Lorin M. Scher

Integrated Medicine and Psychiatry Curriculum for Psychiatry Residency Training: A Model Designed to Meet Growing Mental Health Workforce Needs

Patients with chronic mental illness have significantly higher rates of medical comorbidity and resultant lower life expectancies when compared to the general population [1–3]. This survival discrepancy is not fully accounted for by the higher rate of suicide completion in these patients but, rather, is often attributable to mortality from cardiovascular, metabolic, and other systemic illness. Many such individuals are seen in community mental health settings and have poor access to primary health care. In some cases, the psychiatrist may become the “de facto primary care physician,”while providing some preventive health screening and treatment of general medical conditions. For those patients who are cared for by a primary care provider, the psychiatrist may support preventive medical recommendations with psychopharmacological interventions and the use of psychotherapies such as cognitive behavioral therapy, problem solving therapy, supportive psychotherapy, and motivational interviewing. Strong evidence calls for improved general medical care for people with severe mental illnesses. In a 17-year followup study of over 80,000 people in the USA, those with mental illness died an average of 8.2 years earlier than those without mental illness, with excess mortality primarily due to socioeconomic factors, poor access to effective primary and preventative care, and the burden of chronic health conditions [1]. Moreover, individuals with schizophrenia tend to die 20– 30 years earlier than the population average, even after excluding deaths by suicide [2]. Similarly, those with bipolar disorder have a twofold higher mortality rate than the general population [3]. Patients with major depression are also at higher risk of medical illness, such as diabetes mellitus and ischemic heart disease [4, 5]. The increased risk of diabetes mellitus, metabolic syndrome, cardiovascular disease, and stroke associated with atypical antipsychotics further underscores the need for the psychiatrist to engage in risk factor monitoring, risk reduction, and recognition and management of comorbid medical conditions in their patients [6–8]. Given the significantly increased mortality among psychiatric patients as a result of non-psychiatric medical conditions, it is essential we provide psychiatric training that mirrors significant changes to our mental health delivery system by way of the Patient Protection and Affordable Care Act. Psychiatry residents should receive training about collaborative and targeted preventive medical care, which better approximates current and real-world clinical practice guidelines found in patient-centered medical homes. We suggest one approach to accomplishing this is to provide residents with an Integrated Medicine and Psychiatry (IMAP) curriculum.

Effect of Decreasing County Mental Health Services on the Emergency Department.

STUDY OBJECTIVE We evaluate the effect of decreasing county mental health services on the emergency department (ED). METHODS This is a retrospective before-and-after study at a Level I academic university hospital adjacent to the county mental health treatment center. On October 1, 2009, the county decreased its inpatient psychiatric unit from 100 to 50 beds and closed its outpatient unit. Electronic health record data were collected for ED visits for the 8 months before the decrease in county services (October 2008 to May 2009) and the 8 months after the decrease (October 2009 to May 2010). Data for all adult patients (≥18 years) evaluated for a psychiatric consultation by a licensed clinical social worker were included. Outcome measures included the number of patients evaluated and the ED length of stay for those patients. RESULTS One thousand three hundred ninety-two patient visits included a psychiatry consultation for the study period. The median age was 38 years (interquartile range [IQR] 27, 49), with no difference in age between periods. The mean number of daily psychiatry consultations increased from 1.3 (95% confidence interval [CI] 1.2 to 1.5) before closure to 4.4 (95% CI 4.1 to 4.7) afterward, with a difference in means of 3.0 visits (95% CI 2.7 to 3.3 visits). Average ED length of stay for psychiatry consultation patients was 14.1 hours (95% CI 13.1 to 15.0 hours) before closure and 21.9 hours (95% CI 20.7 to 23.2 hours) afterward, with a difference in means of 7.9 hours (95% CI 5.5 to 10.2 hours). CONCLUSION The number of visits and length of stay for patients undergoing psychiatric consultation in the ED increased significantly after a decrease in county mental health services. This phenomenon has important implications for future policy to address the challenges of caring for patients with psychiatric needs in our communities.

Psychiatrists With Substance Use Disorders: Positive Treatment Outcomes From Physician Health Programs

OBJECTIVE The objective of this study was to compare outcomes of psychiatrists and nonpsychiatrist physicians enrolled in state physician health programs for substance use disorders. METHODS The study used the data set from a five-year, longitudinal cohort study of 904 physicians, including 55 psychiatrists, with diagnoses of substance abuse or dependence consecutively admitted to one of 16 state physician health programs between 1995 and 2001. RESULTS There was a higher proportion of women among psychiatrists than among other physicians, but there were no other significant differences between the cohorts. Five-year outcomes were similar between psychiatrists and the other physicians, with at least 75% of psychiatrists continuing their medical practice after five years of monitoring and treatment. CONCLUSIONS Psychiatrists were not overrepresented compared with other physician groups and had similar clinical outcomes at the five-year follow-up. Physician health programs appeared to be effective treatment programs for psychiatrists with substance use disorders.

Emergency medicine settings

The aging of the population worldwide has been accompanied by increases in the survival of older persons with chronic diseases and the need for urgent evaluation and management when these conditions have exacerbations. The number of individuals with major neurocognitive disorders (NCDs, formerly termed dementia) has been rising exponentially, and patients with schizophrenia and bipolar disorder are living longer with their chronic illnesses. The combination of complex chronic diseases, limited access to primary and psychiatric care, and challenges coordinating timely referrals in the outpatient arena has resulted in the emergency department becoming the de facto portal for psychiatric care for many geriatric patients.

Narcissistic Traits and Suicide: A Case of Supportive Psychotherapy on a Psychosomatic Medicine Service

Among psychiatric comorbidities that are frequently encountered in medically ill patients, severe personality pathology can cause some of the most significant disruptions to the delivery of medical care. Prominent symptoms displayed by these patients may also be less amenable to treatment purely through pharmacotherapy, which can even further exacerbate conflicts with the medical system. The psychosomatic medicine (PM) psychiatry service is frequently called to assist in the management of these patients, and to provide behavioral management plans and help coordinate the treating physicians’ interpersonal approaches to the patients, in addition to recommending pharmacotherapy. Of note, supportive psychotherapy by the PM psychiatrist may be relatively overlooked as a treatment option. This case demonstrates the effective use of supportive psychotherapy techniques in a demoralized and suicidal patient with prominent narcissistic pathology.