Robert Joseph

Teaching psychiatry residents to work at the interface of mental health and primary care

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Models of Care for Co-occurring Mental and Medical Disorders

In this article we review practice models for treating common mental disorders in primary care. Novel treatment approaches by primary care providers and specialty providers, including collaborative care and telepsychiatric models, show considerable promise. An understanding of remaining barriers to improved care suggests several possible solutions and future directions for outpatient psychosomatic medicine.

Psychiatry in the Harvard Medical School—Cambridge Integrated Clerkship: An Innovative, Year-Long Program

ObjectiveThe authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education.MethodA longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry “immersion” experiences, and a variety of clinical and didactic teaching sessions.ResultsThe longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average.ConclusionLongitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

Screening for Psychiatric Disorders in Primary Care Settings

&NA; This issue introduces a new column, focusing on the quality of mental health care. Although health care organizations have long monitored quality of care, the rapid pace of change in recent years—including increased competition, privatization, and shifting incentives—has heightened the importance of such activities. In addition, the emergence of integrated health care systems with advanced information capabilities offers new opportunities to evaluate the care of populations and to identify areas for quality improvement. This column will describe new methods for assessing and enhancing quality and will report on the use of these methods in research studies and real‐world settings. Topics will include (1) improving the detection of mental disorders; (2) promoting evidence‐based treatment using practice guidelines and treatment algorithms; (3) determining the impact of organizational and financial restructuring on quality of care; (4) assessing quality in the treatment of populations by use of performance measures, report cards, and benchmarks; (5) comparing alternative uses of health care resources using cost‐effectiveness analysis; (6) evaluating capabilities and limitations of outcomes measurement as a method of quality assessment; and (7) applying formal quality‐improvement methods to address problems in clinical care. Manuscript proposals and submissions are welcome and can be sent to the column editor ( E‐mail: rhermann@warren.med.harvard.edu).

Developing a Collaborative Care Training Program in a Psychiatry Residency

BACKGROUND Collaborative care is an evidence-based approach for improving quality mental health access in primary care settings. Although job opportunities will grow over the next decade, few psychiatry residencies have established curricula to train the next generation of psychiatrists to work in this expanding model of care. OBJECTIVE In this article, the authors describe the collaborative care training experience at a safety-net academic institution to provide a template for psychiatry residencies designing curricula to prepare psychiatry residents for collaborative care practices.

Medically Unexplained Symptoms: Barriers to Effective Treatment When Nothing Is the Matter.

AbstractPatients with symptoms that elude medical explanation are a perennial challenge to practicing physicians of all disciplines. Articles appear virtually monthly advising physicians how to care for them. Efforts at postgraduate education have attempted to ameliorate the situation but have shown limited or disappointing results at best. Physicians continue either to avoid these patients or to resort to a “seat-of-the-pants” approach to management. Literature on patients with medically unexplained symptoms, along with extensive experience consulting with primary care physicians, suggests that it is not primarily lack of physician skills but rather a series of barriers to adequate care that may account for suboptimal management. Barriers to implementation of effective care reside in the nature of medical education, the doctor-patient relationship, heterogeneity of symptoms and labels, changes in the health care system, and other variables. These impediments are considered here, with suggested potential remedies, in the conviction that the proper care of patients with medically unexplained symptoms can, among other things, bring satisfaction to both the patient and the physician, and help to reduce ineffective health resource utilization.

The relationship between sleep disturbance in pregnancy and persistent common mental disorder in the perinatal period (sleep disturbance and persistent CMD)

Abstract Background: Common mental disorder (CMD) and sleep disturbance are two common conditions among women in late pregnancy, affecting up to 20% and 63% of women, respectively, and may adversely affect their quality of life. Aim: The aim of this study is to examine the relationship between sleep disturbance in pregnancy and persistent CMD among low-income pregnant women living in Brazil. Methods: This was a prospective cohort study conducted with pregnant women recruited from public primary care clinics in São Paulo, Brazil. We performed a longitudinal analysis of 219 women who had CMD from the Self-Report Questionnaire during the 20–30 weeks of pregnancy. Two groups were examined: (1) those who had CMD remission in the postpartum and (2) those who had persistent CMD in the postpartum (measured once in the postpartum period). Poisson regression was used to estimate the degree of association between sleep disturbance in pregnancy and the risk for persistent CMD postpartum. Results: After adjusting for sociodemographic and clinical factors, sleep disturbance during pregnancy is associated with persistent CMD (RR = 1.36, 95% confidence interval: 1.01–1.84). Conclusion: In this sample of low-income pregnant women living in Brazil, the presence of sleep disturbance during pregnancy was associated with persistent common mental disorder in the postpartum period. Identification of sleep disturbance in pregnant women with CMD will be important in order to recognize those women at higher risk of persistent CMD in the postpartum period.

Free Fall: Finding Solid Ground in the Treatment of a Patient with Catastrophic Injury

KT is a 30-year-old single, wheelchair-bound, paraplegic woman. Despite a recent increase in self-injurious behavior and numerous recommendations that she accept more psychiatric help, she has had limited psychiatric treatment since a severe physical injury ten years ago. Her case has presented continual diagnostic and therapeutic challenges because of her medical, psychiatric, and substance abuse comorbidities and her unwillingness to engage in ongoing psychiatric treatment. The third of five children, KT was born and raised in a working class New England city. Her oldest sister (36 years old) works cleaning houses; a sister (34 years old) currently works in a supermarket; a brother (28 years old) works in construction; and a sister (25 years old) is unemployed and lives with her boyfriend. Her father was a fireman and a heavy drinker. He is reported to have been verbally abusive to her mother and occasionally to KT. Nevertheless, KT notes that she was his “favorite” and that he was usually very good to her. Her special status with her father created “tension” between KT and her mother and siblings. The mother is described as “the strongest woman I ever knew,” although their relationship was always strained. KT’s parents separated when she was 7 years old. She spent the next nine years moving back and forth between her mother’s and father’s homes. KT notes that she was not much of a student, never liked school, and began to miss school regularly as an