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.
The authors describe a consultation-liaison relationship between a community psychiatry outpatient service and private community family practitioners, including some problems and solutions that have arisen as a result of this relationship. A medical student clerkship in this consultation-liaison setting is particularly useful in orienting students to community aspects of psychiatric care in primary care practice. Since 50% of medical students from McMaster University enter some form of primary care activity, this exposure and sensitization to community mental health activities is especially relevant.
To document the number and pattern of psychiatric and psychosocial referrals to community resources by family physicians (FPs) and to determine whether referral practices correlate with physician variables.
Cross-sectional survey of referrals by FPs to 34 key psychiatric and psychosocial community resources identified by a panel of FPs, psychiatric social workers, psychiatric nurses, public health nurses, and the local community information service.
Regional municipality of 434,000 persons in Ontario.
Twenty-seven of 34 (79%) community agencies identified 261 FPs who made 4487 referrals to participating agencies (range 0 to 65, median 15, mean 17.19 +/- 13.42).
Number of referrals to all agencies; variables, such as physician sex, school of graduation, year of graduation, and certificate status in the College of Family Physicians of Canada, related to referral patterns.
Referrals to outpatient psychiatric clinics, support services, and general counseling services accounted for 96% of all referrals. Physicians' average annual referral profile was as follows: 8.6 patients to a support service, 6.3 to an outpatient psychiatric service, 1.6 to a counseling service, and 0.46 to a substance abuse service. Referral profiles of individual physicians varied greatly. Female FPs made fewer referrals than male FPs to support services, but both made similar numbers of referrals to psychiatric, counseling, and substance abuse services. The more recent the year of graduation, the greater the number of referrals to psychiatric (r = 0.158, P = 0.0107) and counseling services (r = 0.137, P = 0.0272) and the higher the fraction of referrals to psychiatric services (r = 0.286, P = 0.0001).
Family physicians in Hamilton-Wentworth made few referrals to psychiatric and psychosocial services. Only physician sex and year of graduation correlated significantly with numbers of referrals made. Recent graduates of both sexes made significantly more referrals to psychiatric clinics and counseling services than their older colleagues.
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For 25 years, the Hamilton-Wentworth region has had a well integrated network of psychiatric services. The initial impetus for its establishment came from the founders of the Department of Psychiatry at McMaster University in 1967. They envisaged a regional network of services that integrated the resources of a community-focused university department with those of local community agencies and other mental health care professionals. Over the years, the evolution of the network has been shaped by changes in the size and composition of the faculty, the emergence of additional clinical services and community programs, new directions in the field of psychiatry and changing economic forces and social values.
Data from the Ontario Child Health Study were used to examine the strength of association between child immigrant status and child psychiatric disorder, poor school performance, and use of mental health/social services. Bivariate results indicate that immigrant children are not at increased risk for psychiatric disorder or poor school performance and that they use mental health and social services significantly less often than do their nonimmigrant peers. Implications of the findings are explored.
As industrial development is increasing near northern Canadian communities, human health risk assessments (HHRA) are conducted to assess the predicted magnitude of impacts of chemical emissions on human health. One exposure pathway assessed for First Nations communities is the consumption of traditional plants, such as muskeg tea (Labrador tea) (Ledum/Rhododendron groenlandicum) and mint (Mentha arvensis). These plants are used to make tea and are not typically consumed in their raw form. Traditional practices were used to harvest muskeg tea leaves and mint leaves by two First Nations communities in northern Alberta, Canada. Under the direction of community elders, community youth collected and dried plants to make tea. Soil, plant, and tea decoction samples were analyzed for inorganic elements using inductively coupled plasma-mass spectrometry. Concentrations of inorganic elements in the tea decoctions were orders of magnitude lower than in the vegetation (e.g., manganese 0.107 mg/L in tea, 753 mg/kg in leaves). For barium, the practice of assessing ingestion of raw vegetation would have resulted in a hazard quotient (HQ) greater than the benchmark of 0.2. Using measured tea concentrations it was determined that exposure would result in risk estimates orders of magnitude below the HQ benchmark of 0.2 (HQ = 0.0049 and 0.017 for muskeg and mint tea, respectively). An HHRA calculating exposure to tea vegetation through direct ingestion of the leaves may overestimate risk. The results emphasize that food preparation methods must be considered when conducting an HHRA. This study illustrates how collaboration between Western scientists and First Nations communities can add greater clarity to risk assessments.
To determine whether health care providers are satisfied with an integrated program of mental health care.
Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions.
Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization's Mental Health Program.
Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings.
Satisfaction as shown on 5-point Likert scales.
High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication.
Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.
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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 program's 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.
To obtain descriptions of how family physicians detect and manage mental health problems commonly encountered in their practices and how they function in their role as mental health care providers. Also, to elicit their perceptions of barriers to the delivery of optimal mental health care.
Focus groups with standardized questions were used to elicit descriptive data, opinions, attitudes, and terminology. Convenience samples of 10 to 12 physicians were chosen in each of Ontario's 7 health care planning regions, with a mixture of rural, urban, and university settings. Discussions were audiotaped, transcribed, analyzed, and recurring themes were extracted.
Family physicians' descriptions of the range of problems commonly encountered and their detection and management highlight the unique nature of mental health care in the primary care setting. The realities of family medicine, the undifferentiated nature of presenting problems, the long-term physician-patient relationship, and the frequent overlap of physical and mental health problems dictate an approach to diagnosis and treatment that differs from mental health care delivery in other settings. Difficulties in the relationship with local psychiatric services--accessing psychiatric care (especially for emergencies), poor communication with mental health care providers, and cumbersome intake procedures of many mental health services--were consistently identified as barriers to the delivery of optimal mental health care.
This study confirms the importance of the family physician in the detection and management of mental health problems. It offers insights into how family physicians function in their role as mental health care providers and how they deal with diagnostic and management challenges that are specific to primary care. It also identifies barriers to the optimal delivery of mental health care in the primary care setting, including difficulties at the clinical interface between psychiatry and family medicine. Further studies are needed to explore these issues in greater depth.