Mental Health Services in General Health Care A Conference Report, Volume I (1979) / Chapter Skim
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Appendix C: Postscripts
Appendix C: Postscripts
Pages 259-287
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From page 259... ...
259 APPENDIX C POSTSCRIPTS In accordance with the original conference design, participants in the April 2-3 meeting were encouraged to submit written follow-up comments within 30 days. The following were selected to highlight several of the principal themes concerning mental health services in general heal th care .
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From page 261... ...
This concept also implies that patients who need tertiary care (e.g., those with schizophrenia, sustained depressive conditions, etc.) should be referred to mental health specialists who are competent to evaluate and treat such patients, often with the collaboration of the primary health care provider.
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From page 262... ...
Therefore, management of psychosocial problems in primary care should reduce overall utilization. The findings of this study have implications for the content of educational programs for primary care practice and are pertinent to current debate over policy concerning reimbursement and benefit packages.
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From page 263... ...
The vast majority of primary care physicians in this country work in settings where it will not be possible in the next five years or even ten years to place well-trained mental health professionals. Hence, it will not be enough with this new initiative to focus on the training of mental professionals to work in primary care settings.
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From page 264... ...
Actually the HSA boards and staff as well as the State Health Coordinating Committees and the State Health Planning Development Agencies are not oriented toward mental health programs. There are many instances of effective program integration in the field (other than in the private sector)
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From page 265... ...
I would suggest that the mental health services provided to nonpsychiatric physicians by mental health professionals be described in terms of two broad areas of function: a first category whereby mental health professionals provide direct service to patients, and a second category called liaison functions or indirect services whereby mental health personnel provide service to the nonpsychiatric physician or other members of the health care team. Liaison functions would include such things as providing support, advice, or teaching.
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From page 266... ...
As we saw each of our children with Pica and/or lead poisoning, our approach was to encourage the residents to take a holistic approach to the child, his family and their environment while the psychiatry resident served either as a consultative resource for deeper emotional difficulties or as a leader of discussions with the parents regarding anticipatory guidance and situational adjustment. A third model is in Mobile Medical Care, our volunteer clinic for low-income persons in Montgomery County /Maryland/, where we have both medical and mental health personnel working in the same clinic.
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From page 267... ...
For what appear to be purely fiscal reasons, rather than the beneficent effect of modern therapeutics or a fashionable concern for "community care," old long-stay Victorian units are being systematically emptied out. They are not attractive or suitable places for mental health care, they promote chronicity, they often provide the worst of care and have the least*
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From page 268... ...
After these questions come questions relative to the management of patients with mental illness, as defined in the Conference (that is, anxiety reactions, tile depressive spectrum, schizophrenia and thought disorders, alcohol and drug problems)
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From page 269... ...
, showed that, in a borough regarded as well-served by family doctors, local authority and hospital services, only 5% of a survey sample reported no complaints in the 14 day period prior to being questioned: complaints for which for the most part they had not considered it necessary to consult any doctor. While this and similar enquiries have encouraged speculation as to undiscovered illness which it would be desirable to treat, they have not been held to indicate that all symptoms require referral and that there is no place for reasonable self-management.
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From page 270... ...
The proportion of diagnosed psychiatric disorders currently treated by nonpsychiatrically trained physicians is frighteningly large with estimates ranging from 54 percent (Regier) to 72 percent (J.
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From page 271... ...
. An assumption that was little challenged was that the nonmedically but fully trained mental health practitioner was to be assigned less credibility as a reimbursement-eligible therapist than the medically trained practitioner who was essentially unschooled in the field of mental health practice.
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From page 272... ...
Primary health care includes something more that the diagnosis of pathology and its treatment. The "something more'' that the public expects of primary health care includes assistance with establishing and maintaining behaviors congruent with prevention of illness, coping with illness and disability, and problem solving throughout the life span .
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From page 273... ...
Some assurance of employment suitable to one's preparation would attract nurses to the nursing specialty of primary health care. Quality of the educational programs would increase as the role of nurses in the delivery of primary health care became more uniform.
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From page 274... ...
if ever in internal medicine, at least on the graduate level. In family medicine programs there is more attention to interviewing, but sometimes the basic behavioral scientists who present information about patient-doctor relationships and interviewing skills neglect to provide the particular kinds of tie-ins to clinical service delivery.
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From page 275... ...
This is not to say that there is no place for behavioral scientists, but in many cases, less clinically trained mental health personnel are used to provide teaching or care at less cost. In some cases they provide excellent training or service; in others they form poor role models for the primary physician who does not learn to integrate mental health principles into ongoing practice activities or who never understands the interrelationshps between psyche and some, the appropriateness of multi-disciplinary approaches such as pain management, psychosomatic disease, concomitant and other medical diseases and so forth.
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From page 276... ...
There has been an attempt through policy to train mental health professionals to work in community mental health centers, in other designated mental health facilities but not conjointly with physicians in the general health care delivery system. This complaint and this problem as viewed by primary care physicians must be kept in mind as we work toward the training of psychiatrists, psychologists, and social workers.
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From page 277... ...
Many physicians simply do not see subtle evidence for anger in women or fear and/or sadness in men. The educational experience of most medical students in most medical schools and certainly in most primary care residencies is such that they do not discover the recognition rules taught them by their culture, rules which they brought to medical school or to postgraduate residencies or whatever.
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From page 278... ...
problems which are best treated by the PCP or other nonparental health professionals lest the fact of referral act to confirm the patients' fears that they are suffering from pathological processes when in fact they are confronted with everyday problems of "no~alcy" or "existential problems of living. Mac k Lipkin, Jr., M.D.: Teaching about integrated care is presently difficult.
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From page 279... ...
I do not write as an English family doctor, when I say: Begin with the primary care doctors that you have. This is certainly the least costly and most practical way to go.
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From page 280... ...
If, to paraphrase the Bauhaus expression (Form follows function) , training follows money, policy recommendations should encourage NIMH stipends for primary care psychiatrist training either as part of the general residency or as fellowships in PGY 4 and 5.
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From page 281... ...
There also appeared to be no enthusiasm for the notion that research be undertaken to assess the quality of care offered by the PCP by comparing the relative effectiveness of the PCP and the mental health specialist in treating specified classes of emotional problems. While the psychiatrists seemed to be excessively modest in commending to their medical colleagues the value of specialized mental health training, they appeared considerably less diffident with regard to their special competence relative to their nonmedically trained mental health practitioner associates.
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From page 282... ...
Evaluating modes of delivering such care is difficult' first, in establishing criteria for diagnosis and treatment methods, second, in recognizing cultural variance, third, in finding some sort of control population to compare against the treatment population in terms of attitudes and outcomes. Which outcome item to use is another concern.
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From page 283... ...
Are social workers, psychologists, and psychiatrists interchangeable as psychotherapists or not? How should triage be done and by whom?
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From page 284... ...
. In the sphere of research, it is necessary not merely to look at what specialists think primary care doctors ought to do, patently cannot do or do badly; but at the subtly acquired skills which many excellent family doctors may have evolved, intuitively rather than by Balint seminars, and from experience; a product of continuity of care, familiarity and human involvement.
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From page 285... ...
Alan M Jacobson, M.D.: Offset is a dangerous outcome variable for psychiatric research in primary care settings.
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From page 286... ...
In addition to these fluid, unbounded networks, there are more organized structures of informal social support, e.g., self-help groups such as Alcoholics Anonymous; person-to-person mutual aid such as Widow-toWidow programs; cross-age helping programs such as Foster Grandparents; peer-oriented helping programs such as school peer counseling activities; alternative community service programs such as hospices and shelters for battered families. These social support systems are inherently sensitive to cultural and subcultural variations and build on preferred patterns on help seeking and help accepting.
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From page 287... ...
and the lay treatment network (including self-care; mutual help groups and other social support systems; and the wide variety of community ~ ~ ~ ~ institutions that are not labeled or identified in our society as health care institutions, but which may be very much involved in health promotion, health maintenance and even, at times, health services delivery) should be topics on the agenda to be seriously considered when we are thinking about the future.
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