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Purpose of Review: Mental health practitioners should understand the features of current, publicly available apps; the features of novel, research apps; and issues behind the integration of mobile apps and digital health services into clinical workflows., Recent Findings: The review is based on a research literature and the authors' clinical and healthcare administration experiences. Articles searched-on telepsychiatry, telemental health, mobile mental health, informatics, cellular phone, ambulatory monitoring, telemetry, and algorithms-were restricted to 2016 and 2017. Technologies are used in a variety of clinical settings, including patients with varying mental illness severity, social supports, and technological literacy. Good practices for evaluating apps, understanding user needs, and training and educating users can increase success rates. Ethics and risk management should be considered. Mobile apps are versatile. Integrating apps into psychiatric treatment requires addressing both patient and clinical workflows, design and usability principles, accessibility, social concerns, and digital health literacy.

Mobile health (mHealth), telemedicine and other technology-based services facilitate mental health service delivery and may be considered part of an e-mental health (eMH) spectrum of care. Web- and Internet-based resources provide a great opportunity for the public, patients, healthcare providers and others to improve wellness, practice prevention and reduce suffering from illnesses. Mobile apps offer portability for access anytime/anywhere, are inexpensive versus traditional desktop computers, and have additional features (e.g., context-aware interventions and sensors with real-time feedback. This paper discusses mobile mental health (mMH) options, as part of a broader framework of eMH options. The evidence-based literature shows that many people have an openness to technology as a way to help themselves, change behaviors and engage additional clinical services. Studies show that traditional video-based synchronous telepsychiatry (TP) is as good as in-person service, but mHealth outcomes have been rarely, directly compared to in-person and other eMH care options. Similarly, technology options added to in-person care or combined with others have not been evaluated nor linked with specific goals and desired outcomes. Skills and competencies for clinicians are needed for mHealth, social media and other new technologies in the eMH spectrum, in addition to research by randomized trials and study of health service delivery models with an emphasis on effectiveness., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

(Reprinted with permission from American Journal of Psychiatry 2016; 173:543-546)., (Copyright © 2017 by the American Psychiatric Association.)

Objective: The objective of this study was to assess and describe required and elective components of the 4th post-graduate year (PGY4) in psychiatry residency programs., Methods: We reviewed the websites of all 193 2014-2015 ACGME accredited psychiatry residency programs for content describing the specific components of the PGY4 year., Results: Nearly all residency programs (99 %) had some form of required experiences during the PGY4 year. Ninety-four percent had clinical requirements for PGY4 residents, with longitudinal outpatient clinic being the most common (77 %). All programs offered some elective time during PGY4, but the amount of time ranged from 2 months to 100 %., Conclusion: Virtually all residency programs include some requirements in the 4th year (most commonly didactics and outpatient clinic) in addition to a broad array of elective experiences. Although 3 years may suffice for residents to complete ACGME requirements, a variety of factors may motivate programs to include required 4th year curricula. Future studies should explore the rationales for and possible benefits of programmatic requirements throughout 4 versus only 3 years of psychiatric training.

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., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Patients with Bipolar disorder smoke more than the general population. Smoking negatively impacts mortality and clinical course in Bipolar disorder patients. Prior studies have shown contradictory results regarding the impact of psychosis on smoking behavior in Bipolar disorder. We analyzed a large sample of Bipolar disorder and Schizoaffective disorder, Bipolar Type patients and predicted those with a history of psychosis would be more likely to be nicotine dependent. Data from subjects and controls were collected from the Genomic Psychiatry Cohort (GPC). Subjects were diagnosed with Bipolar disorder without psychosis (N = 610), Bipolar disorder with psychosis (N = 1544). Participants were classified with or without nicotine dependence. Diagnostic groups were compared to controls (N = 10065) using logistic regression. Among smokers (N = 6157), those with Bipolar disorder had an increased risk of nicotine dependence (OR = 2.5; P < 0.0001). Patients with Bipolar disorder with psychosis were more likely to be dependent than Bipolar disorder patients without psychosis (OR = 1.3; P = 0.03). Schizoaffective disorder, Bipolar Type patients had more risk of nicotine dependence when compared to Bipolar disorder patients with or without psychosis (OR = 1.2; P = 0.02). Bipolar disorder patients experiencing more severity of psychosis have more risk of nicotine dependence. © 2015 Wiley Periodicals, Inc., (© 2015 Wiley Periodicals, Inc.)

Objective: This article identifies and describes key considerations toward the development of a clinical guideline intended to optimize telemental healthcare (TMH) of children and adolescents., Methods: The literature was searched with key terms and title words. Of 2824 articles that met primary or secondary key word search criteria, 326 met both criteria, and 118 thematically related directly to child and adolescent TMH. Only 44 studies met levels of evidence I-III and expert recommendation criteria used in clinical guidelines; review of their references found 8 additional studies (52 total). Data from adult, child, and adolescent in-person psychiatric care and adult TMH were applied to provide context in developing the key considerations., Results: TMH guidelines for adults are well delineated, and TMH guidelines for children and adolescents are likely to closely overlap in terms of general clinical, technical, and administrative issues. However, for a child and adolescent focus, modifications of existing general guidelines appear necessary; for example, based on developmental status, family involvement, and patient-site modifications for space and sound. Additional clinical issues include specify who, exactly, is the "patient" (i.e., the patient, family, and /or other stakeholders), modalities of care (i.e., age-related psychotherapies such as play therapy or behavior management), and psychopharmacology., Conclusions: Specific clinical, administrative, and technical issues are key considerations - based on the nuances of established child and adolescent mental healthcare - and must be considered in developing a clinical guideline for TMH of these patients. Developing such guidance should proceed from a careful review of the growing evidence base, and through expert consensus processes.

Access to technology in practice helps physicians manage information, communicate, and research topics; however, those in training receive almost no formal preparation for integrating web-based technologies into practice. One reason for this is that many faculty-aside from junior faculty or those in recent generations-did not grow up using Internet communication, may use it minimally, if at all, in their own practices, and may know little about its forms and varieties. This report presents a case to illustrate how these disparities may play out in the supervisory situation and makes suggestions about helping supervisors integrate technology-awareness into their teaching.

Telepsychiatry (TP; video; synchronous) is effective, well received and a standard way to practice. Best practices in TP education, but not its desired outcomes, have been published. This paper proposes competencies for trainees and clinicians, with TP situated within the broader landscape of e-mental health (e-MH) care. TP competencies are organized using the US Accreditation Council of Graduate Medical Education framework, with input from the CanMEDS framework. Teaching and assessment methods are aligned with target competencies, learning contexts, and evaluation options. Case examples help to apply concepts to clinical and institutional contexts. Competencies can be identified, measured and evaluated. Novice or advanced beginner, competent/proficient, and expert levels were outlined. Andragogical (i.e. pedagogical) methods are used in clinical care, seminar, and other educational contexts. Cross-sectional and longitudinal evaluation using quantitative and qualitative measures promotes skills development via iterative feedback from patients, trainees, and faculty staff. TP and e-MH care significantly overlap, such that institutional leaders may use a common approach for change management and an e-platform to prioritize resources. TP training and assessment methods need to be implemented and evaluated. Institutional approaches to patient care, education, faculty development, and funding also need to be studied.

From a population health perspective, the mental health care system in the USA faces two fundamental challenges: (1) a lack of capacity and (2) an inequitable geographic distribution of services. Telepsychiatry can help address the equity problem, and if applied thoughtfully, can also help address the capacity problem. In this paper we describe how telepsychiatry can be used to address the capacity and equity challenges related to the delivery of mental health services in rural areas. Five models of telepsychiatry are described, including (1) the traditional telepsychiatry referral model, (2) The telepsychiatry collaborative care model, (3) the telepsychiatry behavioural health consultant model, (4) the telepsychiatry consultation-liaison model, and (5) the telepsychiatry curbside consultation model. The strong empirical evidence for the telepsychiatry collaborative care model is presented along with two case studies of telepsychiatry consultation in the context of the telepsychiatry collaborative care model. By placing telepsychiatrists and tele-therapists in consultation roles, telepsychiatry collaborative care has the potential to leverage scarce specialist mental health resources to reach more patients, thereby allowing these providers to have a greater population level impact compared to traditional referral models of care. Comparative effectiveness trials are needed to identify which models of telepsychiatry are the most appropriate for patients with complex psychiatric disorders.

Medical learners, teachers, and institutions face significant challenges in health care delivery and in training the next generation of clinicians. We propose that psychiatry offers lessons which may help improve how we take care of patients and how we teach others to care for patients. Our objective is to discuss what learners and teachers can learn from psychiatry, organized around (1) how we make decisions, (2) how we learn, and (3) how we reflect on our practice. Information from clinical care, education, neuroscience and other aspects of life (e.g. business, creativity, and research) help us on these processes. We make 'good' decisions in concert with patients and learners, by listening to their experiences, asking questions and exploring subjective and objective information. Our learning has a neurobiological basis, and is effectively furthered by personalization, reinforcement, acquisition of critical thinking skills, and assessment of our limitations and errors. Our ability to reflect is determined by attitude, skill, tolerating ambiguity or dissonance, and planning for the unexpected. These processes - in addition to knowledge and other skills - will help physicians be successful in practice, learning and teaching, research and leadership.

Introduction: The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed., Materials and Methods: The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international., Results: Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes., Conclusions: Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.

This study investigated differences in usage of inpatient and outpatient mental health services over a 2-year period following the index hospitalization between 50 decertified and 48 certified subjects with bipolar manic or mixed episode from an inpatient mental health treatment center. The decertified group had higher number of rehospitalization over the 2-year period compared to certified group (mean = 2.26, SE = 0.41 vs. mean = 1.19, SE = 0.24; Wald χ (2) = 5.50, p = 0.02). Median time to first rehospitalization was 40 weeks in the certified and 17 weeks in the decertified group, but the difference in time to rehospitalization failed to achieve statistical significance (p = 0.18). History of prior hospitalization was associated with higher numbers of rehospitalizations and crisis room visits (both p < 0.01) and with shorter time before first rehospitalization (p < 0.001).

Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

Objective: This study evaluated the strategies for postpartum depression (PPD) screening by surveying healthcare providers at a US academic medical centre., Methods: A 10-question survey was administered to 251 Obstetrics/Gynaecology, Paediatrics, and Family Practice physicians, nurses and other healthcare professionals in April-June 2007. It explored PPD screening methods and familiarity with selected screening instruments (EPDS, PDSS and PHQ-9). Familiarity scores were assigned based on Likert scale ratings, from 1 (not familiar at all) to 5 (using it all the time). Score mean values and standard deviations were calculated for each screening tool, overall and across specialty and training status. Pearson chi-square analyses with discrete and categorical variables and ANOVA with continuous variables were conducted, followed by Tukey post hoc analyses to identify significant mean differences., Results: There were 131 completed surveys. Respondents were largely unfamiliar with PPD screening instruments, although Ob/Gyn providers were significantly more aware of each tool than were Paediatrics members. Preferred screening methods were symptom review (83%) and physical examination/observation (65%). Sixty-three per cent of respondents used multiple methods. Timing of screening varied across specialties. Paediatric providers screened earliest (0-4 weeks) of all respondents., Conclusions: Healthcare providers typically screened for PPD using a combination of clinical methods and were less familiar with standardised instruments. Uniform screening protocols across specialties and targeted educational interventions are strongly recommended to promote better detection and collaborative management of PPD.

Objective: Over the past 30 years, clinician-educators have become a prominent component of medical school faculties, yet few of these individuals received formal training for this role and their professional development lags behind other faculty. This article reviews three residency tracks designed to build skills in teaching, curriculum development and assessment, education research, and career development to meet this need., Methods: The residency clinician educator tracks at University of Michigan, Baylor College of Medicine, and University of California Davis are described in detail, with particular attention to their common elements, unique features, resource needs, and graduate outcomes., Results: Common elements in the tracks are faculty mentorship, formal didactics, teaching opportunities, and an expectation of scholarly productivity. Essential resources include motivated faculty, departmental support, and a modest budget. Favorable outcomes include a high percentage of graduates in clinical faculty positions, teaching programs created by the residents, positive effects on recruitment, and enhancement of faculty identity as clinician educators., Conclusion: Clinician-educator tracks in residency present a viable means to address the training needs of clinical track faculty. The programs described in this article provide a model to assist other departments in developing similar programs.

Objective: This study examined predictors of decertification (release from involuntary hospitalization after legal hearing) among inpatients with bipolar disorder., Methods: Records from 1992 to 1997 were examined retrospectively for 50 decertified and 48 certified patients with bipolar disorder. The relationship between demographic and clinical variables and decertification was examined using logistic regression analyses., Results: In the overall multiple logistic regression model, participants were significantly more likely to be decertified if they used a mood stabilizer before the decertification hearing (odds ratio [OR]=6.73, 95% confidence interval [CI]=1.78-25.50) or if they had a comorbid substance use disorder (OR=3.45, CI=1.15-10.34). The odds of decertification increased with the number of prior hospitalizations (OR=3.92, CI=1.73-8.87) and decreased with the length of prior hospitalization (OR=.72 per week, CI=.49-1.04) and number of emergency room visits before admission (OR=.46, CI=.28-.74)., Conclusions: Predictors of decertification in bipolar disorder require further research to guide future efforts to improve inpatient treatment outcomes.

The prevalence of overweight and obesity is approximately 32% among children and adolescents in the United States. Comorbid conditions associated with pediatric overweight and obesity include psychiatric conditions. The purpose of this study was to determine the prevalence of overweight and obesity among children and adolescents presenting for consultation from rural communities to the UC Davis Telemedicine Program (UCDTP), as well as to collect preliminary data to design an integrated disease management program for children and adolescents with obesity and mental illness. Patients aged 21 and under seen for psychiatric consultation at the UCDTP between 2004 and 2006 were included. Retrospective medical record review was conducted to determine the major psychiatric diagnoses, height, weight, body-mass index, and weight status (underweight/at risk for underweight, normal weight, overweight, or obese) for each patient. Of the 230 patients referred, a total of 121 patients had both height and weight values documented. Three patients were underweight; 51 were normal weight; 28 were overweight; 39 were obese. The most common psychiatric diagnoses in the 121 patients were attention deficit/hyperactivity disorder (ADHD; n = 40), bipolar disorder (n = 36), and depression (n = 31). The most common psychiatric diagnoses in patients with available weight and height data who were overweight and obese were bipolar disorder (n = 20), depression (n = 18), and ADHD (n = 17). Approximately 55% of child and adolescent patients seen for telepsychiatry consultation whose charts documented height and weight measurements were overweight or obese. Psychiatric diagnoses in overweight youngsters need to be researched further to determine whether the weight change is primary or secondary to mood and/or to treatments, such as medication. At such a high rate of comorbidity, monitoring the weight status of young psychiatric patients in this population is indicated.

Background: As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints., Methods: A PubMed search was conducted by cross-referencing the terms "sleep deprivation," "insomnia," and "sleep"; "hospitalized," "acutely ill," and "critically ill"; and "medication," "drugs," "hypnotics," "benzodiazepines," and "sedatives." The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search., Results: Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints., Conclusions: Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents.

Background: Multiple factors lead to sleep disturbances in hospitalized medical patients. Inadequate sleep can lead to both psychological and physiological consequences., Methods: A PubMed search was conducted using the terms: ("sleep deprivation," "sleep," or "insomnia") and ("hospitalized," "inpatient," "critical illness," or "acute illness") to review the published data on the topic of sleep in hospitalized medical patients. The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search, including the terms "hospital noise," "hospital environment," "obstructive sleep apnea," and "heart failure.", Results: Few articles specifically addressed the topic of sleep in hospitalized medical patients. Data were limited to observational studies that included outcomes such as sleep complaints and staff logs of wakefulness and sleep. In Part 1, we review normal sleep architecture, and discuss how major medical disorders, the hospital environment, and medications can disrupt sleep during hospitalization. In Part 2, we will propose an evaluation and treatment algorithm to optimize sleep in hospitalized medical patients., Conclusions: Hospitalization may severely disrupt sleep, which can worsen pain, cardiorespiratory status, and the psychiatric health of acutely ill patients. Like vital signs, the patient sleep quality reveals much about patients' overall well-being, and should be a routine part of medical evaluation., ((c) 2008 Society of Hospital Medicine)

Telemedicine has been shown to improve rural patient outcomes in two randomized controlled trials, to increase access to many patients, to serve underserved minorities, and to train primary care providers. Yet, programs are dwindling even after successful grants due to inadequate reimbursement. Studies have been thoroughly done to gauge the payor status of potential rural telemedicine patients, as the "floodgates" are not generally open to all-including those who cannot pay-in typical grants. Or the population of one community may not be representative of others. This study is part of a grant that explored the use of telemedicine for rural service delivery, attempted to get a clear snapshot of whom would be served if all were invited (paying or not), and to understand issues with the reimbursement systems. This article (1) examines the receipts of reimbursement and insurance coverage during the 1-year grant period by determining actual versus projected reimbursements, (2) identifies what payor(s) typical patients use, and (3) identifies problems and barriers for future study. Other administrative issues pertinent to telemedicine and costs are briefly discussed (eg, no-show rates, staffing, scheduling).

Telepsychiatry can be used in two kinds of psychiatric emergencies: one-time clinical events and public health situations associated with mass disaster. Emergency telepsychiatry delivered by videoconferencing has the potential to improve patient care in many settings. Although experience is limited, it has been found to be safe and effective, as well as satisfactory to both emergency department staff and the psychiatric patients treated. The development of comprehensive and standardized guidelines is necessary. There has been little use of acute telemedicine in disaster situations to date. However, telemedicine is becoming part of routine emergency medical response planning in many jurisdictions. Emergency telepsychiatry has the potential to reduce emergency department overcrowding, provide much needed care in rural areas and improve access to psychiatric care in the event of a natural or man-made disaster.

Objective: New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary care setting, particularly in rural areas of the United States and especially for children and adolescents. The aim of this study was to examine the diagnostic characteristics and outcomes for children referred for eMental Health consultations at UC Davis (videoconferencing, telephone, and secure e-mail) from 10 primary care clinics in rural northern California., Method: : A retrospective analysis was conducted on the diagnostic and clinical outcomes of 139 referred children who received a full psychiatric diagnostic evaluation via videoconferencing. Within the group, a convenience sample of 58 initial and 41 three-month follow-up Child Behavior Checklists (CBCLs) was collected., Results: Comprehensive eMental Health programs appear to be effective for psychiatric diagnosis and assessment of children. Attention deficit (36.2%) and mood (28.1%) disorders were the most common diagnostic groupings overall. Most children were seen only once, but a statistically significant improvement between initial evaluation and 3-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the CBCL for girls and boys, respectively., Conclusions: Versatile eMental Health programs, incorporating standardized checklists, may assist in diagnosis and treatment of rural children.

Patients who have diabetes commonly have mood, anxiety, and psychotic disorders. These disorders may have multiple biologic underpinnings. Without treatment, care becomes complicated and outcomes are poor. Early diagnosis and biopsychosocial treatment that integrates medical and psychiatric interventions is highly desirable. Medications have a major role in treatment, although caution must be exercised because of potential side effects. Psychiatric consultation or management may be required for urgent or severe cases. An appreciation of culture, both ethnic and beyond, is a foundation for enhancing physician-patient relations and developing realistic expectations for treatment.

Objective: Telepsychiatry, in the form of live interactive videoconferencing, is an emerging application for emergency psychiatric assessment and treatment and can improve the quality and quantity of mental health services, particularly for rural, remote and isolated populations. Despite the potential of emergency telepsychiatry, the literature has been fairly limited in this area., Method: Drawing on the combined clinical and administrative experiences of its authors, this article reviews the common administrative, legal/ethical and clinical issues that arise in emergency telepsychiatry., Results: An initial set of guidelines for emergency telepsychiatry is presented to generate further discussion to assist those who are considering establishing general telepsychiatry and/or emergency telepsychiatry services., Conclusion: The practices and techniques of emergency telepsychiatry are relatively new and require further examination, modification and refinement so that they may be fully utilized within comprehensive mental health service systems.

This article describes the University of California, Davis Medical Center eMental Health Consultation Service, a program designed to integrate tele-mental health clinical services, provider-to-provider consultation, and provider distance education. During the first year of operation, consultations were provided for 289 cases. The most common diagnoses among children were for attention-deficit hyperactivity disorder-spectrum problems. Among the adult patients, mood disorders were most common. A convenience sample of 33 adult patients who completed the SF-12 health status measure showed significant improvements in mental health status at 3-6 months of follow-up. This model of comprehensive rural outpatient primary mental health care delivered at a distance shows promise for wider application and deserves further study.

Context and Purpose: Rural and suburban populations remain underserved in terms of psychiatric services but have not been compared directly in terms of using telepsychiatry., Methods: Patient demographics, reasons for consultation, diagnosis, and alternatives to telepsychiatric consultation were collected for 200 consecutive, first-time telepsychiatric consultations at rural and suburban clinics., Findings: Rural patients were more likely than suburban patients to be younger than 18 years, using Medicaid, and needing treatment planning (lest they be referred out of the community). Rural patient and primary care physician satisfaction was higher than that of suburban counterparts., Conclusion: Telepsychiatry programs may enhance access, satisfaction, and quality of rural care.

Introduction. Disease management modules (DMM), including education, tracking, support, and medical care, have improved health for patients with asthma and diabetes. For rural patients, novel ways of delivery are needed to access clinical expertise from urban or academic specialists. Telemedicine (telephone and televideo) could be instrumental in this process, though no randomized, controlled trials have assessed their effectiveness.Methods. Self-report and structured psychiatric interviews were used to screen potential depressed subjects. Subjects were randomized to: 1) usual care with a DMM using telephone and self-report questionnaires; or 2) a DMM using telephone, questionnaires, and monthly televideo psychiatric consultation emphasizing primary care physician (PCP) skill development. Subjects' depressive symptoms, health status, and satisfaction with care were tabulated at three, six, and 12 months after study entry.Results. There was significant clinical improvement for depression in both groups, with a trend toward significance in the more intensive module. Satisfaction and retention was superior in the more intensive group. There was no overall change in health functioning in either group.Conclusions. Intensive modules using telepsychiatric educational interventions toward PCPs may be superior, but the most critical ingredient may be administrative tracking of patients, prompted intervention by PCPs, and (when necessary) new ideas by a specialist.

Objective: This article highlights technology innovations in psychiatric and medical education, including applications from other fields., Method: The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education., Results: The introduction of new technologies requires skill at implementation and evaluation to assess the pros and cons. There is a significant body of literature regarding virtual reality and simulation, including assessment of outcomes, but other innovations are not well studied., Conclusions: Innovations, like other uses of technology, require collaboration between parties and integration within the educational framework of an institution.

Objective: This article highlights the importance of distributed broadband networks as part of the core infrastructure necessary to deliver academic research and education programs., Method: The authors review recent developments in the field and present the University of California, Davis, environment as a case study of a future virtual regional academic medical center., Results: Achieving the potential benefits of distributed broadband networks through regional health information organizations will involve considerable collaboration between different academic groups and the development and implementation of standardized technological and business approaches., Conclusions: Broadband technologies offer a substantial opportunity to improve the way academic education and research programs are delivered.

Objective: This article provides an overview of how trainees, faculty, and institutions use technology for acquiring knowledge, skills, and attitudes for practicing modern medicine., Method: The authors reviewed the literature on medical education, technology, and change, and identify the key themes and make recommendations for implementing technology in medical education., Results: Administrators and faculty should initially assess their own competencies with technology and then develop a variety of teaching methods that use technology to improve their curricula. Programs should decrease the general knowledge-based content of curricula and increase the use of technology for learning skills. For programs to be successful, they must address faculty development, change management, and funding., Conclusions: Willingness for change, collaboration, and leadership at all levels are essential factors for successfully implementing technology.

Objective: The authors describe the complexity of social processes for implementing technological change. Once a new technology is available, information about its availability and benefits must be made available to the community of users, with opportunities to try the innovations and find them worthwhile, despite organizational resistances., Method: The authors reviewed the literature from psychiatry, psychology, sociology, business, and technology to distill common denominators for success and failure related to implementing technology., Results: Beneficial technological innovations that are simple to use and obviously save everyone time and effort are easy to inaugurate. However, innovations that primarily serve management rather than subordinates or front-line utilizers may fail, despite considerable institutional effort. This article reviews and outlines several of the more prominent theoretical models governing successful institutional change., Conclusions: Successful implementation of difficult technological changes requires visionary leadership that has carefully considered the benefits, consulted with influence leaders at all organizational levels to spot unintended consequences and sources of resistance, and developed a detailed plan and continuous quality assurance process to foster implementation over time.

Authors reviewed consecutive charts of 155 cognitive-disorder patients from a psychosomatic medicine service in 2001, analyzing factors of age, cognitive-disorder diagnosis, and length of stay. Mean length of stay for this cohort exceeded the typical hospital length of stay, and decreased with age. Increased age was associated with a decreased probability of a delirium-only diagnosis, and was strongly associated with an increased probability of a dementia diagnosis. Among those with dementia, the probability of having an additional diagnosis of delirium was unrelated to age. The case-mix of cognitive disorders differs with age, whereas cognitive disorders are associated with increased length of stay for adult patients of all ages.

Introduction: Rural populations remain underserved in terms of psychiatric services. This study assesses changes over time in the utilization of telepsychiatric services by individual primary care providers (PCPs) and clinics in rural areas, specifically: (a) types of referrals for telepsychiatry service; (b) PCPs' knowledge and skills related to medication dosing; and (c) PCPs' satisfaction with telepsychiatry., Methods: Data with regard to patient demographics, diagnoses, reason for consultation, medication dosing and satisfaction were prospectively collected on the first 200 and the subsequent 200 telepsychiatric initial consultations. A number of educational interventions were implemented during the project., Results: Adult patients were primarily referred for mood and anxiety disorders, particularly for diagnosis and medication treatment planning. Over time, PCPs significantly improved medication dosing and asked for more treatment planning help. PCPs' satisfaction also improved over time., Discussion: Telepsychiatric consultation, in combination with specific educational interventions, appears to facilitate the enhancement of skills and knowledge of PCPs. "Developmental" steps in provider and clinic evolution, along with interventions specific to a given provider's and a given site's needs, ought to be further elucidated.

Many patients who present to neurology settings with somatic complaints have underlying fear of illness, anxiety, or depression. Hypochondriasis, which is one of the somatoform disorders, contributes to high use of services and frustration on the part of clinicians, because diagnostic and treatment interventions often fail. The challenges for clinicians include how to distinguish true somatic symptoms from those associated with fear or other psychiatric symptoms. Our goal is to provide the clinician with an integrated approach for the triage, assessment (history, screening tools, examination, and diagnostic tests), and treatment of these challenging patients. Recommendations are made regarding psychiatric consultation and comanagement between fields for complex patients.

Objective: This article reviews the epidemiology, etiology, assessment, and management of bipolar disorder. Special attention is paid to factors that complicate treatment, including nonadherence, comorbid disorders, mixed mania, and depression., Methods: A Medline search was conducted from January of 1990 through December of 2005 using key terms of bipolar disorder, diagnosis, and treatment. Papers selected for further review included those published in English in peer-reviewed journals, with preference for articles based on randomized, controlled trials and consensus guidelines. Citations de-emphasized original mania trials as these are generally well known., Results: Bipolar disorder is a major public health problem, with diagnosis often occurring years after onset of the disorder. comorbid conditions are common and difficult to treat. Management includes a lifetime course of medication, usually more than one, and attention to psychosocial issues for patients and their families. Management of mania is well-established. Research is increasing regarding management of depressive, mixed and cycling episodes, as well as combination therapy., Conclusions: Bipolar disorder is a complex psychiatric disorder to manage, even for psychiatrists, because of its many episodes and comorbid disorders and nonadherence to treatment.

Telemedicine is one strategy to improve the accessibility and quality of specialty healthcare to rural settings. After nearly 10 years of video evaluation of patients in rural primary care, telephone and e-mail physician-to-physician consultations were initiated to supplement video and hasten treatment initiation. This paper proposes a model of using telephone and e-mail consultations before or in place of video consultations, because the latter are not always available or timely. Two cases are presented in depth to delineate clinical, consultation, and health services issues. Early use of telephone appears to accelerate the telepsychiatric consultation and resulted in clinical improvement for patients. Primary care providers (PCPs) appeared satisfied with the process of these consultations. The average duration of consultation was about 10 minutes for each party. Telephone and e-mail consultation appear satisfactory to providers and inexpensive, but need to be further evaluated in terms of clinical, health service, and cost outcomes.

New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary-care setting, particularly in rural areas of the United States. Some models of service delivery have been successful in suburban and urban settings, but they do not always apply to rural settings. "E-health" innovations like videoconferencing, telephone, secure messaging (e-mail), and the Internet are increasingly being used to provide consultation--liaison service to primary care. This article briefly reviews successful models used in primary care, their application to rural sites, new models for rural sites, and suggestions for future e-health research.

Objective: This article provides a brief overview of important issues for educators regarding medical education and technology., Methods: The literature describes key concepts, prototypical technology tools, and model programs. A work group of psychiatric educators was convened three times by phone conference to discuss the literature. Findings were presented to and input was received from the 2005 Summit on Medical Student Education by APA and the American Directors of Medical Student Education in Psychiatry., Results: Knowledge of, skills in, and attitudes toward medical informatics are important to life-long learning and modern medical practice. A needs assessment is a starting place, since student, faculty, institution, and societal factors bear consideration. Technology needs to "fit" into a curriculum in order to facilitate learning and teaching., Conclusion: Learning about computers and applying computer technology to education and clinical care are key steps in computer literacy for physicians.

We present a case that promotes early intervention and pharmacological treatment for the neuropsychiatric sequelae (frontal lobe syndrome, including cognitive impairment and aggressive behavior) associated with traumatic brain injury (TBI) and delirium. The patient, who sustained significant systemic complications related to his trauma, was previously diagnosed with alcohol and drug dependence and antisocial personality disorder. These antecedent conditions and prolonged systemic complications likely played a complicating role in his course of recovery.

Cross-cultural mental health services were assessed using qualitative interviews and focus groups of 43 mental health clinicians and program directors in one of the most ethnically integrated cities in the U.S. The commonly used strategy of ethnic matching between clinician and patient was found to be difficult to effectively apply to an ethnically diverse and highly integrated patient population. Information from cultural-competency training was also found to be difficult to apply, particularly due to time limitations and language barriers. Implementation of a cultural consultation service, which uses in-depth cultural evaluations and case-based learning, may help bridge these service gaps.

In patients who present to neurology settings with history of epileptic seizures, psychiatric disorders may be the sole manifestation of apparent neurologic symptoms, or they may coexist. Current challenges for clinicians include distinguishing between two disorders and making the correct diagnoses, interpreting test results, and (co-) managing the disorder(s). Our goal is to provide the clinician with an integrated neuropsychiatric approach for the triage, assessment (history, screening tools, examination, diagnostic tests), and treatment (neurologic and/or psychiatric) of these challenging patients. In particular, use of schemata, tables, and algorithms will offer step-by-step approaches and guidelines for the clinician. Recommendations are made for the indications for psychiatric consultation, and co-management is recommended for patients with emergencies, those who fail routine psychiatric treatments, and those with complex presentations or multiple comorbid conditions.

Objective: The topic "A Day in the Life of a Psychiatry Resident" is an opportunity to explore residents' experiences to inform the delivery of education., Methods: An open-ended, qualitative approach was used in a pilot project to explore contemporary residents' experiences with education, similar to a patient-centered model of health care., Results: Key themes for residents include balancing multiple roles at work, balancing work and home, identity formation, diversity (gender, ethnic, cultural, learner styles, and other dimensions), and challenges in training with advances in the field (e.g., neuroscience, technology, culture, spirituality). Contemporary residents have some issues as did their predecessors, but they also have unique experiences, issues, talents, and interests., Conclusions: A larger qualitative analysis of these issues, followed by testing of theories by quantitative methods, is indicated.

The aim of this study was to determine whether outpatient telemedicine specialty consultations to primary care clinicians result in changes in a patient's diagnosis, treatment management, and clinical outcomes. Medical records of patients who received two or more clinical telemedicine consultations in dermatology, psychiatry, and endocrinology were evaluated in a nonconcurrent retrospective analysis. Three indicators were used to measure changes in the processes of care and clinical outcomes: change in diagnosis, change in treatment, and patient clinical improvement. A retrospective review of 223 individual telemedicine patient medical records was conducted. Specialty telemedicine consultations were found to result in changes in diagnoses in 48% of the cases, changes in treatment therapy in 81.6% of the cases, and clinical improvement in 60.1%. These results are consistent with previous literature that has assessed changes in processes of care and outcomes from face-to-face specialty consultations in outpatient clinics. Changes in diagnosis and treatment therapy were found to be associated with clinical improvement with odds ratios (ORs) of 2.66 (95% confidence interval [CI]: 1.47-4.83) and 11.22 (95% CI: 4.49-31.48), respectively. This study found that telemedicine consultations resulted in changes in diagnosis and treatment regimens and also are associated with clinical improvements.