The carved-out system's view.

Rarely do issues of mental health care in medical settings and the medical care of severely and persistently mentally ill patients treated in public mental health get addressed. The best approach to ensure that care is integrated is to reduce obstacles to reimbursement. In particular, carved-out systems should ask questions that highlight areas for change.

Funding for consultation-liaison services in public sector-managed care plans. The experience of the Consultation-Liaison Association of Philadelphia.

Recently, the Commonwealth of Pennsylvania initiated plans to implement a mandated behavioral health carve-out program for Medicaid-eligible persons. The Consultation-Liaison Association of Philadelphia (CLAP) discovered that there was no provision for the coverage of psychiatric services for patients with concomitant medical illness. As a result, the authors responded by initiating a series of actions aimed at ensuring inclusion of such services as part of mental health services to be delivered. CLAP developed a brief position paper that includes a description of the need for such services, the types of services typically delivered, the impact of psychiatric input in the medical setting on costs and other outcomes, and a specific set of recommendations. These efforts have lead to the inclusion of consultation-liaison services in the new plan. A description of recent changes in Medicaid, including expansion of managed care plans, the status of mental health carve outs, and the possibility for inclusion of psychiatric consultations for the medically ill within these plans, is detailed.

Supportive telephone intervention for patients receiving chemotherapy. A pilot study.

Psychosocial interventions have been shown to improve quality of life (QOL) for many cancer patients. A pilot study was conducted to assess the feasibility of a psychoeducational intervention for cancer patients receiving chemotherapy. Eight patients receiving chemotherapy for colorectal carcinoma participated. The intervention is based on a modification of Interpersonal Therapy. It consisted of four sessions, administered biweekly, using a manual format, by a psychiatric nurse clinician over the telephone. The participants also completed a set of QOL measures by telephone to assess tolerance of the planned assessment. The patients received assistance with treatment-related side effects, reported improved ability to communicate with their physician, and gained an understanding of the stresses they discussed. The patients felt satisfied with the emotional support and medical information provided. A randomized trial is planned to test the intervention for patients participating in a cooperative trial sponsored by the National Cancer Institute.

Palliative and supportive care of patients with pancreatic cancer.

Pancreatic cancer tends to be diagnosed at a relatively late stage of disease and often secondary to significant complaints of pain. In addition there is evidence of higher rates of depressive symptoms at diagnosis in pancreatic cancer than in other forms of cancer. These factors, along with the specific tumor anatomy and pathophysiology of pancreatic cancer make palliative considerations central to the care of patients with the disease. The palliative and supportive approach must first include an aggressive evaluation of pain, mood, and emotional symptoms. Attention should be paid to the specific nature of pain complaints and attempts made to make accurate clinicopathological correlates for the pain. Assessment should be complete and ongoing. Pain treatments include pharmacotherapy, invasive anesthetic and surgical procedures, and supportive attention to side effects and other symptoms of disease and treatment. Depression often appears at higher rates than documented in other cancer patients and can be independent of pain complaints and other symptoms present in the preterminal phases of illness. Depression should be treated with pharmacotherapy and supportive psychotherapy as indicated. Hospice should be considered early on in the treatment relationship and can provide pain and symptom management services as well as play an important role in providing emotional support to the patient and family. Attention to pain, mood, psychological distress, and other quality of life issues can often allow for successful treatment of symptoms and improvement in functioning even in the setting of late stage pancreatic cancer.

Identification of PTSD in cancer survivors.

The authors measured the rate and determinants of posttraumatic stress disorder (PTSD) in a group of cancer survivors. Patients who had a history of cancer diagnosis with at least 3 years since diagnosis, receiving no active treatment, such as chemotherapy or radiation, were interviewed (N = 27). Patients, who were part of the DSM-IV PTSD field trial, were compared with a community-based control group matched for age and socioeconomic status. One member of the survivor group (4%) and no members of the control group met criteria for current PTSD (NS). Six of the survivors (22%) and no control subjects met lifetime criteria (P < 0.02). Cancer patients have a higher rate of PTSD than found in the community. Symptoms closely resemble those of individuals who have experienced other traumatic events.

A psychoeducational bereavement-support group for families provided in an outpatient cancer center.

BACKGROUND: Grief is a normal and highly personal reaction to loss. Bereavement care (individual and/or group) can assist family members and friends in coping with their feelings of grief, thereby reducing the possibility of complicated grief reactions. The families and significant others of patients who have died in settings other than a hospice do not automatically have the opportunity for bereavement follow-up. METHODS: An eight-session psychoeducational group that provided psychosocial support and information aimed at assisting in the bereavement process was initiated at an outpatient cancer center. It was led by a family therapist who was a member of a psychosocial services team. Family members and friends of recently deceased patients were invited to participate by letter and phone call. RESULTS: Seven people participated in at least one group session. Participants were asked to complete a face-valid follow-up questionnaire three months after completion of the group. CONCLUSIONS: Group members found the group experience beneficial, especially regarding the opportunity to talk with others who had experienced similar losses, learning about the reactions one would expect in the grieving process, and developing new strategies to deal with the grief associated with the loss.

Dominantly transmitted hematologic dysfunction clinically similar to Fanconi's anemia.

We report a family with a dominantly transmitted syndrome resembling Fanconi's anemia and spanning two generations. This syndrome was characterized by an ill-defined hematologic stem cell disorder, immune dysfunction, poor dentition, hyperpigmented skin, warts, and multiple second trimester spontaneous abortions and included one case of acute myelomonocytic leukemia (acute non-lymphocytic leukemia, M4). This family lacks the characteristic chromosomal aberrations of Fanconi's anemia. We believe this constellation of findings represents an entity not previously described.

Modification of decision-making behavior of third-year medical students.

Modification of physician behavior has been suggested as one approach to controlling health care expenditures. Third-year students participated in an experimental program which attempted both to construct an educational approach that included aspects of such expenditures and to measure the effectiveness of the approach. Students were divided between experimental and control groups, with the former receiving information relative to the appropriate use and costs of diagnostic procedures. Both groups were presented with case studies dealing with specific disease processes discussed in the program. Members of the experimental group scored significantly better in their ability to determine diagnoses, make patient-management decisions, and choose essential diagnostic procedures. Average charges generated by the experimental student group were half the amount generated by the control group. Future studies will be required to determine whether the behavior modification carries forward in practice and to provide a standardized methodology for use by members of the faculty and house staff in educating future medical students.