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With the increased implementation of models that integrate behavioral health with other medical care, there is a need for a workforce of integrated care providers, including psychiatrists, who are trained to deliver mental health care in new ways and meet the needs of a primary care population. However, little is known about the educational needs of psychiatrists in practice delivering integrated care to inform the development of integrated care training experiences. The educational needs of the integrated care team were assessed by surveying psychiatric consultants who work in integrated care. A convenience sample of 52 psychiatrists working in integrated care responded to the survey. The majority of the topics included in the survey were considered educational priorities (>50 % of the psychiatrists rated them as essential) for the psychiatric consultant role. Psychiatrists’ perspectives on educational priorities for behavioral health providers (BHPs) and primary care providers (PCPs) were also identified. Almost all psychiatrists reported that they provide educational support for PCPs and BHPs (for PCP 92 %; for BHP 96 %). The information provided in this report suggests likely educational needs of the integrated care psychiatric consultant and provides insight into the learning needs of other integrated care team members. Defining clear priorities related to the three roles of the integrated care psychiatric consultant (clinical consultant, clinical educator, and clinical team leader) will be helpful to inform residency training programs to prepare psychiatrists for work in this emerging field of psychiatry.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Objective To understand collaborative care psychiatric consultants’ views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care. Method We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary-care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed. Results Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry and effective care. Conclusion Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care and perceiving the care delivered through collaborative care as high quality.

OBJECTIVE This study examined effectiveness of collaborative care for depression among Asians treated either at a community health center that focuses on Asians (culturally sensitive clinic) or at general community health centers and among a matched population of whites treated at the same general community clinics. METHODS For 345 participants in a statewide collaborative care program, use of psychotropic medications, primary care visits with depression care managers, and depression severity (as measured with the nine-item Patient Health Questionnaire) were tracked at baseline and 16 weeks. RESULTS After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes. Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications. CONCLUSIONS Collaborative care for depression showed similar response rates among all three groups.

In medical education, behavioural definitions allow for more effective evaluation and supervision. Ownership of patient care is a complex area of trainee development that crosses multiple areas of evaluation and may lack clear behavioural definitions. In an effort to define ownership for educational purposes, the authors surveyed psychiatry teaching faculty and trainees about behaviours that would indicate that a physician is demonstrating ownership of patient care. Emerging themes were identified through analysis of narrative responses in this qualitative descriptive study. Forty-one faculty (54 %) and 29 trainees (52 %) responded. Both faculty and trainees identified seven core elements of ownership: advocacy, autonomy, commitment, communication, follow-through, knowledge and teamwork. These seven elements provide a consensus-derived behavioural definition that can be used to determine competency or identify deficits. The proposed two-step process enables supervisors to identify problematic ownership behaviours and determine whether there is a deficit of knowledge, skill or attitude. Further, the theory of planned behaviour is applied to better understand the relationship between attitudes, intentions and subsequent behaviour. By structuring the diagnosis of problems with ownership of patient care, supervisors are able to provide actionable feedback and intervention in a naturalistic setting. Three examples are presented to illustrate this stepwise process.

The objective of this study was to describe the work and experiences of psychiatrists practicing integrated care in the community.Consulting psychiatrists working in integrated care participated in an online survey about their experiences, opinions, and advice. Results were analyzed with quantitative and qualitative methods.A convenience sample of 52 psychiatrists from around the country who were working in integrated care responded. Respondents reported that they address a wide variety of clinical problems with a range of treatment strategies. Most reported positive experiences, which were summarized in four themes: working in a patient-centered care model, working with a team, the psychiatrist's role as educator, and opportunities for growth and innovation.The survey documented the experiences of psychiatrists working in integrated care. Findings suggest that integrated care teams allow consulting psychiatrists to leverage their expertise to reach a large number of patients in a variety of practice settings.

Mossy cells are bi-directionally connected through a positive feedback loop to granule cells, the principal cells of the dentate gyrus. This recurrent circuit is strategically placed between the entorhinal cortex and the hippocampal CA3 region. In spite of their potentially pro-convulsive arrangement with granule cells, mossy cells have not been seriously considered to promote seizures, because mossy cells, allegedly one of the most vulnerable cell types in the entire mammalian brain, have long been 'known' to die en masse in epilepsy. However, new data suggest that rumors of the rapid demise of the mossy cells might have been greatly exaggerated.

Objective The objective was to describe the process of care and treatment outcomes of a 36-year-old man with bipolar disorder treated using a collaborative care model in primary care. Methods We reviewed and summarized relevant clinical data describing the patient’s care including the medical record, consultant’s reports and discussions with treating clinicians. A meeting was held with experienced consulting psychiatrists to discuss the case. Results Several barriers to delivery of high-quality care existed including initial loss to follow-up, few social supports and lack of follow-through at the community mental health center existed, along with presence of factors that negatively influence bipolar disorder outcomes including initial unopposed antidepressant use at baseline, concurrent alcohol use and co-occurring anxiety symptoms. Despite these barriers, the collaborative care team was able to engage the patient in care and achieve the patient’s and team’s treatment goals. Conclusion Delivery of primary-care-based collaborative care was associated with reduction of bipolar disorder symptoms and improved functioning in a patient with bipolar disorder.

Collaborative care has emerged as an evidence-based approach to care for patients with common mental health disorders such as depression or anxiety in primary care. To deliver successful collaborative care, a program must build a team with effective “shared workflows.” A psychiatrist functioning in a mental health leadership role may play an important role in the development, implementation, and ongoing improvement of a high-functioning collaborative care team. The process of building such a team involves several stages: leadership commitment, preparing for team building, developing a clear vision for the scope of the program, assessing current resources and workflows, conducting a gap assessment to identify staff and training needs, generating a collaborative care workflow, training staff, program launch, and supporting the ongoing quality improvement efforts of the team.

Recent studies have demonstrated that hippocampal interneurons possess distinct cytoskeletal and cell-signaling proteins in comparison to hippocampal principal cells; however, little is known about the differences in the actin cytoskeleton between these two populations. This study examined the immunoreactivity of alpha-actinin-2, an actin binding/N-methyl-D-aspartate-receptor linking protein, in the rat hippocampal formation using double-labelling immunofluorescence. Alpha-actinin-2 immunoreactivity is seen throughout the hippocampus with heavy labeling observed in the dendrites of granule cells, in CA2 pyramidal cells and in presumed interneuronal somata throughout the dentate gyrus and CA1. All the cells with heavy somatic alpha-actinin-2 immunoreactivity in the dentate gyrus and CA1 were GABAergic interneurons labeled by glutamate decarboxylase (99%). Examination of the neurochemical marker content of the alpha-actinin-2 immunoreactive interneurons revealed that the majority of this population was neuropeptide-Y-positive and a minority was positive for calretinin. Fluid percussion head trauma did not result in significant alterations of alpha-actinin-2 immunoreactivity in hippocampal interneurons. The developmental profile of alpha-actinin-2 immunoreactivity showed the presence of alpha-actinin-2 in the hippocampus at P1, labeling of interneurons by P7 and the adult staining pattern seen by P21. This study demonstrates that principal cells and interneurons are differentially immunoreactive for alpha-actinin-2, and that alpha-actinin-2 staining is restricted to a subpopulation of interneurons. Each of the three classes of cytoskeletal elements have been shown to be differentially expressed in hippocampal interneurons and principal cells, suggesting that the cytoskeleton is a defining feature of neuronal populations. Additionally, the limited expression of alpha-actinin-2 could have important functional implications in N-methyl-D-aspartate receptor localization and modulation.

Parvalbumin-positive interneurons and granule cells of the dentate gyrus exhibit characteristic differences in morphological, cytochemical, physiological, and pathophysiological properties. Several of these defining features, including dendritic morphology, spine density, and sensitivity to insults, are likely to be influenced by the neuronal cytoskeleton. The data in this paper demonstrate striking differences in the expression levels of all three neurofilament triplet proteins, as well as alpha-internexin and beta-tubulin III, between the parvalbumin-positive interneurons and dentate granule cells. Therefore, the molecular composition of intermediate filaments and microtubules in the dendritic domain of parvalbumin-positive dentate interneurons is distinct from the cytoskeleton of neighboring granule cells, indicating the existence of highly cell type-specific cytoskeletal architecture within the dentate gyrus.

Objectives The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. Methods As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. Results Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient–provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient–provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. Conclusions Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Loss of cells from the hilus of the dentate gyrus is a major histological hallmark of human temporal lobe epilepsy. Hilar mossy cells, in particular, are thought to show dramatic numerical reductions in pathological conditions, and one prominent theory of epileptogenesis is based on the assumption that mossy cell loss directly results in granule cell hyperexcitability. However, whether it is the disappearance of hilar mossy cells from the dentate gyrus circuitry after various insults or the subsequent synaptic-cellular alterations (e.g., reactive axonal sprouting) that lead to dentate hyperexcitability has not been rigorously tested, because of the lack of available techniques to rapidly remove specific classes of nonprincipal cells from neuronal networks.We developed a fast, cell-specific ablation technique that allowed the targeted lesioning of either mossy cells or GABAergic interneurons in horizontal as well as axial (longitudinal) slices of the hippocampus. The results demonstrate that mossy cell deletion consistently decreased the excitability of granule cells to perforant path stimulation both within and outside of the lamella where the mossy cell ablation took place. In contrast, ablation of interneurons caused the expected increase in excitability, and control aspirations of the hilar neuropil or of interneurons in the presence of GABA receptor blockers caused no alteration in granule cell excitability.These data do not support the hypothesis that loss of mossy cells from the dentate hilus after seizures or traumatic brain injury directly results in hyperexcitability.

Febrile (fever-induced) seizures are the most common form of childhood seizures, affecting 3%–5% of infants and young children. Here we show that the activity-dependent, retrograde inhibition of GABA release by endogenous cannabinoids is persistently enhanced in the rat hippocampus following a single episode of experimental prolonged febrile seizures during early postnatal development. The potentiation of endocannabinoid signaling results from an increase in the number of presynaptic cannabinoid type 1 receptors associated with cholecystokinin-containing perisomatic inhibitory inputs, without an effect on the endocannabinoid-mediated inhibition of glutamate release. These results demonstrate a selective, long-term increase in the gain of endocannabinoid-mediated retrograde signaling at GABAergic synapses in a model of a human neurological disease.

Head injury is a causative factor in the development of temporal lobe epilepsy. However, whether a single episode of concussive head trauma causes a persistent increase in neuronal excitability in the limbic system has not been unequivocally determined. This study used the rodent fluid percussion injury (FPI) model, in combination with electrophysiological and histochemical techniques, to investigate the early (1 week) and long-term (1 month or longer) changes in the hippocampus after head trauma. Low-frequency, single-shock stimulation of the perforant path revealed an early granule cell hyperexcitability in head-injured animals that returned to control levels by 1 month. However, there was a persistent decrease in threshold to induction of seizure-like electrical activity in response to high-frequency tetanic stimulation in the hippocampus after head injury. Timm staining revealed both early- and long-term mossy fiber sprouting at low to moderate levels in the dentate gyrus of animals that experienced FPI. There was a long-lasting increase in the frequency of spontaneous inhibitory postsynaptic currents in dentate granule cells after FPI, and ionotropic glutamate receptor antagonists selectively decreased the spontaneous inhibitory postsynaptic current frequency in the head-injured animals. These results demonstrate that a single episode of experimental closed head trauma induces long-lasting alterations in the hippocampus. These persistent structural and functional alterations in inhibitory and excitatory circuits are likely to influence the development of hyperexcitable foci in posttraumatic limbic circuits.