The WPA-Lancet Psychiatry Commission on the Future of Psychiatry

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. RESULTS: Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

https://pediatrics.aappublications.org/content/pediatrics/early/2018/02/22/peds.2017-4081.full.pdf

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management

Most efforts aimed at understanding the notable heterogeneity of outcomes in multiple sclerosis (MS) have focused on disease-specific factors, such as symptoms at initial presentation, initial relapse rate, and age at symptom onset. These factors, however, explain relatively little of the heterogeneity of disease outcomes. Owing to the high prevalence of comorbidity in MS and the potential for its prevention or treatment, comorbidity is of rising interest as a factor that could explain the heterogeneity of outcomes. A rapidly growing body of evidence suggests that comorbidity adversely affects outcomes throughout the disease course in MS, including diagnostic delays from symptom onset, disability at diagnosis and subsequent progression, cognition, mortality, and health-related quality of life. Therefore, clinicians need to incorporate the prevention and management of comorbidity when treating patients with MS, but managing comorbidities in MS successfully may require the adoption of new collaborative models of care.

Comorbidity in multiple sclerosis: implications for patient care

Background: Telehealth represents an opportunity for Australia to harness the power of technology to redesign the way health care is delivered. The potential benefits of telehealth include increased accessibility to care, productivity gains for health providers and patients through reduced travel, potential for cost savings, and an opportunity to develop culturally appropriate services that are more sensitive to the needs of special populations. The uptake of telehealth has been hindered at times by clinician reluctance and policies that preclude metropolitan populations from accessing telehealth services.
Objective: This study aims to investigate if telehealth reduces health system costs compared with traditional service models and to identify the scenarios in which cost savings can be realized.
Methods: A scoping review was undertaken to meet the study aims. Initially, literature searches were conducted using broad terms for telehealth and economics to identify economic evaluation literature in telehealth. The investigators then conducted an expert focus group to identify domains where telehealth could reduce health system costs, followed by targeted literature searches for corresponding evidence.
Results: The cost analyses reviewed provided evidence that telehealth reduced costs when health system–funded travel was prevented and when telehealth mitigated the need for expensive procedural or specialist follow-up by providing competent care in a more efficient way. The expert focus group identified 4 areas of potential savings from telehealth: productivity gains, reductions in secondary care, alternate funding models, and telementoring. Telehealth demonstrated great potential for productivity gains arising from health system redesign; however, under the Australian activity-based funding, it is unlikely that these gains will result in cost savings. Secondary care use mitigation is an area of promise for telehealth; however, many studies have not demonstrated overall cost savings due to the cost of administering and monitoring telehealth systems. Alternate funding models from telehealth systems have the potential to save the health system money in situations where the consumers pay out of pocket to receive services. Telementoring has had minimal economic evaluation; however, in the long term it is likely to result in inadvertent cost savings through the upskilling of generalist and allied health clinicians.
Conclusions: Health services considering implementing telehealth should be motivated by benefits other than cost reduction. The available evidence has indicated that although telehealth provides overwhelmingly positive patient benefits and increases productivity for many services, current evidence suggests that it does not routinely reduce the cost of care delivery for the health system.

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Determining if Telehealth Can Reduce Health System Costs: Scoping Review.

Background Many psychiatric disorders including schizophrenia, bipolar disorder and major depression convey an excess burden of cardiovascular morbidity and mortality. The medications used to treat these conditions may further adversely affect cardiovascular risk and exacerbate health disparities for vulnerable populations. There is a clinical need to appreciate the cardiometabolic adverse effects of psychotropic medications. Methods This paper reviews the most relevant cardiometabolic effects of psychotropic medications, organized around the components of metabolic syndrome. When known, the molecular and physiological mechanisms underlying any adverse cardiometabolic effects are detailed. Results Many commonly used psychotropic medications, particularly antipsychotics, mood stabilizers and some antidepressants, have been independently associated with cardiometabolic risk factors such as insulin resistance, obesity and dyslipidemia. Stimulants, antidepressants that inhibit reuptake of norepinephrine, some antipsychotics and valproic acid derivatives may also increase blood pressure. Conclusion Understanding, assessing and subsequently managing cardiometabolic complications of psychotropic medications are important to mitigate the excess cardiovascular morbidity and mortality in the clinical populations prescribed psychotropic medications. There is considerable variability in risk between medications and individuals. Timely management of iatrogenic cardiometabolic effects is critical.

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Cardiometabolic effects of psychotropic medications

the range of opportunities for integration, from improving treatment of mental health conditions in general medical settings to addressing the general medical conditions that lead to early mortality in populations with serious mental illnesses in mental health settings. Of major concern is that 60% of patients with a psychiatric diagnosis do not receive any form of treatment, and over half of those who do will get their care in a general medical setting. Unfortunately, in primarycaresettings,only13%ofthementalhealthcaredelivered is considered to be “minimally adequate” (1). In addition, the presence of a psychiatric diagnosis can increase the overall costs of health care by two or three times, leading to the conclusion that significant cost savings within the health care systemcanbeachievedbyadequatelyaddressingmentalhealth andgeneralmedicalconditionsconcurrently(2).Theshortage

Integrating Primary Care and Behavioral Health: The Role of the Psychiatrist in the Collaborative Care Model.

Widespread implementation of integrated primary care and behavioral health is possible, but workforce shortages, competencies to deliver evidence-based approaches, and sufficient reimbursement are lacking There are numerous telehealth solutions that could be utilized to assist with integration efforts that have the potential to be successfully used alone or in combination This will require that the developers of such technologies understand the current evidence base for effective integration efforts and apply this knowledge to new solutions Evidence-based models of integrated care such as the collaborative care model have a robust evidence base including studies that demonstrate effective delivery from remote locations Technology solutions that can serve as practice extenders by performing some of the tasks, and can expand the competency of primary care providers to treat mild to moderate mental illness, have an emerging literature in the behavioral health arena that shows promise for integrating care More widespread implementation of effective integrated primary care and behavioral health can be accomplished with the help of technology solutions that can address the problems of workforce shortages and competencies Use of these technologies alone or in combination is a growing area of research and development and an untapped frontier that warrants further investigation

Digitally Driven Integrated Primary Care and Behavioral Health: How Technology Can Expand Access to Effective Treatment.

The American Psychiatric Association Integrated Care Workgroup recently convened an expert panel charged with addressing the role of psychiatry in improving the physical health of persons with seri...

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Psychiatry's Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association.

This column describes Project ECHO (Extension for Community Healthcare Outcomes), a teleconsultation, tele-education, telementoring model for enhancing primary care treatment of underserved patients with complex medical conditions. Numerous centers have adapted ECHO to support primary care treatment of behavioral health disorders. Preliminary evidence for behavioral health ECHO programs suggests positive impacts on providers, treatment planning, and emergency department costs. ECHO has the potential to improve access to effective and cost-effective behavioral health care by virtually integrating behavioral health knowledge and support in sites where specialty providers are not available. Patient-level outcomes research is critical.

Leveraging Behavioral Health Expertise: Practices and Potential of the Project ECHO Approach to Virtually Integrating Care in Underserved Areas

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Lori E. Raney

Papers

Integrating Primary Care and Behavioral Health: The Role of the Psychiatrist in the Collaborative Care Model.

Digitally Driven Integrated Primary Care and Behavioral Health: How Technology Can Expand Access to Effective Treatment.

Psychiatry's Role in Improving the Physical Health of Patients With Serious Mental Illness: A Report From the American Psychiatric Association.

Leveraging Behavioral Health Expertise: Practices and Potential of the Project ECHO Approach to Virtually Integrating Care in Underserved Areas

A Framework for Extending Psychiatrists’ Roles in Treating General Health Conditions