5% of the cohort fulfilled our criteria for 'revolving-door' patients. The 'revolving-door' phenomenon was associated with in-patient care at the first contact with the psychiatric services and diagnosis of psychosis or personality disorder. In total, 2% of the cohort became long-stay hospital patients, and this was predicted by psychosis diagnosis. The clinical implications of these findings are that increased attention should be paid to the first assessment of new patients and to the interaction between psychiatric services and patients during the first year of care.     

What is the role of the HIV liaison psychiatrist?

In this article we review the field of HIV liaison psychiatry and illustrate the manner in which psychiatric care can contribute to the health and quality of life of this group of patients. To illustrate our discussion we review experience and findings in relation to affective illness, cognitive impairments, and personality disorder in HIV infection. We also highlight some of the areas where psychiatric care of people with HIV infection is unique from other types of psychiatric liaison work.     

Pathways to mental health services among inhabitants of a Mexican village

Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the 'adverse outcome' and 'near-miss' categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.     

Mobile Outreach Crisis Services (MOCS): an innovative model for taking psychiatric care into the community

Mobile outreach psychiatric services have become a popular model of providing care to the mentally ill. A mobile program has been instituted in Tulsa, Oklahoma, to provide care to homeless mentally ill in Tulsa County and to assist with emergency crisis intervention. The SPMI (Severely and Persistently Mentally III) have been a challenge for both medical and psychiatric providers, and MOCS (Mobile Outreach Crisis Services) was developed to address these problems. This article describes MOCS, briefly reviews recent literature, and discusses ways this program can benefit primary care physicians.     

Compulsory referral to institutionalised psychiatric care and its organizational structure

Nation-wide German Counseling Review regarding psychiatry in 1975 yielded a reasonable reform of psychiatric care in Germany. Especially outpatient and complementary caring concepts promoted the integration of psychiatric patients in their communities. However, this development was paralled by an increase of involuntary hospitalisations in Northrine-Westphalia. Within ten years involuntary hospitalisations doubled in some communities. These findings contrast with recent concepts of a complex community psychiatry with improved caring according to humanitarian principles and those of non-violence. These specific settings must be taken into consideration in developing community psychiatry. The report presents the activity of the working group concerning community psychiatry in Northrine-Westphalia. During its annual meetings a standardised and valid documentation concerning hospitalisation procedures in the communities as a means of quality control was discussed repeatedly. Taking into consideration the data of this survey the complex mechanisms leading to an increase of involuntary hospitalisations becomes understandable. Health reporting on a community level on the topic of involuntary hospitalisations is an important tool for discussion of its complex psychosocial and administrative mechanisms. Discussion about standard procedures in psychiatric emergency care service will thus be enabled.