Reflections of a CHAMPUS-APA peer reviewer.

Peer review is a major professional response to the problems of health insurance coverage for psychiatric services. Standard insurance programs reimburse only services that are conventional and cost-effective. The system assumes that services are skillfully documented by providers. Experience as a peer reviewer helps clinicians acquire skill in documentation.

Forensic training in family practice residencies.

Knowledge and skill in forensic medicine are important in primary care not only for defensive purposes but also because of potential therapeutic value in patient care. The major role in future mental health services envisioned for primary care physicians makes such training especially important. A national survey of family practice residency programs reveals that 47 percent of programs do not address forensic aspects of medical practice. A model forensic medicine curriculum is described that would require minimal adjustment of existing programs. The need for inclusion of forensically qualified clinicians in training programs for primary care physicians is evident.

Health insurance and psychiatry: one peer reviewer's perspective.

For more than twenty years, discrimination against psychiatry by the health insurance industry has been a painful issue, the subject of vigorous action by organized psychiatry. A major breakthrough was the decision by the Civilian Health and Medical Programs of the Uniformed Services (CHAMPUS) in 1967 to extend coverage for outpatient psychiatric service to military dependents. From 1967 to 1970, CHAMPUS expenditures for psychiatric services increased from $90,000 to $400,000. Large sums were paid paid to unaccredited facilities, notably residential treatment centers for children (Armstrong, 1977), thus raising legitimate concerns about quality of care and inappropriate utilization. A more fundamental issue intimidates insurers, the apparent vagueness of psychiatric concepts and criteria for clinical judgments in practice (Liptzin, 1974).

Mental health services in primary health care: yet another era of disillusionment?

Amid the ruins of a mental health care delivery system chronically beleaguered by inadequate planning, financial support, or public consensus, efforts to integrate mental health services with the health services of primary care physicians are considered the best hope to improve access to mental health care. Despite a high prevalence of mental disorder in their patients, most primary care physicians do not recognize, formally diagnose, or treat emotional disorders. Significant personal, professional, and economic issues may compromise effective mental health care delivery in underserved areas, especially poor access to continued medical education and professional support resources. The thrust to provide primary care manpower is at the expense of core health professional training in other needed specialties, including psychiatry. Comprehensive planning for mental health services to underserved populations must consider the shortage and maldistribution of psychiatrists, requirements for professional team and liaison support for effective mental health care delivery by primary care physicians, access to continuing education, and reimbursement for appropriate mental health services. Increasing the mental health role of primary care physicians may otherwise amount to no more than a shift in the locus of expected care delivery.

Mental health training in family practice residency programs.

This paper presents a national survey of psychiatric and behavioral science training in approved family medicine residency programs. A 64 percent response rate resulted in data describing residency programs approved by the American Academy of Family Physicians: the residents, faculty, and curriculum content, and the teaching-learning format utilized in mental health training. Though improvement in the mental health services of primary care providers is a major health issue, training is typically provided by part-time or volunteer faculty; less than 5 percent of the total faculty are full-time psychiatrists. Critical elements of effective curriculum design and content that are inadequate or omitted are discussed.

A curriculum for the psychiatric training of family physicians.

This curriculum is designed with the expectation of considerable involvement by family physicians in mental health care delivery. Psychiatry education is initiated early, before attitudes become fixed, to emphasize self-reliance and mental health problem-solving skills, to make the learning experience longitudinal, and to integrate psychiatric training into the rest of the residents' curriculum. Seminars, clinical experience, and liaison with a mental health team are all utilized in the training design. The effectiveness of this training program will be studied over time to obtain needed data about the best teaching model for the mental health role of the family physician.

The role of the defense psychiatrist in workmen's compensation cases.

Tomorrow's psychiatrist should be more cognizant, competent, and comfortable in forensic science matters. Psychiatric cases are increasingly the subjects of litigation, but justice in the court depends on able advocacy by all parties. Advocacy for patient-plaintiffs is more similar to customary clinical roles than is advocacy for defendant insurance companies, which nevertheless are as needful of competent psychiatric experts as patient-plaintiffs if justice is to be done. Ironically, defense psychiatrist can do much to help patient-plaintiffs if they understand their roles correctly. Since legal systems are designed to produce justice, not therapy, the forensic competence of future psychiatrists will help to make litigation more therapeutic and just for patients. This paper describes the peculiarities of psychiatric work in litigated workmen's compensation cases, focusing on the role of the defense psychiatrist. We will highlight the constructive and therapeutically gratifying potentials of this work. Greater familiarity with the process will help to enlist the interest and participation of psychiatrist in workmen's compensation cases for the ultimate benefit of the patients and improvement of the legal system.

Shaping the mental health role of family physicians.

Family physicians have an important role in mental health care delivery. The psychiatry and family practice faculty at the University of Alabama College of Community Health Sciences recently examined the principal elements of this role and the ways in which these elements might best be incorporated into the teaching/learning process of a family medicine residency. Competency based approaches to curriculum development were chosen to permit flexibility of implementation and to allow involved physicians to participate in definition of their mental health roles. Methods used to construct the curriculum included interviews with graduated residents of the first four classes of the program, literature review, and a modified delphi/nominal group technique with family medicine and psychiatry faculty. The result was a competency based psychiatric curriculum supervised cooperatively by both psychiatry and family medicine faculty. This program is begun early in the residency, is integrated longitudinally into the rest of the residents' curriculum, and utilizes seminars, clinical experience, and liaison with a mental health team in the training design.

Responsibility therapy in community psychiatry.

The author describes a day treatment program using responsibility therapy, a form of behaviorism based on the principles of Alcoholics Anonymous. Mental illness is conceptualized as an addiction or bad habit to be corrected through definition of the client's problems, values, and therapeutic objectives. The program, which is operated by the county, requires high client motivation and the involvement of significant others. About 100 clients enter the program each year; more than half are referrals from the county probation department. A recent study showed that the program is serving the most disabled group of clients as least as effectively as the other county services.

Some behavioral techniques in community psychiatry.

Behaviorist principles operate observably in all aspects of animal life, hence in all therapies and in the community at large. Application of these principles strengthens treatment, notably with unsophisticated clients and sociopaths commonly encountered at Community Clinics. It also makes the program more sellable to taxpayers. Various techniques are described.

The homophile movement: Its impact and implications.

CONCLUSION: We do not conclude that homosexuality must be accepted by society. We do hope that society's attitudes towards homosexuals can be more intelligent, less confused. Perhaps our society will reject homosexuality on a basis of manifestly conscious prejudice of the majority who simply find it distasteful; but at least this will be more honest than many current rationalizations. Perhaps it will be possible and desirable because of changing conditions to accept homosexuality in our culture at some future time. Any sincere effort to confront the issues raised by homosexuality in our culture will be rewarded with a deeper understanding of many other aspects of human life.