The Canadian Psychiatric Association practice profile survey: I. Methods and general sample characteristics.

OBJECTIVE: To describe the rationale, methodology, and general sample characteristics of the Canadian Psychiatric Association (CPA) practice profile survey, a national survey of psychiatrists and psychiatric practice. METHOD: Mail-in interviews were sent to all Canadian psychiatrists listed in their provincial registers and to all active CPA members (total = 3628). Respondents provided general information about their professional activities for one 24-hour day and detailed information for 1 randomly selected hour. Patient information--including sociodemographics, diagnostic profiles, functioning levels, risk of harm to self or others, and disposition--was elicited for 1 patient seen during the random hour as well as for the most seriously ill patient receiving clinical services that day. RESULTS: There was a 45.5% response rate. Questionnaires completed by nonpsychiatrists or with a large percentage of missing or incorrect data were eliminated (107 surveys), resulting in a final sample size of 1570. CPA members and those from Western Canada responded at a higher rate to the survey. The results suggest some cause for concern about future manpower shortages. Most psychiatrists practise eclectically, seeing patients across the life-span, and working in both community and institutional settings. The old and the young appear to be underserviced, compared with adults. CONCLUSIONS: This study represents an important step forward in evaluating the profile and activities of the profession.     

A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.     

Practice patterns of international and U.S. medical graduate psychiatrists

OBJECTIVE: The practice patterns of international medical graduate (IMG) and U.S. medical graduate (USMG) psychiatrists were compared. METHOD: Using data from the 1996 National Survey of Psychiatric Practice, the authors compared IMGs and USMGs in terms of demographic characteristics, practice settings, patients' clinical characteristics, and sources of reimbursement. RESULTS: The IMGs surveyed tended to be older than USMGs, included a higher proportion of women, and were more racially heterogeneous. They worked longer hours, worked more frequently in the public sector, and treated a higher proportion of patients with psychotic disorders. The IMGs also received a higher percentage of their income than USMGs from Medicaid and Medicare, whereas the reverse was true of self-payment. Most of these differences remained significant after psychiatrist's age, gender, race, board certification, and work setting were controlled for. CONCLUSIONS: IMG and USMG psychiatrists have different practice patterns. Policies that substantially decrease the number of IMG psychiatrists may adversely affect the availability of psychiatrists to treat minorities and other underserved populations.     

Measuring the determinants of work values for psychiatrists' services in the resource-based relative value scale study.

OBJECTIVE: As part of the Harvard resource-based relative value scale study, the authors investigated how well the codes in the Physician's Current Procedural Terminology, 4th edition, or CPT-4, match psychiatric services to the work involved in evaluating and managing patients and how patient care characteristics affect different levels of psychiatric work. METHOD: A random sample of over 200 psychiatrists and subspecialists was asked to use 68 typical clinical examples or vignettes to evaluate services described by CPT codes. Data were analyzed by multivariate statistical methods. RESULTS: The survey showed that the existing coding system does not adequately describe the work that psychiatrists do. Within a single code (e.g., 90844, individual medical psychotherapy), there was wide (more than twofold) variation in the estimates, from multiple measurements based on different vignettes, of the amount of work represented. Estimates of work values varied significantly according to treatment setting and patient characteristics: psychiatric services in the hospital showed an average work value 25% greater than that for office services; treating new patients involved 18% more effort than treating established patients; and treating patients described as at risk of harming self or others increased the psychiatrists' work effort by 36%. CONCLUSIONS: Revisions in coding evaluation and management services in the new Medicare fee schedule for psychiatric services should be further refined and then implemented. These revisions would bring the coding system into line with psychiatric practice, making it a better way of accounting for the relative work involved in treating patients of varying difficulty.     

The Senior Psychiatrist Survey I: age and psychiatric practice.

OBJECTIVE: The aim of this study is to determine the effects of age on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP). METHOD: A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: age; location and type of psychiatric practice; hours of work; attitudes towards re-accreditation; changes in work practices over the career; and the perceived benefits and drawbacks of age to psychiatric practice and case selection. RESULTS: Of 1086 eligible subjects, 629 participated. The mean age of the sample was 52.7 years (SD = 13.5). Those psychiatrists favouring re-accreditation were younger. Psychiatrists practising psychotherapy, forensic psychiatry or general psychiatry; working in psychiatric hospitals and private practice were more likely to be older. Older psychiatrists worked shorter hours. There was largely no association between case selection and age. Psychiatrists reporting increased credibility and respect as a benefit of their current age upon their psychiatric practice were older, as were those identifying fatigue and an inability to keep up to date as a drawback of age. Psychiatrists reporting a lack of credibility and respect were younger, as were those who reported increased enthusiasm and optimism. CONCLUSIONS: Age is associated with benefits and drawbacks to the practice of psychiatry and this may be reflected in the different practice profiles of older and younger psychiatrists.     

Comparison of adult and geriatric psychiatric practice patterns: findings from the American Psychiatric Association's Practice Research Network.

OBJECTIVE: The authors explored diagnostic and treatment patterns for patients under and over age 65 seen by a nationally representative sample of psychiatrists participating in the American Psychiatric Association's Practice Research Network. METHODS: Detailed patient information, including demographic and financial characteristics, diagnoses, service utilization, and treatment, was collected by 383 psychiatrists on 1,026 patients to assess the impact of patient age on pharmacotherapy and psychotherapy service use as well as treatment outcomes. RESULTS: Approximately 15% of the patient sample was over age 65. Compared with patients ages 19-64, a lower percentage of geriatric patients had Axis I comorbidity, but a higher percentage had Axis III comorbidity. Geriatric patients were more often treated in hospital settings, and older patients were less likely to have their visits adversely affected by financial pressures of the healthcare system. Over 60% of patients in both age-groups received antidepressants, but there was a disproportionately increased use of antipsychotics and antianxiety/benzodiazepine medications among geriatric patients. Being age 65+ was a strong predictor for "improved" clinician rating on general assessment scores, but failed to be a predictor of receiving psychotherapy or pharmacotherapy. CONCLUSION: There were important differences between subject groups. Overall, American psychiatrists treat a complex group of geriatric patients suffering from major mental disorders complicated by medical comorbidity. Additional studies would further enhance our understanding of the delivery of mental health services to elderly patients and improve training of psychiatrists who help care for our aging population.     

Update of geriatric psychiatry practices among American psychiatrists: Analysis of the 1996 National Survey of Psychiatric Practice.

Using data from the 1996 National Survey of Psychiatric Practice from the American Psychiatric Association (APA), the authors updated information on psychiatrists who are high geriatric providers (HGPs). In 1996, HGPs comprised 18% of the sample. Only 23% reported no geriatric patients in their practice, a 51% reduction from 1988-89; the proportion of HGPs is increasing. HGPs were more often male, minority, international medical school graduates, certified in geriatric psychiatry, and not medical school-affiliated. HGPs worked longer hours/week in direct patient care, had more patient visits/week, and saw more new patients/month, spending more time in hospitals and nursing homes and less time in office-based practice, and seeing more patients with mood disorders, psychotic disorders, and other disorders. Medicare was a proportionally higher payment source. Older psychiatrists were likely to have more patients over age 65. Tracking practice activities of HGPs may help inform policy discussion regarding staffing needs for geriatric patients with late-life mental disorders.     

Mental health reform and evolution of general psychiatry in Ontario.

OBJECTIVES: To discuss developments in Ontario mental health reform, describe general psychiatric services in contrast to tertiary services, describe guidelines for the training of general psychiatrists, and suggest what changes may be required to develop an integrated mental health system (IMHS). METHOD: We review the Ontario government's recent blueprint for mental health reform and the Canadian federal government's document on best practices in psychiatry, in the context of defining general psychiatric services and their relation to tertiary services. From this, we consider the education of general psychiatrists and make suggestions for their training. RESULTS: General psychiatric services correspond to first-line and intensive psychiatric services delivered by community mental health agencies, community psychiatrists, and general hospitals for patients with moderate or serious mental illness. Many suggest that psychiatrists are not being trained to meet the needs of a reformed mental health system. An education program for general psychiatrists should include training in a wide range of community and general hospital settings, work within a multidisciplinary mental health team, and experience working in a shared care model with family physicians. CONCLUSIONS: Along with training general psychiatrists better, we must also develop recruitment and payment incentives, which would allow general psychiatrists who are based in the community and general hospitals to work within an IMHS.     

THE OLDER PSYCHIATRIST AND RETIREMENT

Objective. To determine the clinical practices, retirement plans and post-retirement professional activities of older psychiatrists, comparing retirees with working psychiatrists. Design. Postal survey. Participants. All Fellows of the Royal Australian and New Zealand College of Psychiatrists aged 55 years and over, resident in Australia or New Zealand. Of 468 eligible subjects, 281 (60%) participated. Main outcome measures. Location and type of psychiatric practice; hours of work; retirement plans; anticipated and actual retirement criteria; anticipated and actual post-retirement professional activities; self-rated health. Results. Working psychiatrists comprised 79% of the sample, being significantly younger (mean 63.8 years) than retirees (mean 72.3 years, p < 0.001). Over 62% of respondents worked principally in general psychiatry. Working psychiatrists were mainly in private practice (61%) and retirees had been in public psychiatry (53%, p < 0.001). Working psychiatrists worked about 41 hours/week, 98 (49%) having reduced their hours in the previous 5 years. Retirement plans had been commenced by 124 (61%). Fatigue (27%) and memory impairment (10%) were reported as age-related changes adversely affecting work capacity, raising concerns of competence. Working psychiatrists more often anticipated deteriorating health (p < 0.001) and family/personal reasons (p < 0.01) as retirement criteria and anticipated involvement in a significantly higher number of post-retirement professional activities than retirees reported (p < 0.001). Retirees rated themselves in significantly poorer health than working psychiatrists (p < 0.001), even when age was partialled out (p < 0.001). Conclusions. Most older psychiatrists gradually retire by reducing work hours and developing new interests. The majority of retirees retain involvement in professional activities, but substantially less than anticipated by those still working. © 1997 John Wiley & Sons, Ltd.     

Reducing unnecessary psychiatric consultations for informed consent by liaison with administration.

The frequency of a psychiatric consultation being requested to assess a patients' capacity to give informed consent varies among institutions, with most recent surveys reporting a frequency of between 3% and 8% of all consultations. At Montefiore Medical Center, a hospital policy was interpreted as mandating such consultations for all patients with possible or even definite lack of decisional capacity. From 1987 to 1988, 55% of all psychiatric consultations in the institution were for consent. Only 9% of the consent patients seen had an Axis I diagnosis other than organic mental syndrome (OMS). Because many of these consultations were believed to be unnecessary, with patient clearly able or unable to give consent, the consultation service worked first with administration to modify the guidelines, and then educated the medical and nursing staff as to when consultation was indicated. With this program, the number of consent consultations fell from 958 in 1988 to 177 in 1990, representing a major saving of staff time and third-party billings. In this era of cost containment and outside review of professional practices, psychiatrists must take responsibility for identifying areas where patient services and billings for them are not justified by clinical indications.     

Public and private psychiatry: can they work together and is it worth the effort?

OBJECTIVE: Partnerships in mental health care, particularly between public and private psychiatric services, are being increasingly recognized as important for optimizing patient management and the efficient organization of services. However, public sector mental health services and private psychiatrists do not always work well together and there seem to be a number of barriers to effective collaboration. This study set out to investigate the extent of collaborative 'shared care' arrangements between a public mental health service and private psychiatrists practising nearby. It also examined possible barriers to collaboration and some possible solutions to the identified problems. METHOD: A questionnaire examining the above factors was sent to all public sector mental health clinicians and all private psychiatrists in the area. RESULTS: One hundred and five of the 154 (68.2%) public sector clinicians and 103 of the 194 (53.1%) private psychiatrists returned surveys. The main barriers to successful collaboration identified by members of both sectors were: 'Difficulty communicating' endorsed by 71.4% of public clinicians and 72% of private psychiatrists, 'Confusion of roles and responsibilities' endorsed by 62.9% and 66%, respectively, and 'Different treatment approach' by 47.6% and 45.6%, respectively. Over 60% of private psychiatrists identified problems with access to the public system as a barrier to successful shared care arrangements. It also emerged, as hypothesized, that the public and private systems tend to manage different patient populations and that public clinicians in particular are not fully aware of the private psychiatrists' range of expertise. This would result in fewer referrals for shared care across the sectors. CONCLUSIONS: A number of barriers to public sector clinicians and private psychiatrists collaborating in shared care arrangements were identified. The two groups surveyed identified similar barriers. Some of these can potentially be addressed by changes to service systems. Others require cultural shifts in both sectors. Improved communications including more opportunities for formal and informal meetings between people working in the two sectors would be likely to improve the understanding of the complementary sector's perspective and practice. Further changes would be expected to require careful work between the sectors on training, employment and practice protocols and initiatives, to allow better use of the existing services and resources.     

Gender, isolation, work patterns and stress among old age psychiatrists.

OBJECTIVE: To investigate work patterns and stress in consultant old age psychiatrists over a period of 1 week and to attempt to identify areas amenable to change.DESIGN: Postal survey.PARTICIPANTS: Full-time old age psychiatrists on the list held by the Faculty of Old Age Psychiatry, Royal College of Psychiatrists.MAIN OUTCOME MEASURES: Hours spent on different work activities during a period of 1 week, Stress Checklist score, stressors perceived by respondents. MAIN RESULTS: Men and women doctors did not differ in numbers of hours worked. Consultants working with colleagues worked similar hours to single-handed consultants. Community activity was greater among consultants working with colleagues than among single-handed doctors, whose work was based more in outpatient clinics. For the whole group, time in acute ward rounds correlated positively with stress score and time spent on research at home correlated negatively with stress score.CONCLUSIONS: Doctors spending more than 50 hours at work might be advised to review their work pattern. Excessive time on administrative activities should be reduced. Peer support should be encouraged. Consultants and managers should be sensitive to work patterns and possible sources of stress.     

A survey of early-career child and adolescent psychiatrists: professional activities and perceptions

OBJECTIVE: To assess the career paths and work perceptions of early-career child and adolescent psychiatrists in the United States. METHOD: Analysis of survey data of 392/797 (49.2%) of all U.S. child and adolescent psychiatrists graduating from training in 1996-1998 and on the mailing list of the American Academy of Child and Adolescent Psychiatry. RESULTS: Slightly more than half of those surveyed were women, and most were in their late thirties, white, married, and living in the geographic area in which they trained, with a median income for full-time workers between $121,000 and $150,000. Those with educational debt owed an average of $69,741. The sample was generally very satisfied with their work. They identified clinical work, variety, autonomy, and making a difference as the best aspects, and managed care, paperwork, and overwork as the least desirable aspects. The bulk of hours worked were in solo private practice, public sector, and group practice, with children and adolescents making up 73% of patients treated. The most common treatment modality was medication management. CONCLUSIONS: The present study uses a database approach to defining current practice and workforce issues among early-career child and adolescent psychiatrists. These data may facilitate objective discussion about public policies concerning workforce priorities, barriers, and facilitators to recruitment in this understaffed field.     

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE: The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice. METHODS: Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA). RESULTS: Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis. CONCLUSIONS: Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.     

Child psychiatry practice patterns in Ontario.

OBJECTIVES: To examine the demographics, training, distribution, venues of practice, remuneration patterns, and professional affiliations of child psychiatrists in Ontario. METHOD: In July 1997, questionnaires were sent to 229 Ontario psychiatrists. A second mailing was sent to nonresponders in the fall of 1997. The overall response rate was 66.8%. RESULTS: Compared with other research regarding the ratio of child psychiatrists to children with mental health problems, Ontario fares relatively well (1:6148). Generally, Ontario child psychiatrists report having received formalized training in the speciality. Child psychiatrists are disproportionately concentrated in Toronto and in midsize cities with medical schools compared with rural regions. Out-reach services to smaller communities are provided by 30% of child psychiatrists, but it is not clear whether the services are sufficient and equitably available. Approximately 50% of current psychiatrists will be aged 65 years or older in 15 years, and it is unclear whether sufficient numbers will replace them. The profession appears to be reaching an equitable gender representation. Most child psychiatrists belong to the professional organizations that support the profession; however, they are least likely to belong to the Ontario Psychiatric Association (OPA). CONCLUSIONS: An optimal ratio of child psychiatrists per population served still needs to be determined, with special consideration given to the needs of rural communities. The small ratio of child psychiatrists to the population of children with mental health needs highlights the importance of collaborating with other medical and mental health professionals. Recruiting and retaining child psychiatrists will need to be monitored. Child psychiatrists in Ontario need a unified voice to address these issues.     

The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems

Background Substance abuse among individuals with schizophrenia-spectrum disorders (SSDs) is associated with a range of adverse psychosocial outcomes in the areas of occupational functioning, housing stability, economic independence, access to health care, and involvement with the legal system. The aim of this study was to estimate the effects of substance use disorders (SUDs), SSDS, and dual diagnosis with both disorders on the risk for six important Axis IV psychosocial problems. This was accomplished using a large dataset of patients who are representative of individuals in routine US psychiatric practice. Method Weighted data from the 1999 Study of Psychiatric Patients and Treatments from a practice-based research network of the American Psychiatric Institute for Research and Education were analyzed. Some 615 US psychiatrists provided detailed clinical, psychosocial, and health services information on 1,843 patients, including 285 patients with one or more SUDs without an SSD, 180 patients with a diagnosis of an SSD without substance abuse comorbidity, and 68 dually diagnosed patients. Logistic regression models were used to determine effect estimates (adjusted odds ratios), and corresponding 95% confidence intervals were calculated. Results After adjusting for sociodemographic variables and for SSD diagnosis, SUD diagnosis was independently associated with increased risk for five of the Axis IV psychosocial problems of interest (occupational problems, housing problems, economic problems, problems with access to health care services, and problems related to interaction with the legal system/crime) when compared to all other psychiatric patients (n=1,310). After adjusting for the sociodemographic variables and for SUD diagnosis, SSD diagnosis (compared to all other psychiatric diagnoses) was associated with Axis IV economic problems, but not with the other five psychosocial problems of interest. The presence of both an SUD and an SSD diagnosis (dual diagnosis) was associated with a greater risk for four of the six Axis IV psychosocial problems studied, compared to the risks associated with either diagnosis alone. Limiting the substance of abuse to alcohol resulted in similar findings. Conclusions Although SUDs are associated with increased risk for poor social adjustment, the comorbidity of SUDs and SSDs is associated with greatly compounded psychosocial burdens. These findings, from a large sample of representative US psychiatric patients, demonstrate the ongoing need for improved services and policies for those specially burdened patients with the dual diagnosis of both an SSD and substance abuse or dependence.     

Psychiatric patients and treatments in 1997: findings from the American Psychiatric Practice Research Network

Despite extensive studies on the epidemiology of mental disorders and advances in the treatment of these conditions, there is a paucity of detailed information concerning the characteristics of psychiatric patients and how treatments are administered in routine psychiatric practice. This 1997 observational study collected detailed information from 417 psychiatrists on the demographic, diagnostic, clinical, and treatment characteristics of a systematic sample of 1228 patients. Six hundred thirty-seven patients (51.9%) were women and the mean patient age was 41.9 years. The most common diagnostic category (53.7%) was mood disorders, followed by schizophrenia/psychotic disorders (14.6%), anxiety disorders (9.3%), and disorders of childhood (7.7%). Six hundred seventy-one patients (54.6%) had at least one comorbid Axis I condition and almost half (49.8%) had a history of psychiatric hospitalization. Patients received a mean of 2.0 psychotherapeutic medications, most commonly antidepressants (62.3%). Findings demonstrate that psychiatrists in routine practice treat a patient population with severe, complex conditions.     

Counsellors in primary care: benefits and lessons learned.

OBJECTIVE: To describe a program that integrates mental health counsellors within primary care settings, to present data on the program's impact, and to discuss lessons learned that may apply in other communities. METHODS: This paper describes a Canadian program that brings counsellors and psychiatrists into the offices of 87 family physicians in 36 practices in a community of 460,000 in Southern Ontario. It describes the goals and organization of the program and the activities of counsellors when working in primary care. In addition, it summarizes data from the program's evaluation, including demographic data and the individual problems seen and services delivered (all from the program's database) as well as data on patient outcomes using the General Health Questionnaire (GHQ), the Centre for Epidemiological Studies Depression (CESD) Rating Scale, and consumer-satisfaction questionnaires. RESULTS: Each counsellor sees an average of 161 new cases yearly. The major problems are depression, anxiety, and family problems. In fact, over 70% of individuals who are seen show significant improvements in outcomes. The program has led to a significant increase in access to mental health services, a reduction in the use of traditional mental health services, high levels of satisfaction with counsellors and family physicians, and significant improvements in symptoms and functioning of individuals seen. CONCLUSION: This program has effectively integrated counsellors within primary care settings, increasing the capacity of primary care to handle mental health problems, strengthening links between providers from different sectors, and making mental health care more accessible.     

Comparison of psychiatrists and psychologists in clinical practice

OBJECTIVE: The authors compared data from psychiatrists and psychologists in California to determine whether long-standing differences in clinical practice remain after the introduction of managed care and other changes in mental service delivery. METHODS: Responses from practicing clinicians in California who participated in the 1998 National Survey of Psychiatric Practice and the 2000 California Survey of Psychological Practice were compared on items related to patient caseload, practice profile, and insurance or reimbursement arrangements. RESULTS: Data from 97 psychiatrists and 395 psychologists were available for the study. Psychiatrists reported spending more hours on most aspects of practice and working more total hours per week than psychologists. The weekly caseloads reported by psychiatrists included a greater percentage of persons treated for psychotic conditions than did the caseloads of psychologists. Psychologists reported that their weekly caseloads included a greater percentage of persons treated for anxiety disorders, personality disorders, and other disorders. Psychiatrists reported receiving a greater average payment for services from public insurance, and psychologists reported treating a greater average percentage of patients who did not have insurance coverage. Significant differences in income sources and fee arrangements were observed, and the net reported income of psychiatrists was nearly 80 percent greater than that of psychologists. CONCLUSIONS: Long-standing differences in clinical practice patterns remain between psychiatrists and psychologists despite managed care staffing arrangements and treatment strategies that streamline the practices of both provider groups. The significant income and wage differences between psychiatrists and psychologists may be partly due to supply dynamics of the mental health workforce that adversely affect psychologists.     

The tipping point from private practice to publicly funded settings for early- and mid-career psychiatrists

OBJECTIVE: Practice settings for American psychiatrists were examined for recent trends. METHODS: Surveys were conducted in 1996 (N=970) and 2002 (N=917) among members of the American Psychiatric Association. RESULTS: Between 1996 and 2002 the percentage of direct patient care hours in publicly funded settings increased from 40 to 50 percent for early-career psychiatrists and from 29 to 44 percent for mid-career psychiatrists. By 2002 the percentage of direct patient care hours was higher in publicly funded settings than in solo office practices for early-career psychiatrists (50 percent versus 17 percent) and mid-career psychiatrists (44 percent versus 29 percent). CONCLUSIONS: The popular image of the psychiatrist sitting in a private office does not conform with current survey data, which show that psychiatric practice is increasingly taking place in publicly funded settings. Because it extends to mid-career psychiatrists, the shift from private office practice to publicly funded settings is not just a manifestation of early-career psychiatrists' earning a salary while building up their private practices but is a more enduring change in the landscape of psychiatric practice. The authors discuss the implications of these findings with regard to professional identity and training of psychiatrists.