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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 US. 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.

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.

Consultation-liaison (CL) psychiatry is psychiatry for the medically ill. This review describes the evolution of CL psychiatry from its origins in early 20th century general hospitals to the present era. The differences between CL psychiatry and general psychiatry are emphasized. The CL psychiatrist works in a multi-specialty and interdisciplinary environment whereas the general psychiatrist may not. Because of the CL psychiatrist’s experience with comorbid psychiatric and physical illness, he/she is skilled in the management of psychiatric comorbidity in the medically ill. Healthcare systems now require integrated models of service delivery in resource-sensitive environments. The CL psychiatrist is qualified to advise fellow physicians and other healthcare practitioners in how to manage psychiatric illness. CL psychiatrists have clinical, educational, administrative and research roles that are valuable in the delivery of comprehensive medical care in integrated, outcome-oriented systems.

The University of California (UC), Davis Health System, and California Department of Developmental Services (CDDS) developed the Physician Assistance, Consultation and Training Network (PACT Net) to assist primary-care providers (PCPs) care for patients with developmental disabilities in rural California. This manuscript describes PACT Net, a warm line using phone and e-mail, and its multispecialty panel. A pilot study evaluated whether or not PCPs needed such a consultation service, whether or not it assisted them in providing care, and their overall satisfaction with the service. PCPs were informed on how to request a consultation. Data were collected from patients (demographics), PCPs (satisfaction with preexisting consultation availability and quality, PACT Net consultation reason, preferred mode of contact, duration, and, satisfaction), and specialists (ease, quality of request, and satisfaction). Satisfaction was measured prospectively using a 7-point Likert scale. Data were collected on 30 consultations, 28 by telephone and 2 by e-mail; other data were by combined methods. The average duration of consultation was 47 minutes, and 24 responses occurred within one business day. The top three services requested for consultation were psychiatry (e.g., management of behavioral disturbance), medical genetics (diagnosis), and gastroenterology (miscellaneous). PCPs rated baseline satisfaction with: (1) pre-existing local services at 3.37, (2) timeliness of the PACT Net consultation at 5.45, (3) quality of the communication at 6.3, and (4) overall quality and utility of the consultation at 6.2. Specialists rated the quality of the communication at 6.45, and the ease of the service at 6.46. Phone and e-mail consultation appears satisfactory to PCPs and specialty providers as a way to enhance specialty input to rural patients.

Patients who have had stroke are at significant risk for various neuropsychiatric illnesses. The most common and important of these are poststroke depression and poststroke dementia (attributable to vascular dementia, Alzheimer's dementia, or a combination of mechanisms). Poststroke neuropathology may lead some patients to experience concurrent and "overlapping" mood and cognitive symptoms. Less frequently, poststroke anxiety disorders, psychosis, isolated pathologic expressions of emotions, and apathy or fatigue may be encountered. The authors review the current literature on poststroke neuropsychiatry and offer an integrated approach to pathophysiologic concepts and clinical surveillance, screening, diagnosis, and evidence-based pharmacologic and nonpharmacologic intervention for these clinical problems on the clinical boundary between neurology and psychiatry.

Objective: Telepsychiatry in the form of videoconferencing brings enormous opportunities for clinical care, education, research, and administration. Focusing on videoconferencing, we reviewed the telepsychiatry literature and compared telepsychiatry with services delivered in person or through other technologies. Methods: We conducted a comprehensive review of telepsychiatry literature from January 1, 1965, to July 31, 2003, using the terms telepsychiatry, telemedicine, videoconferencing, effectiveness, efficacy, access, outcomes, satisfaction, quality of care, education, empowerment, and costs. We selected studies for review if they discussed videoconferencing for clinical and educational applications. Results: Telepsychiatry is successfully used for various clinical services and educational initiatives. Telepsychiatry is feasible, increases access to care, enables specialty consultation, yields positive outcomes, allows reliable evaluation, has few negative aspects in terms of communication, generally satisfies patients and providers, facilitates education, and empowers parties using it. Data are limited with regard to clinical outcomes and cost-effectiveness. Conclusions: Telepsychiatry is effective. More short- and long-term quantitative and qualitative research is warranted on clinical outcomes, predictors of satisfaction, costs, and educational outcomes.

Research consistently shows that as many as one in five children and adolescents have mental health problems, and primary care providers (PCPs) identify 19% of children with behavioral and emotional disorders. Although these providers frequently refer children for mental health treatment, significant barriers exist to referral, including lack of available specialists, insurance restrictions, appointments delays, and stigma. Approximately 25% of the population lives in rural settings, and rural departments of health report an even greater problem with access to specialists for rural residents than their urban counterparts. In adults, and probably children and adolescents, the lack of mental health services leads to undertreatment, poor outcomes such as higher rates of suicide and homicide, as well as increased use of emergency services, hospitalizations, and placement in mental health institutions.ABOUT THE AUTHORSDonald M. Hilty, MD, is Professor of Psychiatry and Behavioral Sciences, and Director, Rural Program in Medical Education (Rural-PRIME), UC Davis School of Medicine and Medical Center. Peter M. Yellowlees, MD, MRCP, is Professor of Clinical Psychiatry and Behavioral Sciences and Director of Academic Information Systems, UC Davis School of Medicine and Medical Center. Priya Sonik, MD, is Resident of Psychiatry and Behavioral Sciences, UC Davis School of Medicine and Medical Center. Mikla Derlet, MD, is Assistant Clinical Professor of Pediatrics, UC Davis School of Medicine and Medical Center. Robert L. Hendren, DO, is Professor of Psychiatry and Behavioral Sciences, and Chief; Child and Adolescent Psychiatry; Tsakopoulos-Vismara Chair and Executive Director, M.I.N.D. Institute, UC Davis School of Medicine and Medical Center.Address correspondence to: Donald M. Hilty, MD, Department of Psychiatry and Behavioral Sciences, University of California, Davis, 2230 Stockton Boulevard, Sacramento, CA 95817; fax: 916-734-3384; or e-mail dmhilty@ucdavis.edu. Dr. Hilty; Dr. Yellowlees; Dr. Sonik; Dr. Derlet; and Dr. Hendren have disclosed no relevant financial relationships.

This chapter discusses the prioritization of desired outcomes and ongoing program evaluation in the provision of clinical videoconferencing (CV) services. It provides an overall organizing framework to consider program evaluation from the very early stages of planning. Emphasis is placed on crafting evaluation fitted to specific needs and available resources.

Psychiatric rehabilitation by its very nature is multidisciplinary because of the many competencies required for its implementation. In promoting optimal levels of recovery from schizophrenia and other disabling mental disorders, teams must combine the expert contributions of professionals and paraprofessionals who can individualize a comprehensive array of evidence-based services with competency, consistency, continuity, coordination, collaboration, and fidelity. The authors describe the properties and functions of the multidisciplinary team and key attributes of effective teams. The importance of teams' involving clients, their relatives, and other supporters in setting personally relevant life goals is emphasized. The authors provide examples of the challenges posed by the need to individualize services and of the ways in which barriers to communication and coordination can be overcome. The roles of the various team members are described, including leadership roles and the unique role of the psychiatrist, in the context of newly emerging, evidence-based treatments for psychiatric rehabilitation.

(2000). Psychiatry and Primary Care: New Directions in Education. Harvard Review of Psychiatry: Vol. 8, No. 4, pp. 206-209.

Bipolar disorder is relatively rare in obstetrics and gynecology (ob/gyn) practice compared with depressive and anxiety disorders, but there is a high risk for poor outcomes for patients and their offspring. Ob/Gyn physicians are assuming increasing responsibility for the care of these patients in today’s managed care environment, working independently or in collaboration with a psychiatrist. The clinical presentation of bipolar patients may include mania and/or depression, in addition to more minor mood fluctuations that accompany the emotional and physical changes of pregnancy. The key issue in the differential diagnosis is to rule out medical, surgical, medication, and substance etiologies of mania that are potentially reversible. Indications for routine, urgent, and emergent referrals to a psychiatrist are reviewed. Treatment for bipolar women considering pregnancy includes prepregnancy planning education, involving the patient, family, psychiatrist, ob/gyn physician, and maternal-fetal medicine specialist. Treatment for pregnant bipolar women includes an individualized risk/benefit assessment regarding medication, monitoring levels and adherence to medication if it is used, ongoing patient education, and collaboration between the ob/gyn physician, maternal-fetal medicine specialist, and psychiatrist.

The primary care physician is increasingly important in the delivery of mental health services in the primary care setting. A review of investigations from several decades reveals that mental disorders are present in approximately 25% of primary care patients. [24] Primary care practices serve as the de facto hidden mental health network, providing the sole contact for over 50% of patients with mental illness. [21] Overall, approximately 60% to 70% of patients with anxiety, mood, somatoform, chemical dependency, and psychotic disorders are seen within the primary care setting. [25] Psychotic disorders occur in about 1% of patients in the primary care setting [14] and 3% in the general population. [20] This rate is lower than rates for depression (5%-10%), general anxiety disorder (1.6%-11.9%), panic disorder (1.6%-11%), alcohol disorders (5%-15%), other substance disorders (5.0%-7.1%), somatization disorder (2%-3%), and hypochondriasis (0.5%-6.3%). [13] At least 30% of patients with a psychotic disorder are treated in the primary care setting, [20] and in recent years, this may have increased. These patients have significantly decreased quality of life, capacity to work, and ability to maintain relationships. Patients with a psychotic disorder commit suicide at a rate of 10%. [19]

This paper reviews the epidemiology, etiology, assessment, and management of bipolar disorder. Special attention is paid to factors that complicate treatment, including noncompliance, comorbid disorders, mixed mania, and rapid cycling. Advances in biopsychosocial treatments are briefly reviewed, including new health service models for providing care.A MEDLINE search was done for the period from January 1988 through October 1997 using the key terms of bipolar disorder, diagnosis, and treatment. Papers selected for further review included those published in English in peer-reviewed journals. Preference was given to articles reporting randomized, controlled trials.Bipolar disorder is a major public health problem. The etiology of the disorder appears multifactorial. Diagnosis often occurs years after onset of the disorder. Comorbid conditions are common. Management includes a lifetime course of medication and attention to psychosocial issues for patients and their families. Standardized treatment guidelines for the management of acute mania have been developed. New potential treatments are being investigated.Assessment of bipolar disorder must include careful attention to comorbid disorders and predictors of compliance. Randomized trials are needed to further evaluate the efficacy of medication, psychosocial interventions, and other health service interventions, particularly as they relate to the management of acute bipolar depression, bipolar disorder co-occurring with other disorders, and maintenance prophylactic treatment.

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.

he major results of the Myers et al. Children’s ADHD (attention-deficit/hyperactivity disorder) Telemental T Health Treatment Study (CATTS) are reported in this issue of the Journal. This study has very significant implications for the practice of psychiatry in general, child psychiatry, rural and primary mental health service delivery, and all of us in this era of increasingly integrated care. The findings could lead to better dissemination of existing evidence-based treatments and new modalities of treatment for some psychiatric disorders delivered at a distance, even if the patient is not particularly geographically isolated. Indeed, service delivery in person and by technology to the same and/or different patient(s)—what has been called hybrid care—is an example of a new way to practice and a way that many psychiatrists and other physicians are increasingly using as multiple new technologies permeate our personal and professional lives. This hybrid approach to care is one of many variations on the theme of providing patient-centered care that is affordable, timely, and easy to access. In addition, the CATTS could lead us to change the way we conceptualize practice, and the methods used in the study could become the future standard of practice for the delivery of not only ADHD treatments but also some other treatments in the mental health arena. CATTS is the first randomized study that demonstrates the clinical effectiveness of a truly hybrid approach to mental health service provision in which different synchronous and asynchronous telehealth approaches to care were combined with traditional in-person modalities. Some previous studies have suggested that this hybrid approach holds a great deal of promise, with some investigators postulating that telepsychiatry consultations might be the new standard of practice in certain clinical situations. Several smaller examples of hybrid care have been published. A small, nonrandomized study of 118 primary care patients compared in-person psychiatric care with telepsychiatric care provided by the same psychiatrist, which resulted in hybrid care for most. Patients’ experience of the psychiatrist and satisfaction were equal for either way the care was delivered. A traditional trial of videoconferencing treatment efficacy turned into an example of the use of multiple technologies (videoconferencing, phone, and e-mail) to deliver care in what was effectively a hybrid model. Original collaborative care studies have involved significant patient education, case management, psychiatric consultation in person, patients with depression and anxiety, and co-management of medications by primary care and psychiatric physicians. Fortney

A psychiatric consultation report form was developed to efficiently and accurately meet the stringent Medicare documentation guidelines that go into effect July 8, 1998. This form was designed for use in academic institutions where the consultation team includes teaching physicians, psychiatric residents, and medical students. Medicare has strict requirements regarding who may document each element of the consultation for billing purposes. These requirements were taken into account in the design of this form. Two academic consultation-liaison psychiatric services piloted the form and conducted internal audits to evaluate its usefulness. The accuracy of billing improved twofold at one site because the form facilitated rapid completion of details requisite to justify CPT codes of complex assessments. This saved considerable time and effort over the previous methods used to determine an appropriate level of billing. Critical information was documented more frequently, thereby meeting the documentation requirements more consistently. Instructions for use, criticisms, and cautions are given.

The topic "A Day in the Life of a Psychiatry Resident" is an opportunity to explore residents' experiences to inform the delivery of education.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.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.A larger qualitative analysis of these issues, followed by testing of theories by quantitative methods, is indicated.

Introduction Gathering clinical information about the patient in a therapeutic manner is an important interviewing goal, particularly for the psychiatric interview. Psychiatry clerkship students may use this self-learning module (SLM) to prepare for their first supervised psychiatric interview. Alternatively, this module can help first- and second-year students in a behavioral medicine or psychopathology course prepare for a standardized patient interview. Methods This module presents video clips of a psychiatrist conducting a psychiatric interview of a patient with depressive symptoms. Samples of the key components of the interviews, such as the chief complaint, history of present illness, past treatment history, social and developmental history, cognitive exam, and risk assessment are taught using combinations of video clips, interactive diagrams, and selfassessment quizzes. Additionally, basic interview techniques are discussed and illustrated during the interview. Results This SLM has been implemented within the psychiatry clerkship at the University of California Davis, School of Medicine and piloted in the psychiatry clerkships at both Georgia Health Science University and the University of Florida School Of Medicine. This module was piloted by four students and two faculty members. One of the two faculty reported that the SLM could be adapted for first-, second-, and third-year medical students, as well as to behavioral health students. Three out of four students somewhat agreed or strongly agreed that the module: (a) increased their comfort level with performing the psychiatric interview, (b) increased their comfort level with interacting with mentally ill patients, and (c) increased their comfort level of assessing risk of harm. All four students somewhat agreed or strongly agreed that the module increased their comfort level both with applying psychiatric interview techniques in patient interactions and eliciting a symptom history from patients. This SLM was also presented at the 2011 Association of Directors of Medical Student Education in Psychiatry (ADMSEP) Poster Session where we received extensive feedback and won the ADMSEP “2011 Outstanding Education Poster Award.” Discussion Gathering clinical information about the patient in a therapeutic manner is an important interviewing goal, particularly for the psychiatric interview. This resource successfully teaches learners the components of the psychiatric interview.

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.

Videoconferencing has increased patient access to psychiatric care by linking specialists at academic or regional health centres with primary health care professionals in shortage areas (Hilty et al, 1999, 2002). Preliminary studies have demonstrated positive outcomes and user satisfaction (Hilty et al, 2002). Information is still being sought regarding costs because of a paucity of clinical outcome studies, cost data and randomised trials.

The patient-centered care features quality, affordable, and timely care in a variety of settings – technology is a key part of that – particularly among younger generations and child and adolescent patients. The consumer movement related to new technologies is nearly passing clinicians by, as new ways of communicating with others (text, e-mail, Twitter, Facebook) revolutionizes how we experience life and access healthcare. This paper explores a continuum with healthy, innovative behavior on one end (e.g., social media) and pathological Internet use on the other end – and the range of self-help and e-mental healthcare options being used. Specifically, it focuses on how social media adds to, yet may complicate healthcare delivery, such that clinicians may need to adjust our approach to maintain therapeutic relationships, interpersonal/clinical boundaries, and privacy/confidentiality. We suggest planning ahead to discuss expectations about online communication between doctors and patients as part of the informed consent process, offer other do's and dont's for patients and clinicians, and review applicable guidelines. More research is needed on consumer and patient use of technology related to healthcare, as is an approach to basic and advanced measurement of outcomes.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The declining numbers of clinician-researchers in psychiatry and other medical specialties has been a subject of growing concern. Residency training has been cited as an important factor in recruiting new researchers, but there are essentially no data to support this assertion. This study aimed to explore which factors have influenced motivation to conduct research among senior psychiatry residents. The authors surveyed senior residents, inquiring about their level of interest in research, demographics, background, research experiences, and factors influencing motivation for research. The authors had confirmed participation from 16 of 33 residency programs with a class size of 10 or more. They received 127 responses, a 67% response rate, from participating programs. Residents with high stated interest in research differed from those with low and moderate interest in their research-intense post-residency plans. They were more likely to have graduate degrees. Those planning research careers had a consistent pattern of interest and involvement in research, starting well before residency. The majority of residents had had research exposure in college, but research involvement of those with very high versus lower interest diverged sharply thereafter. Those with high research interest were overwhelmingly male and tended to have lower debt than those with less interest. The great majority of residents appear to have decided whether or not to pursue a research career by the time they reached residency, and few of those with less than the highest research interest were enrolled in research tracks. Efforts to increase recruitment into research should center on identifying early developmental influences, eliminating barriers specific to women, and ensuring adequate funding to provide secure careers for talented potential researchers.

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).

To describe the technical development of an asynchronous telepsychiatry application, the Psychiatric Video Archiving and Communication System.A client-server application was developed in Visual Basic.Net with Microsoft(®) SQL database as the backend. It includes the capability of storing video-recorded psychiatric interviews and manages the workflow of the system with automated messaging.Psychiatric Video Archiving and Communication System has been used to conduct the first ever series of asynchronous telepsychiatry consultations worldwide. A review of the software application and the process as part of this project has led to a number of improvements that are being implemented in the next version, which is being written in Java.This is the first description of the use of video recorded data in an asynchronous telemedicine application. Primary care providers and consulting psychiatrists have found it easy to work with and a valuable resource to increase the availability of psychiatric consultation in remote rural locations.

838 Objective: This study examined the feasibility of conducting psychiatric consultations using asynchronous, or store-and-forward, videobased telepsychiatry. Methods: Video-recorded 20- to 30-minute assessments of 60 nonemergency, English-speaking adult patients in a medically underserved county in California were uploaded along with other patient data to a Webbased record. Two psychiatrists then used the record to provide psychiatric consultations to the referring primary care providers. Results: Eighty-five percent of patients received diagnoses of mood disorders, 32% diagnoses of substance use disorders, 53% diagnoses of anxiety disorders, and 5% other axis I diagnoses. Psychiatrists recommended short-term medication changes for 95% of the patients and provided guidelines for possible future changes. Conclusions: This study—the first study of asynchronous telepsychiatry to be published—demonstrated the feasibility of this approach. This type of assessment should not replace the face-to-face psychiatric interview, but it may be a very helpful additional process that improves access to care and expertise. (Psychiatric Services 61: 838–840, 2010)

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. 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. 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. 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.

This study evaluated the strategies for postpartum depression (PPD) screening by surveying healthcare providers at a US academic medical centre.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.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.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: 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. (Psychiatric Services 61:200–203, 2010)

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. Journal of Hospital Medicine 2009;4:50–59. © 2009 Society of Hospital Medicine.

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. Journal of Hospital Medicine 2008;3(6):473–482. © 2008 Society of Hospital Medicine.

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 provides an overview of how trainees, faculty, and institutions use technology for acquiring knowledge, skills, and attitudes for practicing modern medicine.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.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.Willingness for change, collaboration, and leadership at all levels are essential factors for successfully implementing technology.

This article highlights technology innovations in psychiatric and medical education, including applications from other fields.The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education.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.Innovations, like other uses of technology, require collaboration between parties and integration within the educational framework of an institution.

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.

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.

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.

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.

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.