Lessons Learned or Forgotten? Impacts of COVID-19 on the Future Direction of Global (e-)Mental Health Care.

PURPOSE OF REVIEW: The COVID-19 pandemic has impacted lives globally, posing unique challenges to mental health services exposing vulnerability and limitations within these systems. During the course of the pandemic, telecommunications technologies (e-mental health care) have served a critical role in psychiatric care. It is important to understand current lessons learned in e-mental health care and implications for global mental health systems for both emerging from the pandemic and after the pandemic has ended. RECENT FINDINGS: There are significant regulatory, policy, and evaluation challenges for global e-mental health impacting patients, clinicians, health systems, and decision-makers. These include complex regulatory issues, difficulties of providing care across boundaries, and keeping pace with the implementation of new technologies in behavioral health. The collaborative development of global standards along with policies, appropriate regulations, and developing new models of research and development opens the possibility of improved access to care across national boundaries.

Physician health programmes and malpractice claims: reducing risk through monitoring.

BACKGROUND: Physician health programmes (PHPs) are peer-assistance organizations that provide support to physicians struggling with addiction or with physical or mental health challenges. While the services they offer are setting new standards for recovery and care, they are not immune to public debate and criticism since some have concerns about those who are enrolled in, or have completed, such programmes and their subsequent ability to practice medicine safely. AIMS: To examine whether medical malpractice claims were associated with monitoring by a PHP using a retrospective examination of administrative data. METHODS: Data on PHP clients who were insured by the largest malpractice carrier in the state were examined. First, a business-model analysis of malpractice risk examined relative risk ratings between programme clients and a matched physician cohort. Second, Wilcoxon analysis examined differences in annual rates of pre- and post-monitoring claims for PHP clients only. RESULTS: Data on 818 clients was available for analysis. After monitoring, those enrolled in the programme showed a 20% lower malpractice risk than the matched cohort. Furthermore physicians' annual rate of claims were significantly lower after programme monitoring among PHP clients (P < 0.01). CONCLUSIONS: This is the only study examining this issue to date. While there are a variety of reasons why physicians present to PHPs, this study demonstrates that treatment and monitoring is associated with a lowered risk of malpractice claims and suggests that patient care may be improved by PHP monitoring.

Comparative use of biomedical services and traditional healing options by American Indian veterans.

OBJECTIVE: This study described service use among American Indian veterans, compared use patterns across biomedical care and traditional healing options, and tested whether utilization varied as a function of need or availability. METHODS: A cross-sectional survey of 621 male combat veterans selected from tribal rolls was conducted between 1992 and 1995 in American Indian reservation communities in the Southwest and in the Northern Plains. Measures included assessments of demographic characteristics, physical and mental health conditions, and self-reports of any use during the past year of Veterans Administration (VA), Indian Health Service (IHS), and other biomedical services as well as participation in traditional ceremonies and use of indigenous healing options. RESULTS: Tribal groups were similar in sociodemographic characteristics and in number of health problems and mental and substance use problems during the past year. The same types of services from IHS were available to the two groups, and the geographic distance to these services was similar. VA facilities were more readily available in the Northern Plains than in the Southwest, where they were far from reservation boundaries. Use of IHS services was similar for the two tribal groups, but use of VA services was significantly less in the Southwest. Overall, biomedical services were used more in the Northern Plains, reflecting greater use of VA facilities. However, these differences in overall health service disappeared when traditional healing options were considered. Use of traditional healing was greater in the Southwest, offsetting lower biomedical service use. CONCLUSIONS: When the full array of options is examined, service use functions according to need for health care, but the kind of services used varies according to availability.

A strategic approach to the psychiatric workforce dilemma.

To help build consensus in the field of psychiatry about future psychiatric manpower needs, a 13-step strategic approach to the workforce issue is described. The steps include recognizing the importance of the assumptions that underlie workforce requirements; selecting credible and professional leadership with vision and courage; adopting a strategic plan to clarify workforce assumptions; re-examining the structure and function of established programs; preparing trainees for work in the 21st century; preserving psychiatry's humanistic tradition; enlisting the support of nonacademic psychiatrists; and reinforcing involvement in the fiscal and political aspects of medicine. They also include focusing attention on important policy issues; securing the support of patients, families, and advocates; endorsing a multidisciplinary, biopsychosocial approach to the evaluation and treatment of mental illness; minimizing divisive conflicts within and between national organizations; and developing strategic alliances with other medical disciplines. Implications of the 13-step approach are outlined for psychiatric clinicians, educators, and researchers, as well as for the organizations that serve them.

Substance abuse treatment of American Indian adolescents: comorbid symptomatology, gender differences, and treatment patterns.

OBJECTIVE: To describe the patient population and use of mental health treatment at a residential substance abuse treatment program for American Indian and Alaska Native adolescents. Specifically, this article (1) reports the level of psychiatric symptomatology among the patient population; (2) compares male and female patients in terms of demographics, symptomatology, and receipt of mental health treatment; and (3) examines the degree of association between patient psychiatric symptomatology and the receipt of mental health treatment. METHOD: Medical records were reviewed for all 64 patients admitted over a 1-year period. Data included patient characteristics such as substance use and psychiatric symptomatology as well as the receipt of mental health treatment. RESULTS: Sixty-eight percent of patients screened positive for at least one psychiatric symptom type. Females reported greater substance use and were more likely to report that they were victims of abuse. Females also were more likely than males to receive mental health treatment even though males had at least equal need. Finally, there was no significant relationship between measures of psychopathology and subsequent receipt of mental health treatment. CONCLUSIONS: Reassessment of the methods for identifying and treating patients with comorbid psychopathology within programs of this nature is indicated.

Psychiatry at a crossroad: our role in primary care.

OBJECTIVE: The shortage of primary care physicians is seen as an urgent health systems priority and is supported by a national consensus. Psychiatry is at a crossroad and must reevaluate the profession's role in primary care. This article supports the position that psychiatrists need to be able to medically evaluate and to provide basic primary medical care for seriously mentally ill patients who do not have adequate access to general health care. Many of the seriously mentally ill are difficult to treat when they contact a medical care provider. Because of their psychiatric symptoms, they often are unlikely to receive adequate medical care. Psychiatrists frequently are the only physicians with whom they have consistent contact. METHOD: This article contains a proposal for a new initiative to broaden the role of public psychiatrists to include a primary care role. In addition, new opportunities for dual or triple board certification are reviewed. RESULTS: A new curricular model for primary care training in general psychiatry programs is outlined. The new curriculum would include training for diagnostic and primary care skills to prepare psychiatrists to provide basic primary medical services for the chronically mentally ill. CONCLUSIONS: The new curricular proposal would create an elective psychiatry primary care track. This is possible within current accreditation requirements. Psychiatric residents could receive primary care training throughout their residency.

Shortening length of stay without increasing recidivism on a university-affiliated inpatient unit.

The impact of reducing length of stay on readmission rates was examined for privately insured patients treated on a traditional inpatient unit or in an alternatives program with a shorter stay and a continuum of acute care. Billing data were analyzed for length of stay and readmission rates for all admissions between 1985 and 1992 (N = 1,363). The traditional unit was reorganized in 1990 into the alternatives program. Although the program decreased mean length of stay from 20.2 days to 6.2 full-day equivalents, overall readmission rates did not increase (17.2 percent, compared with 18.6 percent for the traditional unit). Rates increased for a subgroup of patients with psychotic disorders (from 13.7 to 35.2 percent).

A prospective study of the natural course of alcoholism in a Native American village.

This study examines the natural course of alcoholism in a Native American village. We found that the remission rates of alcoholism were quite similar despite the different methods used: life histories (SADS-L interview) showed a 63% remission rate; a 19-year follow-up prospective showed 60% in remission; and following a cohort of all those who developed alcoholism in the village over the previous 19 years revealed a 60.9% remission rate. The data also showed vast differences in drinking problems between men and women. In the span of 19 years, the differences of point prevalence rates of alcoholism between men and women have jumped from that of two times (52% vs 26%) to five times (36.4% vs 7%). Furthermore, the results showed women had a higher rate of alcohol abuse (8.4% vs 3.6%) and a far higher remission rate (82% vs 52%) when compared to men. Three-fourths of the men in the studied sample had a lifetime history of alcohol dependence. They usually began drinking in their teens and developed dependency by their early twenties. About half stopped after an average of 15 years of drinking. The majority (83%) of the subjects who stopped drinking did so spontaneously or for specific personal-related reasons rather than because they received alcohol treatment.

Reliability of the Part II board certification examination in psychiatry: examination stability.

OBJECTIVE: The aim of this study was to examine the reliability (examination stability) of the American Board of Psychiatry and Neurology (ABPN) Part II (oral) examination in psychiatry. METHOD: The authors analyzed the consistency (agreement between grades given by two independent examiners) for a 1-year examination cycle using a weighted kappa statistic and compared different parts of the examination (live patient and videotape), different examination sites, different days, and different times of the day. RESULTS: There was no significant difference in agreement between examiners by different parts of the examination, examination site, day of the week, or time of day. CONCLUSIONS: The stability of the Part II ABPN examination in psychiatry is not influenced significantly by the format or site of administration. Candidate performance is the predominant factor in the determination of passing or failing grades.

Order and chaos : subspecialization and american psychiatry.

Psychiatrie subspecialties have emerged rapidly during the past decade. This article discusses significant influences in nonpsychiatric medicine and psychiatry that led to these developments. The process f or new subspecialty recognition, certification, and accreditation is outlined. The status of the major psychiatric subspecialties is reviewed. The impact of the changing recruitment into psychiatry is discussed for subspecialization, the psychiatric generalist, and psychiatric educational resources.

The natural history of medical and psychiatric disorders in an American Indian community.

In 1969, a Pacific Northwest American Indian community cohort (n = 100) was interviewed for the presence of physical and psychiatric illnesses. The same community was studied again in 1988. This study describes the outcome among the original 100 subjects. The schedule for Affective Disorders and Schizophrenia Lifetime Version (SADS-L) served as the basic interview instrument, supplemented by data from medical records, death certificates, and medical and community informants. Twenty-five subjects had died, 13 from cardiovascular disorders and seven from alcohol-related illnesses. Among the 46 subjects re-interviewed, hypertension, heart disease, and diabetes had become significant sources of medical morbidity. Alcoholism was the most significant cause of psychiatric morbidity, particularly among males. This study indicates that greater attention should be focused upon prevention and treatment of alcoholism, cardiovascular disorders, and diabetes in this community and in other American Indian populations.

Psychiatric epidemiology of an Indian village. A 19-year replication study.

This 1988 study reports the point and lifetime prevalence of psychiatric disorders, using DSM-III-R criteria, of a sample (approximately 25%) of adult members of an Indian village previously studied in 1969. The basic instrument was the Schedule for Affective Disorders and Schizophrenia, augmented by available medical information and administered by experienced psychiatrists. Subjects were interviewed and results were weighed for the age- and sex-distributed population. The results indicated a high point prevalence of alcohol dependence (32.8%), with a lifetime prevalence of 72.8%, among males. The lifetime prevalence of affective disorders among women was also high (36.8%), but less so among men (19.3%). When compared with the DSM-III-R diagnoses of the 1969 study, the point prevalence rates of alcohol dependence and abuse disorders fell from 39% to 21%. Also, fewer subjects were judged to be psychiatrically impaired. Even though the prevalence of psychiatric disorders was lower in the current study, the rates for alcohol disorders and affective disorders were still far higher than those reported in Epidemiologic Catchment Area studies. Alcohol dependence (especially among young men) and affective disorder (among women) were major problems.

Reliability of the Part II Board Certification Examination in Psychiatry: interexaminer consistency.

OBJECTIVE: The aim of the study was to examine the reliability (interexaminer consistency) of the American Board of Psychiatry and Neurology (ABPN) Part II (oral) examination in psychiatry. METHOD: Grades were assigned independently by two examiners who observed the same examination in a 1-year cycle (1,422 candidates, two examinations each). The consistency between these pairs of grades (pass, condition, fail) was analyzed using a weighted kappa statistic. RESULTS: There was perfect agreement between examiners in 67% of examinations, minor disagreement in 26%, and major disagreement in 7% (weighted kappa = 0.54-0.56). CONCLUSIONS: The Part II ABPN examination demonstrates fair to good reliability as measured by interexaminer consistency. Development of more explicit grading criteria should further improve examiner agreement in future examinations.

Psychiatric consultation to a state board of medical examiners.

This article describes the evolution of psychiatric consultation to the Oregon Board of Medical Examiners. The board is charged with the licensing and regulation of physicians in the state of Oregon in order to protect the public and uphold the standards of the medical profession. Psychiatric consultation has focused on the board's investigations of physicians with mental illness and/or substance abuse and physicians who inappropriately prescribe psychoactive drugs or sexually abuse patients. Each of these physician groups is described, and remedial programs for each group are discussed. The authors conclude that psychiatric consultation to medical boards is a feasible and productive activity that can make a positive contribution to the lives of a large number of physicians and patients.

The Program for Public Psychiatry: state-university collaboration in Colorado.

A major focus of state-university collaboration programs in psychiatry has been providing services and manpower from the university to the public mental health system, which in turns provides valuable educational experiences to the university. The Program for Public Psychiatry, a state-university collaboration program in Colorado, was founded on a 25-year relationship between the department of psychiatry at the University of Colorado Health Sciences Center and the Colorado Division of Mental Health. The program has enabled Colorado's two state hospitals and most of its urban community mental health centers to almost completely fill previously vacant psychiatric positions. The collaboration has expanded to include programs for forensic psychiatry and developmental disabilities, as well as to fund educational and research missions in developing the public psychiatric work force.