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OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY A MISSING LINK

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OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY A MISSING LINK Powered By Docstoc
					    OFFICE-BASED PSYCHIATRIC PRACTICE IN THE
           COMMUNITY: A MISSING LINK




           The Coalition of Ontario Psychiatrists, November, 2007




The Coalition of Ontario Psychiatrists is a formal partnership of the Ontario Psychiatric
Association and to:
Send your lettersthe Section on Psychiatry of the Ontario Medical Association. It is concerned
with the provision of high quality mental health services for all Ontarians who need them. The
Coalition of Ontario Psychiatrists represents the 1800 psychiatrists in Ontario.
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Executive Summary:

Office based psychiatrists who practice in the community are an integral
component of our mental health system. They provide high quality patient
care in the patient’s community. Office based psychiatrists can and do treat
complicated patients with a variety of severe psychiatric disorders. Office
based psychiatrists prevent hospitalization. They initiate early treatment for
a variety of conditions. They provide follow-up for complex patients who
have been discharged from hospital and need the expertise of a psychiatrist.
Office based psychiatrists provide ongoing treatment and management for a
variety of chronic psychiatric diseases. Office based psychiatrists working
in the community provide consultations to family doctors and help them
manage their more difficult psychiatric patients. The work of office based
psychiatrists must be recognized and valued for its true worth and supported
by the MOHLTC in order to provide high quality, timely care for the people
of Ontario.

   o The 2004 Agreement between the OMA and the MOHLTC neglected
     office based psychiatrists who practice in the community.
   o The burden of mental illness is significant for individuals and costly
     for society.
   o OHIP billing data cannot be used to assess either the severity or the
     complexity of psychiatric work.
   o Office based psychiatrists treat patients with complex conditions and
     who frequently have more than one psychiatric problem and histories
     of trauma.
   o Family physicians do not have the time or the training to provide the
     complex treatment required by these patients.
   o Wait times data clearly indicate that the province does not have
     sufficient office based psychiatrists to provide both consultations to
     family doctors and the follow up for patients who require the special
     training of a psychiatrist to manage their complex treatments.




       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
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The recent 2004 Agreement between the OMA and the MOHLTC focused

on the provision of psychiatric care in hospitals and psychiatrists working in

these hospitals received significant improvements. In the same agreement

office based psychiatrists providing psychiatric treatment in the community

received inadequate increases. MOHLTC planning documents (HPRC (1),

Making It Happen (2), The Time is Now (3)) are silent regarding the

provision of psychiatric treatment in the community. “The Time is Now”

states the principles of Mental Health Reform.: “These principles included:

moving people living with mental illness to the centre of Ontario’s mental

health system; ensuring that services meet the needs of people living with

mental illness at all stages of life and are delivered as close to home as

possible; and offering better services and support, improved choices, and

streamlined access to services for people living with mental illness and their

families.” (2) This document states that the driving philosophy of mental

health reform is a “recovery philosophy” and is also silent regarding

treatment, without which recovery is not possible.



This raises several questions. What is the burden of psychiatric illness in the

province? What is the need or demand for psychiatric treatment? What do

psychiatrists practicing in the community do?

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
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The Royal College of Physicians and Surgeons of Canada defines Psychiatry

as “the branch of medicine concerned with the biopsychosocial study of the

etiology, assessment, diagnosis, treatment and prevention of mental,

emotional and behavioural disorders alone or as they coexist with other

medical or surgical disorders across the lifespan.” (4) Community-based

psychiatrists (those who practice outside of an institution) provide diagnosis

and treatment to people living in the community.



The 2004 Senate report “Mental Health, Mental Illness and Addiction” (5)

reports the lifetime prevalence of psychiatric conditions as:

                          anxiety disorders 12%

                          schizophrenia              1%

                          mood disorders      9%

                          personality disorders      6%

                          (from Mental Illness in Canada 2002)

They report the Ontario suicide rate as 10 per 100,000 population. Kirby

and Keon report that the direct costs of mental illness in Canada is $6 billion

(for drugs, physicians and hospitals) while the indirect costs (for short-term

disability, long-term disability and premature death) are $8 billion. The

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 4 of 17
figures for drug abuse were $3.4 billion indirect costs and $4.1 billion in

direct costs. It has been reported that the fastest growing claims for

occupational disability are due to psychiatric illnesses (6). Clearly the costs

for society are significant.



The study of the work done by psychiatrists is of interest. Are appropriate

patients being seen? Is the work done by psychiatrists appropriate for their

level of expertise? There have been some studies that have attempted to use

OHIP billing data in order to make these and other evaluations. (for example

Lin & Goering 1999 (7)) These authors note the importance of assessing

the severity of the disorders of those using different providers. They also

note that “the literature suggests that the general practitioner is not always

adequately trained to deliver mental health care and effective therapies

generally requiring more than two or three visits.” (page 24). There are

significant limitations to research using OHIP billing data.       The OHIP

system uses the International Classification of Diseases (8) for diagnoses.

The OHIP computer allows for only one diagnosis and there are no

modifiers to specify the type of disorder or its severity. A common code

(300) includes 10 different groups of different diagnoses: anxiety states;

dissociative, conversion and factitious disorders; phobic disorders;

        OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                      Coalition of Ontario Psychiatrists
                                Page 5 of 17
obsessive-compulsive     disorders;   dysthymic   disorder;   neurasthenia;

depersonalization disorder; hypochondriasis; somatoform disorders and

unspecified nonpsychotic mental disorder. Individually, these diagnoses can

be moderate in severity or quite severe.



A further problem in using OHIP billing data is that there is no way to

encode psychiatric co-morbidities. Thus the severity and the complexity of

the work done are not known using OHIP billing data.



There are three Canadian studies that provide better information. The first

was a survey conducted by the Canadian Psychiatric Association (CPA) in

1997. (9, 10) This survey used the American Psychiatric Association’s

Diagnostic and Statistical Manual (DSM). This is a multi-axial system that

does allow for the diagnosis of more than one clinical disorder at a time

together with a personality disorder. This survey was a Canada-wide survey

of psychiatrists. The CPA sent out questionnaires to Canadian psychiatrists

and asked questions regarding the diagnosis of patients seen on a designated

day. The response rate was 45%. The study did not separate hospital-based

from community-based practices. However, the authors did estimate that

38% of psychiatrists work mainly in hospitals while 37% work in private

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
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offices. The remainder work in a variety of settings. They found that almost

40% of the patients seen had at least one co-morbid clinical psychiatric

disorder and a third had a psychiatric clinical disorder together with a

personality disorder.    Canadian psychiatrists see patients with complex

psychiatric disorders.



The Mental Health Supplement Survey conducted in Ontario in 1990 was a

province-wide epidemiologic study of psychiatric disorder amongst

Ontarians aged 15 to 64 (11). In this study independent interviews were

conducted with residents of private dwellings who were not institutionalized

(11). The study reports that the one year prevalence for one psychiatric

disorder was 14.2 % whereas the one year prevalence for two or more

disorders was 4.5% (12). Due to the methodological limitations of the study

this is likely to have been an underestimate of the one year prevalence of

psychiatric disorders. It is clear that not all of these people could receive

treatment through the hospital system nor is the hospital system appropriate

for many of these people. The care for the majority of these persons must be

undertaken by community-based psychiatrists and family physicians. Many

of the latter consider themselves under-trained to provide this care (13).



       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
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There are two studies from Ontario that examine the work of psychiatrists in

community-based practices. Doidge et al surveyed all of the accredited

psychoanalysts practicing in Ontario in 1992(14). The vast majority of the

psychoanalysts were also psychiatrists. The majority of psychoanalysts are

in office based practices outside of hospitals. Doidge et al had a response

rate of 67%. They asked questions regarding the DSM diagnoses of the

patients being treated as well as their previous history of treatment and their

history of physical and sexual abuse. The mean number of DSM psychiatric

disorders present at the start of the analysis was 4.    Mood disorders were

the most frequent disorder.     Seventy-one percent of the patients had a

personality disorder. A significant proportion of the patients had histories of

abuse: 23% had been sexually abused and 22% had been physically abused.

Some 82% of the patients had received other forms of treatment before

seeking analysis. This study clearly shows that the patients who were being

treated were complicated with significant co-morbidities and significant

histories of trauma. They also frequently had a history of previous failed or

unsatisfactory treatment.



Anderson et al (15) surveyed all of the psychiatrists in private-practice in the

community in Ottawa in 1994. Their goal was to examine whether the

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 8 of 17
patients being seen were the “rich worried well.” This study used the DSM

for diagnoses.    Also examined were the modalities of treatment being

offered and the referral sources for the patients being seen. The response

rate for that survey was 80%. Over 95% of the patients had a psychiatric

clinical disorder (Axis I Disorder) while 58% had a personality disorder

diagnosis. Over 30% of the patients being seen had a degree of psychosocial

stress that is judged as severe, extreme or catastrophic. In this study, 39% of

patients had a past history of physical or sexual abuse.



Anderson et al discovered that community-based psychiatrists in the Ottawa

area offer some 13 modalities of treatments and accept patients from a

variety of referral sources, including hospitals, agencies, family doctors, the

person themselves and school/university. They also examined the income of

the patients, finding that the system does not appear to favour the “rich,

worried well”.



These studies clearly show that the patients seen by community-based

psychiatrists have significant conditions that are complex and require the

skill of a psychiatrist. It is important for the well-being of a community for



       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 9 of 17
patients with psychiatric illnesses to be seen in the least restrictive

environments and that they be treated as close to home as possible. (1, 2)



The province of Ontario has recently gone from a system of regional health

councils to a system of Local Health Integrated Networks (LHIN). All of

the LHINs have identified mental health and addictions as one of their top

priorities. A question arises at this point: Which physician is best able to

provide treatment for psychiatric patients?       The Canadian Psychiatric

Association has repeatedly (16, 17) advocated that “….the patient in need

receives the right intervention, in the right location, at the right time and

from the right practitioner.” (17 pg 3) The College of Family Physicians of

Canada has recently published a position statement on the availability of

family physicians (18) in which they note that currently 15% of Canadians

are without a family physician. Furthermore, as noted previously, (7) family

physicians may not be adequately trained to assess and deliver the necessary

treatments to individuals with severe and complex mental illnesses. Family

physicians can not provide the treatment required when they are in short

supply and do not have the time or the training to perform the work.




       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 10 of 17
Do we have sufficient office based psychiatrists in the community to provide

the required services? Evaluation of waiting lists/times is an indirect way in

which to assess the need/demand for service. The Canadian Psychiatric

Association recently published wait time benchmarks for patients with

serious psychiatric illnesses. (19) The recommended wait time benchmarks

vary according to whether the condition is emergent, urgent or scheduled

and ranges from 24 hours to 4 weeks for the following conditions: first

episode psychosis, mania, hypomania, postpartum mood or psychosis,

depression, or diagnostic and management consultation. The Fraser Institute

has just published the 2007 edition of their hospital waiting lists survey (20).

This year they have included an appendix devoted to a psychiatry waiting

list survey. Their rationale is that “…there has been an increasing amount of

anecdotal evidence presented in the media about the long waiting times that

psychiatry patients experience” (page 74). The survey is limited by a low

response rate (17%). The Fraser Institute asked questions regarding the

waiting times for 11 different treatments ranging from the initiation of a

course of brief psychotherapy to initiating long term psychotherapy to

starting medications to gaining entry to an eating disorders program. The

waiting times for the 11 treatments varied from 6 weeks to 20 weeks in

Ontario (a median of 9.7 weeks). The Fraser Institute also asked what the

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 11 of 17
psychiatrists felt would be a reasonable wait for these treatments and then

compared it to the actual waits. The waits for Ontario patients (with the

exception of accessing sleep disorders programs) were all at least double the

reasonable patient wait to five times the reasonable patient wait. There is

some agreement between the CPA wait time benchmarks and the Fraser

Institute median reasonable patient wait for treatment: the categorizations

are not directly comparable. This data indicates clearly that Ontario is not

providing access to community-based psychiatric treatment that meets the

CPA benchmarks and that it exceeds significantly the waits that psychiatrists

deem to be reasonable. This is confirmed by a survey of family physicians

conducted in 2003 prior to the negotiations for the 2004 agreement with the

MOHLTC: a substantial majority of Family Physicians (83%) report at least

some difficulty in accessing specialist care for their patients (21). One in

four reports that they experience a great deal of difficulty in accessing such

care. The Collaborative Working Group on Shared Mental Health Care also

reports that family physicians have difficulties in accessing psychiatric

consultation and treatment services (22). The above mentioned surveys do

not assess whether hospital-based psychiatrists have difficulty finding a

psychiatrist in the community to follow recently discharged patients. This

problem appears to be invisible: while there are advertisements in

       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 12 of 17
professional journals seeking psychiatrists for institutions, no such

advertisements exist seeking community-based psychiatrists.



There are currently 1821 psychiatrists practicing in the province of Ontario.

There is a recommended psychiatrist to population ratio of 1:8400 last

recommended by the CPA in 1996 (23). This ratio was developed by taking

an earlier ratio of 1:10,000 and “adding an estimation of ‘urgent needs’

based on the number of vacancies in major provincial psychiatric hospitals

as well as the vacancies in universities.” (23). No attempt was made at that

time to estimate the urgent needs for psychiatric care in communities. The

CPA is currently reviewing this position paper. The number of psychiatrists

practicing in Ontario gives the appearance of exceeding the arbitrary

established standard. The number of “full-time equivalent” psychiatrists

practicing in the province is unknown. It is likely that it will be significantly

fewer than 1821 as there are a significant number of psychiatrists on faculty

in the 6 medical schools in the province who have administrative, teaching

and research responsibilities that limit their time for clinical practice. There

is no data on the number of psychiatrists in the province who have part-time

practices or are semi-retired. The wait times data discussed above indicates



       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 13 of 17
that there are insufficient psychiatrists in the province to meet recommended

or reasonable wait times.



Office based psychiatrists in the community are an integral component of

our mental health system. They provide high quality patient care in the

patient’s community. Office based psychiatrists treat complicated patients

with a variety of severe psychiatric disorders. Office based psychiatrists

working in the community prevent hospitalization.        They initiate early

treatment for a variety of conditions.     They also provide follow-up for

complex patients who have been discharged from hospital and need the

expertise of a psychiatrist.      Office based psychiatrists provide both

consultations to family doctors and follow up for patients who require the

special training of a psychiatrist to manage a variety of chronic psychiatric

diseases.



The work of psychiatrists in the community must be recognized and valued

for its true worth and supported by the MOHLTC in order to provide high

quality, timely care for the people of Ontario.




       OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
                     Coalition of Ontario Psychiatrists
                               Page 14 of 17
                          References

1. Health Services Restructuring Commission:  Advice to the
   Minister of Health in Building a Community Mental Health
   System in Ontario February 26, 1999

2. Making It Happen: The Ministry of Health and Long Term Care’s
   implementation plan for Mental Health Reform

3. The Time Is Now: Themes and Recommendations for Mental
   Health Reform in Ontario December, 2002

4. Objectives of Training in Psychiatry. Royal College of Physicians
   and Surgeons of Canada, 2007

5. Mental Health, Mental Illness and Addiction – The Standing
   Committee on Social Affairs, Science and Technology – M. J. L.
   Kirby & W. J. Keon November 2004

6. Quick Facts: Mental Illness and Addiction in Canada. The Mood
   Disorders Society of Canada, May, 2006.

7. Lin, E. and Goerling P.: The Utilization of Physician Services for
   Mental Health in Ontario. Institute for Clinical Evaluative Studies
   July 1999

8. The International Classification of Diseases – 9th Revision – World
   Health Organization

9. Lin, E.; Woodside, D.B.; Rhodes, A.: The Canadian Psychiatric
   Association Practice Profile Survey: I. Methods and General
   Sample Characteristics. Canadian Journal of Psychiatry 2003; 48:
   237-243

10. Woodside, D.B.; Lin E.: The Canadian Psychiatric Association
    Practice Profile Survey: II. General Description of Results. CJP
    2003; 48: 244-249



 OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
               Coalition of Ontario Psychiatrists
                         Page 15 of 17
11. Boyle, M. H.; Offord, D. R.; Campbell, D.; Catlin, G.; Goering, P.;
    Lin, E.; Racine, Y. A.; Mental Health Supplement to the Ontario
    Health Survey: Methodology CJP 1996; 41: 549-558.

12. Offord, D. R.; Boyle, M. H.; Campbell, D.; Goering, P.; Lin, E.;
    Wong, M.; Racine, Y. A.; One-Year Prevalence of Psychiatric
    Disorder in Ontarians 15 to 64 Years of Age. CJP 1996; 41, 559-
    563.

13. Patel, S.Toward a National Strategy on Mental Illness and Mental
    Health: CMA Presentation to the Senate Standing Committee on
    Social Affairs, Science and Technology, March 31, 2004.

14. Doidge, N.; Simon, B.; Gillies, L.A.; and Riskin, R.;
    Characteristics of Psychoanalytic Patients Under a National Health
    Plan: DSM-III-Diagnoses, Previous Treatment and Childhood
    Trauma. American Journal of Psychiatry 1994; 151: 586-590

15. Anderson, K.; Catterson, A.; Gaudet, M.; Govstam. M.; Kerr, P.J.;
    Recher, M.; Waiser, D.; Kaji, J.; Fara, M.: A Cross-Sectional
    Study of Private Psychiatric Practices Under a Single-Payer Health
    Care System. CJP 1997; 42: 395-401

16. Woodside, D. B.: Speaking Points for a Presentation to The Senate
    Standing Committee on Social Affairs, Science and Technology.
    April 20, 2005

17. Proposed mental health commission and federal priorities on
    mental health and mental illness. Submission to the Minister of
    Health, Hon. Tony Clement. In response to the question posed in
    the e-public consultation. January 25, 2007

18. Position Statement: Improving Access to Care for Patients in
    Canada. The College of Family Physicians of Canada. October
    2007

19. Wait Time Benchmarks for patients with Serious Psychiatric
    Illnesses. Canadian Psychiatric Association. March 2006


 OFFICE-BASED PSYCHIATRIC PRACTICE IN THE COMMUNITY
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                         Page 16 of 17
20. Esmail N.; Walker, M.A.: Waiting Your Turn 17th Edition:
    Hospital Waiting Lists in Canada. Fraser Institute 2007

21. Pre-Negotiation Assessments: Family Physicians and Specialists
    Presentation to the Board December 10, 2003 Ontario Medical
    Association

22. Shared Mental Health Care in Canada: Current status, commentary
    and recommendations. A report of the Collaborative Working
    Group on Shared Mental Health Care December 2000.

23. el Guabely, N. CPA Position Paper: Human Resources in
    Psychiatry. CPA October 4, 1996.




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               Coalition of Ontario Psychiatrists
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