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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 Slide 2 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) Slide 3 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. Slide 4 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. Slide 5 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 Slide 6 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) Male3411 Female1413 Slide 7 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% Slide 8 What kind of treatment do you provide to your psychiatric patients? Medication follow-up-85.9% Individual Psychotherapy-24% Family Therapy-7.9% Slide 9 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% Slide 10 How many psychiatric patients, in a month, do you refer to the mental health professionals? Average 7 patients Slide 11 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 Slide 12 What percentage of your general medical patients have mental health issues? Approximately 40% Slide 13 Our Solution Slide 14 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. Slide 15 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. Slide 16 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). Slide 17 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. Slide 18 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 Slide 19 The Training Curriculum (cont.) 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) 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 Slide 20 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 Slide 21 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 Slide 22 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. Slide 23 Outcome Study Results Pre-Test Average : 45.14% Post-Test Average : 63.88% Control Group Average 76.4% Slide 24 Integrated Mental Health Team Upon completion of the training, the participants were invited to join the Integrated Mental Health Team Slide 25 Integrated Mental Health Team Psychiatrist Case Manager 1Case Manager 3Case Manager 2 Out Reach Clinics Out Reach Clinics 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. Slide 26 Benefits of the Integrated Mental Health Team 1. 24/7 hotline for consultation 2. Immediate access to a psychiatrist 3. Medication guidance 4. Inpatient hospitalization, if needed 5. More intense out-patient options Slide 27 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. Slide 28 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 Didactic Requirements Total Hrs: 56 Slide 29 Practicum Requirements: Total Hrs: 64 FocusPopulation AgeSupervision ByHours/Population Psychiatric Evaluation [observation on each population (3); demonstration on each population (3)] Preadolescents Adolescents Adults Psychiatrist6 hrs/Inpatient Medication Checks [observation on each population (3); demonstration on each population (3)] Preadolescents Adolescents Adults Psychiatrist2 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 Psychiatrist12 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 Psychiatrist6 hrs/Inpatient Outpatient Treatment [Individually] Preadolescents Adolescents Adults Psychiatrist12 hrs/Outpatient