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Volume 103, Issue 6 (2004)


 
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Editorials

Thomas C. Meyer, MD, Medical Editor, Wisconsin Medical Journal
Current views on mental health management
(full text PDF)

We are grateful indeed for the interest and dedication of the Mental Health Association of Milwaukee County and the authors they recruited to allow the publication of the timely and helpful review of mental health topics presented here. This issue of the Journal is designed to provide current thinking and managements of common and frequently difficult problems in mental health that may become the province of the primary care physician, mainly because of the scarcity of psychiatric consultation and guidance. Subspecialists, too, may benefit from much of the wisdom contained in these pages e.g. Dr Heinrich’s thoughtful review of unexplained symptoms and the concept of somatization (p 83).

Alan Adkins, MD
Survey suggests partnering relationships will improve
(full text PDF)

Access can be defined as timely patient contact with appropriate providers of needed health services. Timely contact facilitates early diagnosis and treatment. Appropriate providers mean culturally competent practitioners with necessary clinical skills. Needed health services should result in improving the health status of the population being served. Access is centrally important because it correlates with quality of care and health outcomes.

Darold Treffert, MD
PTSD and the practitioner
(full text PDF)

Part of the art of medicine, like in Goldilocks and the Three Bears, is getting it “just right” when it comes to under-diagnosing or over-diagnosing conditions—providing false negatives or false positives—in day-to-day practice. This is especially important, but problematical, when a new diagnosis appears on the scene because, in my experience, such new conditions often either continue to be unrecognized by some practitioners, or are over-recognized by others. Post-traumatic Stress Disorder (PTSD) is one such relative newcomer to “official” diagnoses. PTSD first appeared officially coded as such in DSM-III in 1980, although it had been known by various names before that: “soldiers heart,” “shell shock,” “traumatic neurosis,” or “Gross Stress Reaction,” to name several.

Joseph R. Cline, MD, FACEP
Post-traumatic stress disorder: Early recognition and intervention in the emergency department
(full text PDF)

Post-traumatic stress disorder (PTSD) has become an increasingly recognized condition in society, with significant and far-reaching consequences to the affected individual as well as those close to them. In this issue of the Wisconsin Medical Journal, Lee et al explore the awareness of and procedures for evaluation of PTSD risk in emergency departments (EDs) for victims of trauma. The study evaluates the awareness of the disorder and brings to light how under-appreciated the disorder actually is and how much more there is yet to learn about it. The importance of allied health professionals such as social workers, pastoral care, psychologists, and others in the total care of these patients is emphasized. Equally important is the awareness that effective and consistent risk recognition and intervention is best achieved with on-site professionals. These professionals see situations in the ED as they evolve, recognizing at-risk patients, as well as family members, and intervening with assistance and linkage to follow-up and treatment. Only by early recognition can we effectively reduce the incidence of this disorder.

Shannon Lee, MS; Karen Brasel, MD, MPH; Barbara Lee, RN, PhD
Emergency Care Practitioners’ Barriers to Mental Health Assessment, Treatment, and Referral of Post-Injury Patients
(full text PDF)

Objective: Nearly half of all severely injured patients suffer some form of post-trauma mental stress, but little is known about factors that influence emergency care practitioners’ decisions to refer injured patients to mental health care services. This study aimed to: (1) advance our understanding of the practice barriers that hinder mental health assessment, treatment, and referral of injured patients in emergency care settings, and (2) determine the preferred learning format of emergency care practitioners who desire to gain knowledge about mental health problems after injury.

Methods: Using a mail survey research design, data were collected from a random sample of emergency medicine physicians and nurses in Wisconsin and New York.

Results: Data was provided by 108 respondents with an average of 16 years of emergency care experience. More than half indicated they never refer trauma patients for mental health follow-up. Primary reasons for not dealing with trauma-related mental health issues were insufficient time and lack of symptoms. Providers who were most satisfied with their hospital’s capacity to support mental health care were significantly more likely to refer patients. The top preference for receiving additional training related to mental health needs of trauma patients was on-site lectures.

Conclusion: Injured patients rely on emergency care practitioners to provide multidimensional care. How-ever, few practitioners facilitate mental health referrals for post-trauma victims, despite their known value.

Martha Rasmus, President/CEO, Mental Health Association in Milwaukee County
Mental Health Association partners with physicians in mental health education
(full text PDF)

Physicians encounter many individuals with mental illness in their practice. In fact, they are in a unique position to first recognize and respond to mental disorders. However, the current dynamics of physician practice work against the best inclinations of the provider. Financing arrangements and time constraints make it difficult for the physician to feel like he or she has adequate time to appropriately identify mental disorders. If a mental disorder is identified, the provider may feel ill-equipped to respond, preferring to refer these individuals to specialists. While in some, if not many, instances a referral is an appropriate response, the serious shortage of mental health specialists in many areas of the state will limit the ability of physicians to utilize this option. Additionally, the continuing stigma around mental illness will result in individuals being unwilling to seek care from a specialty provider. As a result, the physician may often be the only available or acceptable provider of mental health services for many individuals.

Commentaries

Clarence Chou, MD
Mental health impacts all practices
(full text PDF)

A physician’s practice frequently deals with the issue of mental disease, whether it is apparent through the words and actions of the patient or manifested through physical symptoms, difficulty in treatment compliance, or disruptive behaviors.

Clarence Chou, MD
Antidepressant medication usage in the pediatric population
(full text PDF)

There has been a significant amount of interest and concern over the use of antidepressant medications in the pediatric population. In October 2004, the FDA recommended that the manufacturers of all antidepressant medications include a “black box” warning of the potential for suicidal thoughts and actions when a child is taking these medications. This “black box,” which is prominently displayed on the drug package inserts, is used only to signify a significant risk associated with a particular medication. The FDA did acknowledge that the “black box” warning is not a contraindication to the use of these medications. There was also discussion as to whether to add to the medication labels information about the studies that often found no difference in effect of most of the antidepressant medications and a placebo, or sugar pill. This paper will discuss the recent history of antidepressant usage, the sequence of the process that led up to the warning, and speculation about the possible mechanisms for the action of the medications. There will be a brief discussion of the general process of the evaluation and treatment of a child with depression, and a brief summary with discussion of future directions in treatment.

Ronald J. Diamond, MD
What primary care physicians need to know about people with schizophrenia
(full text PDF)

Schizophrenia is an illness that attacks people as they first move into adolescence and adulthood, just at the time when they are starting their dreams of what they want their lives to be. It is a disorder that comes with a surprisingly high risk of mortality, from both suicide and medical illness. Even among health professionals, there are many misconceptions about schizophrenia, including the belief that there is invariably a downhill course to the illness. Actually, schizophrenia is an episodic illness, often with ups and downs, and a surprisingly large number of people affected by it are able to live independently, work at jobs they like, and have social relationships that are satisfying. Living with schizophrenia is never easy, but many people with this illness are able to live more complete and normal lives than is commonly believed.

Clarence Chou, MD
Dealing with the “difficult” patient
(full text PDF)

The nature of patient-physician relations has changed over the recent past. Fifteen or 20 years ago, patients related more consistently to their physicians as someone who knew them and their families and were authoritative sources of information and treatment, and physicians saw their patients in a more dependent role. There was little second-guessing or overtly expressed dissatisfaction with treatment. But more recently, there has been a fragmentation of patient care. Patients and their families are more mobile, and managed care has led to experiences of discontinuity of care. Frequently, patients and physicians express concern about the lack of time for interaction, which has an impact on the issues of trust and the ability to clear up misunderstandings. The rise of consumerism, self-help groups, and the Internet have led to more patients questioning and taking a more active role in their treatment. Treatments described as alternative or complementary, which may have less rigorous scientific backing—if any at all—account for a third of all health care dollars spent in this country. A lot of the money is spent because conventional medicine is seen as not addressing the concerns of the patient. In addition, drug advertising has had an impact on the playing field, as patients now come to their physicians’ offices with specific requests. All of these factors have contributed to the increase in physician encounters with patients perceived as being “difficult.”

Original Research

Timothy Howell, MD, MA
Managing medical and psychiatric comorbidities
(full text PDF)

The task of assessing and treating patients with combined medical and psychiatric problems can seem daunting, especially as patients become older, acquire chronic conditions, encounter acute illnesses, and take increasing numbers of medications. Add intercurrent social stressors as well as personality issues that affect how patients cope and this task can seem bewildering. But there has been significant progress made over the past few years in better appreciating how such factors may interact. Representative examples, which will be the focus of this article, include advances in the understanding of how vascular disease or diabetes and depression or cognitive impairment may interact and exacerbate each other. (For two other examples, epilepsy and end-stage renal disease, see the article by Bresnehan elsewhere in this issue.) In addition, evidence is emerging of how adequate treatment of depression may improve outcomes in vascular disease or diabetes, and vice versa. These significant advances in research at the interface of medicine and psychiatry are a source of valuable guidance.

Jerry Halverson, MD; Carlyle Chan, MD
Screening for Psychiatric Disorders in Primary Care
(full text PDF)

Two-thirds of all patients with psychiatric disorders are seen exclusively in primary care settings. Thirty percent of all primary care patients meet DSM-IV-TR criteria for a psychiatric disorder, but many of these patients go undiagnosed.1 Undiagnosed psychiatric disorders harm the patient’s health and functioning. This can be prevented, because early effective treatment leads to better outcomes.2,3 For this reason, there has been piqued interest in finding more efficient ways for primary care to identify those at risk for psychiatric conditions. Current United States Preventative Services Task Force (USPSTF) guidelines encourage screening for psychiatric disorders in primary care.4,5 Increased screening should lead to increased detection and improved management of psychiatric conditions. The purpose of this paper is to acquaint medical providers with several screening tests that are useful for identifying psychiatric risk for patients in their clinics. We will concentrate on the 4 areas of psychiatric comorbidity that are most common—and most commonly missed—in primary care: depression, anxiety, alcohol abuse, and cognitive impairment. We will review the strengths and weaknesses of the individual tests and make recommendations based on the realization that extra time is a luxury few generalists have.

Robert Kinderman, MSW; Bruce Christiansen, PhD; Richard Carr, MD
Are Pre-Authorization Requirements an Access Barrier to Outpatient Mental Health Care for Medicaid Enrollees? A Survey of Providers
(full text PDF)

Background: Pre-authorization requirements permit managed care organizations control over access to care. Anecdotal reports to the Wisconsin Medicaid program suggest that pre-authorization requirements are so onerous that they are barriers to outpatient mental health care.

Methods: Clinicians providing mental health/alcohol and other drug abuse services to Wisconsin Medicaid were surveyed regarding their experiences obtaining outpatient service pre-authorizations from health maintenance organizations (HMO) for Medicaid enrollees. The survey obtained factual information regarding pre-authorization procedures and decisions, as well as clinicians’ attitudes about the pre-authorization process.

Results: Requests for service pre-authorizations are generally responded to in a timely fashion and frequently approved. One hundred fifty seven (44%) respondents rated the HMO that they worked with as above average or the best while 97 (27%) rated it as below average or the poorest. Respondents’ criticisms of their HMO focused on failures to make useful treatment suggestions and a lack of understanding regarding the limited availability of community resources that could be alternatives to treatment. Therapist attitude was more favorable when pre-authorization was sought from the HMO directly rather than through a gatekeeper.

Conclusion: The pre-authorization requirement for outpatient services is not an undue burden for the mental health/alcohol and other drug abuse providers or patients.

David B. Bresnahan, MD
Psychiatric Comorbidity in Epilepsy and End Stage Renal Disease
(full text PDF)

Many chronic serious medical conditions are associated with increased psychiatric comorbidity. Two such conditions are epilepsy and chronic renal failure. While specialists are often involved in the care of these patients, well-established primary care remains an important part of their treatment. When psychiatric conditions arise, primary care providers will often be the first to see these disorders. These can be very complicated patients, and coordination of care between primary care physicians, specialists, and other health care providers is essential. Recognition, treatment initiation, and referral when needed are reviewed in this article.

Jo M. Weis, PhD; Brad K. Grunert, PhD
Post-traumatic Stress Disorder Following Traumatic Injuries in Adults
(full text PDF)

The residuals of traumatic injuries from home or workplace accidents, automobile accidents, physical assault, or other unintentional human error can affect victims both physically and psychologically. Symptoms of post-traumatic stress disorder (PTSD) are common among survivors of accidents and nonsexual assaults and can impede recovery. Early identification of PTSD and timely referrals to mental health providers can greatly reduce medical expenses, disability payments, lost wages, lost work productivity, and direct mental health costs. A physician-screening tool to identify PTSD is outlined in this article and can be completed in a few minutes. Implementation of this screening following traumatic injuries can promote early diagnosis of possible psychological complications and facilitate referral to appropriate mental health professionals.

Serena Clardie, MSW, LCSW
Post-traumatic Stress Disorder Within a Primary Care Setting: Effectively and Sensitively Responding to Sexual Trauma Survivors
(full text PDF)

It is estimated that 1 in 4 females and 1 in 6 males have experienced sexual assault or abuse before the age of 18.1 While the response to such experiences vary, a significant number of survivors will develop post-traumatic stress disorder or another mental illness. Post-traumatic responses can persist for years and may impact a patient’s experience of medical care. Unfortu-nately, consistent inquiry around sexually traumatic experiences is not implemented in primary care settings. As a result, patients may feel retraumatized while receiving care or their mental health symptoms may be misdiagnosed, resulting in inappropriate treatment or referrals. Screening for sexual trauma and gaining an understanding of how to respond empathically to post-traumatic responses enable primary care physicians to provide sensitive and effective care to trauma survivors.

Thomas W. Heinrich, MD
Medically Unexplained Symptoms and the Concept of Somatization
(full text PDF)

Somatization, the physical expression of psychological distress, is a prevalent and important problem. It is seen in a wide variety of clinical settings and represents a significant evaluation and management dilemma. The burden to the patient—coupled with the consequential economic and social costs—can be substantial. As a result, the identification and appropriate management of these patients and their often-challenging symptoms is imperative. The following review attempts to summarize the significant body of work committed to the concept of somatization in the medical, surgical, and psychiatric literature. Articles were found through a Medline Search. The search was performed utilizing the terms “somatoform disorders,” “somatization,” “somatization disorder,” “alexithymia,” and “medically unexplained symptom” for January 1966 through May 2004. Appropriate referenced articles and text were also identified and incorporated.

John M. Gillmore, MD; Carlyle H. Chan, MD
Suicide: A Focus On Primary Care
(full text PDF)

The judgment of the primary care physician is critical in preventing suicide since most mental health care is provided by a primary care doctor. This article will briefly discuss the epidemiology of suicide, then turn to the pragmatic assessment of suicide in the primary care office and treatment issues in patients with elevated suicide risk. Special attention is paid to the risk of suicide with antidepressants because of the recent publicity and the concerns many practitioners have expressed.

Sherri Hansen, MD
Antidepressant Choices in Primary Care: Which to Use First?
(full text PDF)

The past 15 years have seen a tremendous growth in the number of new medications to treat a variety of psychiatric disorders. In 1998 fluoxetine (Prozac) was marketed in the United States and ushered in a new era of medication treatments for major depression and anxiety disorders. As of 2000, fluoxetine had reached $2 billion in United States sales1 and no drug marketed has received as much attention and study. Several other selective serotonin reuptake inhibitors (SSRIs) were marketed soon after and their ease of use, favorable side effect profile, and safety in overdose has made them the first-line pharmacotherapy for mood and anxiety disorders. Along with the SSRIs, other antidepressants with different mechanisms of action have also been marketed and several others are in the final stages of clinical trials. Antidepressants accounted for a staggering global market of $14.5 billion in 2003 and were the third-largest category of prescription medications behind antiulcerants and cholesterol-reducing agents.2

Review Articles

Michael T. Witkovsky, MD
Psychiatric problems of youth in primary care: A review
(full text PDF)

The role of primary care clinicians in the detection, diagnosis, treatment, and outcome monitoring of mental illness in children and adolescents has long been documented. So too has the fact that the vast majority of medical care given to children with psychiatric illness is by primary care clinicians, not child and adolescent psychiatrists. As specialty resources dwindle, or fail to keep pace with the complexities in the understanding of the etiology and treatments of psychiatric illnesses, primary care clinicians become the ‘go to’ people after brief exposure to specialty care or following episodic consultation. The goal of this paper is to discuss—by disease category—tools for detection and assessment, treatments, and issues in collaboration between primary care and specialty care. The advice given here is based in evidenced based medicine, clinical best practices, and practice parameters as suggested by professional academies.

Case Reports

Jennifer Perfetti, MA, LPC; Roseanne Clark, PhD; Capri-Mara Fillmore, MD, MPH
Postpartum Depression: Identification, Screening, and Treatment
(full text PDF)

Depression during the postpartum period is a significant public health concern, affecting 8%-15% of women and resulting in considerable morbidity for women, and their infants and families. Risk, prevalence, and distinguishing features of postpartum mood disorders are provided. Anxiety and depression frequently co-occur, suggesting symptoms of anxiety should also be attended to when screening for postpartum depression. Recommendations include the use of a brief, valid screening instrument as a routine clinical practice and the unique role of the obstetrician/gynecologist, pediatrician, and family practice physician in identification and referral. A summary of evidence-based treatment options for postpartum depression, along with current information about psychotropic medication, is provided to assist in risk-benefit analyses and decision making with patients.

Your Practice

Jonathan W. Hill, RPA, Retirement Plan Consultant
Do you need a durable power of attorney?
(full text PDF)

What would happen if you suddenly became seriously ill or incapacitated? Who would take care of your finances? Are you sure they could legally do it? If you don’t have a durable power of attorney, no one—not even your spouse—will be able to manage your finances on your behalf.

Your Profession

Michael J. Dunn, MD, Dean and Executive Vice President, Medical College of Wisconsin
Outreach program extends reach of mental health knowledge
(full text PDF)

The Medical College of Wisconsin is forming a conduit for transferring our expertise in neuropsychiatric disorders to the community. We aim to improve outcomes for the one in five Americans who will experience a significant episode of mental illness at some point in his or her life.

Your Society

Arthur J. Patek, AB, MD, Editor
The Ottawa Tent Colony for Treatment of Tuberculosis
(full text PDF)

For the benefit of our readers who may be interested in learning what tent life will do for the tubercular patient, we have subjoined a brief statement pertaining to the Ottawa Tent Colony, recently established in Illinois.

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