Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary Care: A Pragmatic Randomized Comparative Effectiveness Trial.

Importance: Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings. Objective: To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics. Design, Setting, and Participants: This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months. Interventions: Two approaches were compared: (1) telepsychiatry/telepsychology-enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing. Main Outcomes and Measures: Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects. Results: Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (ß = 1.0; 95% CI, -0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (ß = 2.0; 95% CI, -1.7 to 5.7; P = .29). Conclusions and Relevance: In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable. Trial Registration: ClinicalTrials.gov Identifier: NCT02738944.

Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care.

BACKGROUND AND OBJECTIVES: Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model. METHODS: After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch. RESULTS: Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged. CONCLUSIONS: These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

Increased Australian outpatient private practice psychiatric care during the COVID-19 pandemic: usage of new MBS-telehealth item and face-to-face psychiatrist office-based services in Quarter 3, 2020.

OBJECTIVE: The Australian federal government introduced new COVID-19 psychiatrist Medicare Benefits Schedule (MBS) telehealth items to assist with providing private specialist care. We investigate private psychiatrists' uptake of video and telephone telehealth, as well as total (telehealth and face-to-face) consultations for Quarter 3 (July-September), 2020. We compare these to the same quarter in 2019. METHOD: MBS-item service data were extracted for COVID-19-psychiatrist video and telephone telehealth item numbers and compared with Quarter 3 (July-September), 2019, of face-to-face consultations for the whole of Australia. RESULTS: The number of psychiatry consultations (telehealth and face-to-face) rose during the first wave of the pandemic in Quarter 3, 2020, by 14% compared to Quarter 3, 2019, with telehealth 43% of this total. Face-to-face consultations in Quarter 3, 2020 were only 64% of the comparative number of Quarter 3, 2019 consultations. Most telehealth involved short telephone consultations of ⩽15-30 min. Video consultations comprised 42% of total telehealth provision: these were for new patient assessments and longer consultations. These figures represent increased face-to-face consultation compared to Quarter 2, 2020, with substantial maintenance of telehealth consultations. CONCLUSIONS: Private psychiatrists continued using the new COVID-19 MBS telehealth items for Quarter 3, 2020 to increase the number of patient care contacts in the context of decreased face-to-face consultations compared to 2019, but increased face-to-face consultations compared to Quarter 2, 2020.

Australian private practice metropolitan telepsychiatry during the COVID-19 pandemic: analysis of Quarter-2, 2020 usage of new MBS-telehealth item psychiatrist services.

OBJECTIVE: The Australian Commonwealth Government introduced new psychiatrist Medicare-Benefits-Schedule (MBS)-telehealth items in the first wave of the COVID-19 pandemic to assist with previously office-based psychiatric practice. We investigate private psychiatrists' uptake of (1) video- and telephone-telehealth consultations for Quarter-2 (April-June) of 2020 and (2) total telehealth and face-to-face consultations in Quarter-2, 2020 in comparison to Quarter-2, 2019 for Australia. METHODS: MBS item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with a baseline of the Quarter-2, 2019 (April-June 2019) of face-to-face consultations for the whole of Australia. RESULTS: Combined telehealth and face-to-face psychiatry consultations rose during the first wave of the pandemic in Quarter-2, 2020 by 14% compared to Quarter-2, 2019 and telehealth was approximately half of this total. Face-to-face consultations in 2020 comprised only 56% of the comparative Quarter-2, 2019 consultations. Most telehealth provision was by telephone for short consultations of ⩽15-30 min. Video consultations comprised 38% of the total telehealth provision (for new patient assessments and longer consultations). CONCLUSIONS: There has been a flexible, rapid response to patient demand by private psychiatrists using the new COVID-19-MBS-telehealth items for Quarter-2, 2020, and in the context of decreased face-to-face consultations, ongoing telehealth is essential.

Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients.

OBJECTIVE: To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK). METHOD: The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting. RESULTS: The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed. CONCLUSION: Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).

Multidisciplinary and Holistic Models of Care for Patients With Dermatologic Disease and Psychosocial Comorbidity: A Systematic Review.

Importance: Psychocutaneous disease affects an underrecognized patient population facing misdiagnosis and a reduced quality of life due to knowledge gaps and insufficient awareness. Clinicians worldwide serve as pioneers in offering specialized care for affected patients through the development of combined clinics. Results yield a framework needed to expand availability and ultimately improve patient outcomes. Objectives: To report key findings generated from an in-depth analysis of available literature, highlight the importance and benefits of providing multidisciplinary care, and provide structural evidence of existing liaison clinics for more widespread future application. Evidence Review: To identify data from inception to November 12, 2019, a search was conducted in PubMed and Google Scholar using the following search strategy: psychodermatology clinic OR psychodermatology liaison OR psychodermatology combined OR psychocutaneous clinic OR psychocutaneous liaison OR psychocutaneous combined OR psychiatry dermatology combined OR psychiatry dermatology clinic. Studies were excluded if they were single-patient case reports; if information regarding the number of patients, clinic setup, and presenting conditions was not provided; and if the reports were published in a language other than English. Findings: A total of 932 studies were screened, and 23 were retained after removal of duplicates and application of inclusion criteria. The combined clinics, varying in structure, design, and setting, provided collective data from 1677 patients in 12 countries worldwide. Results indicate that patients experience barriers in gaining access to care and clinicians lack appropriate knowledge and resources for proper diagnosis and treatment. The implementation of combined clinics provides a cost-reducing avenue in the management of dermatologic disease and psychosocial comorbidity by limiting inaccurate diagnoses, ineffective treatments, unnecessary referrals, and "doctor shopping." Increased patient satisfaction or improved patient outcomes after the use of holistic treatment with pharmacologic and nonpharmacologic therapies was reported by 20 included studies (87%). Conclusions and Relevance: Examined data from the included clinics illuminate the increased need and demand for specialized care. The ability to provide high-quality integrative patient care, potential utility in medical education, and findings of reduced health care expenditures reflect the need for health care leaders to expand specialized care as key for moving forward. Practical clinic models consist of a well-informed dermatologist for identification of psychocutaneous disease, referral if needed, and treatment based on the physician's individual comfort level. Involvement of multiple specialists, including psychiatrists, psychologists, and residents and preferably within teaching institutions, in consultations and management-related discussions is recommended.

The multi-dimensional matrix for consultation-liaison psychiatry (mMAX-LP).

OBJECTIVE: Consultation-liaison psychiatry (CLP) services are particularly susceptible to heterogeneity, developing haphazardly in response to local interests and perceived need. This hampers the generalisability of comparisons between services in terms of service models, resource requirements and outcome data. The objective of this paper therefore is to chronicle the development of a method to meaningfully describe, map and compare different CLP services. METHOD: A review of the literature was followed by multiple site visits in both New Zealand and England, and an extended process of consultation and feedback. RESULTS: Sixteen dimensions common to CLP services were extracted to create a multi-dimensional matrix (mMAX-LP) which had three broad clusters (structure, coverage and relationship with physical health services). The model was applied and discussed with the previously visited hospitals over the succeeding five years. Additionally, the matrix was tested, and its utility demonstrated during the planned reconfiguration of CLP services at a large teaching hospital in South Auckland, New Zealand by tracking the evolution of CLP services. CONCLUSIONS: mMAX-LP shows promise as a useful model for profiling and comparing CLP services; mapping their evolution over time; and sign-posting future service development.

Defining Optimal Care for Functional Gut Disorders - Multi-Disciplinary Versus Standard Care: A Randomized Controlled Trial Protocol.

BACKGROUND: Functional gastrointestinal disorders (FGIDs) are the commonest reason for gastroenterological consultation, with patients usually seen by a specialist working in isolation. There is a wealth of evidence testifying to the benefit provided by dieticians, behavioral therapists, hypnotherapists and psychotherapists in treating these conditions, yet they rarely form a part of the therapeutic team, and these treatment modalities are rarely offered as part of the therapeutic management. There has been little examination of different models of care for FGIDs. We hypothesize that multi-disciplinary integrated care is superior to standard specialist-based care in the treatment of functional gut disorders. METHODS: The "MANTRA" (Multidisciplinary Treatment for Functional Gut Disorders) study compares comprehensive multi-disciplinary outpatient care with standard hospital outpatient care. Consecutive new referrals to the gastroenterology and colorectal outpatient clinics of a single secondary and tertiary care hospital of patients with an FGID, defined by the Rome IV criteria, will be included. Patients will be prospectively randomized 2:1 to multi-disciplinary (gastroenterologist, gut-hypnotherapist, psychiatrist, behavioral therapist ('biofeedback') and dietician) or standard care (gastroenterologist or colorectal surgeon). Patients are assessed up to 12 months after completing treatment. The primary outcome is an improvement on a global assessment scale at the end of treatment. Symptoms, quality of life, psychological well-being, and healthcare costs are secondary outcome measures. DISCUSSION: There have been few studies examining how best to deliver care for functional gut disorders. The MANTRA study will define the clinical and cost benefits of two different models of care for these highly prevalent disorders. TRIAL REGISTRATION NUMBER: Clinicaltrials.govNCT03078634 Registered on Clinicaltrials.gov, completed recruitment, registered on March 13th 2017. Ethics and Dissemination: Ethical approval has been received by the St Vincent's Hospital Melbourne human research ethics committee (HREC-A 138/16). The results will be disseminated in peer-reviewed journals and presented at international conferences. Protocol version 1.2.

A Successful Walk-In Psychiatric Model for Integrated Care.

PURPOSE: Accommodating walk-in psychiatry visits in primary care can improve access to psychiatric care for patients from historically underserved groups. We sought to determine whether a walk-in psychiatry model embedded within an integrated care practice could be sustained over time, and to characterize the patients who accessed care through it. METHODS: We reviewed electronic health records linked to 811 psychiatry encounters in an integrated care practice between October 1, 2015 and September 30, 2017. Primary outcomes were the initial and return psychiatry encounters per month. Secondary outcomes were the demographics and diagnoses of patients who accessed their initial visits through walk-in sessions and scheduled appointments. RESULTS: 490 initial psychiatry evaluations and 321 return encounters took place over the 2-year study period. The volume of initial psychiatry evaluations per month did not significantly change, but the volume of psychiatry follow-up encounters significantly increased after the walk-in session expanded. Medicaid recipients (OR, 1.9; 95% CI, 1.2 to 3.0); individuals without a college degree (OR, 1.7; 95% CI, 1.1 to 2.5); individuals who were single, divorced, or separated (OR, 1.7; 95% CI, 1.1 to 2.5); and individuals who identified as Black or Hispanic (OR, 2.5; 95% CI, 1.7 to 3.6) were more likely to access an initial psychiatry evaluation through a walk-in session as opposed to a scheduled appointment. CONCLUSIONS: Providing psychiatric care on a walk-in basis in integrated care is sustainable. Patients from historically underserved groups may access psychiatric care disproportionately through a walk-in option when it is available.

[Family Psychiatry - The Attachment-Focused, Systemic-Oriented, Integrative Concept of the Family Therapy Centre (FaTC), an Acute Multi-Family Day Clinic]. / Familienpsychiatrie ­ bindungsorientiert, systemisch ausgerichtet, integrativ im akut-tagesklinischen Mehrfamiliensetting: Das FaTZ-Konzept.

Family Psychiatry - The Attachment-Focused, Systemic-Oriented, Integrative Concept of the Family Therapy Centre (FaTC), an Acute Multi-Family Day Clinic Up to three quarters of the children of mentally ill parents develop a mental disorder during their lifetime. The transmission occurs essentially through dysfunctional interaction and disturbed attachment. Parent-child interaction is characterized by a vicious circle of escalating symptoms in the child and increasing helplessness in the parents. For this family psychiatric approaches are helpful, which address the interaction in addition to the individual disorders. The Family Therapy Centre (FaTC) Neckargemünd offers family psychiatric, integrated therapy for parents and children in an acute day clinic multi-family setting. The basic therapeutic principles are attachment orientation, mentalisation and systemic perspective with a multi-family therapy approach. Typical family psychiatric case constellations are presented, for which the concept seems particularly helpful: (1) Early childhood regulatory disorders in interaction with mentally ill parents, (2) mother with PTSD and expansive-aggressive preschool child and (3) adolescents with separation anxiety and depressive-anxious mother. The previous experiences are reflected by a moderated focus group of the entire FaTC team. The FaTC concept was evaluated as very helpful. It was positively judged that the family system is visibly present on site (and not only virtually). The focus is on interaction, therefore causal therapy can be offered rather than symptomatic treatment. Limitations of the concept are therapy of severely aggressive adolescents or parents who do not want to participate. The concept of the FaTC is currently being scientifically evaluated.

Delivering Collaborative Care in Rural Settings: Integrating Remote Teleconsultation and Local Supervision in Rural Nepal.

The collaborative care model can deliver high-quality mental health care. In rural regions, clinical supervision is conducted remotely rather than in person. The authors implemented a remote teleconsultation model in rural Nepal, where the consulting psychiatrist is over 30 hours away. This column describes strategies for several challenges: poor mental health competencies and high turnover among primary care providers; need for urgent consultations; psychiatrist discomfort with lack of direct patient contact; unreliable electricity, technological tools, documentation, and delivery of treatment recommendations; on-site clinicians' low motivation to accept psychiatrist recommendations; and mismatch between the psychiatrist's recommendations and the site's capacity to implement them.

[A Swedish example of integrated perinatal mental health care]. / Bättre perinatalpsykiatrisk vård genom integrerat samarbete - Obstetrik och psykiatri i samverkan kan leda till minskade risker för mor och barn.

Mental disorders are common during the perinatal period and expose mother and child to major risks.  Almost all women in Sweden attend maternal and child health care centers regularly before and after birth. This constitutes a unique opportunity to detect women with early signs of mental disorder or at risk of recurrence of prior illness. Identified women need fast access to diagnostic and treatment providers with specialized knowledge on perinatal mental disorders. As perinatal mental disorders can have severe consequences for mothers and their children a tight cooperation between caregivers is often needed.

[Consultation-liaison psychiatry - steps towards integration of physical and mental health care]. / Konsultation­liasionpsykiatri för integration somatik och psykiatri - I framtidens personcentrerade vård måste psykiatri, psykologi och somatik samverka.

The evidence for the clinical and economical effectiveness of consultation-liaison psychiatry has increased considerably in recent years. However, the development of consultation-liaison psychiatry services in Sweden is lagging behind other countries. Therefore, this article outlines the current state of service development, the potentials of consultation-liaison psychiatry, and the prerequisites for change. Politicians, commissioners and important stakeholders have to realize the potential of a better integration of psychological and physical medicine if the vision of a person-centred and equal care is going to be realised.

Editorial. / Od Redakcji.

no summary.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care.

INTRODUCTION: In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. METHOD: This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). RESULTS: The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. CONCLUSION: Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

[Consultation/liaison addiction medicine: Tools and specificities]. / L'addictologie de liaison : outils et spécificités.

Since the 1970s, the concept of "consultation/liaison (CL) psychiatry" has pertained to specialized mobile teams which meet inpatients hospitalized in non-psychiatric settings to offer them on-the-spot psychiatric assessment, treatment, and, if needed, adequate referral. Since the birth of CL psychiatry, a long set of theoretical books and articles has aimed at integrating CL psychiatry into the wider scope of psychosomatic medicine. In the year 2000, a circular issued by the Health Ministry defined the organization of "CL addiction services" in France. Official CL addiction teams are named "Équipes de Liaison et de Soins en Addictologie" (ELSAs) which are separated from CL psychiatry units. Though this separation can be questioned, it actually emphasizes that the work provided by CL addiction teams has some very specific features. The daily practice of ELSAs somewhat differs from that of psychiatric CL teams. Addictive behaviors often result from progressive substance misuse. In this respect, the ELSAs' practice frequently involves screening, brief intervention, and referral to treatment (SBIRT) interventions, which are rather specific of addiction medicine and consist more of prevention interventions than actual addiction treatment. Moreover, for patients with characterized substance use disorders substantial skills in motivational interviewing are required in ELSA consultations. Though motivational interviewing is not specific to addiction medicine, its regular use is uncommon for other liaison teams in France. Furthermore, substance misuse can induce many types of acute or delayed substance-specific medical consequences. These consequences are often poorly known and thus poorly explored by physicians of other specialties. ELSAs have therefore the role of advising their colleagues for a personalized somatic screening among patients with substance misuse. In this respect, the service undertaken by ELSAs is not only based on relational skills but also comprises a somatic expertise. This specificity differs from CL psychiatry. Moreover, several recent studies have shown that in some cases it was useful to extend liaison interventions for addiction into outpatient consultations that are directly integrated in the consultation units of certain specialties (e.g., hepatology, emergency, or oncology). Such a partnership can substantially enhance patients' motivation and addiction outcome. This specificity is also hardly transposable in CL psychiatry. In France, addiction medicine is an inter-specialty that is not fully-integrated into psychiatry. This separation is also applied for CL services which emphasizes real differences in the daily practices and in intervention frameworks. Regardless, CL psychiatry units and ELSAs share many other features and exhibit important overlaps in terms of targeted populations and overall missions. These overlaps are important to conjointly address, with the aim to offer integrated and collaborative services, within the hospital settings of other medical specialties.

Consultation-Liaison Psychiatry vs Psychosomatic Medicine: What's in a name?

BACKGROUND: In November of 2017, The Academy of the Psychosomatic Medicine voted to change its name to the Academy of Consultation-Liaison Psychiatry. It followed a similar change in which the American Board of Medical Specialties voted to change the name of the field to Consultation-Liaison Psychiatry. OBJECTIVE: The authors, all instrumental in bringing about this change, discuss the history and rationale for this name change.

Editorial. / Od Redakcji.

no summary.

[Mental treatment of refugees in Germany : Model for a stepped approach]. / Psychische Versorgung von Flüchtlingen in Deutschland : Modell für ein gestuftes Vorgehen.

The recent influx of refugees and asylum seekers into Germany poses a challenge for the national healthcare system. In compliance with the present Asylum Seekers Benefits Act, the national healthcare system can be expected to have 1.5 million new members by early 2017. Providing adequate care particularly for people with mental illnesses or disorders will represent an immense challenge for all actors in the system. The circumstances of the flight combined with the foreign linguistic and socio-cultural background increase the severity of the cases and the difficulties of treatment. No procedures or guidelines for treatment have yet been established to ensure a standardized, cost-efficient and therapeutically effective treatment of patients with this background. This article describes the components of a stepped treatment procedure and proposes a stepped and collaborative care model (SCCM) that could be evaluated in nationwide studies. This approach is based on national and international treatment guidelines and aims to provide target-group specific, culturally sensitive methods of diagnosis and treatment. The various steps of the model build on each other, with the first steps relying on technological aids (e.g. online or smartphone options) and support from lay helpers and the more expensive specialist psychiatric and psychotherapeutic therapy only being initiated in cases of more severe mental disorders.