David L. Kaye

Encouraging and sustaining integration of child mental health into primary care: interviews with primary care providers participating in Project TEACH (CAPES and CAP PC) in NY.

OBJECTIVE Project Training and Education for the Advancement of Childrens Health (TEACH) provides training, consultation and referral support to build child and adolescent mental health (MH) expertise among primary care providers (PCPs). This study describes how TEACH engages PCP, how program components lead to changes in practice and how contextual factors influence sustainability. METHOD Thirty PCPs randomly selected from 139 trained PCPs and 10 PCPs from 143 registered with TEACH but not yet trained completed semistructured interviews. PCP selection utilized purposeful sampling for region, rurality and specialty. Interviews were recorded, transcribed and analyzed using grounded theory. RESULTS PCP participation was facilitated by perceived patient needs, lack of financial and logistic barriers and continuity of PCP-program relationships from training to ongoing consultation. Trained PCPs reported more confidence interacting with families about MH, assessing severity, prescribing medication and developing treatment plans. They were encouraged by satisfying interactions with MH specialists and positive feedback from families. Barriers included difficulties implementing screening, time constraints, competing demands, guarded expectations for patient outcomes and negative impressions of the MH system overall. CONCLUSIONS Programs like TEACH can increase PCP confidence in MH care and promote increased MH treatment in primary care and through collaboration with specialists. Sustainability may depend on the PCP practice context and implementation support.

Personal Psychotherapy During Residency Training: A Survey of Psychiatric Residents

ObjectiveThe authors investigate current psychiatric residents’ experiences with and opinions about personal psychotherapy.MethodsThe authors analyzed survey data from randomly selected students in psychiatric residency training programs during the 2005–2006 academic year.ResultsApproximately one-third of respondents were in psychotherapy. Being in a training program affiliated with a psychoanalytic institute and being further along in training were associated with a greater likelihood of being in therapy. Residents identified financial cost and training demands as the top barriers to pursuing psychotherapy. Psychodynamic psychotherapy was by far the most common type; few residents received cognitive behavior therapy.ConclusionA significant minority of psychiatric residents pursue personal psychotherapy, primarily psychodynamic. This number appears to be much smaller than in the past.

Office recognition and management of adolescent substance abuse.

Purpose of review Substance misuse and substance use disorders are important pediatric public health concerns. The prevalence is high, beginning in adolescence through adulthood, and there is marked morbidity. This is especially true in the adolescent population, in whom the three leading causes of death are all associated with substance abuse. The primary care physician is ideally situated to recognize, prevent, and triage significant substance abuse problems. This review will provide recent, relevant information for primary care physicians (PCP) to enable them to have the current knowledge, tools, and attitudes needed to address these issues. Recent findings Epidemiologic studies continue to document the widespread use of licit and illicit substances by youth. Understanding of substance use disorders is moving forward with an increasing clarity of the multiple factors important in the development of these disorders. This has already led to the establishment of effective prevention programs, which may be applicable to the primary care setting. Research into psychosocial treatment is proceeding rapidly, and psychopharmacologic approaches are also being investigated. Evidence-supported approaches to treatment now exist. Summary Substance abuse in youth is a serious public health problem, with significant morbidity and mortality. The primary care physician can make major inroads into effective prevention and treatment by recognizing and addressing these issues in the outpatient office setting.

Long-Term Safety and Use-Effectiveness of Intrauterine Devices *

The long-term safety and effectiveness of Lippes Loops, A, C, and D, Dalkon Shields, Saf-T-Coils, and Cu 7-200 intrauterine devices (IUDs) were evaluated on the basis of 670 insertions in 588 women. Ten-year life-table rates for the Lippes Loops C (291 first insertions) and D (213 first insertions) were evaluated. The Loop C was consistently associated with a significantly higher expulsion rate but lower pregnancy rate as compared with the Loop D. Over-all, the removal rates for these two IUDs were similar. The incidence of pelvic infection and abnormal Papanicolaou smears, the time from IUD removal to conception, pregnancy outcome, and the need for any surgery post-IUD insertion were evaluated for all IUDs and all segments of use.

Clinical Skills Verification in General Psychiatry: Recommendations of the ABPN Task Force on Rater Training

ObjectiveThe American Board of Psychiatry and Neurology (ABPN) announced in 2007 that general psychiatry training programs must conduct Clinical Skills Verification (CSV), consisting of observed clinical interviews and case presentations during residency, as one requirement to establish graduates’ eligibility to sit for the written certification examination. To facilitate implementation of these requirements, the ABPN convened a task force to prepare training materials for faculty and programs to guide them in the CSV process. This article reviews the specific requirements for the CSV experience within general residency programs, and briefly describes the recommendations of the task force for faculty training and program implementation.MethodsMaterials prepared by the ABPN Task Force include background information on the intent of the observed interview, a literature review on assessment methods, aids to train faculty in direct observation of clinical work, directions for effective feedback, notes regarding special issues for cross-cultural trainees, clarification of performance standards, and recommendations for structuring and conducting the assessments.ResultsRecommendations of the task force include the use of a variety of clinical settings for CSV assessments, flexibility in the duration of CSV interviews, use of formative and summative feedback after each CSV assessment, and frequent use of the CSV across all years of training. Formal faculty training is recommended to help establish performance parameters, increase inter-rater reliability, and improve the quality of feedback.ConclusionsThe implementation of the CSV process provides psychiatry training programs with an excellent opportunity to assess how interviewing skills are taught and evaluated. In the process, psychiatry educators have an opportunity to establish performance parameters that will guide the training of residents in patient interaction and evaluation.

Consultation with the Extended Family: Primary Process in Clinical Practice

In this article, the authors have attempted to describe a method from their pattern of experiential family psychotherapy and to demonstrate its usefulness. Consultations with the extended family serve many purposes, but the one the authors highlight is the way they provide access to the unconscious components of the family. The extended family consultation interview is like an emotional hot tub that precipitates what the authors call a family group psychosis, an inherently therapeutic experience.

Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC

OBJECTIVE Although, child mental health problems are widespread, few get adequate treatment, and there is a severe shortage of child psychiatrists. To address this public health need many states have adopted collaborative care programs to assist primary care to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of New York state. PROGRAM DESCRIPTION CAP PC, a component program of New York States Office of Mental Health (OMH) Project TEACH, has provided education and consultation support to primary care providers covering most of New York state since 2010. The program is uniquely a five medical school collaboration with hubs at each that share one toll free number and work together to provide education and consultation support services to PCPs. METHODS The program developed a clinical communications record to track information about all consultations which forms the basis of much of this report. 2-week surveys following consultations, annual surveys, and pre- and post-educational program evaluations have also been used to measure the success of the program. RESULTS CAP PC has grown over the 6years of the program and has provided 8013 phone consultations to over 1500 PCPs. The program synergistically provided 17,523 CME credits of educational programming to 1200 PCPs. PCP users of the program report very high levels of satisfaction and self reported growth in confidence. CONCLUSIONS CAP PC demonstrates that large-scale collaborative consultation models for primary care are feasible to implement, popular with PCPs, and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.

Guidelines for the general psychiatry application process and for inter-residency transitions.

Selecting a psychiatry program is a seminal event. There is often not enough guidance about this process. The American Association of Directors of Psychiatric Residency Training (AADPRT) recognized that this was a high-stakes process and that there was the opportunity to provide input about the process and promoting fairness and consistency, which could help provide the best opportunity for applicants to select where they will train and for programs to accept trainees who are well qualified for what a program offers and will best fit into the learning environment. A workgroup created guidelines included herein for the application process to begin general psychiatry training and to transition from one program to another, including transfer from one General Psychiatry program into another and entry into Child and Adolescent Psychiatry Residencies as well as subspecialty fellowships in psychiatry.