Training Primary Care Physicians and Nurse Practitioners in Psychiatry to meet the Mental Health Nee

1
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

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Letter to President George W. Bush

• Americas mental health service delivery system
  is in shambles
• (Michael F. Hogan, Ph.D., Chairman, Presidents
  New Freedom Commission on Mental Health, October
  29, 2002)

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Current Status of Mental Health Delivery System
in the USA

• 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.

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Current Status of Mental Health Delivery System
in Rural Missouri

• Individuals needing psychiatric services are
  unable to find a trained psychiatrist in a timely
  fashion.
• This situation often leads to first line
  psychiatric care being provided by PCPs who are
  generally untrained.

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Survey of PCPs in Rural Missouri

• Geographic Location 13 most underserved counties
  in Southwest Missouri
• Number of PCPs Surveyed 52
• Physicians 23
• Nurse Practitioners 29

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How many psychiatric patients do you currently
see in your practice weekly?

• Average was 36 patients
• 18 Male
• 18 Female

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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

8
What kind of treatment do you provide to your
psychiatric patients?

• Medication follow-up-85.9
• Individual Psychotherapy-24
• Family Therapy-7.9

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What type of psychotropic medications do you
often prescribe?

• Antidepressant/SSRIs 83
• Zoloft-88.1
• Paxil-83
• Prozac-78
• Atypical Antipsychotic 55
• Zyprexa-61
• Risperdal-55
• Seroquel-48.9

• Anti-anxiety 52.7
• BuSpar-73.5
• Ativan-45.7
• Valium-38.8
• Mood Stabilizer 44.8
• Depakote-57.2
• Lithium-39.7
• Tegretol-37.4

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How many psychiatric patients, in a month, do you
refer to the mental health professionals?

• Average 7 patients

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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

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Our Solution
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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.

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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.

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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 (PCPs) in psychiatry and
  psychopharmacology and developed a project
  entitled Training Enhancement in Rural Mental
  Health (TERMH).

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Training Enhancement in Rural Mental
Health(Project TERMH)

• 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.
• Under this project, PCPs were offered 84 hours
  of didactics and practicum in psychiatry, child
  psychiatry, and psychopharmacology.

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The Training Curriculum

• Topics
• 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

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The Training Curriculum (cont.)

• Topics (cont.)
• 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)

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The Training Curriculum (cont.)

• Topics (cont.)
• 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

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The Training Curriculum (cont.)

• Topics (cont.)
• 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

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Outcome Study

• Methodology
• A Pre and Post Training test, consisting of 110
  multiple choice questions, covering all topics
  included in the curriculum, were administered to
  each participant
• A control group of fourth and fifth year
  psychiatric residents was also given the same
  test.

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Outcome Study Results

• Pre-Test Average 45.14
• Post-Test Average 63.88
• Control Group Average 76.4

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Integrated Mental Health Team

• Upon completion of the training, the participants
  were invited to join the Integrated Mental
  Health Team

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Integrated Mental Health Team
Out Reach Clinics
Out Reach Clinics
Psychiatrist
Case Manager 1
Case Manager 3
Case Manager 2
PCP
PCP
PCP
PCP
PCP
PCP
PCP
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.
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Benefits of the Integrated Mental Health Team

• 24/7 hotline for consultation
• Immediate access to a psychiatrist
• Medication guidance
• Inpatient hospitalization, if needed
• More intense out-patient options

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Non-Accredited Fellowship in Psychiatry and Child
Psychiatry

• 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.
• 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.
• This training is available for general
  practitioners, nurse practitioners, family
  physicians, and pediatricians.
• A child psychiatry track will be offered to
  general psychiatrists and pediatricians.

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Didactic Requirements Total Hrs 56

• 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

• 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

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Practicum Requirements Total Hrs 64