APA Institute on Pyschiatric Services 2015

NEW YORK – An online neurocognitive test designed to provide reliable objective information about memory, concentration, and emotional well-being is a highly effective tool not only for guiding patients to appropriate therapy but for establishing the credibility of the clinician, according to the description of one such tool at the American Psychiatric Association’s Institute on Psychiatric Services.

The neurocognitive evaluation, which most patients complete on their home computers, “employs explicitly measured scales that reassure patients that I have considered multiple factors and am not just giving my off-the-hip guess and impression,” reported Dr. Joseph J. Parks, director of MOHealthNet, the Medicaid authority for Missouri in Jefferson City.

Several proprietary evaluation systems are available, according to Dr. Parks, but his experience has been with a tool called WebNeuro. Physicians develop an account on this online system and then assign a unique code to patients for access. The assessment, which employs validated and standardized tests of cognitive function and related psychometric fields, such as mood and coping skills, takes about 35 minutes to complete.

Results, which are based on comparisons with normative data in a large database, are generated almost immediately. For typical patients, Dr. Parks estimated that it takes 3-5 minutes to interpret the results. Validation studies include one published in 2007 (Behav Res Methods. 2007 Nov;39[4]:940-9).

This assessment tool has a broad number of options over other alternatives, according to Dr. Parks, who called traditional bedside neurocognitive tests “lame.” He suggested that the information gleaned from asking patients to spell words backward or perform uncommon math problems is “unimpressive.’ Ultimately, “you don’t perform these tests most of the time because you have no respect for their value.”

Referring patients for assessment by a neurocognitive psychologist or psychiatrist is another option, but Dr. Parks noted that these specialists are in short supply and not always willing to perform evaluations not linked to treatment. Moreover, it might take weeks for a referral to lead to an appointment and then another delay before the specialist provides a report that is “longer than I need.”

In contrast, the online neurocognitive tests are available at any time and generate data in hard numbers, showing individual patient performance on a variety of scales relative to normal performance. Dr. Parks reports that he uses this evaluation to gain insight on a broad array of potential diagnoses, such as attention-deficit/hyperactivity disorder (ADHD) and dementia. The test allows the clinician to document impaired memory or concentration, and provide information about relative severity. The data are particularly helpful in cases when the patient is not convinced.

“When patients are not happy that I am not prescribing the stimulant that they requested, I can point to the results to say you don’t have ADHD,” Dr. Parks explained. He described patients complaining of problems of concentration who can be reassured when the data suggest that, in fact, their performance is on the upper limits of normal.

“When we discuss the results, having taken the test provides the patient with a much clearer understanding of what I mean by concentration or memory,” Dr. Parks said. “Results of the test make both sides of the conversation more explicit.”

The test also can be repeated to demonstrate the effect of treatment, according to Dr. Parks. Again, an improvement in key scores provides reassurance to the patient when subjective assessments of improvement are doubted.

The test is available in several languages, including Spanish, and it is geared for a third- or fourth-grade reading level. Although Dr. Parks estimated that about 80% of his patients take the test at home, 20% complete the evaluation on a computer at his facility or with assistance from a proctor, such as a behavioral therapist. Dr. Parks said the test is reimbursed by Medicare and about two-thirds of health insurers in Missouri.

Online neurocognitive testing addresses a large number of the deficiencies associated with previous options, according to Dr. Parks. “This is an area that has been so ripe for change.”

Dr. Parks reported no relevant financial relationships.

NEW YORK – An online neurocognitive test designed to provide reliable objective information about memory, concentration, and emotional well-being is a highly effective tool not only for guiding patients to appropriate therapy but for establishing the credibility of the clinician, according to the description of one such tool at the American Psychiatric Association’s Institute on Psychiatric Services.

The neurocognitive evaluation, which most patients complete on their home computers, “employs explicitly measured scales that reassure patients that I have considered multiple factors and am not just giving my off-the-hip guess and impression,” reported Dr. Joseph J. Parks, director of MOHealthNet, the Medicaid authority for Missouri in Jefferson City.

Several proprietary evaluation systems are available, according to Dr. Parks, but his experience has been with a tool called WebNeuro. Physicians develop an account on this online system and then assign a unique code to patients for access. The assessment, which employs validated and standardized tests of cognitive function and related psychometric fields, such as mood and coping skills, takes about 35 minutes to complete.

Results, which are based on comparisons with normative data in a large database, are generated almost immediately. For typical patients, Dr. Parks estimated that it takes 3-5 minutes to interpret the results. Validation studies include one published in 2007 (Behav Res Methods. 2007 Nov;39[4]:940-9).

This assessment tool has a broad number of options over other alternatives, according to Dr. Parks, who called traditional bedside neurocognitive tests “lame.” He suggested that the information gleaned from asking patients to spell words backward or perform uncommon math problems is “unimpressive.’ Ultimately, “you don’t perform these tests most of the time because you have no respect for their value.”

Referring patients for assessment by a neurocognitive psychologist or psychiatrist is another option, but Dr. Parks noted that these specialists are in short supply and not always willing to perform evaluations not linked to treatment. Moreover, it might take weeks for a referral to lead to an appointment and then another delay before the specialist provides a report that is “longer than I need.”

In contrast, the online neurocognitive tests are available at any time and generate data in hard numbers, showing individual patient performance on a variety of scales relative to normal performance. Dr. Parks reports that he uses this evaluation to gain insight on a broad array of potential diagnoses, such as attention-deficit/hyperactivity disorder (ADHD) and dementia. The test allows the clinician to document impaired memory or concentration, and provide information about relative severity. The data are particularly helpful in cases when the patient is not convinced.

“When patients are not happy that I am not prescribing the stimulant that they requested, I can point to the results to say you don’t have ADHD,” Dr. Parks explained. He described patients complaining of problems of concentration who can be reassured when the data suggest that, in fact, their performance is on the upper limits of normal.

“When we discuss the results, having taken the test provides the patient with a much clearer understanding of what I mean by concentration or memory,” Dr. Parks said. “Results of the test make both sides of the conversation more explicit.”

The test also can be repeated to demonstrate the effect of treatment, according to Dr. Parks. Again, an improvement in key scores provides reassurance to the patient when subjective assessments of improvement are doubted.

The test is available in several languages, including Spanish, and it is geared for a third- or fourth-grade reading level. Although Dr. Parks estimated that about 80% of his patients take the test at home, 20% complete the evaluation on a computer at his facility or with assistance from a proctor, such as a behavioral therapist. Dr. Parks said the test is reimbursed by Medicare and about two-thirds of health insurers in Missouri.

Online neurocognitive testing addresses a large number of the deficiencies associated with previous options, according to Dr. Parks. “This is an area that has been so ripe for change.”

Dr. Parks reported no relevant financial relationships.

NEW YORK – An online neurocognitive test designed to provide reliable objective information about memory, concentration, and emotional well-being is a highly effective tool not only for guiding patients to appropriate therapy but for establishing the credibility of the clinician, according to the description of one such tool at the American Psychiatric Association’s Institute on Psychiatric Services.

The neurocognitive evaluation, which most patients complete on their home computers, “employs explicitly measured scales that reassure patients that I have considered multiple factors and am not just giving my off-the-hip guess and impression,” reported Dr. Joseph J. Parks, director of MOHealthNet, the Medicaid authority for Missouri in Jefferson City.

Several proprietary evaluation systems are available, according to Dr. Parks, but his experience has been with a tool called WebNeuro. Physicians develop an account on this online system and then assign a unique code to patients for access. The assessment, which employs validated and standardized tests of cognitive function and related psychometric fields, such as mood and coping skills, takes about 35 minutes to complete.

Results, which are based on comparisons with normative data in a large database, are generated almost immediately. For typical patients, Dr. Parks estimated that it takes 3-5 minutes to interpret the results. Validation studies include one published in 2007 (Behav Res Methods. 2007 Nov;39[4]:940-9).

This assessment tool has a broad number of options over other alternatives, according to Dr. Parks, who called traditional bedside neurocognitive tests “lame.” He suggested that the information gleaned from asking patients to spell words backward or perform uncommon math problems is “unimpressive.’ Ultimately, “you don’t perform these tests most of the time because you have no respect for their value.”

Referring patients for assessment by a neurocognitive psychologist or psychiatrist is another option, but Dr. Parks noted that these specialists are in short supply and not always willing to perform evaluations not linked to treatment. Moreover, it might take weeks for a referral to lead to an appointment and then another delay before the specialist provides a report that is “longer than I need.”

In contrast, the online neurocognitive tests are available at any time and generate data in hard numbers, showing individual patient performance on a variety of scales relative to normal performance. Dr. Parks reports that he uses this evaluation to gain insight on a broad array of potential diagnoses, such as attention-deficit/hyperactivity disorder (ADHD) and dementia. The test allows the clinician to document impaired memory or concentration, and provide information about relative severity. The data are particularly helpful in cases when the patient is not convinced.

“When patients are not happy that I am not prescribing the stimulant that they requested, I can point to the results to say you don’t have ADHD,” Dr. Parks explained. He described patients complaining of problems of concentration who can be reassured when the data suggest that, in fact, their performance is on the upper limits of normal.

“When we discuss the results, having taken the test provides the patient with a much clearer understanding of what I mean by concentration or memory,” Dr. Parks said. “Results of the test make both sides of the conversation more explicit.”

The test also can be repeated to demonstrate the effect of treatment, according to Dr. Parks. Again, an improvement in key scores provides reassurance to the patient when subjective assessments of improvement are doubted.

The test is available in several languages, including Spanish, and it is geared for a third- or fourth-grade reading level. Although Dr. Parks estimated that about 80% of his patients take the test at home, 20% complete the evaluation on a computer at his facility or with assistance from a proctor, such as a behavioral therapist. Dr. Parks said the test is reimbursed by Medicare and about two-thirds of health insurers in Missouri.

Online neurocognitive testing addresses a large number of the deficiencies associated with previous options, according to Dr. Parks. “This is an area that has been so ripe for change.”

Dr. Parks reported no relevant financial relationships.

NEW YORK – Asynchronous telepsychiatry, labeled as a virtual mental health technology, has shown sufficient promise that it is being tested in a randomized trial, according to those instrumental in its development and the trial’s designers. The strategy was outlined at the American Psychiatric Association’s Institute on Psychiatric Services.

The technology, which involves videotaping structured interviews with patients that can be then reviewed by a psychiatrist at some later opportunity and is known as ATP, has demonstrated in pilot programs results in care that are as effective as synchronous, real-time teleconferencing, reported Dr. Lorin M. Scher of the department of psychiatry and behavioral sciences at the University of California, Davis.

The concept of ATP grew out of efforts to expand a collaborative care program that provides access to mental health care services at regional clinics associated with UC Davis. Real-time video conferencing, which allows psychiatrists to collaborate with primary care physicians and care managers to manage the mental health care needs of patients in remote clinics, is now used widely but has some limitations, Dr. Scher report

Courtesy University of California, Davis

“You need to have a psychiatrist available at a particular time, you need the patient to come to the clinic at a particular time, and it is not as cost effective as one would like it to be,” Dr. Scher reported.

The ATP program at UC Davis, which is being led by Dr. Peter Yellowlees, involves an interview conducted by a trained care manager that is recorded, stored, and then viewed by a psychiatrist at a later time. Just as in synchronous consultations, the psychiatrist produces a full report with treatment recommendations. These are made available to the primary care physician and entered into the electronic medical record (EMR). The primary care physician is invited to contact the psychiatrist with subsequent questions or clarifications.

Synchronous telepsychiatry already has been shown to be effective in multiple studies, according Dr. Scher. Evaluations performed with teleconferencing permit psychiatrists to make accurate diagnoses valid for management recommendations. In the context of a collaborative care model, these recommendations have been associated with good quality care and outcomes. The hypothesis for the randomized trial is that asynchronous telepsychiatry will perform as well in this same model.

After enrollment and randomization to synchronous or asynchronous evaluation, “we plan to compare clinical outcomes, patient satisfaction, and cost over a period of 2 years,” Dr. Scher reported. Of the planned enrollment of 150 patients, 55 have already been randomized.

The technology to perform ATP is simple and widely available. Referrals are handled through the UC Davis EMR system. Once the interview is captured, it is transferred to the psychiatrist through a secure server. It is expected that videos will be eventually uploaded directly into the EMR. The reports generated by the psychiatrist are identical whether based on synchronous or asynchronous telemedicine.

The efforts at UC Davis to deliver mental health services through a collaborative care model are a response to the evidence that psychiatric disease is undertreated, particularly in clinics distant from tertiary care centers. Dr. Scher cited published studies suggesting that about 25% of patients visiting a PCP have a mental health complaint. Of those with mental illness, 60% of patients receive no treatment at all, and only 20% are treated by psychiatrists. He also cited evidence that inadequate control of psychiatric disorders like depression incur high costs attracting the attention of third-party payers to new ideas for delivery of cost-effective care.

“There is a lot of disparity in mental health services,” Dr. Scher said. “The question we are asking ourselves is: ‘How as psychiatrists do we spread our skills to serve a large population?’ ”

Telepsychiatry in the context of collaborative care is a model that is already working, Dr. Scher said. The randomized trial will determine whether the ATP variant can be added to synchronous videoconferencing as an equally effective tool.

Dr. Scher reported no relevant financial relationships.

NEW YORK – Asynchronous telepsychiatry, labeled as a virtual mental health technology, has shown sufficient promise that it is being tested in a randomized trial, according to those instrumental in its development and the trial’s designers. The strategy was outlined at the American Psychiatric Association’s Institute on Psychiatric Services.

The technology, which involves videotaping structured interviews with patients that can be then reviewed by a psychiatrist at some later opportunity and is known as ATP, has demonstrated in pilot programs results in care that are as effective as synchronous, real-time teleconferencing, reported Dr. Lorin M. Scher of the department of psychiatry and behavioral sciences at the University of California, Davis.

The concept of ATP grew out of efforts to expand a collaborative care program that provides access to mental health care services at regional clinics associated with UC Davis. Real-time video conferencing, which allows psychiatrists to collaborate with primary care physicians and care managers to manage the mental health care needs of patients in remote clinics, is now used widely but has some limitations, Dr. Scher report

Courtesy University of California, Davis

“You need to have a psychiatrist available at a particular time, you need the patient to come to the clinic at a particular time, and it is not as cost effective as one would like it to be,” Dr. Scher reported.

The ATP program at UC Davis, which is being led by Dr. Peter Yellowlees, involves an interview conducted by a trained care manager that is recorded, stored, and then viewed by a psychiatrist at a later time. Just as in synchronous consultations, the psychiatrist produces a full report with treatment recommendations. These are made available to the primary care physician and entered into the electronic medical record (EMR). The primary care physician is invited to contact the psychiatrist with subsequent questions or clarifications.

Synchronous telepsychiatry already has been shown to be effective in multiple studies, according Dr. Scher. Evaluations performed with teleconferencing permit psychiatrists to make accurate diagnoses valid for management recommendations. In the context of a collaborative care model, these recommendations have been associated with good quality care and outcomes. The hypothesis for the randomized trial is that asynchronous telepsychiatry will perform as well in this same model.

After enrollment and randomization to synchronous or asynchronous evaluation, “we plan to compare clinical outcomes, patient satisfaction, and cost over a period of 2 years,” Dr. Scher reported. Of the planned enrollment of 150 patients, 55 have already been randomized.

The technology to perform ATP is simple and widely available. Referrals are handled through the UC Davis EMR system. Once the interview is captured, it is transferred to the psychiatrist through a secure server. It is expected that videos will be eventually uploaded directly into the EMR. The reports generated by the psychiatrist are identical whether based on synchronous or asynchronous telemedicine.

The efforts at UC Davis to deliver mental health services through a collaborative care model are a response to the evidence that psychiatric disease is undertreated, particularly in clinics distant from tertiary care centers. Dr. Scher cited published studies suggesting that about 25% of patients visiting a PCP have a mental health complaint. Of those with mental illness, 60% of patients receive no treatment at all, and only 20% are treated by psychiatrists. He also cited evidence that inadequate control of psychiatric disorders like depression incur high costs attracting the attention of third-party payers to new ideas for delivery of cost-effective care.

“There is a lot of disparity in mental health services,” Dr. Scher said. “The question we are asking ourselves is: ‘How as psychiatrists do we spread our skills to serve a large population?’ ”

Telepsychiatry in the context of collaborative care is a model that is already working, Dr. Scher said. The randomized trial will determine whether the ATP variant can be added to synchronous videoconferencing as an equally effective tool.

Dr. Scher reported no relevant financial relationships.

NEW YORK – Asynchronous telepsychiatry, labeled as a virtual mental health technology, has shown sufficient promise that it is being tested in a randomized trial, according to those instrumental in its development and the trial’s designers. The strategy was outlined at the American Psychiatric Association’s Institute on Psychiatric Services.

The technology, which involves videotaping structured interviews with patients that can be then reviewed by a psychiatrist at some later opportunity and is known as ATP, has demonstrated in pilot programs results in care that are as effective as synchronous, real-time teleconferencing, reported Dr. Lorin M. Scher of the department of psychiatry and behavioral sciences at the University of California, Davis.

The concept of ATP grew out of efforts to expand a collaborative care program that provides access to mental health care services at regional clinics associated with UC Davis. Real-time video conferencing, which allows psychiatrists to collaborate with primary care physicians and care managers to manage the mental health care needs of patients in remote clinics, is now used widely but has some limitations, Dr. Scher report

Courtesy University of California, Davis

“You need to have a psychiatrist available at a particular time, you need the patient to come to the clinic at a particular time, and it is not as cost effective as one would like it to be,” Dr. Scher reported.

The ATP program at UC Davis, which is being led by Dr. Peter Yellowlees, involves an interview conducted by a trained care manager that is recorded, stored, and then viewed by a psychiatrist at a later time. Just as in synchronous consultations, the psychiatrist produces a full report with treatment recommendations. These are made available to the primary care physician and entered into the electronic medical record (EMR). The primary care physician is invited to contact the psychiatrist with subsequent questions or clarifications.

Synchronous telepsychiatry already has been shown to be effective in multiple studies, according Dr. Scher. Evaluations performed with teleconferencing permit psychiatrists to make accurate diagnoses valid for management recommendations. In the context of a collaborative care model, these recommendations have been associated with good quality care and outcomes. The hypothesis for the randomized trial is that asynchronous telepsychiatry will perform as well in this same model.

After enrollment and randomization to synchronous or asynchronous evaluation, “we plan to compare clinical outcomes, patient satisfaction, and cost over a period of 2 years,” Dr. Scher reported. Of the planned enrollment of 150 patients, 55 have already been randomized.

The technology to perform ATP is simple and widely available. Referrals are handled through the UC Davis EMR system. Once the interview is captured, it is transferred to the psychiatrist through a secure server. It is expected that videos will be eventually uploaded directly into the EMR. The reports generated by the psychiatrist are identical whether based on synchronous or asynchronous telemedicine.

The efforts at UC Davis to deliver mental health services through a collaborative care model are a response to the evidence that psychiatric disease is undertreated, particularly in clinics distant from tertiary care centers. Dr. Scher cited published studies suggesting that about 25% of patients visiting a PCP have a mental health complaint. Of those with mental illness, 60% of patients receive no treatment at all, and only 20% are treated by psychiatrists. He also cited evidence that inadequate control of psychiatric disorders like depression incur high costs attracting the attention of third-party payers to new ideas for delivery of cost-effective care.

“There is a lot of disparity in mental health services,” Dr. Scher said. “The question we are asking ourselves is: ‘How as psychiatrists do we spread our skills to serve a large population?’ ”

Telepsychiatry in the context of collaborative care is a model that is already working, Dr. Scher said. The randomized trial will determine whether the ATP variant can be added to synchronous videoconferencing as an equally effective tool.

Dr. Scher reported no relevant financial relationships.

NEW YORK – A smartphone app designed to provide automated, real-time support for patients with symptoms of schizophrenia demonstrated promising results in a feasibility study, according to data presented at the American Psychiatric Association’s Institute on Psychiatric Services.

The app, called FOCUS, employs an algorithm to provide “semi-tailored care” based on patient responses to specific prompts, explained Dror Ben-Zeev, Ph.D., of the Dartmouth Psychiatric Research Center, Lebanon, N.H., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The goal is to use automation that allows patients with serious mental illness to get control of bothersome symptoms, regulate mood, enhance social functioning, improve sleep, and improve medication adherence.

©Hocus Focus Studio/iStockphoto.com

In a feasibility study, 33 patients with schizophrenia or schizoaffective disorder were evaluated over 30 days while carrying a smartphone equipped with the FOCUS app. Once downloaded, the app does not require a connection to the Internet. It also was said to be easy to operate without particular technological expertise, although technical support was available.

“The most common technical problem was people forgetting to charge their phone,” reported Dr. Ben-Zeev, who noted that the app was designed for individuals with psychotic symptoms, cognitive impairment, and a relatively low reading level. According to Dr. Ben-Zeev, the 33 participants in the feasibility study were reasonably representative of patients with psychotic disease and “not necessarily technologically savvy.”

Three times per day, the timing of which can be programmed for the individual patient, the app engages the patient with the prompt, “Can you check in with FOCUS right now?” When the patient employs the app, which he or she can also access at any time, not just at the scheduled prompts, it initiates a series of questions leading to algorithm-driven guidance to problem solving.

For example, a patient who is being managed for psychotic symptoms might be asked by the app whether he or she is being bothered by voices and, if so, to rate the severity. If voices are posing difficulty for the patient, the app is designed to deliver cognitive-behavioral therapy for controlling this symptom by walking the patient through cognitive exercises. Other algorithms are used for support for other clinical issues, such as mood regulation.

In the feasibility study, the app was used on average 6.4 times per day during the first week by participating patients. In the 4th week of the study, patients used the app on average 4.9 times per day, meaning that the device was used on average more than the three times that the prompt automatically asked for patient engagement. Acceptance was high. Approximately 90% found the device usable, and 88% reported that they would recommend it to others.

The value of the device also was supported by change in symptoms. Although no change was found from baseline in negative symptoms, the reduction in the end-of-study positive scores was significant (P less than .001).

This app is not yet available, but commercial development is being considered. Dr. Ben-Zeev said this is one of several apps for smartphones that might appear in the near future. This includes passive systems that use sensors in the phone to monitor movement or voice stress as potential signals for an impending relapse. This approach makes sense, as recent data suggest that most outpatients with schizophrenia have smartphones.

“Worldwide, more people have access to cell phones than toilets or toothbrushes,” Dr. Ben-Zeev observed. He estimated that more than 80% of patients with schizophrenia in the United States carry a smartphone capable of running the FOCUS app. He expects mobile interventions in psychiatric disease to proliferate over the coming years.

Dr. Ben-Zeev reported no relevant financial relationships.

NEW YORK – A smartphone app designed to provide automated, real-time support for patients with symptoms of schizophrenia demonstrated promising results in a feasibility study, according to data presented at the American Psychiatric Association’s Institute on Psychiatric Services.

The app, called FOCUS, employs an algorithm to provide “semi-tailored care” based on patient responses to specific prompts, explained Dror Ben-Zeev, Ph.D., of the Dartmouth Psychiatric Research Center, Lebanon, N.H., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The goal is to use automation that allows patients with serious mental illness to get control of bothersome symptoms, regulate mood, enhance social functioning, improve sleep, and improve medication adherence.

©Hocus Focus Studio/iStockphoto.com

In a feasibility study, 33 patients with schizophrenia or schizoaffective disorder were evaluated over 30 days while carrying a smartphone equipped with the FOCUS app. Once downloaded, the app does not require a connection to the Internet. It also was said to be easy to operate without particular technological expertise, although technical support was available.

“The most common technical problem was people forgetting to charge their phone,” reported Dr. Ben-Zeev, who noted that the app was designed for individuals with psychotic symptoms, cognitive impairment, and a relatively low reading level. According to Dr. Ben-Zeev, the 33 participants in the feasibility study were reasonably representative of patients with psychotic disease and “not necessarily technologically savvy.”

Three times per day, the timing of which can be programmed for the individual patient, the app engages the patient with the prompt, “Can you check in with FOCUS right now?” When the patient employs the app, which he or she can also access at any time, not just at the scheduled prompts, it initiates a series of questions leading to algorithm-driven guidance to problem solving.

For example, a patient who is being managed for psychotic symptoms might be asked by the app whether he or she is being bothered by voices and, if so, to rate the severity. If voices are posing difficulty for the patient, the app is designed to deliver cognitive-behavioral therapy for controlling this symptom by walking the patient through cognitive exercises. Other algorithms are used for support for other clinical issues, such as mood regulation.

In the feasibility study, the app was used on average 6.4 times per day during the first week by participating patients. In the 4th week of the study, patients used the app on average 4.9 times per day, meaning that the device was used on average more than the three times that the prompt automatically asked for patient engagement. Acceptance was high. Approximately 90% found the device usable, and 88% reported that they would recommend it to others.

The value of the device also was supported by change in symptoms. Although no change was found from baseline in negative symptoms, the reduction in the end-of-study positive scores was significant (P less than .001).

This app is not yet available, but commercial development is being considered. Dr. Ben-Zeev said this is one of several apps for smartphones that might appear in the near future. This includes passive systems that use sensors in the phone to monitor movement or voice stress as potential signals for an impending relapse. This approach makes sense, as recent data suggest that most outpatients with schizophrenia have smartphones.

“Worldwide, more people have access to cell phones than toilets or toothbrushes,” Dr. Ben-Zeev observed. He estimated that more than 80% of patients with schizophrenia in the United States carry a smartphone capable of running the FOCUS app. He expects mobile interventions in psychiatric disease to proliferate over the coming years.

Dr. Ben-Zeev reported no relevant financial relationships.

NEW YORK – A smartphone app designed to provide automated, real-time support for patients with symptoms of schizophrenia demonstrated promising results in a feasibility study, according to data presented at the American Psychiatric Association’s Institute on Psychiatric Services.

The app, called FOCUS, employs an algorithm to provide “semi-tailored care” based on patient responses to specific prompts, explained Dror Ben-Zeev, Ph.D., of the Dartmouth Psychiatric Research Center, Lebanon, N.H., and the Geisel School of Medicine at Dartmouth, Hanover, N.H. The goal is to use automation that allows patients with serious mental illness to get control of bothersome symptoms, regulate mood, enhance social functioning, improve sleep, and improve medication adherence.

©Hocus Focus Studio/iStockphoto.com

In a feasibility study, 33 patients with schizophrenia or schizoaffective disorder were evaluated over 30 days while carrying a smartphone equipped with the FOCUS app. Once downloaded, the app does not require a connection to the Internet. It also was said to be easy to operate without particular technological expertise, although technical support was available.

“The most common technical problem was people forgetting to charge their phone,” reported Dr. Ben-Zeev, who noted that the app was designed for individuals with psychotic symptoms, cognitive impairment, and a relatively low reading level. According to Dr. Ben-Zeev, the 33 participants in the feasibility study were reasonably representative of patients with psychotic disease and “not necessarily technologically savvy.”

Three times per day, the timing of which can be programmed for the individual patient, the app engages the patient with the prompt, “Can you check in with FOCUS right now?” When the patient employs the app, which he or she can also access at any time, not just at the scheduled prompts, it initiates a series of questions leading to algorithm-driven guidance to problem solving.

For example, a patient who is being managed for psychotic symptoms might be asked by the app whether he or she is being bothered by voices and, if so, to rate the severity. If voices are posing difficulty for the patient, the app is designed to deliver cognitive-behavioral therapy for controlling this symptom by walking the patient through cognitive exercises. Other algorithms are used for support for other clinical issues, such as mood regulation.

In the feasibility study, the app was used on average 6.4 times per day during the first week by participating patients. In the 4th week of the study, patients used the app on average 4.9 times per day, meaning that the device was used on average more than the three times that the prompt automatically asked for patient engagement. Acceptance was high. Approximately 90% found the device usable, and 88% reported that they would recommend it to others.

The value of the device also was supported by change in symptoms. Although no change was found from baseline in negative symptoms, the reduction in the end-of-study positive scores was significant (P less than .001).

This app is not yet available, but commercial development is being considered. Dr. Ben-Zeev said this is one of several apps for smartphones that might appear in the near future. This includes passive systems that use sensors in the phone to monitor movement or voice stress as potential signals for an impending relapse. This approach makes sense, as recent data suggest that most outpatients with schizophrenia have smartphones.

“Worldwide, more people have access to cell phones than toilets or toothbrushes,” Dr. Ben-Zeev observed. He estimated that more than 80% of patients with schizophrenia in the United States carry a smartphone capable of running the FOCUS app. He expects mobile interventions in psychiatric disease to proliferate over the coming years.

Dr. Ben-Zeev reported no relevant financial relationships.

NEW YORK – When art therapy is adjunctively combined with cognitive processing therapy in combat veterans with posttraumatic stress disorder, there is a trend for improvement in the Beck Depression Inventory–II score and greater reported patient satisfaction with the therapy, according to interim results from the first known randomized trial to evaluate the addition of art therapy in this setting.

“There are several case studies suggesting a benefit from art therapy in veterans with PTSD, but we believe this is the first controlled study,” reported Dr. Kathleen P. Decker, a psychiatrist with the Hampton (Va.) VA Medical Center, and the Eastern Virginia Medical School, Norfolk. These preliminary data were presented at the American Psychiatric Association’s Institute on Psychiatric Services.

In this ongoing study, 20 veterans with combat PTSD who were undergoing cognitive processing therapy (CPT) in a residential treatment center have so far been randomized to receive art therapy or no art therapy. The hypothesis is that art therapy would improve cognitive processing and thereby further reduce symptoms.

In addition to “engaging the senses,” art therapy “has been hypothesized to assist with externalization and emotional distance,” Dr. Decker explained. “It has also been hypothesized to assist patients [in processing] traumatic memories by creating links between verbal and nonverbal memories, and may organize disassociated memories.”

The data have been encouraging but not definitive, he said. On the basis of the PTSD Checklist Military, symptoms declined significantly from baseline in both groups (P less than.001), but no significant advantage of art therapy was found over CPT alone (P = .5). However, in addition to the more rapid decline in symptoms of depression on the Beck Depression Inventory–II (BDI-II) in those who received adjunctive art therapy, which approached significance (P = .07), high rates of patient satisfaction were recorded in the art therapy group relative to baseline on a semistructured interview with a Likert scale.

“Subjects who received art therapy were more satisfied with their experience of CPT when they received both treatments. Most reported that they would like to continue,” Dr. Decker reported. She noted that no patient reported an increase in distress in the art therapy group, and all patients in the art therapy group completed the protocol. In contrast, two of the patients receiving CPT alone left the program early.

The absence of significant benefit from art therapy across objective measures might be an issue of sample size, according to Dr. Decker, who said a plan is underway to expand the study. It also was emphasized that this study was conducted in a subpopulation of combat veterans with severe PTSD symptoms (although without traumatic brain injury or active psychosis). Dr. Decker suggested it might be appropriate to consider objective tools other than those used in this study to evaluate the impact of art therapy.

Also, he said it might be possible to improve the structure of the art therapy protocol, which remains incompletely validated. In the protocol outlined by Dr. Decker, patients receiving art therapy were encouraged to set goals and identify symptom triggers early in the sequence of sessions. In the final sessions, patients were encouraged to work on reconstructing self-concepts and review the trauma narrative in the context of the artwork.

“Research has shown that art therapy has been a successful tool in symptom reduction and recovery in civilian populations [with] childhood trauma, rape, or other sources of PTSD,” noted Dr. Decker, citing published studies. For the participants in this trial “art therapy was perceived as useful and satisfying,” encouraging additional studies to further objectively evaluate this approach.

Dr. Decker reported no relevant financial relationships.

NEW YORK – When art therapy is adjunctively combined with cognitive processing therapy in combat veterans with posttraumatic stress disorder, there is a trend for improvement in the Beck Depression Inventory–II score and greater reported patient satisfaction with the therapy, according to interim results from the first known randomized trial to evaluate the addition of art therapy in this setting.

“There are several case studies suggesting a benefit from art therapy in veterans with PTSD, but we believe this is the first controlled study,” reported Dr. Kathleen P. Decker, a psychiatrist with the Hampton (Va.) VA Medical Center, and the Eastern Virginia Medical School, Norfolk. These preliminary data were presented at the American Psychiatric Association’s Institute on Psychiatric Services.

In this ongoing study, 20 veterans with combat PTSD who were undergoing cognitive processing therapy (CPT) in a residential treatment center have so far been randomized to receive art therapy or no art therapy. The hypothesis is that art therapy would improve cognitive processing and thereby further reduce symptoms.

In addition to “engaging the senses,” art therapy “has been hypothesized to assist with externalization and emotional distance,” Dr. Decker explained. “It has also been hypothesized to assist patients [in processing] traumatic memories by creating links between verbal and nonverbal memories, and may organize disassociated memories.”

The data have been encouraging but not definitive, he said. On the basis of the PTSD Checklist Military, symptoms declined significantly from baseline in both groups (P less than.001), but no significant advantage of art therapy was found over CPT alone (P = .5). However, in addition to the more rapid decline in symptoms of depression on the Beck Depression Inventory–II (BDI-II) in those who received adjunctive art therapy, which approached significance (P = .07), high rates of patient satisfaction were recorded in the art therapy group relative to baseline on a semistructured interview with a Likert scale.

“Subjects who received art therapy were more satisfied with their experience of CPT when they received both treatments. Most reported that they would like to continue,” Dr. Decker reported. She noted that no patient reported an increase in distress in the art therapy group, and all patients in the art therapy group completed the protocol. In contrast, two of the patients receiving CPT alone left the program early.

The absence of significant benefit from art therapy across objective measures might be an issue of sample size, according to Dr. Decker, who said a plan is underway to expand the study. It also was emphasized that this study was conducted in a subpopulation of combat veterans with severe PTSD symptoms (although without traumatic brain injury or active psychosis). Dr. Decker suggested it might be appropriate to consider objective tools other than those used in this study to evaluate the impact of art therapy.

Also, he said it might be possible to improve the structure of the art therapy protocol, which remains incompletely validated. In the protocol outlined by Dr. Decker, patients receiving art therapy were encouraged to set goals and identify symptom triggers early in the sequence of sessions. In the final sessions, patients were encouraged to work on reconstructing self-concepts and review the trauma narrative in the context of the artwork.

“Research has shown that art therapy has been a successful tool in symptom reduction and recovery in civilian populations [with] childhood trauma, rape, or other sources of PTSD,” noted Dr. Decker, citing published studies. For the participants in this trial “art therapy was perceived as useful and satisfying,” encouraging additional studies to further objectively evaluate this approach.

Dr. Decker reported no relevant financial relationships.

NEW YORK – When art therapy is adjunctively combined with cognitive processing therapy in combat veterans with posttraumatic stress disorder, there is a trend for improvement in the Beck Depression Inventory–II score and greater reported patient satisfaction with the therapy, according to interim results from the first known randomized trial to evaluate the addition of art therapy in this setting.

“There are several case studies suggesting a benefit from art therapy in veterans with PTSD, but we believe this is the first controlled study,” reported Dr. Kathleen P. Decker, a psychiatrist with the Hampton (Va.) VA Medical Center, and the Eastern Virginia Medical School, Norfolk. These preliminary data were presented at the American Psychiatric Association’s Institute on Psychiatric Services.

In this ongoing study, 20 veterans with combat PTSD who were undergoing cognitive processing therapy (CPT) in a residential treatment center have so far been randomized to receive art therapy or no art therapy. The hypothesis is that art therapy would improve cognitive processing and thereby further reduce symptoms.

In addition to “engaging the senses,” art therapy “has been hypothesized to assist with externalization and emotional distance,” Dr. Decker explained. “It has also been hypothesized to assist patients [in processing] traumatic memories by creating links between verbal and nonverbal memories, and may organize disassociated memories.”

The data have been encouraging but not definitive, he said. On the basis of the PTSD Checklist Military, symptoms declined significantly from baseline in both groups (P less than.001), but no significant advantage of art therapy was found over CPT alone (P = .5). However, in addition to the more rapid decline in symptoms of depression on the Beck Depression Inventory–II (BDI-II) in those who received adjunctive art therapy, which approached significance (P = .07), high rates of patient satisfaction were recorded in the art therapy group relative to baseline on a semistructured interview with a Likert scale.

“Subjects who received art therapy were more satisfied with their experience of CPT when they received both treatments. Most reported that they would like to continue,” Dr. Decker reported. She noted that no patient reported an increase in distress in the art therapy group, and all patients in the art therapy group completed the protocol. In contrast, two of the patients receiving CPT alone left the program early.

The absence of significant benefit from art therapy across objective measures might be an issue of sample size, according to Dr. Decker, who said a plan is underway to expand the study. It also was emphasized that this study was conducted in a subpopulation of combat veterans with severe PTSD symptoms (although without traumatic brain injury or active psychosis). Dr. Decker suggested it might be appropriate to consider objective tools other than those used in this study to evaluate the impact of art therapy.

Also, he said it might be possible to improve the structure of the art therapy protocol, which remains incompletely validated. In the protocol outlined by Dr. Decker, patients receiving art therapy were encouraged to set goals and identify symptom triggers early in the sequence of sessions. In the final sessions, patients were encouraged to work on reconstructing self-concepts and review the trauma narrative in the context of the artwork.

“Research has shown that art therapy has been a successful tool in symptom reduction and recovery in civilian populations [with] childhood trauma, rape, or other sources of PTSD,” noted Dr. Decker, citing published studies. For the participants in this trial “art therapy was perceived as useful and satisfying,” encouraging additional studies to further objectively evaluate this approach.

Dr. Decker reported no relevant financial relationships.

NEW YORK – The prevalence of guns in the United States is a public health issue that must be addressed head-on by clinicians – including psychiatrists, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Part of the challenge is bridging the cultural disconnect between some psychiatrists and patients. About 10% of psychiatrists own guns, but the ownership rate among U.S. households ranges from 40%-50%, said Dr. John Rozel, a psychiatrist affiliated with the Western Psychiatric Institute and Clinic at the University of Pittsburgh. “Most of us psychiatrists might not intrinsically get it.”

©Bytmonas/THinkStock

Facing the ubiquity of guns in American life might be a good place to start. The United States has more than 270,000,000 civilian-owned firearms, which is more than the next 18 countries combined, Dr. Rozel said, quoting 2007 data from the global Small Arms Survey. “Wouldn’t it be great if you could get your hands on access to mental health care” as fast as you can get your hands on a gun?

The secure place of guns within American life requires “radical acceptance” on the part of psychiatrists, Dr. Abhishek Jain said at the session.

“The Second Amendment is not going anywhere,” said Dr. Jain, also a psychiatrist with the clinic. “Keep in mind how much buying [of guns] there is in your jurisdiction. Pay attention to your own state laws. Variability is considerable.”

An understanding of these laws needs to occur while recognizing that the public is largely misinformed about the tendency of people with mental illness to turn to violence. “Little population-level evidence supports the notion that individuals diagnosed with mental illness are more likely than anyone else to commit gun crimes,” Dr. Jonathan M. Metzl and Kenneth T. MacLeish, Ph.D., wrote in a recent review (Am J Public Health. 2015 Feb;105[2]:240-9). “Databases that track gun homicides, such as the National Center for Health Statistics, similarly show that fewer than 5% of the 120,000 gun-related killings in the United States between 2001 and 2010 were perpetrated by people diagnosed with mental illness,” according to the Centers for Disease Control and Prevention.

People with mental illness are more likely to hurt themselves than others. Furthermore, tighter gun laws are associated with lower rates of suicide. A recent study found a connection between more stringent laws involving waiting periods, universal background checks, gun locks, and open carrying regulations in four states and a drop in suicide rates (Am J Public Health. 2015;105[10]:2049-58). “We should talk about individual safety,” Dr. Jain said.

Talking with your patients about guns

Dr. Layla Soliman encouraged developing a working knowledge about some of the fine points of guns, such as how they work. “After every tragedy, we see [in the comments section of online articles] ‘why can’t psychiatrists stop these people?’ We’re part of the discussion, whether we want to be or not,” said Dr. Soliman, a psychiatric attending on the inpatient unit at the hospital.

©alexsokolov/thinkstockphotos.com

Asking all patients about the role of guns in their lives should be routine, she said. “We are trained to do this [as part of] a checklist. We have to ask in the same way we ask about past violence [and] substance use.” Document these conversations with patients defensively, Dr. Soliman said. “I would suggest an integrated risk assessment in your documentation.”

Dr. Rozel agreed. “We’ve learned a lot of lessons from our colleagues in pediatrics [and] how they talk with patients about vaccinations,” he said. Dr. Rozel is trained as a child psychiatrist and holds a master of studies in law degree.

Using motivational interviewing is a good way to get patients to open up about their access to guns and how they view them. “It’s about collaboration, not confrontation,” Dr. Rozel said. “It’s about accepting their reality [and] not imposing our will on them. They may not want to have this conversation. Express empathy [by saying]: ‘I don’t want to take any unnecessary chances with your life.’ ”

Dr. Rozel, Dr. Jain, and Dr. Soliman are also assistant professors of psychiatry at Western Psychiatric Institute and Clinic. They said they had no disclosures.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

NEW YORK – The prevalence of guns in the United States is a public health issue that must be addressed head-on by clinicians – including psychiatrists, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Part of the challenge is bridging the cultural disconnect between some psychiatrists and patients. About 10% of psychiatrists own guns, but the ownership rate among U.S. households ranges from 40%-50%, said Dr. John Rozel, a psychiatrist affiliated with the Western Psychiatric Institute and Clinic at the University of Pittsburgh. “Most of us psychiatrists might not intrinsically get it.”

©Bytmonas/THinkStock

Facing the ubiquity of guns in American life might be a good place to start. The United States has more than 270,000,000 civilian-owned firearms, which is more than the next 18 countries combined, Dr. Rozel said, quoting 2007 data from the global Small Arms Survey. “Wouldn’t it be great if you could get your hands on access to mental health care” as fast as you can get your hands on a gun?

The secure place of guns within American life requires “radical acceptance” on the part of psychiatrists, Dr. Abhishek Jain said at the session.

“The Second Amendment is not going anywhere,” said Dr. Jain, also a psychiatrist with the clinic. “Keep in mind how much buying [of guns] there is in your jurisdiction. Pay attention to your own state laws. Variability is considerable.”

An understanding of these laws needs to occur while recognizing that the public is largely misinformed about the tendency of people with mental illness to turn to violence. “Little population-level evidence supports the notion that individuals diagnosed with mental illness are more likely than anyone else to commit gun crimes,” Dr. Jonathan M. Metzl and Kenneth T. MacLeish, Ph.D., wrote in a recent review (Am J Public Health. 2015 Feb;105[2]:240-9). “Databases that track gun homicides, such as the National Center for Health Statistics, similarly show that fewer than 5% of the 120,000 gun-related killings in the United States between 2001 and 2010 were perpetrated by people diagnosed with mental illness,” according to the Centers for Disease Control and Prevention.

People with mental illness are more likely to hurt themselves than others. Furthermore, tighter gun laws are associated with lower rates of suicide. A recent study found a connection between more stringent laws involving waiting periods, universal background checks, gun locks, and open carrying regulations in four states and a drop in suicide rates (Am J Public Health. 2015;105[10]:2049-58). “We should talk about individual safety,” Dr. Jain said.

Talking with your patients about guns

Dr. Layla Soliman encouraged developing a working knowledge about some of the fine points of guns, such as how they work. “After every tragedy, we see [in the comments section of online articles] ‘why can’t psychiatrists stop these people?’ We’re part of the discussion, whether we want to be or not,” said Dr. Soliman, a psychiatric attending on the inpatient unit at the hospital.

©alexsokolov/thinkstockphotos.com

Asking all patients about the role of guns in their lives should be routine, she said. “We are trained to do this [as part of] a checklist. We have to ask in the same way we ask about past violence [and] substance use.” Document these conversations with patients defensively, Dr. Soliman said. “I would suggest an integrated risk assessment in your documentation.”

Dr. Rozel agreed. “We’ve learned a lot of lessons from our colleagues in pediatrics [and] how they talk with patients about vaccinations,” he said. Dr. Rozel is trained as a child psychiatrist and holds a master of studies in law degree.

Using motivational interviewing is a good way to get patients to open up about their access to guns and how they view them. “It’s about collaboration, not confrontation,” Dr. Rozel said. “It’s about accepting their reality [and] not imposing our will on them. They may not want to have this conversation. Express empathy [by saying]: ‘I don’t want to take any unnecessary chances with your life.’ ”

Dr. Rozel, Dr. Jain, and Dr. Soliman are also assistant professors of psychiatry at Western Psychiatric Institute and Clinic. They said they had no disclosures.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

NEW YORK – The prevalence of guns in the United States is a public health issue that must be addressed head-on by clinicians – including psychiatrists, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Part of the challenge is bridging the cultural disconnect between some psychiatrists and patients. About 10% of psychiatrists own guns, but the ownership rate among U.S. households ranges from 40%-50%, said Dr. John Rozel, a psychiatrist affiliated with the Western Psychiatric Institute and Clinic at the University of Pittsburgh. “Most of us psychiatrists might not intrinsically get it.”

©Bytmonas/THinkStock

Facing the ubiquity of guns in American life might be a good place to start. The United States has more than 270,000,000 civilian-owned firearms, which is more than the next 18 countries combined, Dr. Rozel said, quoting 2007 data from the global Small Arms Survey. “Wouldn’t it be great if you could get your hands on access to mental health care” as fast as you can get your hands on a gun?

The secure place of guns within American life requires “radical acceptance” on the part of psychiatrists, Dr. Abhishek Jain said at the session.

“The Second Amendment is not going anywhere,” said Dr. Jain, also a psychiatrist with the clinic. “Keep in mind how much buying [of guns] there is in your jurisdiction. Pay attention to your own state laws. Variability is considerable.”

An understanding of these laws needs to occur while recognizing that the public is largely misinformed about the tendency of people with mental illness to turn to violence. “Little population-level evidence supports the notion that individuals diagnosed with mental illness are more likely than anyone else to commit gun crimes,” Dr. Jonathan M. Metzl and Kenneth T. MacLeish, Ph.D., wrote in a recent review (Am J Public Health. 2015 Feb;105[2]:240-9). “Databases that track gun homicides, such as the National Center for Health Statistics, similarly show that fewer than 5% of the 120,000 gun-related killings in the United States between 2001 and 2010 were perpetrated by people diagnosed with mental illness,” according to the Centers for Disease Control and Prevention.

People with mental illness are more likely to hurt themselves than others. Furthermore, tighter gun laws are associated with lower rates of suicide. A recent study found a connection between more stringent laws involving waiting periods, universal background checks, gun locks, and open carrying regulations in four states and a drop in suicide rates (Am J Public Health. 2015;105[10]:2049-58). “We should talk about individual safety,” Dr. Jain said.

Talking with your patients about guns

Dr. Layla Soliman encouraged developing a working knowledge about some of the fine points of guns, such as how they work. “After every tragedy, we see [in the comments section of online articles] ‘why can’t psychiatrists stop these people?’ We’re part of the discussion, whether we want to be or not,” said Dr. Soliman, a psychiatric attending on the inpatient unit at the hospital.

©alexsokolov/thinkstockphotos.com

Asking all patients about the role of guns in their lives should be routine, she said. “We are trained to do this [as part of] a checklist. We have to ask in the same way we ask about past violence [and] substance use.” Document these conversations with patients defensively, Dr. Soliman said. “I would suggest an integrated risk assessment in your documentation.”

Dr. Rozel agreed. “We’ve learned a lot of lessons from our colleagues in pediatrics [and] how they talk with patients about vaccinations,” he said. Dr. Rozel is trained as a child psychiatrist and holds a master of studies in law degree.

Using motivational interviewing is a good way to get patients to open up about their access to guns and how they view them. “It’s about collaboration, not confrontation,” Dr. Rozel said. “It’s about accepting their reality [and] not imposing our will on them. They may not want to have this conversation. Express empathy [by saying]: ‘I don’t want to take any unnecessary chances with your life.’ ”

Dr. Rozel, Dr. Jain, and Dr. Soliman are also assistant professors of psychiatry at Western Psychiatric Institute and Clinic. They said they had no disclosures.

ghenderson@frontlinemedcom.com

On Twitter @ginalhenderson

NEW YORK – Integrative care, a system in which specialists collaborate with primary care physicians, might go part of the way toward solving the persistent and growing shortage of psychiatrists in the United States, according to an expert speaking at the American Psychiatric Association’s Institute on Psychiatric Services.

“The question to ask is whether we have a workforce shortage or just a misdistribution of resources,” said Dr. Lori E. Raney, medical director, Axis Health System, Durango, Colo. She suggested in a symposium devoted to the psychiatrist shortage that there is evidence, including randomized trials, that support the efficacy of integrative or collaborative care models for many specialties, not just psychiatry.

In psychiatry, integrative care encourages primary care physicians to deliver at least the first steps of care in patients presenting with psychiatric symptoms. Although the specifics of the collaboration might differ according to the integrative care model, psychiatrists are available to guide primary care physicians at any time in regard to diagnosis or initial treatment but assume full control of management only on the more challenging cases, such as those with severe disease or those who are not responding to standard therapies.

The goal is to avoid automatic referrals, which is a common practice for many primary care physicians, even when confronted with mild to moderate complaints of depression or anxiety, Dr. Raney said. As editor of a recently published book called “Integrated Care: Working at the Interface of Primary Care and Behavioral Health” (Arlington, Va.: American Psychiatric Association Publishing, 2015), she is among the leading experts in the concept of integrative care as it relates to psychiatry. Importantly, integrative care in psychiatry has the potential to lead to better outcomes. One reason is that patients are more likely to be treated. According to Dr. Raney, only about 50% of patients referred to a psychiatrist actually make an appointment.

The success of an integrative or collaborative care model is derived from measurement-based outcomes. This means that the primary care physicians and the psychiatrist collaborate on bringing patients to specific treatment goals based on an objective assessment tool. If, for example, symptoms of depression are not reduced to an agreed-upon target within a specific period of time, the psychiatrist and the primary care physician work together to adjust therapy. The psychiatrist becomes directly involved only in the treatment of those who are not improving.

Recounting her own experience, Dr. Raney said guiding primary care physicians toward next-step treatment adjustments requires relatively little time, particularly when compared with one-on-one patient encounters for patients who have been referred.

Reimbursement for the psychiatrist consultations in an integrative care model can be achieved in many ways, but Dr. Raney suggested that this approach is attractive to payers. She said integrative care is compatible with the growing emphasis on outcomes-based, rather than fee for service–based, reimbursement. In the integrative care services she described, the measurement- and evidence-based management conforms with key approaches to optimal management.

Calling integrative care a potentially new gold standard in the efficient delivery of mental health services, Dr. Raney emphasized that this approach “allows us to be accountable to payers,” even as it addresses the psychiatrist shortage.

This shortage is only getting worse, according to an update provided by Dr. Michael A. Flaum of the department of psychiatry, University of Iowa, Iowa City. Speaking in the same symposium in which Dr. Raney proposed integrative care as a solution, Dr. Flaum said there are about 45,000 active and licensed psychiatrists, not including residents, in the United States. This is about half of the estimated need. Moreover, more than half of practicing psychiatrists are older than 55 years of age versus about 40% for physicians overall.

As the number of physicians entering psychiatry has been flat for about 25 years, the ratio of psychiatrists to other specialists has been diminishing, reported Dr. Flaum, citing data from numerous sources. In Iowa, which has one of the worst shortages of psychiatrists of any state in the United States, “we are rethinking the concept of what the workforce is” in psychiatric care. While he reviewed numerous strategies to address the growing unmet need for psychiatric care, he stated, “meaningful integration” of psychiatry with primary care services “may give us the biggest bang for our buck.” He also said such strategies, including delivery of psychiatric care by nonphysicians, such as nurse practitioners and physician assistants, are actively being pursued in his state.

Dr. Raney reported no relevant financial relationships.

NEW YORK – Integrative care, a system in which specialists collaborate with primary care physicians, might go part of the way toward solving the persistent and growing shortage of psychiatrists in the United States, according to an expert speaking at the American Psychiatric Association’s Institute on Psychiatric Services.

“The question to ask is whether we have a workforce shortage or just a misdistribution of resources,” said Dr. Lori E. Raney, medical director, Axis Health System, Durango, Colo. She suggested in a symposium devoted to the psychiatrist shortage that there is evidence, including randomized trials, that support the efficacy of integrative or collaborative care models for many specialties, not just psychiatry.

In psychiatry, integrative care encourages primary care physicians to deliver at least the first steps of care in patients presenting with psychiatric symptoms. Although the specifics of the collaboration might differ according to the integrative care model, psychiatrists are available to guide primary care physicians at any time in regard to diagnosis or initial treatment but assume full control of management only on the more challenging cases, such as those with severe disease or those who are not responding to standard therapies.

The goal is to avoid automatic referrals, which is a common practice for many primary care physicians, even when confronted with mild to moderate complaints of depression or anxiety, Dr. Raney said. As editor of a recently published book called “Integrated Care: Working at the Interface of Primary Care and Behavioral Health” (Arlington, Va.: American Psychiatric Association Publishing, 2015), she is among the leading experts in the concept of integrative care as it relates to psychiatry. Importantly, integrative care in psychiatry has the potential to lead to better outcomes. One reason is that patients are more likely to be treated. According to Dr. Raney, only about 50% of patients referred to a psychiatrist actually make an appointment.

The success of an integrative or collaborative care model is derived from measurement-based outcomes. This means that the primary care physicians and the psychiatrist collaborate on bringing patients to specific treatment goals based on an objective assessment tool. If, for example, symptoms of depression are not reduced to an agreed-upon target within a specific period of time, the psychiatrist and the primary care physician work together to adjust therapy. The psychiatrist becomes directly involved only in the treatment of those who are not improving.

Recounting her own experience, Dr. Raney said guiding primary care physicians toward next-step treatment adjustments requires relatively little time, particularly when compared with one-on-one patient encounters for patients who have been referred.

Reimbursement for the psychiatrist consultations in an integrative care model can be achieved in many ways, but Dr. Raney suggested that this approach is attractive to payers. She said integrative care is compatible with the growing emphasis on outcomes-based, rather than fee for service–based, reimbursement. In the integrative care services she described, the measurement- and evidence-based management conforms with key approaches to optimal management.

Calling integrative care a potentially new gold standard in the efficient delivery of mental health services, Dr. Raney emphasized that this approach “allows us to be accountable to payers,” even as it addresses the psychiatrist shortage.

This shortage is only getting worse, according to an update provided by Dr. Michael A. Flaum of the department of psychiatry, University of Iowa, Iowa City. Speaking in the same symposium in which Dr. Raney proposed integrative care as a solution, Dr. Flaum said there are about 45,000 active and licensed psychiatrists, not including residents, in the United States. This is about half of the estimated need. Moreover, more than half of practicing psychiatrists are older than 55 years of age versus about 40% for physicians overall.

As the number of physicians entering psychiatry has been flat for about 25 years, the ratio of psychiatrists to other specialists has been diminishing, reported Dr. Flaum, citing data from numerous sources. In Iowa, which has one of the worst shortages of psychiatrists of any state in the United States, “we are rethinking the concept of what the workforce is” in psychiatric care. While he reviewed numerous strategies to address the growing unmet need for psychiatric care, he stated, “meaningful integration” of psychiatry with primary care services “may give us the biggest bang for our buck.” He also said such strategies, including delivery of psychiatric care by nonphysicians, such as nurse practitioners and physician assistants, are actively being pursued in his state.

Dr. Raney reported no relevant financial relationships.

NEW YORK – Integrative care, a system in which specialists collaborate with primary care physicians, might go part of the way toward solving the persistent and growing shortage of psychiatrists in the United States, according to an expert speaking at the American Psychiatric Association’s Institute on Psychiatric Services.

“The question to ask is whether we have a workforce shortage or just a misdistribution of resources,” said Dr. Lori E. Raney, medical director, Axis Health System, Durango, Colo. She suggested in a symposium devoted to the psychiatrist shortage that there is evidence, including randomized trials, that support the efficacy of integrative or collaborative care models for many specialties, not just psychiatry.

In psychiatry, integrative care encourages primary care physicians to deliver at least the first steps of care in patients presenting with psychiatric symptoms. Although the specifics of the collaboration might differ according to the integrative care model, psychiatrists are available to guide primary care physicians at any time in regard to diagnosis or initial treatment but assume full control of management only on the more challenging cases, such as those with severe disease or those who are not responding to standard therapies.

The goal is to avoid automatic referrals, which is a common practice for many primary care physicians, even when confronted with mild to moderate complaints of depression or anxiety, Dr. Raney said. As editor of a recently published book called “Integrated Care: Working at the Interface of Primary Care and Behavioral Health” (Arlington, Va.: American Psychiatric Association Publishing, 2015), she is among the leading experts in the concept of integrative care as it relates to psychiatry. Importantly, integrative care in psychiatry has the potential to lead to better outcomes. One reason is that patients are more likely to be treated. According to Dr. Raney, only about 50% of patients referred to a psychiatrist actually make an appointment.

The success of an integrative or collaborative care model is derived from measurement-based outcomes. This means that the primary care physicians and the psychiatrist collaborate on bringing patients to specific treatment goals based on an objective assessment tool. If, for example, symptoms of depression are not reduced to an agreed-upon target within a specific period of time, the psychiatrist and the primary care physician work together to adjust therapy. The psychiatrist becomes directly involved only in the treatment of those who are not improving.

Recounting her own experience, Dr. Raney said guiding primary care physicians toward next-step treatment adjustments requires relatively little time, particularly when compared with one-on-one patient encounters for patients who have been referred.

Reimbursement for the psychiatrist consultations in an integrative care model can be achieved in many ways, but Dr. Raney suggested that this approach is attractive to payers. She said integrative care is compatible with the growing emphasis on outcomes-based, rather than fee for service–based, reimbursement. In the integrative care services she described, the measurement- and evidence-based management conforms with key approaches to optimal management.

Calling integrative care a potentially new gold standard in the efficient delivery of mental health services, Dr. Raney emphasized that this approach “allows us to be accountable to payers,” even as it addresses the psychiatrist shortage.

This shortage is only getting worse, according to an update provided by Dr. Michael A. Flaum of the department of psychiatry, University of Iowa, Iowa City. Speaking in the same symposium in which Dr. Raney proposed integrative care as a solution, Dr. Flaum said there are about 45,000 active and licensed psychiatrists, not including residents, in the United States. This is about half of the estimated need. Moreover, more than half of practicing psychiatrists are older than 55 years of age versus about 40% for physicians overall.

As the number of physicians entering psychiatry has been flat for about 25 years, the ratio of psychiatrists to other specialists has been diminishing, reported Dr. Flaum, citing data from numerous sources. In Iowa, which has one of the worst shortages of psychiatrists of any state in the United States, “we are rethinking the concept of what the workforce is” in psychiatric care. While he reviewed numerous strategies to address the growing unmet need for psychiatric care, he stated, “meaningful integration” of psychiatry with primary care services “may give us the biggest bang for our buck.” He also said such strategies, including delivery of psychiatric care by nonphysicians, such as nurse practitioners and physician assistants, are actively being pursued in his state.

Dr. Raney reported no relevant financial relationships.