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 Slide 2 Letter to
President George W. Bush Americas mental health service delivery
system is in shambles (Michael F. Hogan, Ph.D., Chairman,
Presidents New Freedom Commission on Mental Health, October 29,
2002) Slide 3 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.
Slide 4 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 PCPs
who are generally untrained. Slide 5 Survey of PCPs in Rural
Missouri Geographic Location: 13 most underserved counties in
Southwest Missouri Number of PCPs Surveyed: 52 Physicians: 23 Nurse
Practitioners: 29 Slide 6 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) Male3411 Female1413 Slide 7 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% Slide 8 What kind of
treatment do you provide to your psychiatric patients? Medication
follow-up-85.9% Individual Psychotherapy-24% Family Therapy-7.9%
Slide 9 What type of psychotropic medications do you often
prescribe? Antidepressant/SSRIs 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% Slide 10 How many psychiatric patients, in a month,
do you refer to the mental health professionals? Average 7 patients
Slide 11 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 Slide 12
What percentage of your general medical patients have mental health
issues? Approximately 40% Slide 13 Our Solution Slide 14 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. Slide 15 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. Slide 16
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 (PCPs) in psychiatry and
psychopharmacology and developed a project entitled Training
Enhancement in Rural Mental Health (TERMH). Slide 17 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, PCPs were offered 84 hours of
didactics and practicum in psychiatry, child psychiatry, and
psychopharmacology. Slide 18 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 Slide 19 The Training Curriculum (cont.) Anxiety
Disorders Utilization of Screening Instruments in Primary Care
Settings Mood Disorder in Children and Adolescents (Major
Depressive Disorder, Bi-Polar Disorder, Substance Induced Mood
Disorder) Topics (cont.) Psychiatric Conditions in children and
adolescents Externalizing Disorders ADHD Conduct Disorder
Oppositional Defiant Disorder Internalizing Disorders Depressive
Disorders Anxiety Disorders Psychopharmacology Principles of
Chemical and Electrical Neurotransmission Slide 20 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
Slide 21 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 Slide 22 Outcome Study Methodology: 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. Slide 23
Outcome Study Results Pre-Test Average : 45.14% Post-Test Average :
63.88% Control Group Average 76.4% Slide 24 Integrated Mental
Health Team Upon completion of the training, the participants were
invited to join the Integrated Mental Health Team Slide 25
Integrated Mental Health Team Psychiatrist Case Manager 1Case
Manager 3Case Manager 2 Out Reach Clinics Out Reach Clinics 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. Slide 26 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 Slide 27 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. Slide 28 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 & Bonding Temperament 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 Psychopharmacology
Cognitive Behavioral Therapy Group Therapy Risk Assessment of
Suicide: Adults Children & Adolescent Assessment &
Treatment of Sleep Disorders Principle & Practice of
Psychopharmacology in Psychiatry Geriatric Psychiatry Didactic
Requirements Total Hrs: 56 Slide 29 Practicum Requirements: Total
Hrs: 64 FocusPopulation AgeSupervision ByHours/Population
Psychiatric Evaluation [observation on each population (3);
demonstration on each population (3)] Preadolescents Adolescents
Adults Psychiatrist6 hrs/Inpatient Medication Checks [observation
on each population (3); demonstration on each population (3)]
Preadolescents Adolescents Adults Psychiatrist2 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] Preadolescents
Adolescents Adults Psychiatrist12 hrs/Inpatient History &
Physical [observation on each population (1); demonstration on each
population (2)] Preadolescents Adolescents Adults Nurse
Practitioner or PCP or Psychiatrist 9 hrs/Inpatient
Seclusion/Restraints [observation on each population (1) ;
demonstration on each population (1)] Preadolescents Adolescents
Adults Psychiatrist6 hrs/Inpatient Outpatient Treatment
[Individually] Preadolescents Adolescents Adults Psychiatrist12
hrs/Outpatient