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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

Patient-centered health care questions how to deliver quality, affordable, and timely care in a variety of settings. Telemedicine empowers patients, increases administrative efficiency, and ensures expertise gets to the place it is most needed--the patient. Telepsychiatry or telemental health is effective, well accepted, and comparable to in-person care. E-models of care offer variety, flexibility, and positive outcomes in most settings, and clinicians are increasingly interested in using technology for care, so much so that telepsychiatry is now being widely introduced around the world.

Contemporary healthcare is patient-centered in terms of quality care, access, and affordable options. Stepped and integrated care models emphasize customized care, interdisciplinary teamwork, and integration of services based on co-location, shared responsibility, and funding. Telepsychiatry (TP) is as effective as in-person care and has been broadly used to provide psychosomatic medicine (formerly consultation-liaison psychiatry) to primary care and other healthcare settings. The literature reveals that TP leverages a wide range of treatments at a distance to clinics, nursing homes, and patient homes and how telemedicine models of care provide flexibility for TP services to patients, providers, and caregivers. There is steady growth of the TP evidence base, and geriatric patients are as open to using TP as other populations and report high satisfaction. TP outcomes for geriatric patients are comparable to in-person care and quite in parallel with outcomes for patients of all ages. TP also enables more patient points of entry, addresses patient-provider needs-skill mismatches, and leverages other resources. Telemedicine and TP overcome geographical, physical limitations and access to care obstacles. More formal TP research studies and health services effectiveness studies are needed for geriatric patients in culturally diverse populations, related to team-based or interdisciplinary care, and employing full stepped or integrated care models.

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. 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.

No abstract available Keywords: adolescents; children; e-heatlh; practice guidelines; telehealth; telemental health.

Introduction In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance. Method This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care). Results The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible. Conclusion Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

The growing older adult demographic in the USA and the concomitant increase in older adults with mental illness highlights the critical need for expanding access to mental health care in this population. Older adults with mental illness and/or substance use disorders often first receive clinical attention in the context of primary care settings, which are under-resourced, both in terms of time and professional training. Stigma in seeking mental health care, lack of information about services, and limited transportation to services remain major barriers to mental health care access and utilization among older adults. However, the volume of the current geriatric psychiatry workforce is insufficient to meet the mental healthcare needs of the aging population. Telepsychiatry, the provision of mental health/psychiatric care via live-two way videoconferencing, is one way to bridge the looming gap between available specialty trained providers and the population in need of services. While recognizing that healthcare providers of various specialties and disciplines play a vital role in providing mental health care to older adults, this chapter will primarily focus on academic implications of geriatric telepsychiatry within psychiatric (graduate medical) training programs.

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.

Objective: To examine the feasibility and diagnostic reliability of asynchronous telepsychiatry (ATP) consultations in Spanish and ATP consultation with Spanish-to-English translation. Subjects and Methods: Twenty-four interviews of Spanish-speaking patients were videorecorded by a bilingual clinician who also collected patient history data and gave the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to each patient. The ATP data (video of the interview and patient history) were forwarded for psychiatric consultation and a diagnostic assessment by the investigators. The ATP data were then examined separately by two Spanish-speaking psychiatrists, before being translated into English and then re-examined by two English-speaking psychiatrists. Agreement between the expert diagnoses of the investigators and the diagnoses from the Spanish consultations, the Spanish-to-English translated consultations, and the SCID-I results was assessed using kappa statistics. Results: We found acceptable levels of agreement for major diagnostic groupings among the Spanish- and English-speaking psychiatrists. Kappa values for diagnostic agreement between the expert and the translated consultations, the original language consultations, and the SCID-I were at least 0.52 (percentage agreement, 79%) and higher. Conclusions: ATP consultations in Spanish, and those translated from Spanish to English, are feasible, and broad diagnostic reliability was achieved. The ATP process allows for rapid language translation. This approach could be useful across national boundaries and in numerous ethnic groups. Cross-language ATP may also offer significant benefits over the use of real-time interpreting services and has the potential to improve the quality of care by allowing for the addition of culturally relevant information.

Background. There are many paths to telemental health as an enjoyable career. An academic career involves significant clinical, educational, research, and administrative dimensions. Technology is a key part of personal experience, professional activities, and our societal evolution. Methods. This chapter uses personal and professional narratives about day-to-day work, projects, and key turning points to discuss themes and opportunities for readers. Results. Medicine, telepsychiatry, and other technologies offer a rewarding career path. Intersections of passions and collaboration with others make progress logarithmic rather than additive. My career involves work with trainees, interdisciplinary mental health staff, and colleagues in other areas of medicine and public health initiatives at the community, state, and federal levels. All of these endeavors provide opportunities to apply technology and, in many ways, to improve patient care, communicate with others, and disseminate information—all in all, to be administratively more efficient and effective. Personal and professional use of technologies overlap in some regards, but are very different in others. Conclusions. Technology offers opportunities to learn, teach, and administer programs.

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.

The Association of American Medical Colleges projects an increasing shortage of physicians in rural areas. Medical schools have developed specialty track programs to improve the recruitment and retention of physicians who can serve rural populations. One such program in California includes a variety of unique elements including outreach, admissions, rural clinical experiences, focused mentorship, scholarly and leadership opportunities, and engagement with rural communities. Preliminary outcomes demonstrate that this rural track program has achieved some success in the recruitment, retention, and training of students interested in future rural practice and in the placement of students in primary care residencies. Long-term outcomes, such as graduates entering rural practice, are still unknown, but will be monitored to assess the impact and sustainability of the rural program. This article illustrates the opportunities and challenges of training medical students for rural practice and provides lessons learned to inform newly-established and long standing rural medical education programs.

intervention as compared to other therapeutic options for the individual patient. The full text of the practice guideline includes a detailed description of expert consensus findings and research evidence related to effects of antipsychotic medication in individuals with dementia. It also describes aspects of guideline implementation that are relevant to individual patients’ circumstances and clinical presentation.

This article identifies and describes key considerations toward the development of a clinical guideline intended to optimize telemental healthcare (TMH) of children and adolescents.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.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.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.

Cross-cultural patient mental health-care demands a high standard of communication between the patient and the provider, since linguistic and other differences may influence it and consequently affect quality of care and satisfaction. Geographical distances, culture, religious, and linguistic, make it difficult for some patient populations to access mental health professionals in their desired way. Clinicians with a positive attitude to differences and who advocate for patients may seek out e-Mental Health (eMH) innovations to overcome barriers, increase the quality of mental health care for ethnic minorities, and enhance their own education. Indeed, eMH applications offer new possibilities for reducing disparities in access to relevant mental health care to most vulnerable patient groups, such as refugees, migrants, and asylum seekers worldwide. National and international cross-cultural eMH services may contribute to reduce stigma and improve quality of health care of these groups in their host countries. Equal access to mental health services is a human right, for both domestic and immigrant population in modern communities worldwide.

Our current healthcare system in the United States is characterized by problems with access to timely and evidence-based care, particularly for mental disorders. e-Mental Health (eMH) improves access to care regardless of the point-of-service or barriers involved. Its effectiveness across age, population, and disorders is as good as in-person care, though adjustments for some populations in the approach are necessary. Early intervention is an example of “Cadillac” care or a best evidence-based approach that is easier to distribute via telemedicine. Cadillac care delivered via eMH has the potential to bring evidence-based early-intervention modalities to very young children and their families. However, early access to care is also critical for all populations, particularly those with cultural or medical disadvantages. It appears that eMH may be preferable or better than in-person care in some instances.

Web- and Internet-based resources are remarkably popular with the public, patients, and providers’ interventions over the last decade. Opportunities exist for health information, support groups, formal education programs, tools for self-directed lifestyle and illness management, obtaining advice/consultation, and self- or provider-directed treatments (e.g., cognitive behavioral therapy or e-mental healthcare). Traditional treatments are more easily disseminated to the point-of-service. Modification of regular treatments is being developed, based on smartphone applications and applying virtual reality/avatars from games into medicine. Innovative new treatments for special populations are made possible, and hybrid models of care may be our future. Access to information, providers, that can be adjusted to patient needs and comfort, with or without clinician supervision, which creates a completely new world of opportunities. These steps empower patients to initiate, participate, and steer their care. Clinicians have to become aware of, adapt, and serve new advisory roles to patients, as we are all challenged to make the best healthcare more accessible.

Telemedicine and Internet-enabled clinical systems are already widely available and are starting to have an impact on the doctor-patient relationship and will increasingly do this more in future. Research shows that online MH interventions are as effective as traditional face-to-face therapy for disorders such as depression and anxiety. We explore the impact of technology on the doctor-patient relationship as new technologies and clinical processes are applied to patient care (e.g., virtual patient advocates). In the future, we will likely change clinical processes, add models of care (e.g., hybrids), better apply new technologies to the underserved (e.g., cross-cultural populations), and have even newer technologies to size up.

Contemporary healthcare is patient centered with respect to quality care, access, and affordable options. Stepped and integrated care models emphasize tailored care, interdisciplinary teamwork, and integration of services based on co-location, shared responsibility, and funding. Telepsychiatry (TP) is as effective as in-person care. The literature was reviewed for core concepts and recent developments related to three themes: (1) how TP leverages a wide range of treatments at a distance to clinics, nursing homes, and patient homes, with outcomes as good as in-person care; (2) how geriatric TP is similar to or different from that for other age groups; and (3) telemedicine innovations, in general, that may be inroads for TP services for patients, clinicians, and caregivers. There is steady growth of the TP evidence base that demonstrates that older adult patients are as open to using TP as other populations and report high satisfaction. TP-positive preliminary outcomes compare favorably to in-person care, and TP enables more patient points of entry, addresses patient-provider needs-skill mismatches, and leverages resources. Telemedicine and TP have the potential to eliminate geographical, physical limitations and access to care obstacles. More formal TP research studies and health service effectiveness studies are needed for older adult patients in culturally diverse populations, team-based or interdisciplinary care, and stepped or integrated care interprofessional models.

Objective: This chapter discusses the prioritization of outcomes and evaluation in the provision of synchronous telemedicine (i.e., videoconferencing, STM) services. Methods: This organizational approach may be a shift from seeing what happens with planned services to planning the outcomes and then designing the services—in advance. Results: Basic and advanced areas of evaluation (e.g., satisfaction, technology, cost, clinical and other outcomes) are suggested and involve the many participants in STM in a systematic framework. It also offers suggestions on how to do a needs assessment and how to adjust priorities based on specific needs and available resources in a program. Examples of project improvement apply ideas from theory to clinical and other associated outcomes. References and resources of information are provided for further review. Conclusion: The readers acquire knowledge, skill, and a framework to improve existing programs and help their many participants.

Patient- or person-centered healthcare confronts us with questions on how to deliver quality, affordable, and timely care in a variety of settings. The international history of medicine, patient-centered care models, healthcare financing, and use of technology frame how e-mental health (eMH) develops, is employed, and positively influences outcomes. Models of care and patient-centered approaches are steering eMH services forward from in-person to videoconferencing to online formats—technology complements existing traditional medical approaches. Telemedicine empowers patients, personalizes care, increases administrative efficiency, and ensures expertise gets to the place it is most needed—wherever the patient is. Telepsychiatry, as the oldest eMH application, is effective, well accepted, and comparable to in-person care. As we employ technology, we must maintain high-quality clinical care and professional standards and be sensitive to differences in participants. Good care requires evaluation and attends to clinical, legal, reimbursement about the technological issues. eMH may soon reshape healthcare service delivery particularly as telepsychiatry appears better for some disorders and in some models of care than traditional in-person approaches; online services will boost this shift even more. Mental health providers may soon practice in-person, virtually, or both.

The evidence base in e-Mental Health (eMH), especially telepsychiatry, is substantial, as we proceed in the third active decade of eMH services and sixth decade overall. eMH improves access to quality care for variety of disorders (e.g., depression, anxiety, dementia), treatments (evaluation, medication, therapy), and settings (psychiatric, primary care). It is as good as in-person care – and in some ways better. Some areas are being more thoroughly assessed (e.g., child and adolescent, service delivery models) by traditional research methodology. More work is needed in many areas, though, in terms of elementary quantitative and qualitative indices for the average or regular clinical service or how to implement and improve a program. Specifically, a semistructured approach to services and a practical evaluation approach are needed related to new innovations (digital connectivity between patients and doctors or social media).

Contemporary health care promotes a patient-centered approach, integrates health/mental health care, emphasizes interdisciplinary teamwork, and adopts innovations such as communications technology. Telemedicine, including e-Mental Health (eMH), e.g., telepsychiatry, adds versatility to service delivery by improving access to care, leveraging expertise of key disciplines to the point-of-service, and disseminating education. Key disciplines in integrated care that provide mental health services into primary care are the psychiatrist, mid-level professionals, and nurses. These clinicians provide clinical, administrative, and care coordination expertise or oversight. A more recent addition to this integrated team is the care navigator who essentially coordinates care across all other team members and the patients. Overall, telemedicine, cross-training, stepped care roles, and use of clinically “versatile” clinicians – all of these help to fill “holes” in services for patients. Evidence-based treatment becomes more accessible, better disseminated, and in “real time” with use of health technologies. Best practices for clinical care, education, and program development are needed for integrated care and e-health.

While the patient-centered healthcare movement, like traditional medicine movements, aims to deliver quality, affordable, and timely care in a variety of settings, the consumer movement on new technologies is passing it by with emerging technologies and new ways of communicating with others (text, e-mail, Twitter, Facebook). This chapter builds on what we know about e-Mental Health (eMH), technology and communication progress over the past 50 years in maintaining the tenets of “good” quality care, adjusting slightly to telemedicine models, and considering more significant adjustments for use of social media. The areas of challenges include privacy and confidentiality, health and personal practice, having “good” interpersonal/clinical boundaries, awareness of what information is out there about you, and discussing clear expectations about online communication between doctors and patients as part of the informed consent process. Guidelines, strategies, and tips for the clinician are offered.

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.

The traditional face-to-face doctor-patient relationship is the core of conventional medical practice. One key aspect of this changing relationship is the increasing dependency on asynchronous data collection in clinical consultations. Such electronic communications and data streams may be numeric, text-based, audio, digitized still pictures, video and radiologic, as well as emanating from multiple medical devices. While asynchronous medicine may be established in specialties like radiology and dermatology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor-patient interaction such as primary care, internal medicine, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient, yet even in this specialty it is possible to utilize asynchronous medicine for some types of psychiatric consultations. Asynchronous medicine has the potential to be significantly disruptive to our current healthcare processes, as well as more clinically and economically efficient.

The literature on the efficacy of telepsychiatry for assessing and treating children and adolescents with mental health problems is still developing, but there is evidence that telepsychiatry is diagnostically valid, and that there is high patient and provider satisfaction. Outcome studies are awaited, with the assumption that telepsychiatry has to demonstrate at least as good outcomes and reliability as face-to-face psychiatric care. In this article we suggest, by reviewing the process of telepsychiatry with children, and illustrating relevant issues with five case studies of patients we have seen, that there is a valid case for arguing that in certain children and adolescents, telepsychiatry, as a consultation process, might actually be a superior method of psychiatric assessment to face-to-face consultation. Four factors stand out supporting this view. These are the novelty of the consultation, the capacity to provide direction, the extra distance involved (both psychological and physical), and the authenticity of the interaction. More research in child and adolescent telepsychiatry is indicated.

The authors investigated professional development needs of faculty in the Department of Psychiatry and Behavioral Sciences at the University of California (UC) Davis, while also exploring any existing differences according to gender and academic rank.An online survey was sent to 75 faculty members, and 41 responses (17 women, 24 men) were collected. Respondents rated 29 items on a Likert scale, from "very important" to "not important" and ranked the top three items in order of importance.Very important items included finding meaning in one's work, maintaining integrity and ethics, maintaining one's values and academic vitality, balancing personal and professional demands, a flexible work environment, and preventing and handling burnout. Results were similar across gender and rank.UC Davis men and women academic psychiatrists in different career development stages have similar needs, although paths leading to personal and professional fulfillment may vary according to gender.

Donald Hilty1, Julie S Young1, James A Bourgeois1, Sally Klein2, Kimberly A Hardin31Department of Psychiatry and Behavioral Sciences; 2UC Davis Medical Center; 3Sleep Medicine Fellowship Training Program, University of California Davis, Sacramento, CA, USAAbstract: Insomnia is a leading cause of sleep disturbance in primary care practice affecting >30% of people in the United States and can result in psychological and physiological consequences. We aim for a focused discussion of some of the underpinnings of insomnia and practical tips for management (eg, algorithms). A PubMed search was conducted using English language papers between 1997–2007, with the terms “sleep,” “insomnia”; “primary care” and “clinics”; “comorbid conditions”; “treatment” and “management.” Sleep, psychiatric and medical disorders significantly affect sleep, causing patient suffering, potentially worsening of other disorders and increasing the use of primary care services. We provide an outline for practical assessment and treatment of insomnia in primary care, including the strengths and weaknesses of medications.Keywords: insomnia, primary care, depression, anxiety, sleep, disorder

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 manmade disaster.

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).

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.

Hypochondriasis is a somatoform disorder marked by recurrent preoccupation with fears of having a life-threatening disease despite appropriate work-up and medical reassurance. The etiological explanations for hypochondriasis have evolved over time from a psychoanalytic stance (as an unconscious manifestation of instinctual drives) to social learning, cognitive–behavioral, and biological models that focus on functional values of hypochondriasis and parallels to anxiety disorders. We review recent therapeutic developments while emphasizing the importance of the therapeutic alliance. Although reassurance, psychotherapy, psychopharmacology and mental health referral are clearly indicated, we caution against using them prematurely. Since primary care and nonpsychiatric specialty physicians care for the majority of patients with hypochondriasis, we review the clinical presentations and treatment nuances specific to several different settings.

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.

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 March1990 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.

Background: Web and Internet-based resources are remarkably popular with the public, patients and others as a way to access mental health information, tools for self-care, advice/consultation from a professional, and providerdirected treatments. Objective: This paper provides a framework of a spectrum that includes person-centered health education options (conceptual endpoint), patient and caregiver-centered mental health care interventions (evidence-based literature review), and more formal provider-directed treatments (conceptual endpoint). Methods: The evidence-based literature review was focused on treatment studies, using a minimum of three key words and the 1996-2015 period, resulting in 13,612 articles. This was reduced to 388 (title words used), to 125 (abstracts for methods, design, and outcomes) and 40 (evidence-based criteria of guidelines). Results: Technology is frequently used, is readily accessible and satisfies persons, patients, and caregivers. Its impact on openness to engage with others and begin self-care appears very positive; its ability to help people change behaviors and engage additional clinical services appears modest, though this is inadequately evaluated. Formal treatments over the Internet, asynchronous care models, or traditional video-based synchronous services are as good as or better than in-person services, though an incomplete range of services has been evaluated. Relatively few treatment studies assess outcomes, compare in-person and e-Mental Health care, and or compare technology-based care options to one another; hybrid models of care have emerged, but have rarely been studied. Conclusions: For persons or patients not in care, use of the internet for common, non-acute problems appears to work, though a one-time clinical evaluation may help them place options in context. Clinicians and patients should specifically plan how to use technology and exercise sound judgment, based on guidelines when available. More research is needed on the application of new technologies to clinical care, with randomized trials and health services studies for effectiveness suggested.

“Integrated” behavioral health care most often refers to coordinated primary care and mental health care delivery at a co-located clinical site or psychiatric consultation service to a primary care clinical site. Women’s perinatal medical and mental health is an ideal target for integrated, patient-centered, and family-centered care. A three pronged approach is proposed to: 1) identify solutions for current barriers to mental health care delivery for pre- and postpartum women, 2) understand the relevance, steps toward and other thematic “how to” aspects of improving access to perinatal mental health services for the ongoing health of both mother and child, and 3) learn specifics of addressing maternal mental health, infant dyadic therapy, and enhanced parenting support. It borrows from the areas of stepped care, interdisciplinary teamwork, specific matching of treatments to disorders and stages of illness, and a range of individual, dyad, family and group treatments. These treatments are accessible, reduce stigmatization, and appropriate for dissemination using technology.

Contemporary healthcare has a patient-centered approach, integrates health/mental health care, emphasizes interdisciplinary teamwork, and adopts innovations such as communications technology. Telemedicine (including telepsychiatry) adds versatility to service delivery by improving access to care, leveraging expertise of key disciplines to the point-of-service, and tele-education. Key disciplines in integrated care, wherein psychiatric and other mental health services are provided in a primary care platform, are the psychiatrist, other mental health professionals (i.e., psychologists, social workers, marriage and family therapists), mid-level professionals, and nurses. These clinicians provide clinical, administrative, and care coordination expertise or oversight. Overall, telemedicine, cross-training, stepped care roles, and use of clinically “versatile” clinicians help to fill “holes” in services for patients. Evidence-based treatment becomes more accessible, better disseminated, and in “real-time” with use of technology.

This article highlights the importance of distributed broadband networks as part of the core infrastructure necessary to deliver academic research and education programs. 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. 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. Broadband technologies offer a substantial opportunity to improve the way academic education and research programs are delivered.

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.The authors reviewed the literature from psychiatry, psychology, sociology, business, and technology to distill common denominators for success and failure related to implementing technology.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.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.

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.

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.

This article provides a brief overview of important issues for educators regarding medical education and technology.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.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.Learning about computers and applying computer technology to education and clinical care are key steps in computer literacy for physicians.