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)     

Benefits of comprehensive health care for improving health outcomes in women.

The American Psychological Association Health Care for the Whole Person Task Force was formulated to provide a rationale for integrating behavioral health services in primary care. Collectively, the task force called for a transformation of the biomedical system into one based on the biopsychosocial model. This article is a summary of the Women's Health Committee position paper that reviewed contextual factors in women's health, provided recommendations for clinical service action, and recommended an integrated primary health care system to address women's health needs. This article provides a vision of integrated care and a practical guide for psychology practitioners as they collaborate with other health care providers and health policy groups to improve health outcomes for women over the life course. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating suicide risk in the medically ill patient

Common medical conditions, treatments, medications, and depression can increase the risk of suicide, which is the eighth leading cause of death in the United States. Health care providers are in key positions to prevent suicide because most people seek medical treatment for physical symptoms and they give clues before they commit suicide. Unfortunately, suicide risk typically remains undetected because suicide clues, including depression, are overlooked. This article reviews assessment of suicide risk, incidence of completed suicide, and interventions in primary care settings. Suicide lethality, therapeutic strategies, and referrals are considered. Depression is discussed because it is the most common precipitant of suicide in primary care.     

The Rural Hawai'i Behavioral Health Program: Increasing access to primary care behavioral health for native Hawaiians in rural settings.

Health care access issues present significant challenges for rural populations and health providers. Psychology can support improved access and quality of rural health services through the development of integrated behavior health programs within primary care settings. This article reviews a clinical training and service delivery program, the Rural Hawai'i Behavioral Health Program, which has evolved in response to the pressing health needs of Native Hawaiians in rural communities. Native Hawaiian cultural factors and components of the primary care model that have supported the development of this program will be reviewed. Program expansion, sustainability, and treatment efficacy research will be discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.     

The integration of psychology into primary care: Personal perspectives and lessons learned.

The purpose of this article is to discuss the integration of psychology into a Veterans Affairs Medical Center Primary Care clinic, as experienced by the authors. There has been an evolving need for psychology's presence in primary care, due in part to the increasing number of primary care patients who present with complex physical and psychological issues, as well as institutional procedures for first-line treatment of more common mental health concerns (e.g., depression). Concurrent with the expansion of Medical Center services and patient population, an increasing demand has been placed upon psychology in primary care. To better accommodate the workload, a consultation-oriented model of treatment has been implemented. Within this integrated model, primary care providers and psychologists collaborate to provide multidisciplinary care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Evolution of Behavioral Primary Care.

The financing, organization, and delivery of behavioral health care services has undergone dramatic change in the past 25 to 30 years. The authors trace the evolution of behavioral health care delivery in the United States over the past several decades and find (a) that the value of mental health "carve-outs" has diminished greatly and that they are being replaced by "carve-ins," (b) that primary care physicians (PCPs) are becoming a primary source of mental health care secondary to the introduction of new medications, and (c) that PCP treatment of mental health disorders is suboptimal. The authors conclude that the behavioral health care system is entering an era of flux as it experiments with ways of integrating behavioral and primary care. Opportunities for psychologists are explored. (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.     

Medications prescribed for children with mood disorders: Effects of a family-based psychoeducation program.

Few controlled trials have examined psychotropic medications in children with mood disorders. Multiple medications are often prescribed for these children, who frequently suffer from several comorbid conditions. However, this polypharmacy has been infrequently studied and may lead to adverse drug-drug interactions. Multi-Family Psychoeducation Groups (MFPGs) are an 8-session, manual-driven treatment for children with mood disorders, designed as an adjunct to current medications and psychotherapy. In part, MFPG teaches parents and children to be better consumers of mental health care, including medications. This study examined the effect of MFPG on medications taken by 165 children, ages 8-11, with mood disorders. The authors hypothesized that MFPG would not affect the mean number of medications taken but that the variance in number of medications would decrease from pre- to posttreatment (i.e., the number of medications prescribed for any given child should become more closely distributed around the sample mean). Approximately 70% of participants were diagnosed with bipolar spectrum disorders, and 30% were diagnosed with depressive spectrum disorders. Most had both comorbid behavioral (97%) and anxiety (69%) disorders. Information regarding medications was gathered 4 times: at baseline, 6, 12, and 18 months. Approximately half (n=78) of the participants were randomized into immediate treatment, and half (n=87) were randomized into a 1-year wait-list condition. All were encouraged to continue treatment as usual throughout the study. As hypothesized, no significant pre- to posttreatment differences were found between groups for the mean number of current medications, but variance declined significantly from pre- to posttreatment. Implications and future research goals are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care

BACKGROUND: Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community. OBJECTIVE: To evaluate the impact of a 1-year, senior center-based chronic illness self-management and disability prevention program on health, functioning, and healthcare utilization in frail older adults. DESIGN: A randomized controlled trial. SETTING: A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations. PARTICIPANTS: A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices. INTERVENTION: A targeted, multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner (GNP). MEASUREMENTS: Self-reported Physical function, physical performance tests, health care utilization, and health behaviors. RESULTS: Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF-36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications. CONCLUSIONS: This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice.     

Treatment of active-duty military with PTSD in primary care: Early findings.

The study presents early findings from an ongoing pilot study of a cognitive–behavioral treatment for assisting active-duty military members with deployment-related posttraumatic stress disorder (PTSD) designed for use by psychologists working in an integrated primary care clinic. Treatment protocol is based primarily on Prolonged Exposure but also includes elements of Cognitive Processing Therapy that were adapted for use in primary care. Individuals were recruited from the population of patients consulted to the psychologist by primary care providers during routine clinical care. The 15 participants include active-duty or activated reserve Operation Iraqi Freedom and Operation Enduring Freedom veterans seeking help for deployment-related PTSD symptoms, with a PTSD Checklist-Military Version score 32, and interest in treatment for PTSD in primary care. Baseline and 1-month posttreatment follow-up evaluations were conducted by an independent evaluator. Five participants (33%) dropped out of the intervention after one or two appointments. Using the last observation carried forward for intent-to-treat analyses, the results showed that PTSD severity, depression, and global mental health functioning all significantly improved with the intervention. Fifty percent of treatment completers no longer met criteria for PTSD. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The case of myoepithelioma of the parotid gland

STUDY OBJECTIVE: To determine whether the environment of a moving ambulance affects the ability of our-of-hospital care providers to auscultate breath sounds. METHODS: Out-of-hospital care providers assessed breath sounds with a previously described breath-sounds model in a quiet environment (control) and in a moving ambulance. The setting was a nonurban emergency medical services system and an interhospital transport agency based at a 600-plus-bed tertiary care center. The participants were physicians, transport nurses, and advanced life support EMS providers routinely involved in the emergency out-of-hospital treatment and transportation of the ill and injured. The accuracy with which participants identified the presence or absence of breath sounds in the two environments was compared with the use of the chi 2 test, with the alpha-value set at .05. RESULTS: The accuracy of breath-sounds assessment in the control environment was 96% (251 of 260); the sensitivity was 96% and the specificity 97%. The accuracy of breath-sounds assessment in the experimental environment was 54% (140 of 260); the sensitivity was .09% and the specificity 98%. Participants were significantly less likely to hear breath sounds in the moving ambulance than in the quiet room (P < .001). CONCLUSION: Assessment of breath sounds is hampered by the environment of a moving ambulance.     

Updates in pediatric emergency medicine for the office practitioner

Emergently ill or injured children may access care through their primary care provider, through prehospital emergency medical services, or directly in a hospital emergency unit. Primary health care providers and emergency care providers need to have the skills, proper equipment, and medications available to care for these children. This paper reviews recent articles on the prevention, evaluation, treatment, and outcomes of illness and injury in children, which should be of interest to primary and emergency care givers. Areas of recent research include the epidemiology, prevention, and evaluation of childhood injuries and the evaluation of infants and children with fever. Other areas reviewed are respiratory disease and the treatment of gastroenteritis. Also reviewed are articles on the role of the primary care physician in emergency medical services for children.     

Psychology practice: Design for tomorrow.

This article offers a blueprint for modernizing the delivery of high-quality behavioral health care and for improving access to care by a public sorely in need of psychological services. The blueprint brings together disparate elements of psychology practice into a more unified structure, an updated house, based upon advances in the essential building blocks: evidence-based practice, treatment guidelines, technology, classifications of function, diagnostic systems, outcomes measurement, and integrated health care. The goal is twofold: to make psychological services more accessible to the public and to position psychology for an increasingly major role in health care in order to serve the public weal in diverse communities. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A case of Rathke''s cleft cyst with apoplexy

OBJECTIVE: To develop and evaluate a model of integrated primary dental and medical care. DESIGN: 3-year prospective study. SETTING: A general dental practice and a general medical practice occupying the same building in Glasgow. INTERVENTION: Regular staff meetings, joint use of patient records systems and information derived from patient questionnaires. Dentistry was included in established screening programmes such as child health surveillance and care of elderly. Staff were encouraged to participate in joint work practices and joint consultations were carried out. MAIN OUTCOME MEASURES: Patient registration, avoidance of discrepancies in information, reduction of secondary referrals, joint work practices. RESULTS: The number of registered joint patients attending both medical and dental practices increased by 90%. The joint use of patient record systems avoided discrepancies in patient information which would have affected the quality of patient care. Including dentistry in child health surveillance and care of elderly screening programmes resulted in an increase in 0-5 year olds registering with dentists from 36% to 68% (P < 0.001) and with > 75 year olds from 47% to 71% (P < 0.001). Joint consultations reduced the need for secondary referrals. CONCLUSIONS: This model of health care demonstrated the potential for coordination and integration of functions between the dental team and the primary care team. Integrated primary dental and medical care requires attitudinal change in health care professionals and requires greater emphasis in education and training of health care professionals in the future.