Marilyn Craven

Shared Mental Health Care in Canada

The family physician already plays an extensive role as a provider of mental health care in almost every community in Canada. In theory, the family physician and the psychiatrist are natural partners in the mental health care system. While neither may be able to meet every need of a patient with a mental disorder, each can offer complementary services, which enables them to play a key role at different stages of an episode of illness and the subsequent period of recovery. Too often, however, family physicians and psychiatrists fail to establish the collaborative working relationships that would strengthen the role of the family physician, enhance the consultative role of the psychiatrist, and improve the quality of care their patients receive.

Integrating mental health services within primary care : A Canadian program

The increasingly prominent role of the family physician in delivering mental health care can be enhanced if productive and collaborative relationships can be established with local mental health services. This paper describes a Canadian program that has achieved this by bringing mental health counselors and psychiatrists into the offices of 87 family physicians in 35 practices in a community in Southern Ontario. The paper describes the program, the activities of counselors and psychiatrists within the practices, and the administrative structures set up to coordinate these activities. Data is presented from the evaluation of the first year of the programs operation (13 practices and 45 family physicians) during which time 3085 referrals were received. The program made mental health care more available and accessible, increased continuity of care, provided additional support for the family physician, offered new opportunities for continuing education, and led to a reduced and more efficient use of other mental health services. The components of the program can be adapted to most communities.

Depression in Primary Care: Current and Future Challenges:

Objectives: To describe the current state of knowledge about detection and treatment of major depressive disorder (MDD) by family physicians (FPs), and to identify gaps in practice and current and future challenges. Methods: We reviewed the recent literature on MDD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or International Classification of Diseases, Revision 10) in primary care, with an emphasis on systematic reviews and meta-analyses addressing prevalence, the impact of an aging population and of chronic disease on MDD rates in primary care, detection and treatment rates by FPs, adequacy of treatment, and interventions that could improve recognition and treatment. Results: About 10% of primary care patients are likely to meet criteria for MDD. The number of cases will increase as the baby boomer cohort ages and as the prevalence of chronic disease increases. The bidirectional relation between MDD and chronic disease is now firmly established. Detection and treatment rates in primary care remain low. Treatment quality is frequently inadequate in terms of follow-up and monitoring. Formal case management and collaborative care interventions are likely to provide some benefits. Conclusions: Low detection rates and low treatment rates need to be addressed. Planned reassessment may improve detection rates when the FP is uncertain whether MDD is present, but further research is needed to determine why FPs frequently do not initiate treatment, even when MDD is detected. A caring, attentive FP who monitors depressed patients is likely to have considerable placebo effect. Greater focus on integrated, concurrent treatment for MDD and chronic physical diseases in the middle-aged and elderly is also required.

Sharing care : The psychiatrist in the family physician's office

Objective: One way of strengthening ties between primary care providers and psychiatrists is for a psychiatrist to visit a primary care practice on a regular basis to see and discuss patients and to provide educational input and advice for family physicians. This paper reviews the experiences of a program in Hamilton, Ontario that brings psychiatrists and counsellors into the offices of 88 local family physicians in 36 practices. Method: Data are presented based on the activities of psychiatrists working in 13 practices over a 2-year period. Data were gathered from forms routinely completed by family physicians when making a referral and by psychiatrists whenever they saw a new case. An annual satisfaction questionnaire for all providers participating in the program was also used to gather information. Results: Over a 2-year period, 1021 patients were seen in consultation by one full-time equivalent psychiatrist. The average duration of a consultation was 51 minutes, and a family member was present for 12% of the visits. Twenty-one percent of the patients were seen for at least one follow-up visit, 75% of which were prearranged. In addition, 1515 cases were discussed during these visits without the patient being seen. All participants had a high satisfaction rating for their involvement with the project. Conclusions: Benefits of this approach include increased accessibility to psychiatric consultation, enhanced continuity of care, support for family physicians, and improved communication between psychiatrists and family physicians. This model, which has great potential for innovative approaches to continuing education and resident placements, demands new skills of participating psychiatrists.

An integrated regional Emergency Psychiatry Service

This paper presents a model of an integrated Psychiatric Emergency Service serving Hamilton, a community of 450,000 in Southern Ontario. It describes the evolution of the service and how it has integrated five separate, hospital-run Emergency Psychiatric Services into a single service. The principles of the service and ways in which it operates are outlined and the advantages and drawbacks of the model are discussed. The authors conclude that such a model leads to a more efficient use of resources and is adaptable to most urban communities with a similar, or even larger population.

Case Reviews in the Family Physician's Office*

The majority of patients with emotional or psychiatric disorders are treated in the primary care setting without psychiatric input. Psychiatrists need to find ways of helping family physicians manage these patients without necessarily taking over their care. One way of achieving this is for a psychiatric consultant to visit the family physicians office on a regular basis to discuss the physicians problem cases. This paper describes such a pilot project, outlines the kinds of problems family physicians discussed and recommendations that were made, and discusses the benefits of this collaborative approach.

Les soins de santé mentale partagés au Canada

Le médecin de famille joue déjà un rôle primordial à titre de pourvoyeur de soins de santé mentale dans la plupart des collectivités du pays. En principe, le médecin de famille et le psychiatre sont des alliés naturels dans un système de soins de santé mentale. Bien qu’aucun ne puisse répondre à tous les besoins d’un patient souffrant de troubles mentaux, l’un et l’autre peuvent offrir des services complémentaires leur permettant de jouer un rôle clé à différentes étapes d’une maladie ainsi qu’à la période subséquente de rétablissement. Il arrive cependant trop souvent que médecin de famille et psychiatre n’arrivent pas à établir la collaboration apte à renforcer le rôle du médecin de famille, à enrichir le rôle de consultant du psychiatre et à améliorer la qualité des soins dispensés au patient.