Training Primary Care Physicians and Nurse Practitioners in Psychiatry to meet
the Mental Health Needs in Rural Missouri
Syed Arshad Husain, M.D., FRC Psych, FRCP (C)Professor and Chief of Child & Adolescent Psychiatry
School of Medicine
University of Missouri-Columbia
Columbia, Missouri USA
Letter to President George W. Bush
“America’s mental health service delivery system is in shambles”
(Michael F. Hogan, Ph.D., Chairman, President’s New Freedom Commission on Mental Health, October 29, 2002)
Current Status of Mental Health Delivery System in the USA
The number of individuals with Severe Persistent Mental Illness (SPMI) has reached epidemic proportion.
The shortage of psychiatric hospital beds is endemic.
Severe shortage of general and child psychiatrists in all locations, including rural areas.
Current Status of Mental Health Delivery System in Rural Missouri
Individuals needing psychiatric services are unable to find a trained psychiatrist in a timely fashion.
This situation often leads to first line psychiatric care being provided by PCP’s who are generally untrained.
Survey of PCP’s in Rural Missouri
Geographic Location: 13 most underserved counties in Southwest Missouri
Number of PCP’s Surveyed: 52
•Physicians: 23
•Nurse Practitioners: 29
How many psychiatric patients do you currently see in your practice weekly?
Average was 36 patients
18 Male
18 Female
Under 13 Years
(Average)
13-18 Years
(Average)
18 Years and Older
(Average)
Male 3 4 11
Female 1 4 13
What diagnostic categories of psychiatric patients are you currently seeing?
Anxiety Disorders-92.3%Bi-Polar Disorder-84.8%Major Depression-84.5%ADHD-77.4%Substance Abuse-73.8%PTSD-67.7%Schizophrenia-45.5%ODD/Conduct Disorder-40.8%
What kind of treatment do you provide to your psychiatric patients?
Medication follow-up-85.9% Individual Psychotherapy-24%Family Therapy-7.9%
What type of psychotropic medications do you often prescribe?
Antidepressant/SSRI’s – 83% Zoloft-88.1% Paxil-83% Prozac-78%
Atypical Antipsychotic – 55% Zyprexa-61% Risperdal-55% Seroquel-48.9%
Anti-anxiety – 52.7% BuSpar-73.5% Ativan-45.7% Valium-38.8%
Mood Stabilizer – 44.8% Depakote-57.2% Lithium-39.7% Tegretol-37.4%
How many psychiatric patients, in a month, do you refer to the mental health
professionals?
Average – 7 patients
What are the common reasons for referral of psychiatric patients to other
resources?
Treatment Failure Suicidal Ideation Diagnostic Questions Need for Inpatient Care Significant Drug Dependence Patients on Multiple Psychotropic Medications
What percentage of your general medical patients have mental health issues?
Approximately – 40%
Our Solution
Lessons Learned from the War Zones and Disaster Areas
During the siege of Sarajevo, there were only 100 mental health professionals who could provide psychological help to 60,000 children living in Sarajevo. This disparity between the providers and the consumers, created a need to train indigenous workers in Trauma Psychology. Thus, “Teachers As Therapists” program was created.
Teachers As Therapists
We trained 2,000 teachers as “lay-therapists”. Who provided psychological help to over 20,000 children and their families in Bosnia and Herzegovina.
Since then, this strategy has been successfully used in Kosovo, Chechnya, Palestine, Afghan refugee camps in Pakistan, 11 Republics of former Soviet Union, Gujrat, India, tsunami stricken Sri Lanka and Banda Ache, Northern Pakistan and now in Katrina affected areas in the USA.
Application of “Teachers As Therapists” Model in Rural Missouri
To combat the shortage of Psychiatrists in Rural Missouri, we proposed to train primary care practitioners (PCP’s) in psychiatry and psychopharmacology and developed a project entitled “Training Enhancement in Rural Mental Health” (TERMH).
Training Enhancement in Rural Mental Health(Project TERMH)
The US Department of Labor supported Project TERMH and awarded a three-year grant of 2.7 Million Dollars to train primary care physicians, nurse practitioners, and other physicians in Rural Missouri.
Under this project, PCP’s were offered 84 hours of didactics and practicum in psychiatry, child psychiatry, and psychopharmacology.
The Training Curriculum
Topics
Classification system in psychiatry. Multi-axial System Diagnostic & Statistical Manual-IV Psychiatric Assessment History taking Mental Status examination iii. Mini-mental status iv. Diagnostic formulation v. Multi-axial diagnosis
Small groups, practice of interview
techniques
Post Traumatic Stress Disorder (PTSD)
i. Assessment in children
ii. Resiliency factors
iii. Co-morbidity
iv. PTSD in the elders
The Training Curriculum (cont.)
Anxiety DisordersUtilization of Screening
Instruments in Primary Care SettingsMood Disorder in Children and Adolescents (Major Depressive Disorder, Bi-Polar Disorder, Substance Induced Mood Disorder)
Topics (cont.)
Psychiatric Conditions in children and adolescents
Externalizing DisordersADHD
Conduct Disorder Oppositional Defiant Disorder Internalizing Disorders Depressive Disorders Anxiety Disorders Psychopharmacology Principles of Chemical and Electrical Neurotransmission
The Training Curriculum (cont.)Topics (cont.)
Interview Technique for Child and Adolescent Patients Diagnosis and Management Mood Disorders in Adults I Interviewing Adult Patients Diagnosis and Management Mood Disorders in Adults II Interviewing Depressed Adults and Elderly Diagnosis and Management of Schizophrenia and other Psychotic Disorders Interviewing Psychotic Adult (Small group practice) Substance Use Disorders Interviewing Chemically Dependent Patients Management of ADHD and Depression in Children and Adolescent Demonstration of ADHD, ODD, and Anti-Social Aggressive Teenager
The Training Curriculum (cont.)
Topics (cont.)
Identifying Psychiatric Emergencies in a Primary Care Setting Principles and Technique of Psychotherapy Demonstrating Psychotherapy Techniques Principle of Case Management and Concept of Integrated Mental Health Team
Outcome StudyMethodology:
A Pre and Post Training test, consisting of 110 multiple choice questions, covering all topics included in the curriculum, were administered to each participant
A control group of fourth and fifth year psychiatric residents was also given the same test.
Outcome Study Results
Pre-Test Average : 45.14%
Post-Test Average : 63.88%
Control Group Average – 76.4%
“Integrated Mental Health Team”
Upon completion of the training, the participants were invited to join the “Integrated Mental Health Team”
Integrated Mental Health Team
Psychiatrist
Case Manager 1 Case Manager 3Case Manager 2
Out Reach
Clinics
Out Reach
Clinics
PCPPCPPCPPCPPCPPCP PCP PCP
Patients
* The Psychiatrist may be in contact with any member of the Integrated Mental Health
System in the interest of treating a patient based on a referral or the need of a PCP.
Benefits of the “Integrated Mental Health Team”
1. 24/7 hotline for consultation
2. Immediate access to a psychiatrist
3. Medication guidance
4. Inpatient hospitalization, if needed
5. More intense out-patient options
Non-Accredited Fellowship in Psychiatry and Child Psychiatry
Due to the success of Project TERMH, the US Department of Labor awarded a second grant to support the “Non-Accredited Fellowship in Psychiatry and Child Psychiatry”.
This fellowship represents an expansion of Project TERMH to 120 hours of training, with 56 hours of didactics and 64 hours of practicum in an inpatient setting.
This training is available for general practitioners, nurse practitioners, family physicians, and pediatricians.
A child psychiatry track will be offered to general psychiatrists and pediatricians.
DSM-IV: A Multi-axial System for Psychiatric Diagnosis
Psychiatric Assessment
Mental Retardation and Autism Child and Adolescent Development &
Disorders Delirium, Dementia, and Mental Disorders
Due to General Medical Condition Depression & Bi-Polar Disorder in Adults Psychosis & Schizophrenia Anxiety Disorders & PTSD Substance Related Disorders Theories of Child Development:
Attachment & BondingTemperament
Moral & Religious Development Classification of Child & Adolescent
Psychiatry
Diagnostic Assessment in Children Interview Techniques with Children &
Adolescents Attention Deficit Hyperactivity Disorder
and Conduct Disorder Depression and Anxiety Disorders in
Children Psychiatric Treatment of Children:
Pediatric PsychopharmacologyCognitive Behavioral TherapyGroup Therapy
Risk Assessment of Suicide: AdultsChildren & Adolescent
Assessment & Treatment of Sleep Disorders
Principle & Practice of Psychopharmacology in Psychiatry
Geriatric Psychiatry
Didactic Requirements Total Hrs: 56
Practicum Requirements: Total Hrs: 64Focus Population Age Supervision By Hours/Population
Psychiatric Evaluation[observation on each population (3);
demonstration on each population (3)]
PreadolescentsAdolescentsAdults
Psychiatrist 6 hrs/Inpatient
Medication Checks[observation on each population (3);
demonstration on each population (3)]
PreadolescentsAdolescentsAdults
Psychiatrist 2 hrs/Inpatient
Treatment Team(will attend 2 on each population)[will include formulation of
treatment plan and medication management on the patient the psych evaluation was demonstrated on]
PreadolescentsAdolescentsAdults
Psychiatrist 12 hrs/Inpatient
History & Physical[observation on each population (1);
demonstration on each population (2)]
PreadolescentsAdolescentsAdults
Nurse Practitioner or PCP or Psychiatrist
9 hrs/Inpatient
Seclusion/Restraints[observation on each population (1) ;
demonstration on each population (1)]
PreadolescentsAdolescentsAdults
Psychiatrist 6 hrs/Inpatient
Outpatient Treatment [Individually]
PreadolescentsAdolescentsAdults
Psychiatrist 12 hrs/Outpatient
