Use of psychiatric services by patients referred to a consultation unit

The psychiatric case registers for the hospital catchment area were examined to determine the use of psychiatric services over a 14-year period by a 4-year cohort of consecutive inpatient referrals to the consultation-liaison service of a British general hospital. Two-thirds of the subjects had no other psychiatric care during the survey period, but a third made considerable use of a wide range of specialist psychiatric services. Alcohol problems and dementia were notably associated with complex history of psychiatric management. Management of patients with repeated episodes of psychiatric care requires close collaboration with other services.     

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.     

Psychiatric disorders and medical care utilization among people in the general population who report fatigue

OBJECTIVE: To study the prevalence of fatigue in the general population and its association with psychiatric disorders, somatization, and medical utilization. SETTING: The public-use data tape from the 1984 National Institute of Mental Health Epidemiologic Catchment Area Study. PARTICIPANTS: Household sample of 18,571 subjects. INTERVENTIONS: Structured psychiatric interviews were reviewed to study the prevalence of complaints of current and lifetime fatigue and their relationship to selected psychiatric disorders. RESULTS: Fatigue has high current (6.7%) and lifetime (24.4%) prevalences in the general population. Medically unexplained fatigue also has high current (6.0%) and lifetime (15.5%) prevalences. When compared with those reporting no current fatigue, subjects who reported current (one-month) fatigue were significantly more likely to have experienced current and lifetime episodes of major depression, dysthymic disorder, panic disorder, and somatization disorder. They also had significantly higher mean numbers of lifetime and current DSM-III psychiatric diagnoses, medically unexplained physical symptoms (not just fatigue-related symptoms), and visits to health care providers than did patients without current episodes of fatigue. CONCLUSIONS: The high prevalence of fatigue in the general population appears to be significantly associated with increased lifetime and current risk for affective, anxiety, and somatoform disorders, as well as increased utilization of medical services. These data suggest that assessment of both medical and psychological health may be essential for the proper care of patients with fatigue.     

Psychiatrists' and internists' knowledge and attitudes about delivery of clinical preventive medical services

OBJECTIVE: Changes in the health care environment have placed a greater responsibility on psychiatrists to deliver basic primary care services. The study assessed baseline knowledge and attitudes about clinical preventive medical services among psychiatric faculty and psychiatric residents at a tertiary care medical center. METHODS: Residents and faculty in psychiatry and general internal medicine completed a structured questionnaire, including 20 case scenarios, that assessed their baseline knowledge of clinical preventive medical services, their attitudes concerning delivery of those services, and their beliefs about the effectiveness of those services in changing patients' behavior. The case scenarios and knowledge questions were based on the clinical preventive medical services recommendations outlined by the U. S. Preventive Services Task Force. RESULTS: Psychiatrists reported more frequent assessment of and counseling about the use of illicit drugs and weapons, and internists were more likely to query about measures related to physical health such as cancer screening and immunizations. The two groups reported similar attitudes toward the need for and the efficacy of preventive medical services. Commonly cited barriers to the delivery of preventive care included lack of time and education. Psychiatrists scored reasonably well on baseline knowledge about guidelines for preventive medical services, particularly given their recent lack of specific education in these matters. CONCLUSIONS: Psychiatrists believe clinical preventive services are important and express interest in their delivery. Additional educational interventions are needed to train psychiatrists in clinical preventive services to avoid missed clinical opportunities for intervention in psychiatric populations that may have poor access to other medical care.     

Reorganizing departments of psychiatry, hospitals, and medical centers for the 21st century

Market forces are reshaping health care, transforming it from a public service into a product that is sold in a highly competitive marketplace. This transformation has been particularly disruptive for hospital departments of psychiatry and medical centers that were the early targets for managed care efforts at cost containment. To survive, health care institutions have embarked on a clinical and administrative re-engineering process. The author describes a series of steps for reconfiguring departments, hospitals, and medical centers as they enter the 21st century. The steps include identifying the leadership team, formulating a mission statement and strategic plan, creating a legal entity capable of achieving the organization's goals, drawing up an organizational chart, and developing the provider network. Other steps in the process include enhancing the continuum of services offered, developing administrative capability, dealing with managed care, paying attention to fundamental business practices, integrating psychiatric services into the health care system, and marketing psychiatric services.     

Dexamethasone concentration in vitreous and serum after oral administration

OBJECTIVE: To assess the outcomes of changes in mental health policy introduced in Italy in 1978. METHODS: Data on psychiatric services, before and after the policy change, are presented. Effects of change are evaluated through indicators related to four issues: transfer of care, criminalisation of the mentally ill, suicides, and homelessness. RESULTS: Admissions of new patients to mental hospitals have been stopped and the size of the mental hospital population is now very low (26 per 100,000 population). Psychiatric care has been shifted to community services including general hospital psychiatric units. There has been an overall reduction of psychiatric hospitalisation. However, the provision of residential facilities is inadequate and community services are unevenly distributed across the country. Few negative effects of changing patterns of care have been reported, although the low quality of data limits the validity of such a conclusion. Outcome of care in areas where the full range of community services is available has been rated as satisfactory. CONCLUSIONS: Although care of the mentally ill has been shifted to community services, we lack hard data on the social and clinical outcome of community care at the nation-wide level. Long-term monitoring and evaluation of community services is a high priority in Italy.     

Changes in medical problems and use of medical services following psychological intervention.

Important life changes and significant psychological stress occur before, during, and after episodes of physical illness in the lives of many individuals. Significant life-adjustment or developmental difficulties have been shown to be associated with high use of medical services. This article discusses the reduction in medical problems and use of medical facilities with referral for psychological services. On the assumption that psychologists can contribute significantly to reduction in patients' psychological stress levels and associated physical complaints, a new self-image for many psychologists could be that of health care professional. Furthermore, this self-image and role could be implemented by having psychologists contribute to the treatment of patients in a continuous manner, starting with the initial patient visit to a health care facility. (44 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient management in geriatric psychiatry by ambulatory care services. Results of an empirical analysis

This study was designed to provide information to which extend home-based nursing care services for the elderly take part in the care for older people with mental disorders. Also of interest was the involvement of clinical facilities and services of the geropsychiatric treatment system in the health care for the clients. A one day data collection in 29 nursing care services in two North Rhine-Westphalian regions could raise informations about 1,246 clients aged 60 years and over 1,522 persons (41.8%) had a mental disorder, diagnosed by a nursing and/or medical professional. 68% of the mental disordered clients had dementia or a demential disorder, 6% a functional psychosis, and 31% a neurotic, psychogenic disorder or substance abuse (small number of clients with two and more diagnoses). 82% of clients with mental disorders had one or more additional somatic disease(s). These diseases were mostly the cause for the involvement of home-based nursing care service. Barely 8% of clients with mental disorders were placed from clinical facilities and services of the geropsychiatric treatment system into the nursing care services. Beside the home-based care, only a 12% of mental disordered received clients outpatient psychiatric treatment. Systematic cooperation between the nursing care services and the system of (gero-) psychiatric treatment was a rare exception.     

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.     

Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE: To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied. METHODS: A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units. RESULTS: After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units. CONCLUSION: Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.     

Access to ambulatory care for American Indians and Alaska Natives; the relative importance of personal and community resources

The debate on health care reform in the United States has been greatly influenced by various national studies showing a strong relationship between lack of public or private health care coverage and inadequate access to health services. There is also much concern about deficiencies in the availability and delivery of services to certain population groups--especially for those living in the most remote and sparsely populated areas of the country. However, national studies have generally not demonstrated that the use of health services is strongly associated with urban/rural residence or the supply of medical providers. In this study, we show that national studies can obscure the problems of certain population groups including American Indians and Alaska Natives. Using data from the 1987 National Medical Expenditure Survey, the findings show that the availability of medical providers as well as place of residence were strongly associated with the use of health care by American Indians and Alaska Natives. Although American Indians and Alaska Natives included in this study were eligible to receive health care free of charge from the Indian Health Service (IHS), financial factors were also significantly associated with use due to the use of services other than those provided or sponsored by IHS. Also, the results show that while geographic and supply factors have only modest effects on the average travel time to medical providers for the U.S. population as a whole, travel times are dramatically longer for American Indians and Alaska Natives living in rural areas and where there are few medical providers. In addition, there appear to be fewer hospitalizations in areas where there are IHS outpatient services. We conclude by discussing the need for health care reform to take into account the diversity of a large country such as the U.S., and the special needs of population groups that are usually not adequately represented in national studies.     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.     

The place of psychotherapy in an institution of social security

In a social security system that includes prepaid, integral medical care, psychiatric services function in prevention, treatment and rehabilitation in a close relationship with the rest of medical care, the psychotherapies are part of an eclectic system of psychiatric attention, but also of the psychological aspects of institution-patients, institution-beneficiaries and institution-staff relationships. Within diverse psychotherapeutic schools, common denominators of the therapeutic process are outlined, as well as the background philosophy of the system.     

Utilization of on-site primary care services by HIV-seropositive and seronegative drug users in a methadone maintenance program

The feasibility of on-site primary care services and their use by human immunodeficiency virus HIV-seropositive and seronegative injecting drug users within an outpatient methadone maintenance program are examined. A 16-month prospective study was conducted within an ongoing cohort study of HIV infection at a New York City methadone program with on-site primary care services. The study group consisted of 212 seropositive and 264 seronegative drug injectors. A computerized medical encounter data base, with frequencies of primary care visits and with diagnoses for each visit, was linked to the cohort study data base that contained information on patients' demographic characteristics, serologic status, and CD4+ T-lymphocyte counts. Eighty-one percent of the drug injectors in the study voluntarily used on-site primary care services in the methadone program. Those who were HIV-seropositive made more frequent visits than those who were seronegative (mean annual visits 8.6 versus 4.1, P < .001), which increased with declining CD4+ T-lymphocyte counts; 79 percent of those who were seropositive with CD4 counts of less than 200 cells per cubic millimeter received on-site zidovudine therapy or prophylaxis against Pneumocystis carinii pneumonia, or both. Common primary care diagnoses for patients seropositive for HIV included not only conditions specific to the human immunodeficiency virus but also bacterial pneumonia, tuberculosis, genitourinary infections, asthma, dermatologic disease, psychiatric illness, and complications of substance abuse; those who were seronegative were most frequently seen for upper respiratory infection, psychiatric illness, complications of substance abuse, musculoskeletal disease, hypertension, asthma, and diabetes mellitus. Vaginitis and cervicitis,other gynecologic diseases, and pregnancy were frequent primary care diagnoses among both seropositive and seronegative women.     

Deinstitutionalization and schizophrenia in Finland: I. Discharged patients and their care

Finland has experienced one of the most rapid psychiatric deinstitutionalization processes in the world. Since 1980, the use of psychiatric beds has decreased about one-third. The effects of this deinstitutionalization were studied in the national Discharged Schizophrenia Patient Project. The study used three representative samples of patients with schizophrenia who were discharged from mental hospitals in 1982, 1986, and 1990, and followed them for 3 years. Patients with schizophrenia discharged at the beginning of the 1990s were older and more disturbed, and had been ill for a longer time than patients discharged at the beginning of the 1980s. The use of outpatient care increased and that of hospital care decreased, but because of the increased residential outpatient care, the total amount of residential care did not change during the study period. However, readmissions to the hospital increased. In patients with a long duration of illness, the increase in readmissions was exceptionally high; these patients also seemed to be losing their share of the residential outpatient services. On the whole, from the point of view of the psychiatric treatment system, deinstitutionalization seemed to have proceeded fairly successfully. The system proved able to redirect and use the available resources more effectively and to modify the structure of services according to the changing needs of patients discharged from hospitals. The well-developed social services have also supported this adaptation to the decreasing use of mental hospital beds.     

Use of health services for anxiety disorders: a multisite study in Quebec

OBJECTIVE: We investigated patient characteristics and use of services for anxiety disorders among patients seeking care from participating clinicians at 7 anxiety clinics in Quebec: 3 general hospital clinics, 3 psychologist-run clinics, and one psychiatric hospital clinic. METHODS: Persons eligible for the study were those who were visiting the clinics for the first time, had a current diagnosis of an anxiety disorder, and could communicate in French or English. Subjects recruited through advertisements were excluded. Data, collected by a self-administered questionnaire, included demographics, treatment history, use of services for anxiety, and the Beck Anxiety Inventory (BAI). RESULTS: The sample comprised 235 subjects: 146 seen at 3 general hospital clinics, 54 at 3 psychologist-run clinics, and 35 at a psychiatric hospital clinic. There were statistically significant differences by clinic type in the prevalence of specific anxiety diagnoses, BAI score, referral source, antidepressant use, and use of services. High-intensity use (10 or more consultations during the previous year) was reported by 23.4% of the sample for medical services and 19.6% for mental health services. Multiple logistic regression identified variables associated with high-intensity use of medical services (higher BAI score, 1 to 4 years since first sought treatment, and less than 12 years of education) and high-intensity use of mental health services (clinic type, obsessive-compulsive disorder [OCD], and 5 or more years since first sought treatment). CONCLUSIONS: The patient populations seen at different types of anxiety clinics differ in several respects, including referral source, previous treatment, and severity of symptoms. Regardless of type of clinic, patients with a longer time since they first sought treatment use more services, particularly mental health services. Those with less education use more medical services than those with greater education.     

Relation between number of cardiovascular risk factors/events and noninvasive Doppler ultrasound assessments of aortic compliance

BACKGROUND: Health care episodes are traditionally created for a specific condition using defined relevant diagnosis and procedure codes and a start and end period. Our goal is to use 1987 to 1989 medical claims data to create distinct episodes of care as a result of injury. METHODS: Claims for 102,000 people younger than 65 years were obtained from Medstat Systems, Inc. Injury claims were identified by International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes and separated into 10 body regions. Using linked inpatient and outpatient claims data, we established clear zones--a maximum period for a return visit for medical treatment--for each of 10 body regions injured by hospitalization status. These clear zones were used to create episodes of injury. RESULTS: A total of 295,165 injury claims created 79,564 episodes of injury. Limb and trunk injuries typically have the most follow-ups in terms of number of claims and spacing between claims. Brain injuries, even for admitted patients, result in an average of fewer than two follow-up claims. On average, hospitalized patients require only one more follow-up than nonadmitted patients. CONCLUSIONS: This paper presents a method for identifying injury episodes using a medical claims database. The analysis suggests that follow-up to check for minor long-term sequelae of brain injury is rare.     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

Aortic pseudoaneurysm in the L3-L4 disc space after lumbar disc surgery. A case report

OBJECTIVES: This paper explores the relationship of state hospital and general hospital psychiatric caseloads in a statewide system of care. METHODS: Probabilistic population estimation was applied to general hospital and state hospital data sets. RESULTS: General hospitals provide inpatient psychiatric services to more people than do state hospitals, and a significant number are served in both sectors. There were notable differences in use patterns related to patient gender and age. CONCLUSIONS: These results demonstrate that probabilistic methodologies can significantly enhance the value of existing databases for epidemiological research.