The Canadian Psychiatric Association practice profile survey: II. General description of results.

OBJECTIVE: To provide an overview of the results of the Canadian Psychiatric Association (CPA) practice profile survey (PPS), 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: Psychiatrists work 10 hours daily on average and take calls for 5 hours. Sixty percent of the overall work time is in the provision of direct patient care, and fee-for-service payments account for 55% of hours worked. Forty percent of the clinical work is provided in a hospital setting, and 34% is in a private office. Agency work accounted for only 6% of clinical hours worked. Relatively few practitioners provide services to children, older, or forensic patients. The average patient seen is female, aged 40 years, unmarried or with a marital disruption, significantly impaired in multiple areas of functioning, and likely to suffer from depression (21%), schizophrenia (14%), an anxiety disorder (13%), or bipolar disorder (12%). Comorbid Axis I and Axis II disorders are common (each over 30%) and fairly high rates of suicidal (15% to 30%) and homicidal (10% to 20%) risk are present. CONCLUSIONS: This paper suggests a wide diversity of practice in psychiatry in Canada, with services being provided to a wide range of individuals with many different conditions.     

A survey of private practice psychiatrist's training and activity in activity in Aquitaine, France, in 1993

This study was conducted to gather information regarding the current professional activities of French private practice psychiatrists. METHOD: A mail survey was carried out in an attempt to find more about the characteristics of the 380 private practice psychiatrists in Aquitaine (south west France) in 1993. Data are reported in terms of psychiatrist's characteristics (demographics, training and practice activities), patient characteristics and trends in treatment modalities. RESULTS: There was a good response rate (55%), and this enabled us to statistically analyze the data to determine profiles of activities. For the respondents in this survey, the median age is 45 years and 30.7% of respondents are women. The portion of responders reporting a qualification in Neuropsychiatry versus Psychiatry, is low (1/7). The patients seen in private practice are generally young females with anxiety and affective disorders. An important feature was the trend for psychotherapy training and practice. Psychoanalytically oriented and individual psychotherapy were predominant over other forms of psychotherapy. Half of the psychiatrists reported using pharmacotherapy in combination with psychotherapy. There are only little differences in the practice of young and female psychiatrists. CONCLUSION: The impact of psychodynamic theories on the training of French private practice psychiatrists is still very important. Interestingly, these same psychiatrists seem to use an eclectic approach to their practice of psychiatry; about half of the respondents report using pharmacological treatments in combination with psychoanalytically oriented psychotherapy.     

The geriatric psychiatry workforce in 2002: analysis from the 2002 National Survey of Psychiatric Practice.

OBJECTIVE: Using the 2002 National Survey of Psychiatric Practice (NSPP), authors update demographic and professional work activities of a nationally representative sample of the psychiatric workforce who treat geriatric patients. METHODS: The sampling frame for the 2002 NSPP used the American Medical Association's Masterfile of Physicians. Professional, demographic, and patient data are compared between general and self-reported geriatric psychiatrists. Authors also present detailed analyses comparing high geriatric providers (HGPs; geriatric caseloads >20%), and board-certified geriatric psychiatrists (BCGPs). RESULTS: The proportion of HGPs in the 2002 NSPP was 26.0% of all respondents and was 28.1% among American Psychiatric Association (APA)-member respondents. Among the APA-member psychiatrists, this reflected a 55% increase from the 1996 NSPP. Of HGPs, 31.0% were certified in geriatric psychiatry. As compared with general psychiatrists, proportionally fewer men and American medical-school graduates were self-reported geriatric psychiatrists. Geriatric psychiatrists saw nearly three times as many geriatric patients and five times as many dementia patients as did their generalist counterparts. Mood-disorder patients were the largest treatment group, however. Investigators observed no significant differences in professional and practice characteristics between HGPs and BCGPs. CONCLUSIONS: About 1 in 4 psychiatrists in the 2002 survey are HGPs. Geriatric psychiatrists treat proportionally more geriatric patients than do generalists, but they do not have exclusively geriatric practices. The similarities between HGPs and BCGPs raise issues about the incentives for geriatric psychiatry certification, but not the need to train subspecialists to serve as faculty and community resources.     

Psychiatric genetics: a survey of psychiatrists' knowledge, opinions, and practice patterns

OBJECTIVE: Knowledge about the genetic basis of psychiatric illness is growing rapidly, and psychiatrists may be called upon to incorporate this information into clinical practice. The goal of this study was to assess psychiatrists' familiarity with and attitudes toward genetic information. METHOD: We surveyed 844 participants, the majority of whom were psychiatrists, attending a continuing medical education course in the fall of 2002 and measured knowledge, opinions, and current practice patterns in regard to psychiatric genetics. RESULTS: Responses were received from 352 psychiatrists (54% of those surveyed). Most psychiatrists correctly answered fewer than half of survey items assessing general and psychiatric genetic knowledge. While 83% considered it their role to discuss genetic information with patients and families, fewer than 25% felt prepared or competent to do so. In response to hypothetical questions regarding genetic testing, a substantial proportion of psychiatrists indicated willingness to use such tests for diagnostic clarification, as well as presymptomatic and even prenatal risk prediction. The majority of respondents expressed interest in further genetics education. CONCLUSIONS: Our results suggest that psychiatrists view genetic information as clinically relevant, but have limitations in knowledge that may impact the incorporation of psychiatric genetics into clinical practice.     

Treatment-resistant depression: a survey of practice habits of Canadian psychiatrists.

Treatment-resistant depression is a fascinating yet poorly defined condition. The various management strategies in use are a source of controversy. The objective of this survey was to determine how Canadian psychiatrists treat patients with "intractable depression." This information may be used to plan future research into the management of treatment-resistant depression. It may also provide information about the practices of Canadian psychiatrists and help direct residency training. Confidential questionnaires were mailed to all psychiatrists residing in Canada registered with the Canadian Psychiatric Association. Respondents indicated that 12.4% of their depressed patients were "resistant to treatment." Respondents were asked to rank a list of treatment choices in the order they would use them to treat patients with treatment-resistant depression. Ninety-five point eight percent of respondents used tricyclics as the first treatment of choice. Almost equal portions of respondents chose a second tricyclic, a monoamine oxidase inhibitor (MAOI) or a combination of lithium and tricyclics as their treatment of second choice.     

The relationship between psychiatry and religion among U.S. physicians

OBJECTIVE: This study compared the religious characteristics of psychiatrists with those of other physicians and explored whether nonpsychiatrist physicians who are religious are less willing than their colleagues to refer patients to psychiatrists and psychologists. METHODS: Surveys were mailed to a stratified random sample of 2,000 practicing U.S. physicians, with an oversampling of psychiatrists. Physicians were queried about their religious characteristics. They also read a brief vignette about a patient with ambiguous psychiatric symptoms and were asked whether they would refer the patient to a clergy member or religious counselor, or to a psychiatrist or a psychologist. RESULTS: A total of 1,144 physicians completed the survey, including 100 psychiatrists. Compared with other physicians, psychiatrists were more likely to be Jewish (29% versus 13%) or without a religious affiliation (17% versus 10%), less likely to be Protestant (27% versus 39%) or Catholic (10% versus 22%), less likely to be religious in general, and more likely to consider themselves spiritual but not religious (33% versus 19%). Nonpsychiatrist physicians who were religious were more willing to refer patients to clergy members or religious counselors (multivariate odds ratios from 2.9 to 5.7) and less willing to refer patients to psychiatrists or psychologists (multivariate odds ratios from .4 to .6). CONCLUSIONS: Psychiatrists are less religious than other physicians, and religious physicians are less willing than nonreligious physicians to refer patients to psychiatrists. These findings suggest that historic tensions between religion and psychiatry continue to shape the care that patients receive for mental health concerns.     

Spirituality and psychiatry in Canada: psychiatric practice compared with patient expectations.

OBJECTIVE: This study compares psychiatrists' and psychiatric patients' practice, attitudes, and expectations regarding spirituality and religion. METHOD: We mailed surveys to all Canadian psychiatrists registered with the Royal College of Physicians and Surgeons of Canada (n = 2890). The response rate was 42% (n = 1204). We recruited patients from a Canadian on-line survey (n = 67) and from a local mental health clinic (n = 90). RESULTS: Psychiatrists had lower levels of beliefs and practices than did patients and the general population. In both groups, 47% felt there was "often or always" a place to include spirituality in psychiatric assessment, although the perceived importance differed. Among patients, 53% felt it important to have this issue addressed, and 24% considered the psychiatrist's spiritual interest important in their choice of psychiatrist. Barriers to addressing the issue of spirituality and mental health related to psychiatrists' concern regarding its appropriateness and patients' perception that interest is lacking. Psychiatrists' own beliefs and practices were strong predictors of spiritual inquiry. CONCLUSIONS: Although psychiatrists report lower levels of spiritual and religious belief than do patients, they acknowledge that it is important to include this topic in patient care. Increased discussion and education may lower reported barriers to including spirituality and religion in routine psychiatric assessment.     

Psychiatrists’ Comfort Using Computers and Other Electronic Devices in Clinical Practice

This report highlights findings from the Study of Psychiatrists’ Use of Informational Resources in Clinical Practice, a cross-sectional Web- and paper-based survey that examined psychiatrists’ comfort using computers and other electronic devices in clinical practice. One-thousand psychiatrists were randomly selected from the American Medical Association Physician Masterfile and asked to complete the survey between May and August, 2012. A total of 152 eligible psychiatrists completed the questionnaire (response rate 22.2 %). The majority of psychiatrists reported comfort using computers for educational and personal purposes. However, 26 % of psychiatrists reported not using or not being comfortable using computers for clinical functions. Psychiatrists under age 50 were more likely to report comfort using computers for all purposes than their older counterparts. Clinical tasks for which computers were reportedly used comfortably, specifically by psychiatrists younger than 50, included documenting clinical encounters, prescribing, ordering laboratory tests, accessing read-only patient information (e.g., test results), conducting internet searches for general clinical information, accessing online patient educational materials, and communicating with patients or other clinicians. Psychiatrists generally reported comfort using computers for personal and educational purposes. However, use of computers in clinical care was less common, particularly among psychiatrists 50 and older. Information and educational resources need to be available in a variety of accessible, user-friendly, computer and non-computer-based formats, to support use across all ages. Moreover, ongoing training and technical assistance with use of electronic and mobile device technologies in clinical practice is needed. Research on barriers to clinical use of computers is warranted.     

Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses.

OBJECTIVE: To compare the opinions of Canadian psychiatrists regarding dissociative disorder diagnoses with those of previously surveyed American psychiatrists. METHOD: We sent a 1-page questionnaire to a stratified representative sample of 550 Canadian psychiatrists. RESULTS: Eighty percent of Canadian psychiatrists responded. Fewer than one-third replied that dissociative amnesia and dissociative identity disorder should be included without reservations in the DSM-IV; fewer than 1 in 7 felt that the validity of these diagnoses was supported by strong scientific evidence. French- and English-speaking Canadians had similar opinions. Overall, Canadians were significantly less accepting than Americans. CONCLUSION: Both Canadian and American psychiatrists show little consensus regarding the diagnostic status or scientific validity of dissociative amnesia and dissociative identity disorder.     

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.     

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.     

Canadian geriatric psychiatrists: why do they do it? A Delphi study.

OBJECTIVE: To generate hypotheses regarding influential factors that have contributed to the practice of geriatric psychiatry by geriatric psychiatrists. METHOD: Using the Delphi technique, designed to generate ideas and consensus, a sample of members of the Canadian Academy of Geriatric Psychiatry (CAGP) was asked to provide ideas on what factors were influential in their decision to devote a significant part of their practice to geriatric patients. These items were then synthesized into a questionnaire and rated for their degree of influence by the same group of psychiatrists. RESULTS: A total of 41 items were rated according to their degree of influence. The most influential items were related to geriatric psychiatry residency training experiences that were perceived to be positive or adequate. Supervision characteristics and interest in the medical psychiatric nature of the field were also deemed influential. CONCLUSIONS: This study generates the hypothesis that the nature of the educational experience during psychiatry residency has a significant influence on the practice of geriatric psychiatry.     

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.     

Mental health service use in a nationally representative Canadian survey.

BACKGROUND: Previous Canadian surveys have noted a wide range of prevalence rates for mental health service use and found no consistent relation between type of contact with mental health professionals and severity of illness. This study is the first investigation to examine the prevalence and correlates of mental health service use in a nationally representative Canadian survey. METHODS: The Canadian Community Health Survey Cycle 1.1 was conducted between 2000 and 2001 (n = 125,493; respondent age 12 years and over; response rate; 84.7%). Respondents were asked whether they had contacted a professional because of emotional symptoms in the past year and about their experience of barriers to treatment. DSM-IV major depression and alcohol dependence diagnoses were assessed with the Composite International Diagnostic Interview Short Form. The relation between a range of measures of clinical severity and the type of professional contacted for emotional symptoms was examined. RESULTS: The prevalence of 12-month help seeking for emotional symptoms was 8.3% (99%CI, 8.10 to 8.55); an additional 0.6% (99%CI, 0.49 to 0.62) of the sample perceived a need for treatment without seeking care. Respondents endorsing contact with multiple professionals or with psychiatrists only had higher levels of severity than those who had contact with family doctors only or nonphysician professionals only. CONCLUSIONS: Although untreated depression remains a significant problem in Canada, more severe illness was more likely to be associated with seeing a psychiatrist (or multiple professionals), indicating a relation between greater severity of mental illness and receiving more specialized care.     

Psychiatry in the Nazi era.

OBJECTIVES: To update Canadian psychiatrists on recent information from newly discovered Berlin archives about the actions of physicians, especially psychiatrists, during the era of National Socialism in Germany and to encourage introspection about the role of the medical profession, its relationship with government, and its vulnerability to manipulation by ideology and economic pressures. METHOD: This is a selective review of the literature on the collaboration of physicians, especially psychiatrists, in the sterilization, experimentation, and annihilation of patients with mental illness before and during World War II. RESULTS: Directed to value the health of the nation over the care of individual patients and convinced that a hierarchy of worth distinguished one person from another, German psychiatrists were enlisted to commit atrocities during the Nazi period. CONCLUSIONS: The values of care and compassion can be eroded; this knowledge demands constant vigilance.