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PubMed1992

Treatment of behavioral symptomatology of Alzheimer's disease, with emphasis on aggression: current clinical approaches.

A scientific information base is developing which focuses on understanding and managing behavior problems in geriatric populations, especially those with dementing illnesses such as Alzheimer's disease. Many of these behavior problems occur in long-term care settings, which have a high prevalence of residents exhibiting emotional and behavioral disorders, often secondary to psychiatric illness. Prior to beginning treatment, behavior disorders must be systematically evaluated and understood to insure optimum care planning. One approach to effectively treating these disorders is to first separate them into two categories: those not amenable to psychotherapeutic medication treatment (nonpsychiatric disorders) and those that are amenable (psychiatric disorders). Specific nonpharmacological treatments may benefit those nonpsychiatric behavioral disorders and include behavioral and environmental paradigms. The psychiatric disorders, especially aggression and assaultive behavior, may be treated beneficially using a variety of psychopharmacological agents, including antianxiety agents, neuroleptics, carbamazepine, beta-blockers, and lithium. The most effective approach toward treating the psychiatric behavior disorders often combines both medication and nonmedication strategies.

Activities of Daily Living↗
PubMedDate not supplied

HIPAA and the special status of psychotherapy notes.

HIPAA regulations grant special status to psychotherapy notes, placing greater restrictions on their use and disclosure versus other information in a patient's record. Regulations specifically prohibit health plans from requiring the disclosure of psychotherapy notes in their consideration of health claims. However, this issue is surrounded by much confusion. If the information in psychotherapy notes is found only in the psychotherapy notes, it is protected under this provision. However, information that rightfully belongs in the more accessible part of the record is not considered part of psychotherapy notes. In addition, there are certain circumstances in which a provider may be required to disclose psychotherapy notes. This article discusses the definition of psychotherapy notes under HIPAA, comments on the relevance of psychotherapist-patient privilege, and provides important information for the case manager when managing psychiatric patients.

Confidentiality↗
PubMed1994

Using an appeals panel to mediate mental health care UR disputes.

The certification of admission and lengthy psychiatric hospitalizations raises fundamental issues related to the appropriateness of treatment. The author presents several case examples to illustrate how an appeals panel resolves disputed utilization review decisions regarding inpatient psychiatric treatment.

Decision Making, Organizational↗
PubMed1989

[Simulated illnesses. Especially Munchausen syndrome].

Factitious disorders pose considerable problems for doctors with respect to diagnosis and therapy. Simulation, the conversion syndrome and the Muenchausen syndrome should be distinguished as individual aspects of the disease. The Muenchausen syndroms has a unfavourable prognosis, as it is difficult to diagnose, in addition to which the patients in question are not approachable for necessary psychiatric treatment.

Expert Testimony↗
PubMed2001

Do older people receive equitable private psychiatric service provision under Medicare?

OBJECTIVE: The objective of this study is to determine the 1998 rates, types, regional variation and Medicare expenditure of private psychiatry services for older people in Australia, as compared with younger adults and with 1985-1986 data. METHOD: Medicare Benefits Schedule Item Statistics for the psychiatric item numbers 300-352 and item 14224 were obtained from the Health Insurance Commission for each State and Territory. The items were examined in the age groups 15-64 years, 65 years and over and 75 years and over. Main outcome measures were per capita service provision by age group, State and Territory and Medicare expenditure by age group. RESULTS: During 1998, 6.4% (5765.6 per 100 000) of private psychiatric services were to patients aged > 64 years. Patients aged 15-64 received 2.7 times the number of psychiatric services per capita than patients > 64 and 3.6 times that of patients aged > 74 years. Patients aged > 64 received more hospital and nursing home consultations, home visits and electroconvulsive therapy per capita, while younger adults used more office-based consultations, longer consultations, and group therapy. Victoria had the highest per capita rate (7659.2 per 100 000) and the Northern Territory the lowest (540.4 per 100 000), although the highest proportion of services to older patients was in Western Australia. Per capita the proportion of Medicare expenditure allocated to adults aged less than 65 years was 4.1 times that for adults over 64 years. CONCLUSIONS: Private psychiatric service provision to older people is inequitable when compared with younger adults. The proportion of Medicare private psychiatry expenditure on older adults has declined since 1985-1986.

Adolescent↗
PubMed1998

Medical necessity and psychotherapy.

Managed care and, specifically, the need to conform to medical necessity requirements have had a dramatic effect on medical and psychiatric practice, especially on psychotherapy. The author describes the progression of the concept of medical necessity from a simple accounting of services reimbursable by insurance companies to an ambiguous term without definitional consensus. He describes its relationship to the medical model and discusses the incongruity between medical necessity and certain aspects of psychotherapy. He proposes a broader concept--health necessity--based on an evaluation on the merits of the advantages, disadvantages, and costs of medical and psychiatric services.

Humans↗
PubMed2001

The development and evaluation of the brief depression screen in medically ill disability claimants.

OBJECTIVE: There is literature demonstrating elevated prevalence of depression in primary care. Yet there remains a need for a brief depression screen designed and evaluated specifically for use among medically ill patients. Our objective was to develop and validate a brief, unobtrusive screen for depression among severely medically ill long-term disability claimants. METHODS: The study sample consisted of 480 long-term disability claimants, less than 55 years of age, with one of the following illnesses: cancer, diabetes, myocardial infarction, rheumatoid arthritis, stroke, or multiple sclerosis. Each subject completed a questionnaire that included 26 potential screening items. A subset of subjects was administered the SCID, which served as the gold standard for the DSM-IV depression and dysthymia diagnoses. RESULTS: The Brief Depression Screen, a three-item screen for major depressive disorder and dysthymia, was developed. About 34 percent of the sample met criteria for major depressive disorder or dysthymia. The Brief Depression Screen detected 75 percent of those subjects in this sample. Furthermore, nearly half of the subjects with positive screen results met criteria for depression or dysthymia. These results are comparable to those of the eight-item Burnam screen, but not as sensitive as the more widely used, twenty item CES-D. CONCLUSION: The Brief Depression Screen was developed and evaluated for use with severely ill long-term disability claimants. In practice, a positive screen for depression is to be followed with a comprehensive diagnostic assessment that could be conducted by a trained clinician. Further research is warranted to determine whether the identification and treatment of depression in disability claimants with non-psychiatric medical illnesses will facilitate return to work, even in the presence of comorbid medical illnesses.

Depressive Disorder↗
PubMed2006

Disability pension for psychiatric disorders: regional differences in Norway 1988-2000.

The aim of this study was to describe regional differences in the incidence of disability pensions (DPs) with psychiatric diagnoses, and to determine whether these differences were related to age and/or gender. We compared the incidence rates of new DPs including all diagnoses, with DP with psychiatric diagnoses in Norwegian regions from 1988 to 2000. The population at risk was all individuals aged 16-67 in each year. Individuals already on DP were excluded. Cases were collected from the Norwegian National Insurance Administration. The results showed that the incidence rate ratio (IRR; Norway reference) for DP with psychiatric diagnoses was most elevated for men 1.41 (95% CI 1.27-1.58) and women 1.48 (95% CI 1.34-1.64) living in the most rural region. Men in the urban area had a higher IRR, 1.33 (95% CI 1.26-1.40), than urban women, 1.02 (95% CI 0.96-1.07). The incidence more than doubled in the youngest age group (16-29 years) and decreased in the oldest age group (60-67 years) between 1988 and 2000. The findings conclude that individuals living in semi-rural regions of Norway are more likely to receive a DP with a psychiatric diagnosis than those living in urban areas. Large gender differences were found in the urban area. Further research is needed to investigate the impact of the psychiatric healthcare system and access to rehabilitation on psychiatric disability.

Adolescent↗
PubMed2005

[Reform in mental health services--from whence and to where].

For years the subject of mental health has been neglected in Israel, and reform of mental health services is now of paramount importance. Psychiatric medicine has altered considerably over the years, and emphasis is shifting from treatment in mental health institutions to treatment at the community level. This transition is the result of the awakening of groups in our society advocating civil rights for the mentally ill and their integration into the community. This process is also bolstered by the advent of new anti-psychotic drugs. However, the social and medical infrastructure set up to deal with these issues has been found lacking. Over the past few years the Minister of Health has appointed a number of committees to address this issue, and they have all recommended extensive reform of mental health services in Israel. The recommendations handed down by the committees are for: (1) Restructure of mental health services, with emphasis on community services and gradual reduction of psychiatric beds; (2) Allocation of additional funding specifically ear-marked for the mentally challenged, enabling transfer of stabilized patients out of the hospital setting and often lengthy and unnecessary hospitalization, into community rehabilitation centers; (3) Transfer of responsibility for health insurance for mentally ill people from the State to the Health Funds, enabling integration of psychiatric treatment into the general treatment framework. The reform has already been initiated. This body of work will review the stages, processes and the difficulties that preceded the reform.

Community Mental Health Services↗
PubMed1992

Cancer survivors.

Cancer survivorship is becoming a newly defined entity. Cancer therapies can produce many late physical effects by adversely affecting every organ system. Psychosocial issues that have been studied include: psychiatric, self-concept, school performance, and behavioral adjustment, employment and insurance discrimination, and marital status. Quality-of-life assessments in adult survivors is comparable to controls but is diminished for children with disease or treatments that affect the CNS. The greatest fear for cancer survivors is the 10 to 20 times greater risk of SMN as compared with persons with no history of cancer. Infertility and sexual dysfunction are real concerns for survivors that usually go unexpressed. Some cancers have a familial predisposition; however, treatments do not appear to increase the risk of birth defects or childhood cancers in the offspring. Lower socioeconomic status adversely affects cancer survival because of lost opportunities for cancer screening, other diseases, and untreated cancer. The primary care physician can competently care for cancer survivors and should emphasize health promotion and risk prevention behaviors, topics especially applicable for this patient population.

Antineoplastic Agents↗
PubMed1990

Managed care: a means of rationing psychiatric treatment.

Some form of patient care review has become an integral component of most health insurance plans. The author describes the numerous ways in which such review negatively affects the therapeutic relationship between the doctor and the patient. Pressured to cut costs, reviewers are unlikely to be objective in their evaluation of the need for treatment. Many are not qualified to review particular types of treatment. Avenues for appeal of reviewers' decisions are weak. The intensity and frequency of review are often disruptive both to the treatment and to the psychiatrist's practice. Some patients discontinue treatment after learning that their care is being reviewed because of fears about loss of confidentiality or other reasons. Informed consent procedures relating to release and protection of confidential information are inadequate. The author emphasizes the need for setting standards for review organizations that will help overcome these and other problems.

Confidentiality↗
PubMedDate not supplied

[Which wards or hospital departments admit mentally ill patients? An analysis of hospital admissions recorded by the German Statutory Sickness Insurance Body in the light of the introduction of German budgeting practice].

STUDY OBJECTIVE: As from 2004, a diagnosis-related group financing system will be introduced in all somatic departments and wards in Germany. In future, only psychiatric and psychosomatic departments will continue the system of patient-related per capita budgeting. In view of this fact, it is necessary to determine which hospital wards or departments admit mentally ill patients, as the funding--and hence the therapeutic options available--will vary fundamentally between psychiatric and somatic departments. METHOD: An evaluation was made of more than 1,000,000 hospitalised patients on the books of the country's second largest medical insurance organization, the DAK, in the year 2001. Of these cases, almost 68,000 were in the diagnostic category F (psychiatric diagnoses) ICD-10. FINDINGS: Some 32.4 % of cases where the main diagnosis upon dismissal was psychiatric were admitted to somatic wards, most of them (19.3 % of the total) to internal medicine wards. A comparison between the different Federal States of Germany showed that the practice of admitting a substantial proportion of psychiatric diagnoses to somatic wards was not a merely regional problem, but widespread throughout the country. A disproportionately large number of those in somatic wards, mainly internal medicine wards, were in the diagnostic categories F13 (medication dependency), F10 (alcohol-related), F0-09 (cerebral organic disorders) and F40-48 (neurotic disorders). As a rule, the duration of hospital stay on somatic wards was less than half as long as on psychiatric wards. Two thirds of the internal medicine departments that dismissed patients with psychiatric diagnoses were in general hospitals that did not have their own psychiatric department. On the internal medicine wards the second most common diagnostic group in the age group 16-64 years, after ischaemic heart disease (I25), was alcohol-related disorders (F10). CONCLUSIONS: On the basis of these findings one could expect to find "mixed funding" of specific types of psychiatric diagnosis upon the introduction of the German budgeting practice system, although as a rule this will probably apply mainly to internal medicine departments with psychiatric budgets. As this system encourages shorter periods of hospitalization it seems likely that some of these patients will be transferred to psychiatric/psychosomatic wards after just a few days. However, it appears unlikely that there will be a corresponding increase in the number of psychiatric beds. For this reason, it is important that provision be made to accommodate psychiatric cases elsewhere, preferably in somatic, mainly internal medicine, wards. This expansion of capacity should also include the extension of activities carried out by the psychiatric/psychosomatic counselling and liaison services, as well as the introduction of short crisis intervention techniques and the so-called qualified detoxification of alcohol-abuse patients on internal medicine wards. As the present system offers no incentive to general hospitals to take such measures we can expect demand for beds in psychiatric/psychosomatic hospitals to increase. Furthermore, it is probable that there will also be an increase in the number of re-admissions of such patients, especially alcoholics, to somatic wards.

Adolescent↗
PubMedDate not supplied

Factors associated with the use of psychiatric consultations in short-term general hospitals.

A significant number of patients in general hospitals suffer from psychiatric distress or illness, but not all receive psychiatric consultation. This study examined several potential predictors of such consultation. These included patient characteristics (age, sex, race, insurance, disease stage, and number of medical diagnoses), characteristics of hospital stay (number of procedures, other consultations, length of stay, discharge destination), hospital characteristics (size, percent occupancy, teaching status, presence of a psychiatric unit, type of control), and community characteristics (region, urban/rural setting). Data were derived from a national sample of 327 hospitals. Parallel analyses using stepwise logistic regression were carried out across four samples: patients determined at discharge to have been hospitalized for diabetes, hip fracture, chronic obstructive pulmonary disease, and coronary artery bypass surgery. Results show a wide variation in the use of psychiatric consultations across different subgroups. Longer lengths of stay, urban setting. Northeast region, younger patient age, and other consultations were the most consistent predictors of the probability of psychiatric consultation. These variations may reflect differences in the need for consultation, differential recognition of these needs by providers, or differential availability of psychiatric consultation services. Moreover, they may have implications for equity and/or quality of hospital care.

Female↗
PubMed1991

[Violence by patients towards personnel/furniture in a psychiatric department. Patients' characteristics and reactions of the staff].

Violent behaviour by patients in the Psychiatric Department in Frederiksberg Hospital was registered during a period of seven months. A total of 135 violent episodes by a total of 35 patients were registered. Female patients were responsible for 84% of the episodes. 53% occurred during day hours and were often precipitated by attempts to limit the behaviour of the patients. In 111 cases, violence was directed to the staff. Staff members experienced sequelae in 87 cases. None of the episodes were notified to the local insurance organisations.

Denmark↗
PubMed2005

Prodromal interventions for schizophrenia vulnerability: the risks of being "at risk".

Given the morbidity and difficulty of treating psychotic disorders, including schizophrenia, there has been a move toward identifying and treating adolescents and young adults who appear to be clinically at risk or "prodromal" to psychosis. The field now has greater specificity in identification, with rates of 40-50% conversion to frank psychosis within 1-2 years. There is further evidence that medications and other treatments may have some efficacy for "prodromal" patients, though with variable side effects. However, controversy remains about some of the inherent risks in prodromal research, such as medication exposure and stigma among false-positives. In this paper, we add to this discussion through an analysis of ethics in prodromal research from the more established field of predictive genetic testing. Issues are raised about the effects of information on patients, families, and institutions, as well as future insurability, the limits of confidentiality (as it relies on discretion of patients and families), the autonomy of minors with psychiatric symptoms, and even the risks for the true-positive patient.

Confidentiality↗
PubMedDate not supplied

Connections to primary medical care after psychiatric crisis.

BACKGROUND: Patients presenting with a psychiatric emergency face a unique set of challenges in connecting to primary care. OBJECTIVES: We tested the hypothesis that, in contrast to usual care, case management will result in higher rates of connection to primary care. We examined variables affecting primary care entry, including insurance status, hospital admission, and concurrent linkages to mental health care. RESEARCH DESIGN/METHODS: This article reports on a preliminary outcome of an ongoing randomized controlled trial conducted with 101 patients presenting in an urban psychiatric setting. Patients were randomized to a case management team or to usual care. The need for medical care was assessed by documenting medical comorbidity. RESULTS: Average age of the sample was 37.5; 65% were male, and 78% had low income; 37% were African American and 9% were Hispanic. Within 3 months of study enrollment, 57% of the intervention group was successfully linked to primary care compared with 16% of the usual care group, a difference that was statistically significant (P < .001). Associated positive predictors for linkage to primary care included mental health care visits and success in obtaining health insurance. Inpatient hospital stay at the time of psychiatric crisis was negatively associated with later attendance at primary care. CONCLUSIONS: Case management intervention was effective in establishing linkage to primary care within 3 months. Ongoing work will evaluate primary care retention and physical and mental health outcomes.

Adult↗