In Canada, in recent years, there has been increased interest in the issue of subspecialization in psychiatry. One hundred and forty-four members of the Section on Psychosomatic Medicine of the Canadian Psychiatric Association responded to a survey about their opinions on teaching, training, continuing education, and designation of consultation-liaison (C-L) psychiatry as a subspecialty. Fifty-five percent of respondents agreed that C-L psychiatry should receive designation as a psychiatric subspecialty, 35% were opposed, and 10% did not give an opinion. The results also indicated that formal teaching in C-L psychiatry has increased, particularly over the past 20 years; that training in C-L psychiatry is believed by many to have been inadequate, regardless of when the training took place; and recent graduates were more likely than psychiatrists graduating more than 10 years ago to agree that C-L psychiatry should be designated as a subspecialty. Psychiatrists who devote more of their time to the care of patients with combined medical and psychiatric illness were also more likely to favor subspecialty designation. Factors unique to Canada that may influence attitudes toward psychiatric subspecialization include the number and geographic distribution of psychiatrists, their educational background, and governmental funding priorities.
In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.
This paper outlines the evolution of the training of Canadian physicians and other professionals in the mental health care needs of older adults over the past 2 decades, which has culminated in long-awaited subspecialty recognition by the Royal College of Physicians and Surgeons of Canada (RCPSC). Despite the fact that Canada has more than 4000 psychiatrists officially recognized by RCPSC, and a national body of more than 200 members who practice primarily in geriatric psychiatry, the status of geriatric psychiatry as a subspecialty of psychiatry in Canada remained "unofficial" until 2009.
Early along the pathway toward subspecialization, Canadian educational efforts focused on enhancing the capacity of primary care physicians and other mental health professionals to meet the mental health needs of older adults. Over the past decade, and with the encouragement of RCPSC, Canadian psychiatric educators have carefully and collaboratively defined the competencies necessary for general psychiatrists to practice across the life span, thereby influencing the psychiatry training programs to include dedicated time in geriatric psychiatry, and a more consistently defined training experience.
With these two important building blocks in place, Canadian psychiatry was truly ready to move ahead with subspecialization. Three new psychiatric subspecialties - geriatric, child and adolescent, and forensic - were approved at the RCPSC in September 2009.
The developments of the past 20 years have paved the way for a subspecialty geriatric psychiatry curriculum that will be well-aligned with a new general psychiatry curriculum, and ready to complement the existing mental health work force with subspecialized skills aimed at caring for the most complex elderly patients.