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.

Morbidity and mortality in the commitment process.

This study reports a prospective evaluation of 189 patients who entered the commitment process in Oregon. Patients were assessed for commitment status, morbidity, and mortality at six and 19 months. Twenty-nine percent were formally committed. The committed group consisted largely of violence-prone, psychotic patients plus a small number of elderly, demented subjects with serious medical illness. A mortality of 10% included the elderly who died of medical causes and young adult patients who completed suicide. The findings justify psychiatry's concern for patient welfare in commitment systems, especially for the group that is released and not committed. The study is compared with six additional commitment studies, with emphasis on methodology and implications for further research.

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.

Validity of the MMPI with native Americans.

A study was conducted to determine the validity of the MMPI for 142 American Indian patients from Pacific Northwest tribes. All the MMPI profiles were similar and had significant elevations in the Sc, Pd, and Pa scales. There was no significant difference between diagnostic groups on many clinical scales. Nonpsychotic, depressed Indian patients could not be distinguished from schizophrenic patients on any clinical scale, and there were no significant differences between antisocial-alcoholic patients and those with situational reactions. There were minimal differences between the Northwest Coast, Plateau, and Plains cultural groups. The authors believe that the similarity of all subgroup profiles demonstrates a significant cultural influence on the results of the MMPI in this population of American Indians.

Psychiatric and nonmedical decisions on commitment.

The civil commitment statutes of Oregon were changed in 1973 and 1975 to include nonphysician court examiners and public prosecutors in the commitment hearing. To evaluate the effect of these changes the authors compared the commitment decisions actually made by panels composed of two physicians with those made by panels with one physician and one nonphysician mental health professional. They also compared the commitment decisions made by six groups of medical and nonmedical people involved with the commitment process regarding five case vignettes. They found that decisions made by the nonmedical mental health professionals were not significantly different from those made by the psychiatric examiners.

Indian children and tribal group homes: new interpretations of the Whipper Man.

The authors describe a community-based children's home and child welfare program among a tribe of Plateau Indians. The program has been effective because it is compatible with this Indian culture, which accepts extended family and community responsibility for child care. The authors feel that the program demonstrates principles of primary prevention in community mental health.

Evaluation of a regional Indian alcohol program.

The authors analyzed follow-up data collected by an Indian counselor and a psychiatrist on 83 American Indian alcoholic men. Follow-up status was judged by an interdisciplinary panel according to a six-step rating scale. The 44 percent improvement rate compares favorably with other treatment programs, especially in view of the selection process, which favored difficult patients. The authors suggest that the interdisciplinary rating panel is an approach that can prevent erroneous judgments of the drinking status of American Indians.

Required educational objectives in community psychiatry.

Community psychiatry is an essential requirement of approved residency training. The authors present a format of required educational objectives for this experience. They feel that recent attempts to limit psychiatric consultation to the consultation-liaison model are restrictive and incomplete. In their view of the psychiatrist's role, community consultation techniques are essential skills for the psychiatric practitioner.

Residency curriculum in forensic psychiatry.

The authors describe the development of a curriculum in forensic psychiatry in a general psychiatric residency training program. Educational objectives for both knowledge and skills are presented. The authors detail training experiences at each level of psychiatric residency, including electives available for fourth-year residents. They encourage other training programs to share similar reports with a view toward the development of standards in the training of residents in forensic psychiatry.

Does community care for the mentally ill make a difference? A tale of two cities.

Matched groups of schizophrenic patients in Portland, Ore., and Vancouver, B.C., were compared approximately 1 year following discharge from an index hospitalization. Whereas Vancouver boasts a rich network of accessible private services and a public mental health system that provides a model of care for the chronically mentally ill, Portland's aftercare facilities at the time of the study were limited. One year after discharge the Vancouver cohort experienced fewer readmissions, was more apt to be employed, and reported a higher level of well-being, all of which suggest that community aftercare positively affects the negative symptoms of schizophrenia.

Training psychiatrists to work with community support systems for chronically mentally ill persons.

Community support programs are becoming a major priority in community mental health centers throughout the country. The authors present a training design that integrates principles and skills associated with this model into a 4-year residency training program. The aim of such programs is to keep young psychiatrists involved and in the forefront of the newer approaches to the treatment of chronically mentally ill persons.

Psychiatric reactions to disaster: the Mount St. Helens experience.

Following the 1980 Mount St. Helens volcanic eruption, psychiatric reactions were studied in the disaster area and in a control community. Using the new criterion-based diagnostic method for psychiatric epidemiologic research, the Diagnostic Interview Schedule, the authors found a significant prevalence of disaster-related psychiatric disorders. These Mount St. Helens disorders included depression, generalized anxiety, and posttraumatic stress reaction. There was a progressive "dose-response" relationship in the comparison of control, low-exposure, and high-exposure groups. The dose-response pattern occurred among both the bereaved and the property-loss victims.

Developing minimal national standards for clinical experience in psychiatric training.

There are no minimum standards for the clinical training of psychiatrists with regard to the type and number of patients evaluated or treated. Interest in establishing such standards derives from a need for greater accountability, a high fail rate on the clinical portion of the American Board of Psychiatry and Neurology examinations, and an increasing demand for precise documentation of competence in specific areas by hospital privileging committees. Although considerable disagreement exists as to what the overall requirements should be, some minimum requirements can be agreed on. The authors discuss concerns about minimal standards and make suggestions for further development of standards.

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 VA psychiatry service as a setting for residency education.

The authors report data from a survey of chairmen of academic departments of psychiatry and chiefs of Veterans Administration (VA) psychiatry services concerning administrative relationships between academic psychiatry departments and VA psychiatry services and the education of psychiatry residents in VA settings. The extent and quality of relationships, the interdependence of academic departments and VA psychiatry services, factors important for good VA training, and advantages and disadvantages of using the VA for residency education are documented. The authors present their conclusions and recommendations for improving the quality of relationships between academic departments and VA psychiatry services and for strengthening psychiatric education in the VA setting.

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.

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.

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.

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.