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Concept: Psychiatrist

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The experience of burnout has been the focus of much research during the past few decades. Measures have been developed, as have various theoretical models, and research studies from many countries have contributed to a better understanding of the causes and consequences of this occupationally-specific dysphoria. The majority of this work has focused on human service occupations, and particularly health care. Research on the burnout experience for psychiatrists mirrors much of the broader literature, in terms of both sources and outcomes of burnout. But it has also identified some of the unique stressors that mental health professionals face when they are dealing with especially difficult or violent clients. Current issues of particular relevance for psychiatry include the links between burnout and mental illness, the attempts to redefine burnout as simply exhaustion, and the relative dearth of evaluative research on potential interventions to treat and/or prevent burnout. Given that the treatment goal for burnout is usually to enable people to return to their job, and to be successful in their work, psychiatry could make an important contribution by identifying the treatment strategies that would be most effective in achieving that goal.

Concepts: Medicine, Psychiatrist, Health care, Mental disorder, Mental health, Mental health professional, Psychology, Psychiatry

48

IMPORTANCE There have been recent calls for increased access to mental health services, but access may be limited owing to psychiatrist refusal to accept insurance. OBJECTIVE To describe recent trends in acceptance of insurance by psychiatrists compared with physicians in other specialties. DESIGN, SETTING, AND PARTICIPANTS We used data from a national survey of office-based physicians in the United States to calculate rates of acceptance of private noncapitated insurance, Medicare, and Medicaid by psychiatrists vs physicians in other specialties and to compare characteristics of psychiatrists who accepted insurance and those who did not. MAIN OUTCOMES AND MEASURES Our main outcome variables were physician acceptance of new patients with private noncapitated insurance, Medicare, or Medicaid. Our main independent variables were physician specialty and year groupings (2005-2006, 2007-2008, and 2009-2010). RESULTS The percentage of psychiatrists who accepted private noncapitated insurance in 2009-2010 was significantly lower than the percentage of physicians in other specialties (55.3% [95% CI, 46.7%-63.8%] vs 88.7% [86.4%-90.7%]; P < .001) and had declined by 17.0% since 2005-2006. Similarly, the percentage of psychiatrists who accepted Medicare in 2009-2010 was significantly lower than that for other physicians (54.8% [95% CI, 46.6%-62.7%] vs 86.1% [84.4%-87.7%]; P < .001) and had declined by 19.5% since 2005-2006. Psychiatrists' Medicaid acceptance rates in 2009-2010 were also lower than those for other physicians (43.1% [95% CI, 34.9%-51.7%] vs 73.0% [70.3%-75.5%]; P < .001) but had not declined significantly from 2005-2006. Psychiatrists in the Midwest were more likely to accept private noncapitated insurance (85.1%) than those in the Northeast (48.5%), South (43.0%), or West (57.8%) (P = .02). CONCLUSIONS AND RELEVANCE Acceptance rates for all types of insurance were significantly lower for psychiatrists than for physicians in other specialties. These low rates of acceptance may pose a barrier to access to mental health services.

Concepts: Mental health, Health care, Health insurance, Mental health professional, Psychiatrist, Psychiatry, Physician, Medicine

13

Aims and method To establish an initial conceptualisation of how psychiatrists understand and use formulation within adult psychiatry practice. Twelve psychiatrists took part in semi-structured interviews. Transcripts were analysed using a constructivist grounded theory methodology. Results Formulation was conceptualised as an addition to diagnosis, triggered by risk, complexity and a need for an enhanced understanding. Participants valued collaborative formulation with psychologists. Multiple contextual factors were perceived to either facilitate or inhibit the process. Barriers to formulation led to a disjointed way of working. Clinical implications Findings contribute to an understanding of formulation within psychiatry training and practice.

Concepts: Psychiatrist, Grounded theory, Cognition, Mental health professional, Perception, Psychiatry, Clinical psychology, Psychology

12

OBJECTIVES: Electronic Medical Records (EMR) have the potential to improve the coordination of healthcare in this country, yet the field of psychiatry has lagged behind other medical disciplines in its adoption of EMR. METHODS: Psychiatrists at 18 of the top US hospitals completed an electronic survey detailing whether their psychiatric records were stored electronically and accessible to non-psychiatric physicians. Electronic hospital records and accessibility statuses were correlated with patient care outcomes obtained from the University Health System Consortium Clinical Database available for 13 of the 18 top US hospitals. RESULTS: 44% of hospitals surveyed maintained most or all of their psychiatric records electronically and 28% made psychiatric records accessible to non-psychiatric physicians; only 22% did both. Compared with hospitals where psychiatric records were not stored electronically, the average 7-day readmission rate of psychiatric patients was significantly lower at hospitals with psychiatric EMR (5.1% vs. 7.0%, p=.040). Similarly, the 14 and 30-day readmission rates at hospitals where psychiatric records were accessible to non-psychiatric physicians were lower than those of their counterparts with non-accessible records (5.8% vs. 9.5%, p=.019, 8.6% vs. 13.6%, p=.013, respectively). The 7, 14, and 30-day readmission rates were significantly lower in hospitals where psychiatric records were both stored electronically and made accessible than at hospitals where records were either not electronic or not accessible (4% vs 6.6%, 5.8% vs 9.1%, 8.9 vs 13%, respectively, all with p=0.045). CONCLUSIONS: Having psychiatric EMR that were accessible to non-psychiatric physicians correlated with improved clinical care as measured by lower readmission rates specific for psychiatric patients.

Concepts: Psychiatrist, Health care, Doctor-patient relationship, Physician, Hospital, Medicine, Patient, Psychiatry

11

Given low psychiatrist participation in insurance networks, this study examines how psychiatrists are reimbursed in network and out of network under commercial insurance relative to other providers for the same diagnoses and services.

Concepts: Mental health professional, Physician, Neuropsychiatry, Psychiatrist, Psychiatry

10

The purpose of this paper is to set out informal, provisional and comprehensive but concise guidelines for mother-infant (perinatal) mental health (psychiatry), as an area of specialisation. It is informal in the sense that the authors are clinicians and researchers from many different nations, who share a common goal and vision, speaking on their own behalf and not with the backing of any authority or society. It is provisional in the expectation that it can be improved by criticism and new research findings. It is a comprehensive summary of the development of the specialty, its core knowledge and recommended investigations and interventions. It is concise (under 6,000 words, taking less than an hour to read) in order to increase readership and facilitate translation. No attempt has been made to parade the evidence for these suggestions, because the document would have been too long to translate, and for many to read. Instead, drafts were circulated for criticism by those included in the authorship, resulting in a consensus (finalised by the three principal authors), providing a framework to guide service provision, clinical practice and research. The full list of authors, from 33 nations, is given in the postscript. They include mother-infant (or parent-infant) and perinatal adult or child psychiatrists and those with a special interest; mother-infant, perinatal and forensic psychologists; psychiatric nurses; the founders of Postpartum Support International and the Association for Postnatal Illness; representatives of social work and obstetrics and the management of these services, and research scientists working in the field.

Concepts: Mental health, Medicine, Psychiatrist, Clinical psychology, Childbirth, Psychology, Mental health professional, Psychiatry

8

Aims and method To review the literature to examine the factors that may be affecting recruitment into psychiatry in the UK. We systematically searched four databases to identify studies from 1974 to 2016 and identified 27 papers that met the specified inclusion criteria. Results Most papers (n = 24) were based on questionnaire surveys. The population in all studies comprised of 1879 psychiatrists, 6733 students and 220 746 trainees. About 4-7% of students opt for a career in psychiatry. Enrichment activities helped to attract students more towards psychiatry than just total time spent in the specialty. Job content in terms of the lack of scientific basis, poor prognosis and stigma towards psychiatry, work-related stress and problems with training jobs were common barriers highlighted among students and trainees, affecting recruitment. Job satisfaction and family-friendly status of psychiatry was rated highly by students, with lifestyle factors appearing to be important for trainees who tend to choose psychiatry. Clinical implications Negative attitudes and stigma towards psychiatry continue to persist. Teaching and training in psychiatry needs rethinking to improve student experience and recruitment into the specialty.

Concepts: Stress, Student, Psychiatrist, Training, Clinical psychology, United Kingdom, Medicine, Psychiatry

8

Individuals undergoing long-term psychiatric treatment frequently choose to stop taking psychiatric medications. To enhance service user choice and prevent undesirable outcomes, this first U.S. survey of a large sample of longer-term users sought to increase knowledge about users' experience of medication discontinuation.

Concepts: Pharmacology, Psychiatric medication, Psychiatrist, Psychiatry, Medicine

7

Negative public attitudes towards psychiatry hinder individuals coming for treatment and prevent us from attracting and retaining the very brightest and best doctors. As psychiatrists we are skilled in using science to change the thoughts and behaviours of individuals, however, we lack the skills to engage entire populations. Expertise in this field is the preserve of branding, advertising and marketing professionals. Techniques from these fields can be used to rebrand psychiatry at a variety of levels from national recruitment drives to individual clinical interactions between psychiatrists and their patients.

Concepts: Mental health professional, Psychiatrist, Psychiatry, Skills, Clinical psychology, Physician, Critical thinking, Psychology

7

Although the great physicians of past centuries might have called it something else, proficiency at promoting mindfulness has always been and should remain part of a doctor’s clinical toolkit.

Concepts: Psychiatrist, Physician, Medicine