Robert M. McCarron

Psychiatrists for Medically Complex Patients : Bringing Value at the Physical Health and Mental Health/Substance-Use Disorder Interface

BACKGROUND In their current configuration, traditional reactive consultation-liaison services see a small percentage of the general-hospital patients who could benefit from their care. These services are poorly reimbursed and bring limited value in terms of clinical improvement and reduction in health-service use. METHOD The authors examine models of cross-disciplinary, integrated health services that have been shown to promote health and lower cost in medically-complex patients, those with complicated admixtures of physical, mental, social, and health-system difficulties. CONCLUSION Psychiatrists who specialize in the treatment of medically-complex patients must now consider a transition from traditional consultation to proactive, value-added programs and bill for services from medical, rather than behavioral, insurance dollars, since the majority of health-enhancement and cost-savings from these programs occur in the medical sector. The authors provide the clinical and financial arguments for such program-creation and the steps that can be taken as psychiatrists for medically-complex patients move to the next generation of interdisciplinary service.

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.

Clinical management of comorbid diabetes and psychotic disorders.

Individuals with psychotic disorders experience substantial health disparities with respect to diabetes, including increased risk of incident diabetes and of poor diabetes outcomes (eg, diabetes complications and mortality). Low-quality medical care for diabetes is a significant contributor to these poor health outcomes. A thoughtful approach to both diabetes pharmacotherapy and drug management for psychotic disorders is essential, irrespective of whether treatment is given by a psychiatrist, a primary care provider, or an endocrinologist. Exposure to drugs with high metabolic liability should be minimised, and both psychiatric providers and medical providers need to monitor patients to ensure that medical care for diabetes is adequate. Promising models of care management and team approaches to coordination and integration of care highlight the crucial need for communication and cooperation among medical and psychiatric providers to improve outcomes in these patients. Evidence-based programmes that promote weight loss or smoking cessation need to be more accessible for these patients, and should be available in all the settings where they access care.

An academic-community partnership to improve care for the underserved.

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

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.

Preventive medical services use among community mental health patients with severe mental illness:the influence of gender and insurance coverage.

INTRODUCTION This study examines predictors of reduced preventive health service use in patients with severe mental illness by examining psychiatric diagnoses and demographic factors. METHOD Of 387 patients approached in 4 community mental health clinics regarding their preventive health services use from January 2005 to May 2007, 234 (60.5%) were interviewed. Of those participants interviewed, 221 had a DSM-IV-TR diagnosis of (1) primary psychotic disorder (schizophrenia or schizoaffective disorder), (2) bipolar disorder, or (3) recurrent major depressive disorder. Psychiatric disorders and demographic factors that predicted high service utilization were analyzed using analysis of variance and χ² tests. RESULTS In the linear predictive model, use of preventive services was not statistically different among the 3 diagnostic groups. Participants with primary psychotic disorder used a similar number of preventive services compared to those with bipolar disorder and major depression. Women used more services than men (P < .01), and individuals with health insurance used more than uninsured participants (P < .001). CONCLUSION Male gender and not having medical insurance were predictive of lower preventive health service use in this sample of patients with severe mental illness. Further research is needed to replicate these findings and to improve use of preventive health services in people with severe mental illness.

Integrated Care: Nonfasting Screening for Cardiovascular Risk Among Individuals Taking Second-Generation Antipsychotics

Ischemic heart disease (IHD) is the leading cause of mortality among adults with severe mental illness. Although gains in reducing mortality from IHD through screening, risk reduction, and early intervention have been realized for the general public, rates of recognition and treatment among individuals with mental illness continue to be poor. Obtaining blood samples from patients who have been fasting for eight to 12 hours is challenging for adults with severe mental illness and presents an additional obstacle to screening and treatment. This column outlines newer guidelines for cholesterol and diabetes screening that provide valid alternatives to fasting blood draws, thereby significantly reducing this common barrier to recognition of leading risk factors for IHD.

A novel approach to medicine training for psychiatry residents.

ObjectiveA unique rotation was developed to address limited outpatient internal medicine training in psychiatric residency by the University of California, Davis, Department of Psychiatry and Behavioral Sciences, which provides medical care to patients with mental illness.MethodsThe number of patients seen by the service and the number of psychiatric consults was determined from electronic records for the 2005–2006 academic year. Evaluations by psychiatry residents completing the rotation were reviewed. Three internist-psychiatrists and one family medicine-psychiatrist provided supervision.ResultsA total of 1,255 patients were treated during the 2005–2006 academic year. The quality of the educational experience was positive, with an overall rating of 4.43 on a scale from 1 to 5 with 5 being the highest.ConclusionTraining psychiatry residents in internal medicine can be better integrated into their psychiatry education in a creative fashion when the teaching and supervision is provided by jointly trained attendings in internal medicine/psychiatry or family medicine/psychiatry. The success of the rotation contributed to the development of a combined internal medicine and psychiatry residency program.

The DSM-5 and the Art of Medicine: Certainly Uncertain

The recently published Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is regarded as the primary source of information for psychiatric diagnostic criteria, but critic...

Understanding Preventive Health Screening Services Use in Persons with Serious Mental Illness How Does Integrated Behavioral Health Primary Care Compare

Objective People with serious mental illness have reduced life expectancy, in large part due to reduced access to medical services and underutilization of preventive health services. This is a cross-sectional study that compared preventive services use in an integrated behavioral health primary care clinic (IBHPC) with two existing community mental health programs. Methods Participants completed questionnaires about preventive health services use that contained 33 questions about demographic clinical information, and use of preventive health services, from October 2010 to December 2012. Services examined included mammogram, Papanicolaou Test, prostate specific antigen, digital rectal exam, fecal occult blood test, and flexible sigmoidoscopy or colonoscopy; blood pressure, height and weight, cholesterol, and blood sugar for diabetes; and influenza immunization, Hepatitis C Virus (HCV), and Human Immunodeficiency Virus (HIV) antibodies. A health service utilization score was developed and used as primary outcome for data analyses. Results In the multivariate analyses female gender (p < 0.05), race/ethnicity (p = 0.01 for Asian, p = 0.04 for Hispanic/Latino, both compared to White), program type (p < 0.001), and having a primary care provider (p < 0.001) were significant predictors of higher services use. IBHPC was associated with higher overall service utilization compared to one community mental health program (p < 0.001) but was similar when compared another (p = 0.34). There was high variability in use of individual services among the clinical programs. Conclusion More studies are needed to examine the effectiveness of integrated care in improving use of health screening services. Characteristics of the clinic in relation to use of preventive services deserve further study.