The depressions of Alzheimer's disease: sorting, pharmacotherapy, and clinical advice.

Research describing wide prevalence variation of Alzheimer's disease (AD) and comorbid depression is explained in light of subsyndromal depressions, the use of standardized diagnostic instruments and procedures, and the subcortical and cortical components of mood. There appear to be several "depressions" of AD. Against this backdrop, double-blind, placebo-controlled studies of antidepressant use in AD are reviewed and methodologic problems identified. Evidence for efficacy in controlled trials is weak, but open-label trials are, as expected, more encouraging. The potential efficacy of new agents for the depressions of AD receive comment. A heuristic model makes use of the conclusions developed, the stage of illness, and a preliminary classification scheme for the depressions of AD; this model provides a rational basis for thinking about medication selection for AD depressions. Clinical decisions are illustrated.

An econometric model of an episode of mental health care for patients with mild conditions: implications for caregiver substitution.

This article presents a model of the number of hours of mental health care, the concurrent improvement in the patient's condition, the probability the patient will receive medications, and the reasons for treatment termination. The variables related to these aspects of mental health care are analyzed separately for patients of psychiatrists, psychologists, and social workers. Estimates of the average length of treatment, the average price and income elasticities, and the average cost of treatment are obtained from the model. The major conclusions from this study are that psychiatrists do not have a benefit-cost advantage in the treatment of relatively mild conditions, and that consumer responsiveness to variations in price appear to be largely confined to the decision to seek treatment. These and other findings provide a basis for making tentative recommendations about personnel substitution and reimbursement policies in mental health.

A market analysis comparing the practices of psychiatrists and psychologists.

Data are analyzed that describe the clinical work of representative samples of psychiatrists and clinical psychologists who practiced in one of 62 markets for mental health services in the United States during 1982 and 1983. For psychiatrists, intensity of treatment (ie, mean face-to-face treatment minutes per patient per month) varied from 107 to 368 minutes vs 124 to 283 minutes for psychologists. Multiple regression models explain these variations somewhat differently for each provider group. Whereas the patient's severity or stage of illness is explanatory for both psychiatrists and psychologists, only psychologists appear to alter intensity of treatment in response to local economic conditions. Psychiatrists have large diversified practices, whereas psychologists tend to treat fewer persons and the bulk of these have less severe mental and emotional conditions. Neither practitioner group appeared to provide services in excess of their perceptions of patient need. These and other important similarities and differences are explored, and the advantages of local market focus for examining relevant public policy issues are discussed.

Variations in the intensity of psychiatric treatment across markets for mental health services in the United States.

Data are analyzed that describe the clinical work of 800 psychiatrists who practiced in one of 62 markets for mental health services in the United States during 1982 or 1983. Intensity of treatment (i.e., mean face-to-face treatment minutes per patient per month) ranges from a low of 107 minutes to a high of 368 minutes. Each of two multiple regression models accounts for 60 percent or more of the observed variation. Most of the variation in intensity of treatment can be accounted for with variables associated with the patient's severity or stage of illness and the type of treatment provided. Patients who fall on the midrange of the severity scale tend to consume the most treatment time per month. None of the economic variables were significant at any reasonable level. These findings have immediate implications for the development of more functional prospective payment systems for the financing of mental health care and for the longer-term debate over the nature of mental health services markets.

Estimated distribution of effort by providers of mental health services to U.S. adults in 1982 and 1983.

A national sample of psychiatrists, psychologists, social workers, and primary care physicians responded to a survey of their professional activities. From these data, the authors estimate that during a representative 60-day period, 6.7% of U.S. adults visited one of these types of professionals for a mental or emotional condition. All four groups spent the largest portion of their time with nonpsychotic patients. Most patients with schizophrenia, mania, or major depression were treated by psychiatrists. Services from primary care physicians were usually provided in the context of a concurrent physical condition. Psychologists and social workers tended to treat the less severe mental and emotional conditions.

Preliminary production functions describing change in mental health status.

Change in mental health status is analyzed as a function of hours of professional treatment, patient attributes, treatment characteristics, and environmental factors for each of seven clusters of conditions typically seen by psychiatrists, psychologists, or social workers. One of two regression strategies was effective in characterizing the relationship between status change and the input variables for each condition cluster. In each model, initial severity was significantly associated with change in mental health status, and it captured most of the unexplained variance. Provider time was predictive of improvement for only some conditions and providers. On average, mental health services appear to make patients better, but improvement is not terribly impressive. Moreover, the marginal benefits of treatment fall off as the number of contact hours increases.

Markov models and the utilization of mental health services: a study of endogenously depressed patients.

Patients in the mental health care system typically make more or less irregularly spaced visits to psychiatrists, both within and between episodes of a given illness. A Markov model is constructed which can predict the utilization of psychiatric services for such patients. Unlike previous Markov models of utilization, the current model takes as its starting point a model of an actual disease, specifically, endogenous depression. It is shown how one can estimate the parameters of both the model of utilization and the model of depression using data which were collected for clinical research purposes. The models provide reasonable fits to the data. Several applications of the models are worked out. In addition to predicting the utilization of mental health services, the models can be used to predict incidence, prevalence and recovery rates and to predict the changes in utilization which parallel changes in treatment regimens.

A study of referral failures for potentially suicidal patients: a method of medical care evaluation.

To learn more about the methodological problems inherent in medical care evaluation studies, a quality assurance committee conducted a study of rates of referral failure for potentially suicidal patients seen in the psychiatry division of a university hospital's emergency room. A simple 5-point scale was used to identify for study a similarly ill patient group: 296 patients with moderately to extremely severe suicide potential. The rates of referral failure for the emergency room's psychiatry division were 24 per cent for referrals within the university hospital system and 33 per cent outside the system, which compared favorably with other facilities. Outlier analysis-a statistical procedure that holds promise for medical care evaluation studies-was used to identify clinicians whose rates of referral failure differed significantly from their peer's rates of. As a result, an instance of substandard performance was identified and corrected through the transfer of information about exceptionally good performance.

Strategies to attract psychiatrists to state mental hospital work. Results from a survey of potential employees.

Psychiatric residents in five states were surveyed concerning the persuasiveness of 20 policy options designed to make career work in a state mental hospital (SMH) more attractive. The most persuasive options involved either part-time employment or structural changes within the health care provision system. Persuasive structural changes included integration with other health care facilities, increased use of allied health personnel, and improved quality of care within the SMH. Further analysis was performed to examine differences across subpopulations of respondents and to examine differences among types of classes of options. both long- and short-term remedies designed to help alleviate the shortage of psychiatrists in SMHs are discussed.

How psychiatrists allocate their professional time: implications for educational and manpower planning.

Data collected from 900 general psychiatrists graduating from 27 state hospital and university residency programs between 1961 and 1976 is used to determine certain patterns of patient care productivity among psychiatrists. The study relates differences in amount of hours spent per patient per month and number of inpatients and outpatients in treatment to psychiatrists' medical background (U.S. or foreign) and residency training (state hospital or university). The findings indicative that state hospital and university residency programs may instill different clinical behaviors in their graduates; possible changes in psychiatric residency programs are suggested. The author also proposes that the study data can be used to make rough estimates of the numerical range of psychiatrists needed in health care systems or in the U.S. as a whole.

An analysis of the movement to private psychiatric practice.

Survey data were analyzed from 900 psychiatrists who graduated between 1961 and 1976 from one of 17 state mental hospitals (SMHs) or ten university psychiatry residency programs in one of five states and are used to describe the differential influence of (1) foreign or US medical education, (2) SMH or university training program, and (3) years since graduation on the decision to take a job in either a private, public, or university medical school practice setting. Descriptive statistical models show that (1) about 25% of all respondents chose a private, 55% a public, and 20% a university for their first job, and (2) substantial numbers of both foreign and US medical graduates (FMGs, USMGs) left public jobs and chose and remained in private jobs, so that 55% of respondents had their current job in the private sector. Type of residency training was associated only with first job choice. Compared with USMGs, more FMGs initially took and remained in public jobs. These models highlight manpower problems. In fact, most of the respondents did not confine their work to a single kind of practice setting.

Documenting a shortage of psychiatrists: the repair shop model.

The author presents a model for documenting a shortage of psychiatrists. The model employs efficiency, work load, and work time to determine numbers of psychiatrists needed for a hospital setting. Survey data collected from 900 psychiatrists were used to quantify these variables and to identify possible determinants of variation. Differences in residency training were associated with differences in efficiency. As presented, the model is incomplete and cannot be used to explicity define manpower requirements. The author's discussion expands the model and focuses on the complexity of documenting a true shortage or surplus of psychiatrists.

Psychiatric education in the emergency room: must teaching stop at 5 p.m.?

The authors surveyed psychiatric residency programs to see what educational resources were available to residents assigned to provide emergency services during evening and nighttime hours. Almost half the sample of 89 programs assigned first-year residents to provide emergency care. The primary immediate means of support for the residents was telephone assistance, in 49 per cent of the programs, or the presence of a non-psychiatrist professional, in 35 per cent. The general lack of educational resources reflects the traditional dispositional model of emergency psychiatry, the authors say, with its emphasis on briefly evaluating the patient and referring him elsewhere for services; current training practices cannot meet the goals of the crisis system model in which a comprehensive treatment program is begun in the emergency room.

The impact of the Health Professions Educational Assistance Act on state mental health systems.

One effect of the Health Professions Educational Assistance Act of 1976 is to severely limit the number of foreign medical graduates entering the United States. To examine the impact of the law in Michigan, the authors gathered data on the number of psychiatrists practicing in the state and projected future manpower needs. They conclude that it is unlikely that, given other provisions in the law, American medical graduates can numerically replace foreign medical graduates, and that alternative manpower resources will have to be developed. State mental health systems must form new relationships with universities and the private psychiatric sector, and new methods of training personnel and sharing resources must be developed. The authors emphasize the importance of giving state mental health systems sufficient time and resources to develop effective manpower plans.

Psychiatric manpower for state mental hospitals. A continuing dilemma.

A shortage of psychiatrists continues to exist in state mental hospitals (SMHs), and Public Law 94-484 is likely to aggravate this problem. A telephone survey was done of 50 state departments of mental health to collect data about (1) the number and kinds of SMHs in each state;(2) the percentage of psychiatrists in SMHs who are foreign medical graduates; and (3) strategies for attractiing psychiatrists to SMHs. States with SMH residency training programs employed significantly more psychiatrists and paid significantly lower salaries than did states without these programs. Nine states reported no or few problems obtaining psychiatric staff. These nine states employed more psychiatrists and had a smaller proportion of foreign medical graduates than the remaining 41; salaries were similar. Sets of strategies for obtaining psychiatrists were identified for all 50 states. The strategies of competitive salaries, university affillation, and incorporating the SMH into an interdependent network of quality mental health care delivery systems are examined in detail.