Psychiatry and primary care medicine in Canada

Summary Primary care medicine has developed rapidly in Canada as elsewhere during the last 25 years. It is a natural sequela to the trend to specialization following World War II and primary practice itself has now reached the status of a specialty. The result has been a longer and more thorough educational process and this process has invited psychiatry to introduce the bio-psychosocial model to medical practice. Although Canadian psychiatry has not itself developed a primary practice frame of health care delivery, it has contributed to primary care residency education. The Canadian national health insurance scheme has facilitated the development of the non-psychiatric physician's interest in the psychological and social issues of health and illness by offering medical coverage in most provinces for psychotherapy. In addition, the generally unlimited payment for all forms of psychiatric care allow ready consultation by physicians to psychiatrists.     

Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.

OBJECTIVE: To determine the prevalence of anxiety and depression in a residents' clinic and if these diagnoses are associated with patients being perceived as difficult, as well as how often these diagnoses are documented in the patients' charts. METHODS: This was a cross-sectional study conducted in a general internal medicine residents' clinic. A total of 135 patients were given the Primary Care Evaluation of Mental Disorders questionnaire (DSM-IIIR version) and their physicians filled out the Difficult Doctor-Patient Relationship Questionnaire after the visit. Charts were reviewed for documentation of a diagnosis of anxiety or depression. RESULTS: Major depression was present in 26 percent, dysthymia 16 percent, major depression in partial remission 9 percent, generalized anxiety disorder 13 percent, and panic disorder 7 percent. Overall, 38 percent had at least one and 21 percent had more than one diagnosis. Of patients with one psychiatric diagnosis, 9 percent were classified as difficult versus 100 percent of patients with four diagnoses. Documentation of depression was noted for 43 percent of patients with major depression but only 9 percent with an anxiety disorder. CONCLUSIONS: Anxiety and depression were very common among the patients in this clinic, and increasing numbers of diagnoses were associated with patients being classified as difficult. Residents diagnosed depressive disorders as often as practicing physicians in other studies, but anxiety less well. The high prevalence of mental disorders has implications for resident education in that they need to be prepared to care for these patients, but residents also may benefit from exposure to sites with more typical prevalences of these illnesses.     

Psychiatrists' judgments of dangerousness in patients on an acute care unit

Statistical analyses suggest that psychiatrists emphasize hostility, agitation, previous assaultiveness, and suspiciousness as factors predictive of violence in psychiatric inpatients. When the actual correlates of violence in these patients are evaluated, a different picture of the assaultive inpatient emerges. Examination of differences between the cues emphasized by clinicians to make their predictions and the empirical correlates of violence suggests ways of improving the accuracy of clinical judgments of inpatients' dangerousness.     

Treating problem-solving deficits on an acute care psychiatric inpatient unit

Neuropsychological deficits in problem-solving are commonly found in patients with schizophrenia and severe affective disorders. However, in an acute care setting, treatment efforts do not typically target these deficits, even though they can impede recovery. This study aimed to evaluate the effectiveness of short-term problem-solving remediation in acutely ill psychiatric inpatients. Twenty-eight psychiatric inpatients identified as having a verbal problem-solving deficit received 6 h of either verbal problem-solving remediation or placebo instruction. Before and after treatment a nurse rated the patient's psychiatric status and the patient completed verbal and nonverbal problem-solving tests, and a self-report rating of symptoms and ability to cope with symptoms. Both groups of patients improved on the measure of verbal problem solving, but those receiving problem-solving remediation improved significantly more. Both groups made symptomatic improvement, but the patients receiving problem-solving remediation made significantly more improvement on the measure of coping ability and the nurses rated them as more improved, both psychiatrically and with regard to coping skills. Verbal problem-solving deficits are responsive to short-term remediation in an acute care setting, and treatment effects may generalize to improve ability to cope with psychiatric symptoms.     

Effects of a psychiatric intensive care unit in an acute psychiatric department

Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients. Controlled studies evaluating the effects of the procedure are lacking. The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit (PICU) and not in a psychiatric acute department. In a naturalistic study, one group of consecutively referred patients had access only to the PICU, the other group to the whole acute unit. Data were obtained for 56 and 62 patients using several scales. There were significant differences in reduction of behaviour associated with imminent, threatening incidents (Broset Violence Checklist), and actual number of such incidents (Staff Observation Aggression Scale-Revised) in favour of the group that was treated in a PICU. The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents.     

Activity situations on an Alzheimer's disease special care unit and resident environmental interactions, time use, and affect

Routine activity situations on an Alzheimer's disease (AD) special care unit were examined with respect to residents' social and physical environmental interactions, time use, and apparent affect. Using a computer-assisted observational tool, observers recorded prevailing activity situations and corresponding behaviors and affects of seven residents every 10 minutes, from 8:00 AM to 8:00 PM, across four days. Although meals/snacks and some activity groups were positively associated with use of physical objects and engagement in activities, residents were predominantly environmentally disengaged, inactive, or without positive affects during the most prevalent activity situations of background media, downtime, and television. Findings suggest that routine activity situations may act as potent environmental influences on the quality of life (QOL) of people with AD and mediate the effectiveness of other environmental interventions undertaken on their behalf.