Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review.

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period.

Clinical management of comorbid diabetes and psychotic disorders.

Individuals with psychotic disorders experience substantial health disparities with respect to diabetes, including increased risk of incident diabetes and of poor diabetes outcomes (eg, diabetes complications and mortality). Low-quality medical care for diabetes is a significant contributor to these poor health outcomes. A thoughtful approach to both diabetes pharmacotherapy and drug management for psychotic disorders is essential, irrespective of whether treatment is given by a psychiatrist, a primary care provider, or an endocrinologist. Exposure to drugs with high metabolic liability should be minimised, and both psychiatric providers and medical providers need to monitor patients to ensure that medical care for diabetes is adequate. Promising models of care management and team approaches to coordination and integration of care highlight the crucial need for communication and cooperation among medical and psychiatric providers to improve outcomes in these patients. Evidence-based programmes that promote weight loss or smoking cessation need to be more accessible for these patients, and should be available in all the settings where they access care.

General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors.

OBJECTIVE: Integrated care models are an evidence-based approach for integrating physical and behavioral health services. The American Association of Directors of Psychiatric Residency Training Integrated Care Task Force sought to describe current practices for providing training in integrated care to general and child and adolescent psychiatry residents. METHODS: Directors of US general and child and adolescent psychiatric residency training programs were anonymously surveyed to examine current practices in educating their residents in integrated care. Based on themes that emerged from the survey, the authors make recommendations for integrated care education of general and child and adolescent psychiatry residents. RESULTS: Fifty-two of 197 (26%) general and 36 of 111 (32%) child and adolescent program directors responded. Results demonstrate that a majority of responding general psychiatry (78%) and child and adolescent psychiatry (CAP) (72%) training programs offer integrated care rotations, many of which are electives for senior residents. The Veterans Health Administration (VA) and Federally Qualified Health Centers are common venues for such rotations. Sustainable funding of these rotations is a concern. Fewer than half of programs offer integrated care didactics. CONCLUSIONS: This report is intended to help program directors consider options for starting or optimizing their own integrated care curricula. Future research should examine the educational value, and the overall value to health care systems, of training in the integrated care model.

The medical-psychiatric coordinating physician-led model: team-based treatment for complex patients.

OBJECTIVE: We propose a patient care model involving psychiatrist-led multispecialty teams for treatment of the most treatment-refractory segment of "complex" outpatients. We call the psychiatrist taking this leadership role the Medical-Psychiatric Coordinating Physician. METHOD: The authors conducted a pilot study for this treatment model with 52 office-based outpatient cases each involving complex patients, and each with at least 2 major treatment failures. They followed these patients empirically for at least 18 months. Outcomes examined included Hamilton Anxiety Rating Scale; Hamilton Depression Rating Scale; and Health Related Quality of Life-14 scores (HRQOL-14, modified), in association with a comprehensive treatment review. RESULTS: Comprehensive treatment review indicated sustained improvement in at least 2 of 4 clinical dimensions (utilization, treatment adherence, symptomatology, and quality of life) in 44 of 52 patients. Included were Hamilton Anxiety Rating Scale scores that improved significantly from 26.27 ± 7.5 to 18.13 ± 5.74 (p < 0.0001) and Hamilton Depression Rating Scale scores that improved from 22.02 ± 7.10 to 14.58 ± 6.46 (p < 0.0001). The Health-Related Quality of Life-14 improved significantly for general health from 2.54 ± 1.03 to 2.12 ± 1.06 (p < 0.0001), and sick days per month from 11.22 ± 7.76 to 6.60 ± 7.51 (p < 0.0001). CONCLUSIONS: The Medical-Psychiatric Coordinating Physician-led multispecialty team method may be advantageous for the ongoing outpatient treatment of management-intensive, complex patients. We offer this model as having a place among the available integrated care models for the treatment of comorbid psychiatric-systemic medical illness.

Teaching psychiatry residents to work at the interface of mental health and primary care.

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

A novel approach to medicine training for psychiatry residents.

OBJECTIVE: A unique rotation was developed to address limited outpatient internal medicine training in psychiatric residency by the University of California, Davis, Department of Psychiatry and Behavioral Sciences, which provides medical care to patients with mental illness. METHODS: The number of patients seen by the service and the number of psychiatric consults was determined from electronic records for the 2005-2006 academic year. Evaluations by psychiatry residents completing the rotation were reviewed. Three internist-psychiatrists and one family medicine-psychiatrist provided supervision. RESULTS: A total of 1,255 patients were treated during the 2005-2006 academic year. The quality of the educational experience was positive, with an overall rating of 4.43 on a scale from 1 to 5, with 5 being the highest. CONCLUSION: Training psychiatry residents in internal medicine can be better integrated into their psychiatry education in a creative fashion when the teaching and supervision is provided by jointly trained attendings in internal medicine/psychiatry or family medicine/psychiatry. The success of the rotation contributed to the development of a combined internal medicine and psychiatry residency program.