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259 APPENDIX C POSTSCRIPTS In accordance with the original conference design, participants in the April 2-3 meeting were encouraged to submit written follow-up comments within 30 days. The following were selected to highlight several of the principal themes concerning mental health services in general heal th care .
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261 (1) Advantages of Coordinated Mental Health and General Health Care. Albert J. Solnit, M.D.: . . . The major advantage of bringing together primary and mental health care knowledge and personnel is the primary and secondary preventive impact on the continuity of effective care for patients. This concept also implies that patients who need tertiary care (e.g., those with schizophrenia, sustained depressive conditions, etc.) should be referred to mental health specialists who are competent to evaluate and treat such patients, often with the collaboration of the primary health care provider. When primary physicians and their teams include preventive men- tal health knowledge and techniques in their repertoire, the care of patients should be increasingly humanized. Moreover, such health care should assure more effective continuity of care and opportunities to maximize primary and secondary prevention of physical and mental health conditions. Mack Lipkin, Jr., M.D.: The goal of integrated primary health care and mental health service can be justified on humanistic grounds, the grounds of caring. However, additional data argue for such integration. First, the nature of disease and illness phenomena is that they are, in fact, integrated. Second, a significant majority of the cases, ranging from 30 to 80%, according to criteria and study, involve psychologi- cal as well as disease issues. Third, a subset of cases, in our experience 4% (visits in an HMO), require integrated care. Failure to provide such in these cases leads to increased costs, decreased satisfaction, and occasionally unnecessary morbidity and mortality. Barbara Starfield, M.D., M.P.H. (By coincidence, at the time of the conference Dr. Starfield was just completing an epidemiological study of psychosocial and psychosomatic disorders in pediatric case loads. The psychosocial disorders, including learning disabilities and behavioral dysfunctions, have become increasingly prevalent; together with psychosomatic dis- orders, they are present in about 20% of pediatric cases. She has applied the term "the new morbidity" to this phenomenon. An abstract follows of her unpublished report, "The Prevalence of Psychosocial and Psychosomatic Diagnoses among Children in Primary Care Facilities.")
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262 The Prevalence of Psychosocial and Psychosomatic Diagnoses Among Children in Primary Care Facilities (Abstract) In this study in seven primary care facilities, the proportion of children recognized as having psychosocial problems was much higher than generally assumed. Although there was great variability among the facilities the prevalence was at least 5% and as much as 15% except in the hospital teaching facilities where it was much lower. The prevalence was higher in children in poor families. The variability among facilities was much less for psychosomatic problems, which were diagnosed in 8-10% of children. The variability in diagnosis of psychosocial problems is most likely a result of differences in the extent to which different practitioners recognize this type of problem. For both types of problems, but especially for psychosocial ones, the proportion of visits with the diagnoses was much less than the proportion of children with them, so that the management of these problems was not associated with a relatively large number of visits. Available evidence suggests that individuals with unresolved psycho- social problems make more than their share of visits for other diag- noses. Therefore, management of psychosocial problems in primary care should reduce overall utilization. The findings of this study have implications for the content of educational programs for primary care practice and are pertinent to current debate over policy concerning reimbursement and benefit packages.
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263 (2) Organizational Issues. Gordon H. Deckert, M.D., F.A.C.P.: I certainly agree with the data that the majority of the mentally ill are cared for in primary care settings. Beyond this I tend to believe that the majority of these patients will be taken care of by primary care physicians and in settings where being able to implement the model of a team of mental health professionals working with primary care physicians is unlikely. This is a point I want to emphasize since most of the presentations tended to come from individuals working in the large metropolitan areas of the northeast coast and metropolitan areas of California. The vast majority of primary care physicians in this country work in settings where it will not be possible in the next five years or even ten years to place well-trained mental health professionals. Hence, it will not be enough with this new initiative to focus on the training of mental professionals to work in primary care settings. In many instances (I would daresay even most instances) the delivery will have to come from primary care physicians themselves. Stephen King, M.D.: The British contribution /to the Conference/ . . . pointed dramatically to the difficulties inherent in attempts to effectively integrate the private fee-for-service system extant in the United States. There is a significant rapidly growing system of care directly supported by ADAMHA and HSA. In Region IV alone, the Bureau of of Community Health Services supports approximately 300 projects at a cost of $200,000,000 which along with 500+ NHSC provider assignees is providing medical care to 3,000,000 people. This resource could easily be galvanized with an effective operational linkage with the CMHC's. Such a model would cause by its effect a great deal more to happen, even in the private sector. It should not cost more dollars to integrate these programs locally -- providing single point access and point responsibility for catchment area populations were to be established. Primary care resources and CMH resources tend to care for very different populations of people. The information presented at the conference would tend to support the hypothesis that the nature of clinical needs of these two populations are different, suggesting to me that some scrutiny of the purposes of the various programs is warranted. It is my impression that a major contribution to the present schism arises at the legislation/congressional level. The present legislation is increasingly undergirding a conceptual isolation of the programs, especially in the mental health area. The constituency
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264 is particularly turf jealous. Also, along this line is the lack of attention to the issue by the planning legislation (93-641~. Actually the HSA boards and staff as well as the State Health Coordinating Committees and the State Health Planning Development Agencies are not oriented toward mental health programs. There are many instances of effective program integration in the field (other than in the private sector) often established in the face of bureaucratic indifference. These are always, I think, the result of assertive and immaginative local leadership. . . . I would like to assume that it is in the vested self interest of all that there be integration of these elements of care, and further, that this care must be available to all to be effective. When this integration and access are assured, they are accomplished in the field, in an arena which is most distant from those arenas of academia and research and which is often buffeted by unthinking administrative policy decisions by the responsible agencies. There is in truth no discernible national health policy which speaks to the importance of the complete Herman being, of an organism needing care, a policy which is oriented toward effective coordination of available resources over which we have control. Jeffry L. Houpt, M.D.: The problem begins with the term "primary care" medicine. It tends to imply that we are talking about the integration of mental health services with primary care physicians as opposed to other nonpsychiatric physicians who provide primary care medicine. I think it is important to keep in mind that primary care physicians are only one group of physicians with whom we need to be concerned. I make this point because I left the conference concerned that we support a pluralistic system and think about ways of integrating mental health services with the internists, surgeons, pediatricians, and obstetricians/gynecologists who also practice primary care . met Scone. If we are going to take a flexible approach to this particular subject, we cannot pattern ourselves completely after the British system. Under their system, all people see the generalist first before seeing a specialist. Mental health services are provided by the "G.P.," or on occasion with the assistance of a social worker. Recommendations are rather one-sided for such a model: (1) better education for primary care physicians in psychiatric management and (~) atternpti~g to strengthen referral for severe psychopathology. While such an approach is clearly viable, and in some areas the only reasonable approach, I'd like to keep alive (l) the notion of integrated ~~ulti-specialty clinics or offices for providing .
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265 primary care medicine and (2) the notion that mental health profes- sionals can provide some of these services. I would suggest that the mental health services provided to nonpsychiatric physicians by mental health professionals be described in terms of two broad areas of function: a first category whereby mental health professionals provide direct service to patients, and a second category called liaison functions or indirect services whereby mental health per- sonnel provide service to the nonpsychiatric physician or other members of the health care team. Liaison functions would include such things as providing support, advice, or teaching. The essence of my ideas are that we provide a flexible system. Both primary care physicians and multi-specialty groups could be developed to meet the need for general medical care. Programs could be developed to utilize mental health professionals in providing direct and indirect services to either the primary care physician or the multi-specialty group. There is no need to force such a hard line of distinction between "primary care" and secondary care when it comes to providing mental health services. George J. Cohen, M.D.: Comparing three systems of provision of mental health services in primary care settings, I think it is important to indicate the intensity of those mental health services as well as procedural factors. In my score of years in private practice my approach was very similar to Dr. Pakula's, i.e., essentially preventive, with anticipatory guidance based on normal stages of child development and my assessment of both the child's and the parents' temperaments. In addition there were many times when either the family or I would feel a need for counseling regarding behavior problems. This was usually set up at an after hour session for which a separate charge was generated. Fortunately in a largely middle class practice most families are able to afford this cost out of pocket. _At Children's /National Children's Medical Center, Washington, D.C./, both in the past few years in my full-time work in the Out- patient Department and in my 17 years of working in the Lead Poisoning Clinic, a different set of circumstances prevails. In the general Medical Clinic we try to encourage the residents to do some anticipatory guidance especially when the children are in for health check-ups. In addition there is a steady flow of youngsters with the usual childhood behavior problems and habit disorders such as bed wetting, school phobias, and somatic or functional complaints, e.g., headaches, abdominal pains. Here again we encourage the resi- dents to look beyond the symptoms and to identify situational or emotional factors. This however is often done on a somewhat scatter shot basis because the attending physician cannot work with each and every resident with each and every patient. However, as patients are discussed in follow-up and as charts are reviewed, these questions
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266 often surface even if the resident has not requested a consultation initially. In our Lead Poisoning Pica Clinic which has not been absorbed into the general Medical Clinic team structure, I supervised both pediatric and psychiatric residents. As we saw each of our child- ren with Pica and/or lead poisoning, our approach was to encourage the residents to take a holistic approach to the child, his family and their environment while the psychiatry resident served either as a consultative resource for deeper emotional difficulties or as a leader of discussions with the parents regarding anticipatory guidance and situational adjustment. A third model is in Mobile Medical Care, our volunteer clinic for low-income persons in Montgomery County /Maryland/, where we have both medical and mental health personnel working in the same clinic. There consultation is available on a face to face profes- sional basis, and the medical and mental health records are available in the same jacket; any professional can see what another has been accomplishing in his work with the patient. In all of these settings one of the most important things is a relationship between the primary care health person and the mental health person. This means the primary physician must choose mental health experts with whom he can work comfortably, as well as open communication in both directions. In private practice this was frequently difficult, especially if the patient went to a mental health clinic or other agency where there was often great reluctance to reveal any information to the referring physician. However, the private mental health consultant was usually able and willing by phone to render such information. In the Children's Hospital clinic setting such personal contact is available, but the primary physician must often be pushed to take advantage of it, and often will refer the patient to the psychiatry clinic but not follow-up on the patient The presence of both the mental health and the medical health workers at the same time at the same place at Mobile Medical Care obviates some of this difficulty. Alan M. Jacobson, M.D.; Funding was, is, and will be a major stumbling block to the reasonable policy of bringing psychiatry and primary care practice into at least shouting distance. The use of categorical monies for linkage grants is a useful first step, but should be tested in other settings besides neighborhood health centers and HMO's. I could envision social workers, trained and supervised by liaison psychia- trists and funded by linkage grants to CMHC's, approaching private general practices located in the catchment area. A second approach could take advantage of the Blue Cross reimbursement policy already in place whereby hospitals build into physician outpatient fees the cost of social work time. This could
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267 be expanded to Blue Shield coverage for private practices which employ social workers and could even be used for psychiatric super- vision and consultation time. Direct psychiatric treatment would be funded by current methods. Thomas Madden, M.D.: Because of the absence of a universal primary care service in the U.S.A. there exist large areas where both physical and mental health care are lacking. It seemed to me that the Conference gave very little attention to this specific problem, although its existence is probably the main reason for such a conference being necessary at this time. These needs are made acute by what is happening in many individual States. For what appear to be purely fiscal reasons, rather than the beneficent effect of modern therapeutics or a fashion- able concern for "community care," old long-stay Victorian units are being systematically emptied out. They are not attractive or suitable places for mental health care, they promote chronicity, they often provide the worst of care and have the least* skilled and the least rewarded staffs; but it is certain that in the community, facilities for care are usually lacking and the receiving community is often quite unprepared and unwilling, both in terms of arrangements and attitude, to receive or welcome. (*I throw no stones. It is the same at home.) An important priority will be the need for half-way houses, pro- tected living and working environments, hostels, etc; and let us hope once again that such facilities will not all or even mostly be sited in the old and decaying neighborhoods; for in both countries the attitude seems to prevail that areas which have become habituated to tolerating anything may be allowed to tolerate everything. Having said all this, I would not welcome special units, teams, solutions for immediate need without considering what might be their effect 5 to 10 years ahead. If such are set up, their existence must not later be used as justification for saying that there is no need for primary care, for a supply of family doctors, for example.
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268 (3) Provider Roles and Skills. Carolyn B. Robinowitz, M.D.: . . . Certain issues of quality should be studied and addressed. There are implications about quality programs related to those sixty million prescriptions of Valium yearly, as well as the accuracy of diagnosis and appropriateness of certain management plans of referral patterns. . . . While I realize that this is both simplistic and obvious, I continue be appalled at how little attention is paid to quality or to what needs to be taught. There is a tendency in making family medicine a legitimate specialty to require that family physicians know everything that their specialist counterparts do in each area. While any educator can recognize that it would be impossible to teach and learn all this material in a three year residency program, we often behave as though we expect it of the primary care physician. Therein, I think, lies one of the major problems for the long-term viability of the field. I do worry that in our concern to develop specialist primary care practitioners capable of intervening early, promoting health education and responsibility for patients' health care and providing continuous skilled and long-term care, we may also set up demands for someone who has more knowledge and skill than it is possible for anyone to have. By making these demands (or creating these expectations in the public's mind), we are setting up the possibility of major disappointment with the real limits of the field. This disenchantment may then cause the pendulum to swing back the other way and lose support for what should be a growing and necessary field. On the other hand, the practitioner who has the sense of needing to do more and be all things to all people and experiences constant frustration in meeting this challenge may end up being a "drop-out" to enter a specialty in which knowledge and skills seem more circumscribed. Gordon Deckert, M.D., F.A.C.P.: First, primary care physicians in my experience do not hesitate to ask me for ''help" in dealing with patients in their practice. I do not find them nearly as resistant as they are often portrayed. However, in the main their first query pertains to patients with psychosomatic disorders. Their second concern usually is how to deal with the psychological responses of patients to illness, in short to what we would call adjustment reactions. After these questions come questions relative to the management of patients with mental illness, as defined in the Conference (that is, anxiety re- actions, tile depressive spectrum, schizophrenia and thought disorders, alcohol and drug problems). Depending upon the study, 25% to 30% of patient visits to primary care physicians fall into this latter
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269 category. The priorities of primary care physicians must be considered when we approach them and by emphasis they have not been the priorities of the Conference, in my opinion. In my experience, primary care physicians do not need to be con- vinced that a large share of their practice falls into the arena of what I call "psychological medicine.': The skeptical physicians are those in health sciences centers. What primary care physicians in practice are skeptical about relates to the quality and practicality of the offerings from the mental health professions. From long experi- ence they have discovered that most continuing education programs or educational approaches to them tend not to be very practical or helpful within the context of their particular practice. I am really quite convinced that physicians in practice are much more sensitive to the problems in their practice than the data would indicate but like most physicians they tend to record information and make diagnoses in categories for which they feel they can offer some assistance. In many instances they simply do not know how to be helpful to certain categories of patients with psychological problems. Thomas Madden, M.D.: It is necessary to examine and draw conclusions from the work of Darrell Regier and his colleagues. Their work shows that, in much the same way as the ubiquitous OP of the United Kingdom system, the primary care doctors of the Ua S.A., be they internists, pediatricians, ob/gynecologists, old-style G.P.s or the new generation of family doctors working the community (the latter, I believe, with more skill due to better preparation for the task), are providing a service accounting for the majority of requirements, in those areas at least where such doctors are to be found. They are in fact handling a major part of the mental illness in the community and providing con- tinuing care in those more serious cases, in which specialist doctors and institutions are only episodically involved. It is important to examine what help, what resources, what further training these physicians need. . . . With regard to 'feeling unwell,' whether expressed in somatic or psychiatric symptomatology, a well-known study in the Guy's area (Wadsworth, Butterfield and Blaney, 1971), showed that, in a borough regarded as well-served by family doctors, local authority and hospital services, only 5% of a survey sample reported no complaints in the 14 day period prior to being questioned: complaints for which for the most part they had not considered it necessary to consult any doctor. While this and similar enquiries have encouraged speculation as to undiscovered illness which it would be desirable to treat, they have not been held to indicate that all symptoms require referral and that there is no place for reasonable self-management.
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277 logical medicine cannot be practiced with this model in mind. Rather, one must use the individual response specific model. In my experience, until this concept is thoroughly grasped by my workshop attendees, they will continue to ask such unscientific questions as "How do you treat depression?", "How do you treat anxiety reactions?", etc. Once they grasp that we do have something specific to offer in terms of process when one approaches a specific kind of patient who presents with a specific constellation of findings, we are off and running. The next major theme is the perceptual task. By this I mean that many physicians simply do not see the evidence for primary emotions in the fact in front of their face. They are much better at hearing evidence but they are relatively unskilled visually. They are in the situation of not seeing data and hence not making the precise diagnosis and hence not treating certain patients effectively. They would be in a similar situation with other patients if they did not feel the enlarged liver or did not hear the presystolic rumble or did not notice the elevated white count in a lab report. I'm not speculating in making this observation. Many physicians simply do not see subtle evidence for anger in women or fear and/or sadness in men. The educational experience of most medical students in most medical schools and certainly in most primary care residencies is such that they do not discover the recognition rules taught them by their culture, rules which they brought to medical school or to postgraduate residencies or whatever. Finally, unless one can bring some model for therapeutic intervention all of the above comes to naught e I have evolved a model of therapeutic intervention which I call 'The Therapeutic Sequence" which seems very helpful in didactic sessions with primary care physicians. This is all outlined in a chapter on "Interviewing Techniques" in the latest Textbook of Family Practice published by Saunders and edited by Conn and Rakel. Morris B. Parloff, Ph.D.: An oft-repeated "solution" was that of providing the physician with additional training, but there was no agreement on what the physician was to be trained to do. Recommendations ranged from providing broader training in the behavioral and social sciences (presumably to promote a more humanistic approach to patients); improving diagnostic skills to permit the physician to undertake triage in determining whether the patient's problems required specialized attention; or enabling the physician, independently, to provide effective treatment of the full spectrum of emotional disorders. In my view ~c won ~ a Indeed be appropriate for physicians in the course of early academic training to receive information which might permit them to differentiate among the following classes of problems: 1. those problems that will improve over time with or without formal psychiatric intervention (e.g., crisis reactions, sadness rather than ~ ~ , . ~ . .
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278 depressions, phobias in young children, etc.), 2. problems which require treatment lest the condition worsen or the patient become more vulnerable to stresses, and 3. problems which are best treated by the PCP or other nonparental health professionals lest the fact of referral act to confirm the patients' fears that they are suffering from pathological processes when in fact they are confronted with everyday problems of "no~alcy" or "existential problems of living. Mac k Lipkin, Jr., M.D.: Teaching about integrated care is presently difficult. In Rochester, despite the presence of a nationally recognized group with a charismatic leader, the impact on the overall organization of care has been extremely variable. For the most part, trainees in this institution behave predominantly in ways similar to the prevailing biotechnical culture. Our analysis of this problem leads to the following conclusion. In order to affect behavior (as opposed to lip service ideology) of trainees, the important behavioral levers which control their behavior must be managed. Most significant is the role of the prac- tice culture. Here, the role model concept is useful, but errors have been made in recognizing who the role models are. The attending physician is one. However, in the tertiary hospital, the housestaff themselves provide their own role models. Students, as well, look up to the housestaff. Thus it is our belief that a role model cascade is necessary in which a core group of those capable of producing integrated care influence housestaff and attendings, as well as students. Learning in this area is difficult because the concepts are complex and painful; exhausting psychological effort is involved in applying them; and, at present, the prevailing disease oriented culture is not hospitable. To counter these deterrents, trainees need to experience positive integration oriented learning at each level of their growth. What is needed, then, is a cascade of role models -- a critical mass of model professionals, people who believe in and can cogently practice integrated care. As well, model services are needed which prove, in their structure, belief in integrated care. Both model professionals and model services must stem from a conceptual frame- work in which the case for integrated care is clear and convincing. This then must also reach the curriculum and every clinical teaching service. This is seldom a priority, as services stem from analytic discipline and integration stresses synthesis. Government roles in relationship to development of an integrated conceptual framework, curriculum, model services and model professionals can be multifaceted. Centers of excellence are needed to train teachers.
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279 Money is needed for research in the applied issues of integration of care and the underlying basic scientific issues. Money with strings attached in terms of training and service formation could be very helpful in providing opportunities for those with skills in this area to achieve some potency in the presently biotechnically dominated teaching institutions. Especially needed is career support for mid- level persons in this area, since otherwise they must get support from other kinds of activities. . . . Finally, the notion of the great potential marginal gain in this area was mentioned. At this point in history, relatively small investments in centers of excellence, training of teachers, and creation and study of model services can well be expected to pro- duce large gains relative to the costs. This is a major argument for well-targeted government support, at this time, for study of inte- gration of care. Thomas A. Madden, M.D.: Primary care providers: helping the helpers The resolution of these problems does not require (as some speakers seemed to imply) investigations into "Who should provide?", or even "How well do the present providers perform?" (although this . is a very interesting subject), or into "fit types of new instit_tion will be needed?" Even to set out in such a direction may imply that . one has in effect already concluded that the present primary care doctors ought not to continue to do the job, a decision which defies both logic and experience elsewhere. The question ought rather to be: How may they be helped to do it better? I do not write as an English family doctor, when I say: Begin with the primary care doctors that you have. This is certainly the least costly and most practical way to go. Whatever the present inadequacies of provision and cover, solving one problem in health is often the way to solving more. Hence the long-term answer in the mental health sphere is precisely the same as that for any other aspect of health: the provision of adequate primary care for all areas and the training of physicians and other professionals for this work. This continues to have implications for the medical schools in training (and far better than heretofore) the future primary care doctor and in assuring a proper supply of such doctors to the com- munities. Our workshop particularly emphasized the need for medical studies to include: (1) the patient in the family context and (2) the patient in the community.
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280 Alan M. Jacobson, M.D.: The move toward primary care oriented psychiatry, in whatever form this takes, necessitates a shift in the ego ideal of psychiatry and therefore a restructuring of psychiatric training. If, to para- phrase the Bauhaus expression (Form follows function), training follows money, policy recommendations should encourage NIMH stipends for primary care psychiatrist training either as part of the general residency or as fellowships in PGY 4 and 5.
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281 (5) Quality of Care Issues. Morris B. Parloff, Ph.D.: Quality of Care and Professional Affiliation It seemed odd to me that so little interest was expressed by either the primary care provider or the psychiatrist in determining the quality of mental health services which, according to claims, are being so promiscuously and effectively provided by the nonpsychiatri- cally trained physician in treatment sessions limited to 13-20 minutes each. There also appeared to be no enthusiasm for the notion that research be undertaken to assess the quality of care offered by the PCP by comparing the relative effectiveness of the PCP and the mental health specialist in treating specified classes of emotional problems. While the psychiatrists seemed to be excessively modest in com- mending to their medical colleagues the value of specialized mental health training, they appeared considerably less diffident with regard to their special competence relative to their nonmedically trained mental health practitioner associates. Evidence of the Effectiveness of Psychotherapy In casting about for evidence of the efficacy of psychotherapy, a rather oblique set of data were presented, intended presumably to impress the PCPs and the authors of potential health insurance legislation. The evidence presented was not that the specialized practice of psychotherapy is demonstrably effective in ameliorating the discomfort of the patient and enhancing his/her functioning, but rather that psychotherapy provides a cure for excessive utilization of medical facilities. While the evidence is clear that some emotion- ally disturbed patients make excessive use of medical facilities and that appropriate psychiatric care may reduce such inappropriate drains on medical resources, this fact appeared to be less impressive to private practitioners and physicians working in community mental health clinics than to those in HMOs. Concern about the patient's welfare requires that the patient be provided appropriate medical care rather than simply less medical care. The persistent efforts to justify mental health services on the equivo- cal evidence of cost-offset is not only unpersuasive but promises to be ill-advised. Costs should continue to be of lessor priority at this stage of the field's development than evidence regarding the quality of care provided. Neil J. Elgee, M.D.: My main concern is that we seem to be implicitly accepting as a given, in the administrative and political context, the complete
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282 whole undifferentiated spectrum of "psychiatric services" -- like buying and administering a package. . ~ I am not persuaded that an analytic hour with an M.D. represents quality. In Camelot, it is true, I would be in favor of everything we discussed and every- body's program. I fear, however, if we promote undifferentiated psychosocial services, we may fail to get much of anything at all or may dilute the good with the undifferentiated. As of my present reading of the situation, I would want to concentrate. George J. Cohen, M.D.: Certainly as we all agreed there is a gut feeling that most of us have and which is often expressed by patients that attention to emotional areas is really important and helpful. Evaluating modes of delivering such care is difficult' first, in establishing criteria for diagnosis and treatment methods, second, in recognizing cultural variance, third, in finding some sort of control population to compare against the treatment population in terms of attitudes and outcomes. Which outcome item to use is another concern. The number of visits for non-psychiatric complaints was shown to have many many flaws. If we don't consider the variation in training, experience and interest of the primary and mental health therapists, comparisons are virtually impossible. Another important item to consider is the initial state of physical and mental health of the patient and whether an increase or decrease in utilization is a goal.
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283 (6) Research Needs. Neil J. Elgee, M.D.: . /I would/ support research in all aspects of psychosocial disease. _ Justification for wholesale delivery of therapeutic interventions is not yet persuasive and should remain in the research arena. Vincent J. Felitti, M.D. . . . It is clear that a pluralistic system is already in place -- the relationship of psychiatry to primary care already exists in the solo practice sector, in HMO's, in university settings, and in group practices. We don't need to know what to do, we are already doing it. What we need is to know what works best and where to allocate future resources. I was quite disappointed during the meeting to see that there was so little interest in studying the outcome of the integration of psychiatric services into primary care settings. . . A number of important questions need to be answered and the HMO setting pro- vides a unique opportunity to do this because for the first time a large closed system is available in which the complex ramifications of psychotherapy can be studied. The simple fact of having a uni- fied medical chart serving all specialties is a sudden, significant advantage. Should entry into the psychiatric system be patient determined or only by referral from a provider? Should it be passive, or should an outreach program be used? What types of therapists are most cost effective? Are social workers, psychologists, and psychiatrists interchangeable as psychotherapists or not? How should triage be done and by whom? What types of therapy are affordable and demonstrably effective? What should be the limit on duration of therapy? There is a small amount of significant information (e.g., Malan, D., Archives of General Psychiatry, November 1976) indicating that a one time visit may be significantly beneficial. What measures of effectiveness of therapy do we have? Two issues need to be addressed here. The first is the effectiveness of therapy to the patient and the second is the effectiveness of therapy to the overall system. Does effective psychotherapy decrease perverse medical utilization? Does ineffective psychotherapy increase it? Clearly outcome studies are not only difficult, but resisted. Some of the difficulties, and none of the resistance, may have been reduced by Hans Strupp of Vanderbilt University who had an important article out recently. He describes using a tripartite system which makes diagnostic use of those very issues that had always been a source of disagreement and confusion in the past.
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284 For the first time a major undertaking is underway relating psychiatric treatment to general medical care. If, in a flurry of goodwill and good intent, the outcome of this is not studied we shall have missed a golden opportunity. Thomas A. Madden, M.D.: . . . I consider it important NOT to devote research funds to the development of ever more sensitive indices of personal misery and dysfunction, such as might tend to show that 90% of the population 'could do with' brief or longer psychotherapy (however defined). To follow such a direction would be betrayal of those in need, when so many serious problems, untouched let alone unsolved, abound in so many countries and here. . . . In the sphere of research, it is necessary not merely to look at what specialists think primary care doctors ought to do, patently cannot do or do badly; but at the subtly acquired skills which many excellent family doctors may have evolved, intuitively rather than by Balint seminars, and from experience; a product of continuity of care, familiarity and human involvement. At the Institute of Psychiatry, such an approach has been made by Dr. Norma Raynes, a sociologist and anthropologist who has developed interesting techniques of direct observation. (In publication) . . . In any comparison of the results of therapy by drugs, with or without psychotherapy, it is necessary to look at a much more im- portant and complex dimension, that of the patient's coping resources; to build into the enquiry, however difficult, some measure of the patient's position in the social network as a factor strengthening individual resources and chances of recovery. In the wider sense, this means family, friends and neighbors, even the members of the primary care team or lay counselors. As it happens, there is work precisely on the topic of post infarction career and the use of lay counselors. A useful reference is Angela Finlayson's "Social Networks as Coping Resources" (Social Science and Medicine, Vol 10, pp 97-103, Pergamon Press, Great Britain, 1976~. Need, not entrenched interest, skillful lobbying or special pleading should determine priority. With such obvious and gross needs, to some of which I have alluded, one would not want to encourage inquiry into, say, the wide range of normal mood changes reported as pathology by hypersensitive surveys. In research, as the whole volume of Michael Shepherd's work and his talk to the Conference reveal, the cooperation of teaching hospital and practicing community doctors becomes a two-way process. The learned institute acquires a population for its study which is not selected, hospital-based. (In this case, it was the Maudsley
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285 doctors who first acknowledged the existence of a very large and ill defined 'psycho-social' group of patients known to G.P.s but not at that time to hospitals.) Conversely, I believe that every G.P. who has participated in any part of that work, now over many years, has thereby sharpened perception and skill in management. Alan M. Jacobson, M.D.: Offset is a dangerous outcome variable for psychiatric research in primary care settings. I would instead suggest funding for repli- cation of Goldberg's and Shepherd's intervention studies in U.S. settings. Outcome variables developed for these and recent U.S. psychotherapy outcome studies offer a variety of measures which could be used in addition to offset of medical utilization. Morris B. Parloff, M.D.: A major concern of the conferees appeared to be service delivery and providing some advocacy for the alleged advantages of particular delivery systems such as neighborhood centers, CMHCs, HMOs, private practice, group practice, team functions, etc. This all appears to be predicated on the belief that knowledge regarding the efficacy of the techniques to be delivered has already been well established. Little attention was paid to the prior question of establishing the efficacy of treatment techniques under ideal conditions. This step is prerequisite to any research which attempts to establish the adequacy of the treatment delivery systems since such research con- founds efficacy of treatment with adequacy of delivery. Mac k Lipkin, Jr., M.D. Research concerning integrated aspects of care has been touched on in the conference. However, certain issues were not focused on with depth. One of these is the need for greater clarity about the underlying conceptual models or paradigms being employed. Second is the need for meaningful population-based studies with a problem (as opposed to diagnostic) orientation. Third, there is a need for outcome measures which measure goals of care systems in contrast to present haphazard specialty-based goals or the equally mindless body count approach.
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286 (7) Social Support Systems. Marie Killilea Although the importance of supportive others in times of crisis has been recognized for many years, the use of personal and social networks in health and mental health clinical practice and research, and in the design of services, is a relatively new occurrence. Social support systems include naturally occuring helping net- works which often seem to be invisible because they are so much a part of the fabric of our lives. Help is given and received outside the structure of human services agencies. This help is based on a commitment of reciprocity and exchange, e.g., within the family; in kin and friendship networks; in neighborhood helping networks. In addition to these fluid, unbounded networks, there are more organized structures of informal social support, e.g., self-help groups such as Alcoholics Anonymous; person-to-person mutual aid such as Widow-to- Widow programs; cross-age helping programs such as Foster Grandparents; peer-oriented helping programs such as school peer counseling activi- ties; alternative community service programs such as hospices and shelters for battered families. These social support systems are inherently sensitive to cul- tural and subcultural variations and build on preferred patterns on help seeking and help accepting. Many community institutions which have other objectives as their primary mission in society also have important social support func- tions; e.g., the workplace, the church, the school, and the medical care institution. Operational definitions of social support include Sidney Cobb's: that social support is information that tells a person that he/she is loved, valued and is part of a network of communication and mutual obligation; and Gerald Caplan's: that support systems are attachments between individuals, and between individuals and groups, that a) promote emotional mastery; b) offer guidance about the field of relevant forces, expectable problems, and methods of dealing with them; and c) provide feedback about behavior which validates identity and fosters improved competence. The processes of social support have emotional, cognitive, and instrumental components. Several reviews of research studies, including the Task Panel Report on Community Support Systems of the President's Commission on Mental Health, have found that the cumulative evidence suggests that social support may play a major role in modifying the deleterious health effects of stress, in influencing the use of health services, and in affecting other aspects of health behavior such as adherence
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287 to medical regimens. Underlying these studies are several alter- native hypotheses: that social support has a direct effect on health; that social support provides a buffer against the effects of high stress; or, that social support has a mediating effect which stimu- lates the development of coping strategies and promotes mastery. The evidence from these studies, and the new questions raised by them, points to directions for the future. There is a need: to develop the research base, and to experiment with pilot and demonstra- tion projects on the relation of-social support, stress, health and the utilization of health and mental health services. In the United States, the family is the chief decision-maker about health care and the major purchaser of health services, rather than government which essentially is only a payer for medical ser- - vices rendered. The' lay referral network (how people get to services) and the lay treatment network (including self-care; mutual help groups and other social support systems; and the wide variety of community ~ ~ ~ ~ institutions that are not labeled or identified in our society as health care institutions, but which may be very much involved in health promotion, health maintenance and even, at times, health services delivery) should be topics on the agenda to be seriously considered when we are thinking about the future. While there are not at the present time many models of the medical care system stimulating the development of social and community support systems, where they are absent, to address pressing health care needs, some examples do exist and should be further explored. With the prospect of national health insurance, the necessity of finding effective ways to link health and mental health services with effective social and community support systems becomes of crucial importance. .
Representative terms from entire chapter: