The costs of compliance.

While the many costs of noncompliance have frequently been reviewed, this article addresses some of the costs of compliance, to the detriment of patients, doctors, and the doctor-patient relationship, and to the benefit of the pharmaceutical companies. Some psychiatric history is reviewed to analyze why psychiatric practice has become so focused on making specific diagnoses and treating those with specific medicines, even as fewer than 50% of patients follow medical advice. Some evidence for specific drug treatments is presented, and the powerful effects of nonspecific therapies, usually dismissed as confounders, are explored. Lastly, an argument for collaboration rather than compliance is made, imploring physicians to tailor individual treatment to each patient, and encouraging patients to be active in their own care.

Training community-based primary care physicians in the screening and management of mental health disorders among Latino primary care patients.

OBJECTIVE: To evaluate a quality improvement intervention to improve the screening and management (e.g., referral to psychiatric care) of common mental disorders in small independent Latino primary care practices serving patient populations of predominantly low-income Latino immigrants. METHODS: In seven practices, academic detailing and consultation/liaison psychiatry were first implemented (Stage 1) and then supplemented with appointment scheduling and reminders to primary care physicians (PCPs) by clinic staff (Stage 2). Acceptability and feasibility were assessed with independent patient samples during each stage. RESULTS: Participating PCP found the interventions acceptable and noted that referrals to language-matched specialty care and case-by-case consultation on medication management were particularly beneficial. The academic detailing and consultation/liaison intervention (Stage 1) did not significantly affect PCP screening, management or patient satisfaction with care. When support for appointment scheduling and reminders (Stage 2) was added, however, PCP referral to psychiatric services increased (P=.04), and referred patients were significantly more likely to follow through and have more visits to mental health professionals (P=.04). CONCLUSION: Improving the quality of mental health care in low-resourced primary care settings may require academic detailing and consultation/liaison psychiatric intervention supplemented with staff outreach to achieve meaningful improvement in the processes of care.

Elements of dynamics IV: neuronal metaphors--probing neurobiology for psychodynamic meaning.

The essentiality of neuronal connections can be seen by the frenetic activity which dissociated neurons in culture exhibit in an attempt to re-establish functional connections. Through these interactions, neurons gain access to trophic factors, such as nerve growth factor, which determine whether they live or die. Connection and successful interaction with others is thus a biological imperative for neurons. The properties of a given neuron are determined both by the inherent genetic program and by changes in its genetic expression induced by cell-to-cell interaction. In other words, plasticity of neuronal function reflects not only cellular properties but is a consequence of its relationships. Since it is reasonable to assume that the emotional experience of organisms derives from the biological properties of their brain cells, it seems fruitful to probe the basic biology of these cells for metaphors that might yield insight into psychological properties. Clinical examples illustrate how using these concepts can enlighten the processes by which psychotherapeutic change can occur. In addition, perhaps understanding the underlying neurobiology can add scientific legitimacy to clinical psychodynamic work, and can reduce the tension between "biological" and "psychological" psychiatry. These ideas might be used to develop a new framework to strengthen the teaching of psychotherapy.