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Health care policies are subject to scientific and economic constraints. It is necessary to develop research and evaluation policies, particularly in mental health services. In the area of drug treatment, new methodologies in phase II studies, and a true research program of phase IV, are needed. Furthermore, evaluation of practices needs new scientific programs. This last point is also relevant for psychotherapies. Comparative studies about criteria of indications must be developed.
Recent epidemiological surveys that have attempted to include the need for treatment of mental disorders are reviewed, and it is concluded that the greatest unmet need is for those with non-psychotic disorders. Recent studies on factors that influence the natural history of such disorders reveal that these are largely social and environmental; one study suggests that genetic factors are only important in the group that have longer time courses. Those factors within the medical encounter that produce better outcomes are reviewed, and non-specific factors and supportive therapy are found to be important. Some additional advantages are to be obtained with specific antidepressant treatments (either pharmacological or problem-solving) and with re-attribution skills for psychologically determined somatic symptoms. The implications of these findings are discussed from the standpoint of the primary care team, the community mental health team and self-help materials.
The present article reviews the recent molecular genetic findings in affective disorders. Results of linkage and association studies are discussed in regard to the main limitations of these approaches in psychiatric disorders. On the whole, linkage and association studies contributed to the localisation of some potential vulnerability genes for Bipolar affective disorder on chromosomes 18, 5, 11, 4, 21 and X. The hypothesis of anticipation in affective disorders is also considered in light of interesting results with trinucleotide repeat mutations.
Mental health service delivery in the general health care sector is restricted with regard to understanding the magnitude and impact of mental illness in the medically ill (co-morbidity), as well as the significance of current mental health service delivery. A new model in development in the framework of a Biomed2 grant is presented. It consists of case-finding through complexity of hospital care prediction (COMPRI) followed by an integral health service needs assessment (INTERMED). It might serve to develop a more structural relation with the general health care sector for the management of mentally co-morbid high utilizing patients.
Quality assurance is the corrective action applied to any observed discrepancy between optimal and actual level of medical care requiring continuous quality control. Obviously, quality assurance is of utmost importance also in psychiatric practice. Quality care as defined by the degree of adherence to standards and guidelines can be measured in terms of structural, process and outcome indicators applied to inpatient, outpatient and complementary services. To promote the implementation of practice guidelines into psychiatric care conceptual, methodological, and organisational requirements must be taken into account.
There are extrinsic as well as intrinsic limits to the resources available for health care. Therefore, economic factors have become an essential part of medical activity, leading to a disruption of the traditional doctor-patient relationships. A new economic approach of health care (ie, through managed care) and ethical attitude (to overcome the limits of managed care) are essential, especially in psychiatric practice.
The limits of the role of psychiatrists are becoming increasingly vague as a consequence of the confusion on the theoretical model, the excessive size of the field and the managed care movement that is deeply altering the way psychiatric services are delivered. A thorough reflection has to be made about the need to strengthen the professional identity of future psychiatrists in the course of their training. Theoretical orientation of psychiatrists depends, to a large extent, on the training that they received during residency and the type of practice they undertake. It is necessary, therefore, to consider that the institutional path and expected activities in the program of training postgraduates is particularly important for the development of the identity of the resident as a psychiatrist. The criteria for elaborating these programs have to take into account, not only the opinion of the teachers and of the residents, but also many other parameters, one of which is the description of what makes a true psychiatrist in his or her clinical practice, so as to adapt the content of programs to the realization of inherent objectives to the activities described.