Harry Prosen

Depression in Canadian general practice attenders.

In this study, depression among patients visiting general practitioners was examined by administering a short self-report measure of depression to 1,250 patients visiting 37 general practitioners in three Canadian centres (Winnipeg, Brandon and Virden). According to scores on the CES-D scale, 66.8% of the patients were judged to be normal, 11.8% were experiencing mild depression, 13.3% moderate depression and 8.1% were experiencing fairly severe depression. Depression scores were highest among female patients, patients who lived in Winnipeg, patients who were unemployed and patients who were divorced or separated.

The Canadian certification examination in psychiatry. III. Towards better certification techniques.

Although there has been much criticism of specialty certification examinations there is general agreement that they are an important safeguard of competence in medical specialties where the consumer cannot judge this. The Canadian Royal College has made strenuous attempts to improve certification techniques but these have not been heretofore widely reported. This paper reports on the rationale for the replacement of the essay examination by multiple choice questionnaires, the problems associated with MCQ, and the efforts made to improve the fairness, validity and reliability of the clinical (oral) examination. These efforts have been in the areas of selection of examiners, training for examiners, standardization of marking and the conduct of the examination. A description is given of the conduct of the examination and what the examiners look for in the candidates performance. The development and increasing importance of the In-Training Evaluation are discussed. The publication of A Residents Guide to Psychiatric Education with multinational participation advances the possibility of future reciprocity in psychiatric examinations conducted in several English speaking countries.

The certification examination: opinions of royal college examiners.

There has been increasing concern among candidates and psychiatrists regarding the Canadian written and oral certification examinations. Views of candidates and psychiatrists have been obtained. The results presented in this survey were obtained through a questionnaire that was completed by 64 past and present Royal College examiners. General support for the establishment of guidelines for the selection of examiners, for increased emphasis on the use of in-training evaluations and for the need of clear operational criteria for examiners and candidates was voiced. Finally, the evaluation model that most responding examiners favoured included re-introducing one part essay into the written examination. Overall, although finding it exhausting, most examiners enjoy examining and are satisfied with the present system. Recommendations concerning improvements to the present system are presented.

In favour of psychiatry.

When the President-Elect introduces the President on this occasion he is already considering what he will say when his own turn comes in a years time. Discussions with my predecessors indicated that they, like me, searched, asked opinions from others and gathered materials in quest of important themes to present to the membership. Most read what other Presidents of both the Canadian and American Psychiatric Associations have said and with this preparation, an appreciation grows that many issues are not new and have been well examined before. Our Association has benefited from a variety of presidential addresses ranging from great declamations to humble and personal statements of considerable value to us, such as that made by Dr. Douglas McLean last year. (I) In conducting this review some similarities of pattern were found in the problems and promises of Psychiatry. American Psychiatric Association Presidents have recently had their own special theme, discussing the important events that have happened during their term of office, and demonstrating an increasing interest and contribution to international Psychiatry. This has also provided similar interesting opportunities and impetus for us in Canada. We have all tried to deal with specific psychiatric political issues in terms of our own hopes and beliefs.

On direct patient participation in the cost of their psychiatric care. Part I. A review of the empirical and experimental evidence.

In the midst of a sociopolitical debate regarding access to health services, an evaluation is required of the therapeutic impact of the direct participation by some patients in the cost of their psychiatric treatment. Empirical clinical concepts regarding the need for a direct payment of treatment by the patient have evolved. Initial rigorous practice systems have lead to more flexible methods allowing for the recognition of third-party financing. Psychoanalytic theory has addressed the issue most extensively, but other conceptual frameworks have reached similar conclusions as well. The experimental evidence to either support or refute the position that the direct payment of a fee has a beneficial effect on therapeutic outcome remains limited. The focus has been on studying the impact of fee manipulation, but a tested correlation of other motivators such as patients insight, therapists attitudes and behaviour and social pressures is mostly lacking. Two patient populations appear to be delineated. Fee participation is of particular value to the financially secure and to the educated while patients in need of less intensive involvement, with reality testing disturbance and limited insight benefit particularly from third party insurance. Different patient populations should have the right to choose different payment options.

On direct patient participation in the cost of their psychiatric care. Part II: Access to services, impact on practice and training implications.

A review of the relation between insurance and psychiatric services addresses the economic concerns involved. Under third-party reimbursement, a range of predictability and stability of treatment costs is observed; overall cost benefit and effectiveness for a variety of therapeutic procedures is demonstrated and socio-cultural factors play a role in the users demand behaviour. The cost of medical care is a small percentage of the systems total cost and judicious use of psychiatric consultation reduces medical and surgical expenditures. Inherent difficulties for the profession exist in a universal health care scheme. The acceptability of psychological impairment and the confidentiality dilemma are among the issues reviewed. Further attention must be paid to the therapists fee, behaviour and income needs A traditional defensiveness regarding these matters should be overcome through a peer review process in order to further delineate responsible financial norms of psychiatric practice. The “laissez-faire” attitude observed in most of our training programs towards financial matters must be addressed in order to participate effectively in the ongoing sociopolitical dialogue on the funding of healthcare.

THE MENTAL HEALTH ADMINISTRATOR AS ORGANIZATIONAL CONSULTANT

The mental health administrator is frequently in a position to serve as a consultant to other mental health organizations. This paper illustrates some of the principles of consultation, describing a year-long consultation to a department of psychiatry under new leadership. The aspects of consultation described include: (1) the consultation request; (2) the orientation of consultant and consultee; (3) the consultation contract; and (4) the consultation process.

Training in formal psychotherapy in the psychiatric residency program.

This report has been prepared by the Nucleus Committee of the Section on Psychotherapy of the Canadian Psychiatric Association. It is based on a questionnaire study of training in formal psychotherapy in psychiatric residency programs. We received replies from ten of the twelve university centres in Canada which currently have such programs, and from some selected centres in the United States and Great Britain. Our findings support the contention that psychoanalytically-based training in psychotherapy is a generally accepted mandatory feature of residency programs in Canada. This training is carried out in a similar way in both the United States and Canada. Our study indicated that there is a tendency in Canada for this training not to be as organized as it should be and we recommend that steps be taken to improve this situation. Particular concerns were lack of knowledge of the numbers of patients treated in psychotherapy by a resident during the residency program and the number treated for more than a year. Stemming from the further discussions of the Nucleus Committee, recognizing the facts that there are a number of different valid theoretical orientations to psychotherapy and that there are differences among centres which lead to different teaching techniques, we also recommended: a) That the resident be exposed to different theoretical approaches, but in such a way as to avoid excessively confusing him. b) As one method of achieving objective (a), that a resident receive supervision from at least two different teachers during his residency. c) That, providing other aspects of the program are adequate, didactic seminars need not total more than forty. d) Because interviewing skills and psychodynamic understanding are essential skills of the psychiatrist, that whatever the particular orientation and methods pertaining to training in psychotherapy in a teaching setting, the psychotherapeutic approach should pervade the residents total learning experience. e) That formal training in psychotherapy should begin in the first residency year, with the practical experience optimally being individualized according to the residents level of development of psychotherapeutic skills. f) That the resident should have experience in treating patients in formal psychotherapy for more than a year. g) Where the residents experience of psychotherapy deviates significantly from what he can expect when he is fully qualified, that the nature and implications of these deviations be clarified with him by the supervisor (s); these deviations include failure to obtain objective (f), and limitations on psychotherapy that are a direct result of factors that are unique to the training situation. We also commented on other features of the supervisory role, including responsibilities to patients.

Book Review: Holding on or Letting go: Men and Career Change at MidlifeHolding On Or Letting Go: Men and Career Change at Midlife by OshersonSamuel D.. New York: The Free Press, 258 pp.,

general indifference on the part of the residents to the problems of delinquency and crime. When youth, especially adolescent males, become excluded from conventional society, they tend to form sub-cultural groups in an effort to find support and approval for their behaviour. Street-corner society then sets the patterns of life for many of the potential delinquents. Thus the neighborhood its residents and their expressed attitudes, behaviour patterns and cultural norms moulds the life of the growing youngster. The author views the solution to the problem of juvenile delinquencyas therefore being resolved by the residents and the institutions of the community. Community organization is referred to as a process, encompassing the procedures, techniques and strategies used in formulating, planning and implementing social welfare programs. An organization of local residents within a neighborhood can serve as an action group to eliminate contributory influences to delinquency, provide constructive relationships, and ensure better utilization of existing community welfare services, as well as advocating additional community resources. The author writes solely from a sociological perspective. The style is basic and is directed to volunteers and local residents concerned with the problem of delinquency. This book deals with such practical issues as building a neighborhood organization, community fund raising, principles of evaluating municipal and township youth organizations and provides a model set of bylaws that can be utilized by a fledgling neighborhood committee. The bibliography mainly lists sociological studies, particularly those from Chicago. Therapeutic pessimism surrounds the term juvenile delinquency. The incidence of neurological and psychopathological conditions that can either contribute to or mimic various antisocial behaviours is high but unfortunately such factors are not addressed in this book. The author is most enthusiastic about the effectiveness of improving community conditions. Unfortunately this is not balanced by a presentation of other data that are contrary to this view. Considering that the data specifying the causes of antisocial behaviour are drawn from diverse populations and theorists, it is simplistic to attempt to explain such conduct by any single explanation. It is also difficult to partial out the differential effects of genetics and the environment in the development of juvenile delinquency. It is also fair to say that adequate studies of treatment effectiveness are yet to be conducted. This book may be of interest to the lay public but in my view cannot be recommended to readers of this Journal.

19.95, 1980.

SummaryPrimary care medicine has developed rapidly in Canada as elsewhere during the last 25 years. It is a natural sequela to the trend to specialization following World War II and primary practice itself has now reached the status of a specialty. The result has been a longer and more thorough educational process and this process has invited psychiatry to introduce the bio-psychosocial model to medical practice. Although Canadian psychiatry has not itself developed a primary practice frame of health care delivery, it has contributed to primary care residency education. The Canadian national health insurance scheme has facilitated the development of the non-psychiatric physicians interest in the psychological and social issues of health and illness by offering medical coverage in most provinces for psychotherapy. In addition, the generally unlimited payment for all forms of psychiatric care allow ready consultation by physicians to psychiatrists.