Alex Richman

Electroconvulsive therapy: a Canadian perspective.

Recent ECT practices in Canada are reviewed from a historical perspective with respect to specific criticisms. Utilization is decreasing; utilization rates vary widely between Provinces and between regions; disproportionate numbers of females have been receiving ECT; a substantial group of patients diagnosed as neurotic and schizophrenic continue to receive ECT; criteria and guidelines for its use are not consistently applied. Expected rates of ECT used are estimated, based on theory and practice as well as on published data on the epidemiology of affective disorders. Data on actual Canadian usage are reviewed and compared with an estimated minimum ratio of 30–45+ cases per year of non bi-polar depression per 100,000 population requiring ECT. Results show that there may be a substantial number of patients in some Provinces for whom ECT is the best available treatment and who are not receiving it. There is some ethical concern associated with possible under-use of ECT as the best therapy available for certain patient groups. Clinical cases and patterns of care should be reviewed at the hospital level to determine how best to effect improvements in the use of this treatment.

Alcohol consumption and morbidity in the Canada Health Survey: Inter-beverage differences

This study examined inter-beverage differences in the relationship between alcohol consumption and health status as reported by 17 249 respondents to the Canada Health Survey. Self-reported morbidity rates (bed-days, activity loss, doctor visits) were computed for consumers of beer, wine, liquor and for those with no specific beverage preference. These rates were compared with the level of expected morbidity based on each groups demographic attributes. Subsequently, dose-response relationships were described relating frequency and quantity of consumption to a standardized morbidity rate for each beverage-preference group. In general, the results supported the importance of inter-beverage differences as an intervening variable in the relationship of consumption to morbidity. Overall morbidity rates and both frequency and quantity dimensions of the dose-response relationship varied markedly as a function of type of beverage consumed. Beer drinkers, in particular, varied from other consumers they had significantly lower rates of morbidity than expected. Increases in frequency of beer drinking were associated with reductions in morbidity, but mildly deleterious effects were associated with excessive consumption.

The relevance of socio-demographic and resource factors in the use of acute psychiatric in-patient care in the Atlantic Provinces of Canada.

This study assessed the inter-relations of socio-demographic, resource and policy factors with standardized measures of short-term psychiatric bed-use in 42 counties of Atlantic Canada. The policy factor made up two-thirds of the total variability (61%) accounted for among males, and nearly one-half of the 47% accounted for among females. An accurate assessment of in-patient resource needs is seen as resulting from intertwining morbidity surveys with utilization studies.

General hospital psychiatry: Are its roles and functions adjunctive or pivotal? ☆

General hospital psychiatric divisions are an important part of the mental health care delivery system; however, in Canada and the United States, their role and function have not been well defined. In most places, the general hospital is peripheral to the mental hospital, and is thus an adjunctive element in the resulting two-tier mental health care delivery system. The adjunctive type of general hospital psychiatric division provides brief treatment to highly selective types of patients, and is relatively inaccessible to a wide variety of patients. In contrast, the general hospital can be central to the mental health care delivery system--in a pivotal position to patients, other mental health facilities, and community agencies. Important features of the pivotal type are: defined catchment areas, broad admitting criteria and effective discharge planning, linkages with extramural and community programs, staff reorientation, appropriate architectural features, and the ability to hear and respond to the needs of the community. The pivotal type of general hospital psychiatric division can provide appropriate levels of inpatient care, as well as the linkages and backup to extramural and community programs for the long-term mentally ill. The mental hospital would no longer be used as a backup for general clinical disorders, involuntary patients, or patients usually rejected by adjunctive hospitals. There would be collaboration with other agencies in developing programs for special clinical groups (low prevalence disorders), as well as for alcoholism, psychogeriatrics, and adolescent disorders. This article reviews the current polemic on the role and function of the general hospital psychiatric division, as part of the mental health care delivery system.

Use of psychiatric services by the elderly in Canada.

There is increasing emphasis on identifying mental disorders in the elderly and developing appropriate mental health services. However, there are few quantitative studies on service use by the elderly. This paper gives a national perspective on the use of psychiatric services by the aged in Canada, and details two of the health care studies used to assess their mental health needs in southern New Brunswick. The elderly now make up a higher proportion of the long-term mental hospital population than they did 20 years ago. Despite the increase in number of short-stay general hospital psychiatric units, there are still marked differences in their use by the elderly. There is a marked decrease in short-term psychiatric in-patient care after the sixth decade. As well there are marked regional variations. The results of a Level of Care Survey in a New Brunswick mental hospital shows the discrepancies between the needs for care and the level of care actually received. In comparison with other patient sub-groups, elderly long-stay mental hospital patients had the highest proportion (79%) deemed suitable for care in alternative settings outside the hosptial. The anonymized merged statistical file revealed that the elderly mentally ill were more likely to be identified and cared for within non-specialized wards of general hospitals, and least likely to have contact with mental health clinics. Instead of adding new services to the existing system, reallocation and redirection of existing resources are crucial strategies in improving the mental health services for the elderly. The general hospital is an important area for psychiatric consultation and back-up to primary care services.

After how many detoxications is rehabilitation probable

The outcome of alcohol detoxication programmes was assessed in Ontario and New York. Clinical records showed that less than 40% of patients completed the referral from thier fist detoxication to a rehabilitation programme and that the probability of entering a rehabilitation programme decreased markedly as the number of detoxications increased. Also, as the number of detoxications increased, patients were admitted to the centers more frequently and at shorter intervals. Only a small percentage showed marked benefit from multiple treatments. The success of detoxication facilities in achieving rehabilitation appeared limited.

Involuntary hospitalization in Canadian psychiatric inpatient facilities, 1970-1978.

This study is concerned with providing quantitative information on involuntary hospitalization of the mentally ill in Canada. It presents national statistical data on involuntary hospitalization to provincial mental and psychiatric hospitals, and psychiatric units of general hospitals for the period 1970–1978. The data used are based on the statistical information on psychiatric in-patients collected by the Mental Health Program of Statistics Canada for the period 1970–1978. The data indicate a moderate decline in involuntary admission rates. Men had consistently higher involuntary admission rates and women had consistently higher voluntary admission rates for the same period. Of the total commitments 22% were to psychiatric units of general hospitals. A high commitment rate was found for the elderly. As this is the first national quantitative analysis, both in Canada and in the international literature, the information presented should provide a useful objective perspective for a historical review of involuntary admissions to mental and psychiatric hospitals and psychiatric units of general hospitals.

Physician practice style variations.

This article studies the variation in physician practice style among geographic regions and across time. A physician practice profile is defined and a simple model for profile variation is developed. Ratios are calculated for the components of the profile--ambulatory visit rate, hospitalization rate and length of hospitalization--and studied in terms of adaptation to resource constraint and nonspecific style. The methods are applied to hospital use in the Census Metropolitan Areas of Canada.

The relationships of recidivism to program evaluation

The concept of recidivism is relevant to program evaluation because: (1) most program evaluators ignore the impact of recidivism on the treatment program; (2) treatment programs must be able to deal with patients who have had numerous previous admissions; (3) the nature and impact of recidivism on treatment programs have received little attention from researchers on attitudes and treatment expectations. Program evaluation is concerned with relating program objectives and patient outcome. Most evaluations do not categorize their patients by amou.nt of previous treatment and many ignore the outcome for readmissions. On the other hand, studies of recidivism frequently ignore the favorable experience of patients in the community or those who enter other treatment programs. Program effectiveness is not adequately reflected by readmission rates alone; nor is utilization of treatment resources adequately predicted by evaluation of outcome for a group of admissions. ‘Treatment may have a favorable outcome for a majority of patients while the recidivism of a minority absorbs so much treatment resources that clinical attention is diverted from those who might benefit most.

A Tale of Two Perspectives: Regulation Versus Self-Regulation. A Financial Reporting Approach (from Sarbanes–Oxley) for Research Ethics

Reports of research fraud have raised concerns about research integrity similar to concerns raised about financial accounting fraud. We propose a departure from self-regulation in that researchers adopt the financial accounting approach in establishing trust through an external validation process, in addition to the reporting entities and the regulatory agencies. The general conceptual framework for reviewing financial reports, utilizes external auditors who are certified and objective in using established standards to provide an opinion on the financial reports. These standards have become both broader in scope and increasingly specific as to what information is reported and the methodologies to be employed. We believe that the financial reporting overhaul encompassed in the US Sarbanes–Oxley Act of 2002, which aims at preventing accounting fraud, can be applied to scientific research in 4 ways. First, Sarbanes–Oxley requires corporations to have a complete set of internal accounting controls. Research organizations should use appropriate sampling techniques and audit research projects for conformity with the initial research protocols. Second, corporations are required to have the chief financial officer certify the accuracy of their financial statements. In a similar way, each research organization should have their vice-president of research (or equivalent) certify the research integrity of their research activities. In contrast, the primary responsibility of the existing Research Integrity Officers is to handle allegations of research misconduct, an after-the-fact activity. Third, generally accepted auditing standards specify the appropriate procedures for external review of a corporation’s financial statements. For similar reasons, the research review process would also require corresponding external auditing standards. Finally, these new requirements would be implemented in stages, with the largest 14 research organizations that receive 25% of the total National Institutes of Health funding, adopting these research oversight enhancements first.