Should psychologists obtain prescribing privileges? A survey of family physicians.

The question of whether psychologists should be granted prescribing privileges has generated considerable interest and debate. Family physicians' views are important because of their growing role as gatekeepers to specialty services and the frequency with which they encounter patients with mental health treatment needs. A national sample of family physicians was sent a questionnaire that assessed their current collaborative practices with psychologists and psychiatrists and their views about granting prescribing privileges to psychologists. The response rate was 40% (N?=?397). High rates of communication and collaboration were reported. Most respondents opposed prescribing privileges for psychologists. Subgroups of physicians differed, and certain medications (antidepressants, anxiolytics) appeared more acceptable than others for psychologists to prescribe. These results could provide impetus to those psychologists seeking prescribing privileges. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medical referrals for hypnotherapy: opinions of physicians, residents, family practice outpatients, and psychiatry outpatients

Previous studies surveying attitudes and education regarding the clinical use of hypnosis have been conducted with patient populations only. The current study was undertaken to assess the attitudes, experiences, training levels, and interest in future education regarding the use of hypnosis by staff physicians, medical resident physicians, family practice outpatients, and psychiatry outpatients. All subjects were drawn from a 400-physician group practice in Central Texas affiliated with a large university health science center. Results indicate that the majority of physicians (79%) and residents (67%) had received no prior training and even fewer had experienced hypnosis. The percentages for personal experience with hypnosis were similar for psychiatric outpatients, physicians, and residents. The need for patient and practitioner education was elucidated by the high rate of endorsement of misconceptions regarding hypnosis by patients (over half) and by some medical practitioners as well. Limited awareness of the appropriate applications of hypnosis was reported. However, 85% of practitioners expressed an interest in hypnosis education. Further research in medical setting demographics is recommended to validate generalizability of results and facilitate construction of medical education programs in hypnosis.     

Continued prescribing of inappropriate drugs in general practice

We present an evaluation of the FASTMAP method with special reference to the issue of fine-mapping, using both 'real-life' and constructed data, and demonstrate some of the shortcomings of the method. Since the advantages of FASTMAP in terms of savings in computer resources compared to LINK-MAP are enormous, further improvements of the FASTMAP method would be highly desirable.     

A survey of audit activity in general practice

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care.     

A planning group for psychiatric outpatients

Planning leisure time successfully can contribute to a patient's ability to function in the spheres of work and family as well. A leisure-time planning group for psychiatric out-patients is described in this article and includes the treatment principles upon which the group is based, the format of the sessions, and the goal-setting techniques employed. A concrete, highly structured, and self-actualizing approach was used to help patients discover and develop their interests. Members often encountered similar problems in their attempts to plan leisure time despite their varied backgrounds and skills in planning, which led to the use of specific approaches in dealing with these common problems, and also suggested a wider application for the Planning Group.     

Sertindole, a new atypical antipsychotic for the treatment of schizophrenia

Recent studies have shown that at least some of the functional effects of serotonin (5-HT) on motoneuron excitability are direct and are mediated via postsynaptic 5-HT receptors on motoneurons. To determine the spatial distribution of direct inputs from the serotonin system on the proximal and distal dendrites of individual motoneurons, we examined identified motoneurons in vivo with a combination of immunohistochemical localization of 5-HT-immunoreactive boutons and intracellular staining with horseradish peroxidase. Seventeen intracellularly stained motoneurons from 12 adult cats were analyzed with light microscopy. Quantitative analysis of 5-HT boutons apposed to dendrites of five representative motoneurons that were entirely reconstructed in three dimensions (each from the lumbosacral spinal cord of a different animal) revealed a total of 7,848 contacts (1,570+/-487 contacts/postsynaptic neuron; mean +/- SD) over the dendrites of these cells. Analysis of contacts on the soma of two of these cells, and on the somas of an additional 12 intracellularly stained motoneurons, revealed a wide range of somatic contacts (11-211 contacts/cell) on motoneuron cell bodies, with an average of 52 contacts/cell. These results indicate that the vast majority of 5-HT-immunoreactive boutons are apposed to dendritic branches rather than to the somatic surface of motoneurons. The spatial distribution of contacts essentially matched the distribution of surface membrane area of the postsynaptic neuron, resulting in a relatively uniform density of contacts (<1/100 microm2) on proximal and distal dendrites. Consequently, the frequency of contacts was higher on the proximal dendritic compartments where available membrane area is greater. There was no preferential distribution of contacts to particular dendrites. Light/electron microscopic correlations were performed on 21 boutons that contacted dendrites (n = 7) of three motoneurons from different animals. At the electron microscope level, most appositions (18/21; 85.7%) selected by our light microscopic criteria were confirmed as direct contacts when the 5-HT boutons were examined through serial sections. Synaptic junctions, generally small and symmetric, were positively identified in only a subset of these cases (n = 6; 28.6%), in part due to the obscuring effects of the peroxidase histochemical precipitate present in both pre- and postsynaptic profiles. A few 5-HT boutons (3/21; 14.3%) selected as contacts by our light microscopic criteria were in fact separated from the adjacent labeled dendrites; in two of these three cases, the separation was due to intrusion of very thin glial lamellae (<0.3 microm in cross section). These results indicate that the bulbospinal serotonergic system(s) provide a significant, direct synaptic input to spinal motoneurons that innervate hindlimb muscles. The nature of the modulatory actions exerted by such widespread synaptic inputs will affect all regions of the somatodendritic membrane and will ultimately depend on the nature of the 5-HT receptors present over different parts of the postsynaptic neuron's dendritic tree.     

Quetiapine: a new atypical antipsychotic for the treatment of schizophrenia

In the first of a new series of updates on recent advances in medication, RICHARD GRAY outlines the dibenzothiazepine quetiapine, which offers an alternative to conventional antipsychotics for the treatment of schizophrenia, with fewer side effects.     

Emergency treatment of psychotic symptoms. Pharmacokinetic considerations for antipsychotic drugs

Psychotic symptoms related to mental and medical disorders can pose a medical emergency. Selecting an appropriate antipsychotic medication to treat this emergency is based on the clinical situation, preferred route of administration, pharmacokinetic profile of the antipsychotic and the medications currently being taken by the patient. Intramuscular preparations are usually preferred over oral medication when the patients are not co-operative and require drugs with a faster onset of action and good bioavailability. High potency antipsychotics such as haloperidol and fluphenazine are effective in stabilising patients with psychotic symptoms quickly. Loxapine is an alternative when sedation is necessary and molindone is useful if a short-acting antipsychotic is required. Rapid neuroleptisation with intramuscular preparations of antipsychotic achieves therapeutic drug concentrations more rapidly, and also provides optimal control of psychotic symptoms. If the patient is cooperative, liquid oral preparations can be used; they are as effective as intramuscular formulations. If long term treatment with an antipsychotic in necessary and patients are stabilised, they can be switched from intramuscular to oral preparations. The oral dose is usually 1.5 to 5 times the total intramuscular dose per day, based on the bioavailability of the antipsychotic medication. If the patient is currently taking antipsychotic medication when the emergency situation occurs, it is usually adequate to increase the dose of antipsychotic drug. Appropriate dose adjustment or antipsychotic selection is necessary when drug interactions are expected. An in-depth knowledge of the pharmacokinetic profile and drug interaction profile of antipsychotic in necessary for the selection of the appropriate antipsychotic for any given emergency situation.     

Oral fluoroquinolones for maintenance treatment of melioidosis

Fifty-three hands with carpal tunnel syndrome had pre- and postoperative evaluations of median nerve distal motor latency (from wrist to thenar muscles) and orthodromic sensory nerve conduction velocity (from thumb and middle finger to wrist). At 6 months we observed a neurophysiological return to normal in all cases with normal preoperative distal motor latency and in about 50% of the hands with preoperative distal motor latency between 4 and 6 ms. Prolongation of the distal motor latency over 6 ms was not followed by return to neurophysiological normality, although some degree of sensory function was restored in the majority of cases.     

Peer consultation groups for psychologists in private practice: A national survey.

We report the results of the first national survey of psychologists in private practice regarding their participation in peer consultation groups. The sample (71% return) was drawn from 800 randomly selected psychologists listed in the National Register of Health Service Providers in Psychology. We found that 23% of the sample currently belonged to peer consultation groups, and 24% had belonged in the past. Of those not currently in groups, 61% expressed the desire to belong if one were available. There were virtually no significant demographic differences between current members and nonmembers. We examined the following group characteristics: formation, length of existence, size, membership, leadership, theoretical orientation, range of experience, time and place, content, and group process. Groups tended to be small, informal, and leaderless; however, we found great variation among groups on all dimensions. Findings also showed a high degree of satisfaction with membership. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Training for independent practice: A survey of graduate programs in clinical psychology.

Administered a questionnaire to 112 directors of clinical training programs to investigate the types of training opportunities relative to independent practice that doctoral programs in clinical psychology are offering students. Findings indicate that 87% of PsyD programs and 35% of PhD programs offered some training. Results indicate that private practice as a professional activity for psychologists has become more accepted, that increased training is being offered, but that negative attitudes toward private practice still remain in a small sector of academia. (4 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial.

Research has shown that mindfulness-based treatment interventions may be effective for a range of mental and physical health disorders in adult populations, but little is known about the effectiveness of such interventions for treating adolescent conditions. The present randomized clinical trial was designed to assess the effect of the mindfulness-based stress reduction (MBSR) program for adolescents age 14 to 18 years with heterogeneous diagnoses in an outpatient psychiatric facility (intent-to-treat N = 102). Relative to treatment-as-usual control participants, those receiving MBSR self-reported reduced symptoms of anxiety, depression, and somatic distress, and increased self-esteem and sleep quality. Of clinical significance, the MBSR group showed a higher percentage of diagnostic improvement over the 5-month study period and significant increases in global assessment of functioning scores relative to controls, as rated by condition-na?ve clinicians. These results were found in both completer and intent-to-treat samples. The findings provide evidence that MBSR may be a beneficial adjunct to outpatient mental health treatment for adolescents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physicians' view of practice guidelines. A survey of Italian physicians

After more than 10 years of development, two different views of practice guidelines are emerging: either as an educational tool for the medical profession, or as a forum where health care issues can be debated by physicians and non-medical groups. Physicians use practice guidelines in the former model to set their own standards of good quality care, while the latter approach needs contributions from other components in order to decide what should be provided by our health care systems. In a survey of Italian physicians' opinions and attitudes toward practice guidelines, responders supported the "narrowest" model. More than 80% stated that improvement of quality of care and reduction of variation in clinical and practice styles should be the aim of practice guidelines, without representatives from outside the medical profession being involved (61%, 79% and 86% disagreed with a possible involvement, respectively, of patients, health care administrators and representatives of the public at large). Overall, 38% of physicians had a positive attitude toward guidelines viewed as a quality assurance tool for the medical profession. Overall, physicians seem to ignore that the need to rationalize health care calls for input from other professions and members of society. Indeed, most of the issues facing medicine today are mainly a matter of how much value our societies attach to the benefit expected from the available health services. The answers as to what should be done in health care probably cannot be left to the medical profession alone.     

The maintenance of boundaries in psychotherapeutic practice.

A questionnaire (the Therapist Boundary Questionnaire) designed by the authors was sent to 250 randomly selected male, and 250 randomly selected female members of American Psychological Association (APA) Division 29 (Psychotherapy) to explore the establishment and maintenance of 2 types of boundaries in psychotherapy: logistical (session begin/end times, payment issues, scheduling) and conceptual (self disclosure, theoretical orientation, availability between sessions). Results from the 213 respondents (aged 32–83 yrs) indicate that patients challenged established boundaries relatively infrequently, and psychotherapists accommodated their requests in most cases. This finding stands in opposition to the generally accepted image of the psychotherapist standing firm in the face of persistent attempts by patients to challenge existing boundaries, and suggests a spirit of cooperation and good faith underemphasized in theoretical writings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)