Emergency medical services for children: Beyond lights and sirens.

This article describes the history of emergency medical services for children and identifies important mental health issues. It discusses the roles of psychologists in such services, including intervening with children and their families during times of crisis, helping others who are providing the physical care of children to mitigate rather than exacerbate children's emotional distress, and attending to the emotional needs of health care providers who treat children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health intensive outpatient programming: An outcome and satisfaction evaluation of a private practice model.

The current economic climate of mental health care requires an adaptation of traditional treatment paradigms for practitioners to succeed in the marketplace. Psychologists have not really capitalized on their training and expertise in developing outpatient treatment models for acute care. A private practice outpatient program, based in crisis intervention and group therapy, is described. The effectiveness of a mental health intensive outpatient program (IOP) in a private practice setting is demonstrated. IOPs represent an opportunity for private practice groups to collaborate with larger systems of care while providing clinically effective, consumer friendly, and safe treatment for acute patients in traditional outpatient settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment of Department of Veterans Affairs primary care patients with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common among Veterans Affairs (VA) primary care patients and may be managed via multiple treatment pathways. Using the Behavioral Model of Health Service Use (Anderson, 1995), this retrospective study based on medical chart review examined factors associated with three types of mental health treatment: intervention by a 1) primary care provider (PCP), 2) primary care-mental health integration (PC-MHI) provider, and 3) specialty mental health (SMH) provider. A second goal was to describe PTSD treatment services for patients not receiving SMH by detailing the content of mental health treatment provided by PCPs and PC-MHI providers. Electronic medical record data for a five year time period for 133 Veterans were randomly selected for review from a population 6,637 primary care patients with PTSD. Results indicated that the evaluated needs of participants (i.e., number of unique medical and psychiatric disorders) were associated with Veterans receiving more intensive services (i.e., SMH). PCPs commonly addressed patients' mental health concerns, but patients often declined referrals for mental health treatment. PC-MHI consultations most often focused on medication management and supportive psychotherapy. (PsycINFO Database Record (c) 2011 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.     

Outcome and cost of child abuse

OBJECTIVE: To compare the cases of child abuse (CA) with other admissions in a pediatric intensive care unit (PICU) for differences in patient-specific health care costs, severity of illness (SI) and mortality, and describe their outcome. METHOD: A retrospective cohort study of all patients admitted to the PICU between January 1991 and August 1994. Discharge diagnosis, age, SI, mortality rate, length of stay, hospitalization charges ($Hosp), and mortality were retrieved. RESULTS: There were 937 admissions; 13 were secondary to CA. Cases of CA represented 1.4% of admissions and 17% of deaths. CA patients had the highest SI (61%), $Hosp ($30,684), daily charges ($5,294) and mortality rates (53%) than any other group. In our patients, SI is a factor that affects charges. Even when compared to a cohort group with SI, child abuse patients had higher daily hospitalization charges (p < .05). The medical bills for the acute care of a CA patient averaged $35,641 per case. Even with these expenditures, 70% died and 60% of the survivors had severe residual morbidity. CONCLUSION: These results confirm that interventional medical care in response to severe CA is very costly and the ultimate outcome is significantly worse than other diseases. Therefore, we believe it is imperative to allocate resources to prevention.     

Mental health care: Access, stigma, and effectiveness.

Discusses the lack of commitment by the US as a nation to ensure that high-quality mental health care will be provided to all who are in need. The mental health benefits under Medicare and Medicaid programs are meager at best. Psychologists and other nonphysician health care providers are not considered bona fide professionals. Prevention, program evaluation efforts, and the use of alternatives to traditional inpatient care, such as halfway houses and crisis intervention programs, are not treated under the current reimbursement system. An "efficacy proposal" created by US Senators D. K. Inouye and S. M. Matsunaga is described. The essence of the proposal was modeled after the current Food and Drug Administration requirements for safety and efficacy for all new drugs and medical devices. In addition to these 2 requirements, the notion of "appropriateness" or "cost-effectiveness" was added. This proposal, which was deleted in 1980, would have established an interdisciplinary commission comprised of representatives of both the scientific and clinical communities. The commission would have been charged with the responsibility for making recommendations as to what types of mental health services, and under what conditions, should be reimbursed under the Social Security Act. It is concluded that the establishment of an independent entity with the charge of seriously reviewing the "probably public benefit" of providing psychotherapy would be in the national interest of the US. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

Problems with resistance in pediatric intensive care

Antibiotic resistance in the neonatal and pediatric intensive care environments has not been rigorously investigated. There is reason to believe that the epidemiology of antibiotic resistance in these settings may be different from that in other hospital settings because the patients' preadmission health status, the maturity of their immune systems, and their outpatient exposure to antibiotics are different from those seen in adults. At the present time, the areas of greatest concern are the outbreaks of infection caused by methicillin-resistant Staphylococcus aureus in the neonatal ICUs and the emergence of antibiotic-resistant Gram-negative bacteria in pediatric intensive care units (PICU). In the former, colonization and transmission by nursery personnel remains one of the great challenges in infection control. In the latter, new information is emerging which challenges the notion that antibiotic-restriction policies might be an effective means for modulating the emergence of antibiotic-resistant Gram-negative pathogens in the pediatric intensive care environment. It appears that these organisms are largely imported into the ICU from the community and are not a result of antibiotic practices within the unit itself. This observation requires that strategies to control these organisms in the PICU be reassessed.     

Medical crisis counseling in a health maintenance organization: Preventive intervention.

Mental health clinicians can play a cost-effective role in reducing distressing psychological symptoms accompanying diagnosis of chronic illness. Medical crisis counseling (MCC) is a focal short-term intervention directly addressing illness-related psychosocial problems. A randomized clinical trial tested the effectiveness of MCC. Counseling was offered to patients who had cancer that was newly diagnosed, 1st heart attacks, or adult-onset diabetes and was contrasted with a control group receiving an HMO's standard mental health care. Significant reductions in distress attributable to MCC were noted in some patient groups. No increases in overall medical costs and some decreased mental health utilization and costs were noted with MCC use. Practitioners can easily apply MCC to improving patients' quality of life and mental health, without adding to health care costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

In the aftermath of Hurricane Katrina: A personal story of a psychologist from New Orleans.

The author, a psychologist living in New Orleans and specializing in trauma work, describes her personal story in the aftermath of Hurricane Katrina. The immediate response to the crisis, her personal feelings related to the devastation of her community, and ways to organize a mental health response are elaborated. The author describes the work of the trauma team from the Louisiana State University Health Sciences Center in providing immediate outreach and mental health services on the cruise ships set up to house first responders in New Orleans, in schools, and in the community. The author describes psychological first aid in crisis response and provides vignettes illustrating the experiences of first responders, children, and families. Finally, the lessons learned by the author are elaborated. Along with negatives, positive lessons can be learned with such a life-transforming experience. The importance of recognizing vicarious traumatization is emphasized as well as the crucial need for self-care for victims, survivors, and mental health providers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Responding to trauma—extraordinarily meaningful.

The behavioral and psychological component of trauma is critical. It is noted that the National Highway Traffic Safety Administration seeks to ensure that every citizen in the US is served by an organized and coordinated system of timely and effective emergency medical care. However, the field of emergency medical services is changing and these changes require new players and partners. States are focusing on inclusive systems of emergency medical care that encompass trauma care and injury prevention. Thus, behavioral scientists will play a greater role than ever before. An example is given of training for trauma intervention, in which a school of professional psychology operates the local hospital emergency room crisis service. Staffed by faculty and students, they triage, treat, or refer all mental health emergencies. A case is also made for more research on causation and prevention of accidental deaths and injury. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

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.     

The psychological impact of rape victims.

This review article examines rape victims' experiences seeking postassault assistance from the legal, medical, and mental health systems and how those interactions impact their psychological well-being. This literature suggests that although some rape victims have positive, helpful experiences with social system personnel, for many victims, postassault help seeking becomes a "second rape," a secondary victimization to the initial trauma. Most reported rapes are not prosecuted, victims treated in hospital emergency departments do not receive comprehensive medical care, and many victims do not have access to quality mental health services. In response to growing concerns about the community response to rape, new interventions and programs have emerged that seek to improve services and prevent secondary victimization. The contributions of rape crisis centers, restorative justice programs, and sexual assault nurse examiner programs are examined. Strategies for creating more visible and impactful roles for psychologists and allied professionals are also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrated health delivery systems: Psychology's potential role.

Describes the ways in which psychologists are defining their role within integrated health delivery systems (IHDSs). The integration of psychological services with primary medical care is discussed. Examples of medical crisis counselling services as part of a medical practice and PhD student preparation for professional work in IHDSs are provided. Recent collaboration between the military and the APA Committee for the Advancement of Professional Practice's Task Force on Primary Care is mentioned. For psychology, the key will be legislatively broadening psychologists' defined role within the generic health delivery system to match their existing everyday clinical role in health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Taking on managed care: One reviewer at a time.

The ethical standing of the managed care reviewer who would make determinations of medical necessity in mental health practice is called into question. The ethical standards governing each of the major mental health professions are reviewed in reference to this activity. Each profession has provisions in its standards suggesting that such utilization review of psychotherapy is, at least, of questionable ethical standing. The author describes his personal effort to hold each reviewer to account for these alleged breaches of professional ethics. A recommendation is made for the ethics officers of the respective mental health professions, in concert, to make explicit their respective professions' stance against such ethical misconduct when their members engage in such review. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Associating supplemental case management activities with ethnic minority children’s reduced use of psychiatric emergency services.

Studying children and adolescents receiving publicly financed outpatient treatment, the authors investigated whether receipt of supplemental case management was associated with reduced odds of ethnic minority children’s and adolescent’s receipt of crisis care, and whether the minority’s reduction was greater than the reduction for Whites. The data were 97,618 Medicaid records of mental health services provided to children and adolescents ages 0–18 years in California’s public mental health system. The study’s quasi-experimental research capitalized on a large, multisystem, and multiyear data set to address key challenges to internal and external validity. Results indicated that receiving case management along with outpatient treatment was associated with significantly reduced odds of crisis service use for Blacks, Asian Americans, and Latinos especially. The results provide preliminary evidence that supplementing outpatient care with case management helps to close a troubling disparity in mental health treatment access. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Provision of psychotherapy under managed health care: A growing crisis and national nightmare.

Managed care was intended to save money by eliminating unnecessary services. However, for both physical medicine and mental health care, it is easier to save money by simply cutting needed services. This is what is happening in managed care in the US today. However, data exist for arriving at reasonable procedures to provide real help and still be cost-conscious, a fact that is being ignored by managed care companies. The German national health system covers up to 300 sessions of psychotherapy if needed, but only 3% of their outpatient medical costs are used for such psychotherapy. Unfortunately, the American managed care systems aim at short-term cost savings, even if it means higher costs in the long run (or making patients go outside the managed care health plan for help or forgo getting psychological help at all). (PsycINFO Database Record (c) 2010 APA, all rights reserved)