Transcript Training Primary Care Practitioners (PCP) in Psychiatry

Training Primary Care Physicians and
Nurse Practitioners in Psychiatry to meet
the Mental Health Needs in Rural Missouri
Syed Arshad Husain, M.D., FRC Psych, FRCP (C)
Professor and Chief of Child & Adolescent Psychiatry
School of Medicine
University of Missouri-Columbia
Columbia, Missouri USA
Letter to President George W. Bush
“America’s mental health service delivery
system is in shambles”
(Michael F. Hogan, Ph.D., Chairman,
President’s New Freedom Commission on
Mental Health, October 29, 2002)
Current Status of Mental Health Delivery
System in the USA
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The number of individuals with Severe
Persistent Mental Illness (SPMI) has reached
epidemic proportion.
The shortage of psychiatric hospital beds is
endemic.
Severe shortage of general and child
psychiatrists in all locations, including rural
areas.
Current Status of Mental Health Delivery
System in Rural Missouri
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Individuals needing psychiatric services are
unable to find a trained psychiatrist in a timely
fashion.
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This situation often leads to first line
psychiatric care being provided by PCP’s who
are generally untrained.
Survey of PCP’s
in Rural Missouri
Geographic Location: 13 most underserved counties in
Southwest Missouri
Number of PCP’s Surveyed:
52
•Physicians:
23
•Nurse Practitioners:
29
How many psychiatric patients do you
currently see in your practice weekly?
Average was 36 patients
18 Male
18 Female
Under 13 Years
(Average)
13-18 Years
(Average)
18 Years and Older
(Average)
Male
3
4
11
Female
1
4
13
What diagnostic categories of psychiatric
patients are you currently seeing?
 Anxiety
Disorders-92.3%
 Bi-Polar Disorder-84.8%
 Major Depression-84.5%
 ADHD-77.4%
 Substance Abuse-73.8%
 PTSD-67.7%
 Schizophrenia-45.5%
 ODD/Conduct Disorder-40.8%
What kind of treatment do you provide to
your psychiatric patients?
 Medication
follow-up-85.9%
 Individual Psychotherapy-24%
 Family Therapy-7.9%
What type of psychotropic medications do
you often prescribe?
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Antidepressant/SSRI’s – 83%
 Zoloft-88.1%
 Paxil-83%
 Prozac-78%
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Anti-anxiety – 52.7%
 BuSpar-73.5%
 Ativan-45.7%
 Valium-38.8%
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Atypical Antipsychotic – 55%
 Zyprexa-61%
 Risperdal-55%
 Seroquel-48.9%
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Mood Stabilizer – 44.8%
 Depakote-57.2%
 Lithium-39.7%
 Tegretol-37.4%
How many psychiatric patients, in a
month, do you refer to the mental health
professionals?
Average – 7 patients
What are the common reasons for referral
of psychiatric patients to other
resources?
Treatment Failure
 Suicidal Ideation
 Diagnostic Questions
 Need for Inpatient Care
 Significant Drug Dependence
 Patients on Multiple Psychotropic Medications
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What percentage of your general medical
patients have mental health issues?
Approximately – 40%
Our Solution
Lessons Learned from the War Zones
and Disaster Areas
 During
the siege of Sarajevo, there were only
100 mental health professionals who could
provide psychological help to 60,000 children
living in Sarajevo. This disparity between the
providers and the consumers, created a need to
train indigenous workers in Trauma Psychology.
Thus, “Teachers As Therapists” program was
created.
Teachers As Therapists

We trained 2,000 teachers as “lay-therapists”. Who
provided psychological help to over 20,000 children and
their families in Bosnia and Herzegovina.

Since then, this strategy has been successfully used in
Kosovo, Chechnya, Palestine, Afghan refugee camps in
Pakistan, 11 Republics of former Soviet Union, Gujrat,
India, tsunami stricken Sri Lanka and Banda Ache,
Northern Pakistan and now in Katrina affected areas in the
USA.
Application of “Teachers As
Therapists” Model in Rural Missouri
 To
combat the shortage of Psychiatrists in Rural
Missouri, we proposed to train primary care
practitioners (PCP’s) in psychiatry and
psychopharmacology and developed a project
entitled “Training Enhancement in Rural Mental
Health” (TERMH).
Training Enhancement in Rural Mental Health
(Project TERMH)
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The US Department of Labor supported Project TERMH
and awarded a three-year grant of 2.7 Million Dollars to
train primary care physicians, nurse practitioners, and
other physicians in Rural Missouri.
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Under this project, PCP’s were offered 84 hours of
didactics and practicum in psychiatry, child psychiatry,
and psychopharmacology.
The Training Curriculum
Topics
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Classification system in psychiatry.
Multi-axial System
Diagnostic & Statistical Manual-IV
Psychiatric Assessment
History taking
Mental Status examination
iii. Mini-mental status
iv. Diagnostic formulation
v. Multi-axial diagnosis
Small
groups, practice of interview
techniques
Post Traumatic
Stress Disorder (PTSD)
i. Assessment in children
ii. Resiliency factors
iii. Co-morbidity
iv. PTSD in the elders
The Training Curriculum (cont.)
Topics (cont.)
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Psychiatric Conditions in children
and adolescents
Externalizing Disorders
ADHD
Conduct Disorder
Oppositional Defiant Disorder
Internalizing Disorders
Depressive Disorders
Anxiety Disorders
Psychopharmacology
Principles of Chemical and Electrical
Neurotransmission
Anxiety
Disorders
Utilization of Screening
Instruments in Primary
Care Settings
Mood Disorder in Children
and Adolescents
(Major Depressive
Disorder, Bi-Polar
Disorder, Substance
Induced Mood Disorder)
The Training Curriculum (cont.)
Topics (cont.)
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Interview Technique for Child and Adolescent Patients
Diagnosis and Management Mood Disorders in Adults I
Interviewing Adult Patients
Diagnosis and Management Mood Disorders in Adults II
Interviewing Depressed Adults and Elderly
Diagnosis and Management of Schizophrenia and other Psychotic Disorders
Interviewing Psychotic Adult (Small group practice)
Substance Use Disorders
Interviewing Chemically Dependent Patients
Management of ADHD and Depression in Children and Adolescent
Demonstration of ADHD, ODD, and Anti-Social Aggressive Teenager
The Training Curriculum (cont.)
Topics (cont.)
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Identifying Psychiatric Emergencies in a Primary Care Setting
Principles and Technique of Psychotherapy
Demonstrating Psychotherapy Techniques
Principle of Case Management and Concept of Integrated Mental Health Team
Outcome Study
Methodology:
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A Pre and Post Training test, consisting of 110 multiple
choice questions, covering all topics included in the
curriculum, were administered to each participant
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A control group of fourth and fifth year psychiatric
residents was also given the same test.
Outcome Study Results
 Pre-Test Average
:
 Post-Test Average
 Control
45.14%
: 63.88%
Group Average – 76.4%
“Integrated Mental Health Team”
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Upon completion of the training, the participants
were invited to join the “Integrated Mental Health
Team”
Integrated Mental Health Team
Out Reach
Out Reach
Psychiatrist
Clinics
Case Manager 1
PCP
PCP
Clinics
Case Manager 2
PCP
PCP
Case Manager 3
PCP
Patients
* The Psychiatrist may be in contact with any member of the Integrated Mental Health
System in the interest of treating a patient based on a referral or the need of a PCP.
PCP
PCP
PCP
Benefits of the
“Integrated Mental Health Team”
1.
2.
3.
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24/7 hotline for consultation
Immediate access to a psychiatrist
Medication guidance
Inpatient hospitalization, if needed
More intense out-patient options
Non-Accredited Fellowship in
Psychiatry and Child Psychiatry
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Due to the success of Project TERMH, the US Department of Labor
awarded a second grant to support the “Non-Accredited Fellowship in
Psychiatry and Child Psychiatry”.
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This fellowship represents an expansion of Project TERMH to 120 hours of
training, with 56 hours of didactics and 64 hours of practicum in an
inpatient setting.
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This training is available for general practitioners, nurse practitioners,
family physicians, and pediatricians.
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A child psychiatry track will be offered to general psychiatrists and
pediatricians.
Didactic Requirements Total Hrs: 56
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DSM-IV: A Multi-axial System for
Psychiatric Diagnosis
Psychiatric Assessment
Mental Retardation and Autism
Child and Adolescent Development &
Disorders
Delirium, Dementia, and Mental Disorders
Due to General Medical Condition
Depression & Bi-Polar Disorder in Adults
Psychosis & Schizophrenia
Anxiety Disorders & PTSD
Substance Related Disorders
Theories of Child Development:
Attachment & Bonding
Temperament
Moral & Religious Development
Classification of Child & Adolescent
Psychiatry
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Diagnostic Assessment in Children
Interview Techniques with Children &
Adolescents
Attention Deficit Hyperactivity Disorder
and Conduct Disorder
Depression and Anxiety Disorders in
Children
Psychiatric Treatment of Children:
Pediatric Psychopharmacology
Cognitive Behavioral Therapy
Group Therapy
Risk Assessment of Suicide:
Adults
Children & Adolescent
Assessment & Treatment of Sleep
Disorders
Principle & Practice of
Psychopharmacology in Psychiatry
Geriatric Psychiatry
Practicum Requirements: Total Hrs: 64
Focus
Population Age
Supervision By
Hours/Population
Psychiatric Evaluation
[observation on each population (3);
demonstration on each
population (3)]
Preadolescents
Adolescents
Adults
Psychiatrist
6 hrs/Inpatient
Medication Checks
[observation on each population (3);
demonstration on each
population (3)]
Preadolescents
Adolescents
Adults
Psychiatrist
2 hrs/Inpatient
Treatment Team
(will attend 2 on each population)
[will include formulation of
treatment plan and medication
management on the patient the
psych evaluation was
demonstrated on]
Preadolescents
Adolescents
Adults
Psychiatrist
12 hrs/Inpatient
History & Physical
[observation on each population (1);
demonstration on each
population (2)]
Preadolescents
Adolescents
Adults
Nurse Practitioner or PCP
or Psychiatrist
9 hrs/Inpatient
Seclusion/Restraints
[observation on each population (1)
; demonstration on each
population (1)]
Preadolescents
Adolescents
Adults
Psychiatrist
6 hrs/Inpatient
Outpatient Treatment
[Individually]
Preadolescents
Adolescents
Adults
Psychiatrist
12 hrs/Outpatient