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.     

Changes in the provision of psychiatric services at a psychiatric district hospital

Changes in the provision of psychiatric services within the last decennials are probably best understood if the impact of national socialism on clinical psychiatry is regarded. Many psychiatrists took part in the "Aktion T4" the organised killing of their patients, at least they did not resist campaigns directed to killing or sterilisation patients. After WW II, a period of silence and acceptance of inhuman circumstances in the large mental state hospitals appeared, when in the sixties a new generation of psychiatrists was no longer willing to continue the traditional system of mental health care delivery. The Expert Commission on Mental Health Care reported a comprehensive agenda on reformation of service delivery in 1975, which was influential in the development of alternative structures of psychiatric services. Most mental state hospitals reduced their capacities and parallel to this process smaller units, devoted to principles of community psychiatry, associated to general hospitals were created. Overall, the number of hospital driven beds decreased at about 33 %, but in the large hospitals at two thirds within the last 25 years in Baden-Wurttemberg. This process of deinstitutionalization was accompanied by the development of structures for community care, internal reorganization and modernization, and important steps in budget development, which lead to better treatment opportunities for all kinds of psychiatric institutions. The concrete and historical reality of these circumstances and changes, and possible future directions are exemplified for the psychiatric hospital in Weinsberg.     

Psychiatric manpower: an overview.

There are approximately 25,000 to 30,000 psychiatrists in the United States, some 17,000 of whom are in actual clinical practice. As part of an overview of psychiatric manpower, the authors show the distribution of psychiatrists by state and present population-per-psychiatrist ratios. In discussing the distribution of psychiatrists in various work settings, they note that the decreasing percentages of psychiatrists in community mental health centers may be related to such factors as the large number of non-hospital-based centers, growing antimedical attitudes in centers, and psychiatrists' inclination to work in a setting similar to their training site. They believe that federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities. Such an approach would result in the recruitment and retention of greater numbers of psychiatrists in public service settings.     

CMHC's: Relationships with academia and the state

We have surveyed all community mental health centers (CMHC's), state departments of mental health, and university departments of psychiatry in the country to ascertain the status of their relationships with one another. The response rate to a one page questionnaire was 33%.An overwhelming percentage, 88%, of CMHC's have relationships with state hospitals and/or academia. Most often they consist of a service relationship. The control for such relationships is most often shared or there is no one controlling organization.The benefits of such relationships include improved communication, improved access to state hospitals, and improved quality of inpatient and outpatient care. CMHC's who responded to our survey did not think that relationships with the state or academia resulted in improved recruitment of psychiatrists and improved residency training-but state and academic respondentsdid. All, however, agreed that research, long-term care, and recruitment of other staff are minimally improved by collaborative relationships.This contribution was originally presented in May 1986 as part of a Symposium entitled Whither CMHC's: Current Trends and Future Possibilities at the Annual Meeting of the American Psychiatric Association in Washington, DC. Address reprint requests and correspondence to the authors at 645 West Redwood St., Baltimore, MD 21201     

Assuring quality in community mental health centers. The need for psychiatric practice guidelines

Many have expressed concern regarding both the deterioration in the quality of patient care provided by CMHCs and the exodus of competent psychiatrists from them. Earlier efforts by the Joint Commission to serve as an accrediting body for CMHCs were ineffective. Two factors may well have contributed to this. First, the Joint Commission's community mental health "Principles" were not medically based and, therefore, may not have been sufficiently able to assure quality of care, especially for the seriously mentally ill. Secondly, the "Principles" did not enjoy widespread use among CMHCs. Heretofore, CMHCs have not been required to meet national accrediting standards to qualify for governmental and other third-party reimbursement. Tying reimbursement to a meaningful accreditation process, as is done for hospitals, would solve the latter problem. Redressing the former problem might be accomplished by incorporating guidelines for psychiatric practice, such as those proposed in this article, into JCAHO's and CARF's accreditation standards for CMHCs. Such standards would then, by linking authority to responsibility, provide the CMHC psychiatrist with a foundation upon which to reasonably practice and thereby assure quality patient care. Although 55% of CMHCs were headed by psychiatrists in 1971, only 8% had psychiatrist CEOs as of 1985. Although psychiatrists need not be administratively in charge of CMHCs, the importance of their clinical leadership role is undeniable. Yet, in many centers, this role has been sorely compromised. It is anticipated that a clearer delineation of the psychiatrist's and, more specifically, the medical director's role will benefit all involved: patients, families, psychiatrists, other clinical staff, executive directors, and CMHC boards of directors. Centers that have strong psychiatric leadership will clearly benefit in three ways: (1) liability risk will be kept to a minimum; (2) recruitment and retention of competent psychiatrists will be enhanced; and (3) with CMHCs remaining clearly in the medical mainstream, they will be assured of continued governmental and other third-party healthcare funding. O'Leary, President of JCAHO, writes the following: The Joint Commission has never placed a direct role in the development of clinical standards, and we do not intend to begin now. But we do urge appropriate specialty groups to establish this task as a high priority. While consensus standards are inherently imperfect, they do reflect unique collections of wisdom and experience.(ABSTRACT TRUNCATED AT 400 WORDS)     

Public mental hospital work: pros and cons for psychiatrists

The extensive literature concerning public mental hospitals has largely been written from the perspective of administrators and systems analysts; most of the reports emphasize the frustrations and problems of working in public mental hospitals and the continued exodus of psychiatrists from these facilities. The author addresses the pros and cons of such a career choice from the viewpoint of one who has been an "Indian" rather than a "chief" for a decade. He suggests that the current financial situation in both private practice and academia makes work in public mental hospitals increasingly attractive.     

Pathway to psychiatric care in Japan: A multicenter observational study

Background

This study examines pathways to psychiatric care in Japan using the same method as the collaborative study carried out in 1991 under the auspices of the World Health Organization.

Methods

Thirteen psychiatric facilities in Japan were involved. Of the 228 patients who contacted psychiatric facilities with any psychiatric illness, eighty four visiting psychiatric facilities for the first time were enrolled. Pathways to psychiatric care, delays from the onset of illness to treatment prior to reaching psychiatrists were surveyed.

Results

Thirty three patients (39.4%) directly accessed mental health professionals, 32 patients (38.1%) reached them via general hospital, and 13 patients (15.5%) via private practitioners. The patients who consulted mental health professionals as their first carers took a longer time before consulting psychiatrists than the patients who consulted non-mental health professionals as their first carers. The patients who presented somatic symptoms as their main problem experienced longer delay from the onset of illness to psychiatric care than the patients who complained about depressive or anxiety symptoms. Prior to the visit to mental health professionals, patients were rarely informed about their diagnosis and did not receive appropriate treatments from their physicians. Private practitioners were more likely to prescribe psychotropics than physicians in general hospitals, but were less likely to inform their patients of their diagnosis.

Conclusion

This first pathway to psychiatric care study in Japan demonstrated that referral pathway in Japan heavily relies on medical resources. The study indicates possible fields and gives indications, underlining the importance of improving skills and knowledge that will facilitate the recognition of psychiatric disorders presenting with somatic and depressive symptoms in the general health care system and by private practitioners.     

The Impact of Managed Care on Psychiatry

It is estimated that 50% of all practicing psychiatrists have at least one contract with a managed care organization (AMA, 1994). As the field of psychiatry increasingly adopts the tools of managed care, it is important for researchers to clarify the extent to which managed care affects the practice of psychiatry, and how the changing practice climate in turn affects patients seeking mental health care. A diverse array of managed care techniques have been introduced into the profession of psychiatry in an effort to alter treatment patterns. One commonly used tool, utilization review, can alter treatment patterns by restricting access to treatment alternatives and providing incentives to practitioners to meet managed care goals. Other managed care tools are the determination of "medical necessity" and the use of triage and treatment guidelines among insured enrollees requesting services. These guidelines serve as selection criteria to help determine not only which members of the insured population receive treatment for mental health care, but also to determine the allocation of enrollees to staff members and to prescribe the starting point for the types of services received. Managed care psychiatrists may find changes not only in their client populations and treatment alternatives, but in many other aspects of their practice. Some psychiatrists working in managed care have become increasingly involved in treatment teams. Other psychiatrists contracting with MCOs are reserved for medication management, consultation, or administration in carved-out mental health departments or agencies. Little is known about the extent to which managed care restrictions affect psychiatrists' patient care roles, collaborative relationships with other mental health professionals, and the degree to which psychiatrists are involved in administration of managed mental health care benefits. The era of managed care has constrained the clinical decision making of psychiatrists whose magnitude and impact on job satisfaction and labor market responses are unknown. Surveys of general physicians in MCOs have provided a framework for understanding some of the difficulties and opportunities faced by managed care psychiatrists, but have failed to shed much light on many aspects of medical practice specific to the provision of mental health care within the boundaries of managed care. Future research in this area would help fill this gap, and assist in shaping the roles of psychiatrists in managed mental health care organizations.     

The public image of psychiatrists

The image of psychiatry is directly related to the knowledge that the public has of psychiatry and to the psychiatrists role as a "public informer". The time has come for psychiatrists to organize and have their opinions on all aspects of the mental health care system and mental illness heard in the media. After a review of different causes of the negative public image of psychiatrists, the reasons for which psychiatrists need to change their public image are outlined with some suggestions for increase public recognition. The importance of developing more research on the effect of mass media on the mental health care system is also outlined.     

Critical evaluation of the current status of general hospital psychiatry in Japan]

The number of beds necessary for medical care was determined in 1985 by the Secondary Medical Law Act, therefore community medical care has been functioning well. However, the number of beds necessary for mental care is still defined according to each prefecture, which results that community mental care is not always adequate. The total number of beds for the mentally ill is 360,000, of which general hospitals have only approximately 20,000 (5.8%). This means that in-patient mental care in Japan mostly depends upon mental hospitals. In order to promote mental care in general hospitals and to improve the position of psychiatrists in all medical fields, the Japanese Society of General Hospital Psychiatry (JSGHP) was established in 1988. In this article, the author describe the current problems in mental care and discuss about the topics concerning general hospital psychiatry in Japan.     

A profile of community mental health center psychiatrists: Results of a national survey

A national survey of community mental health center psychiatrists was designed to assess the extent to which they experience professional burnout. 214 psychiatrists responded to the survey. The largest single group of respondents (23.4%) was attracted to community mental health primarily by normative values (e.g., serving the indigent). The critical variable which has or would cause most of the respondents to leave their community mental health center is conflict over the psychiatrist's role and/or value. Despite problems encountered by many, 78.5% of respondents expressed a greater than 50% overall satisfaction in their work at Community Mental Health Centers. 34.1% of respondents have practiced in a community mental health center for more than 10 years. 31.7% of respondents spend half-time or less of their working time in a community mental health center, raising questions about possible limitations in psychiatrist roles. Thirty-one of respondents spend more than three quarters of their community mental health center time evaluating and treating patients, raising questions as to whether community mental health center psychiatrists are utilized in oversight roles appropriate to their levels of expertise.Presented at the Institute on Hospital and Community Psychiatry, Montreal, Canada, October 13–17, 1985 and at the Annual Meeting of the National Council of Community Mental Health Centers, Las Vegas, Nevada, April 2–5, 1986. The Authors gratefully acknowledge the grant-in-aid from the Burroughs Wellcome Company which made this survey possible.     

Treatment strategy for women with puerperal psychiatric disorders--psychopharmaco-therapy and its impact on fetus and breast-fed infants]

Women have the most possibility of suffering from mental disorders during pregnancy and postpartum periods in their whole life time. Especially, postnatal depression is not uncommon with an incidence of 10-20%, fortunately a screening system has been developed, and in Japan the Edinburgh Postnatal Depression Scale (EPDS) is now practically used in both hospitals and community health service centers. Additionally most mental disorders during this period are not severely disturbed, so they do not have to be necessarily treated by psychiatrists. Severely disturbed cases, however, which include postnatal depression with self or infant harm thought or puerperal psychosis are to be treated by psychiatrists and tend to have psychopharmaco-therapy. In using psychotropic drugs attention must be paid for both women and their babies. Impact on breast-fed babies while mothers take psychotropic drugs have been reported, mostly as case reports. We have reported the controlled studies, (1) The 25 mothers with postnatal depression were treated by tricyclic antidepressants, of which 10 breast-fed and 15 did not. The drugs were amitriptyline, imipramine, clomipramine, dothiepine, (2) The 30 mothers with puerperal psychosis were treated by antipsychotic drugs, of which 12 breast-fed and 18 did not. The drugs were chlorpromazine, trifluoperazine, perphenazine and haloperidol. Both antidepressants and neuroleptics were transferred through breast-milk and a few % of maternal dose per kilogram were injected to their babies by calculating drug concentration ratios of in breast-milk/in serum. None of the breast-fed infants had adverse effects, and no developmental difference was found compared to bottle-fed infants using the Bayley Development Scale during infancy. Furthermore, the breast-fed infants were followed up as long as possible up to 30 months and no significant developmental delay was found. In addition, we reported a case study on four breast-fed babies whose mothers took fluoxetine. The infants had no adverse effects. Pregnant women and their fetuses need to be more carefully monitored. Three preliminary cases were reported here; the pregnant women took clomipramine, sulpiride, haloperidol and chlorpromazine. Drug concentrations in maternal plasma in late pregnancy and postnatally and in umbilical cords were almost the same, which meant they were freely transferred from mothers to babies. Regarding the neonate's outcome, all were full turn born with normal birth weight with good Apgar scores. Weight gain in one month was normal which meant all babies had normal sucking without hypotonic muscle. Psychiatrists must accumulate these date and contribute as one of specialists in perinatal mental health in multi-disciplinary team.     

Informed diagnosis and psycho-education on psychiatric illnesses by primary care physicians--a result from pathway to psychiatric care in Japan study]

On the path to psychiatric care, many patients who experience their first episode of mental disorder consult general practitioners or physicians of general hospitals before consulting psychiatrists. Some patients receive proper care promptly while others experience a delay in treatment. We investigated treatments and psycho-education given to patients by general practitioners or physicians of general hospitals, particularly focusing on informed diagnosis. We conducted a multi-center collaborative study in Japan. In this study, 15 facilities participated, including 4 university hospitals, 3 general hospitals, and 8 psychiatric hospitals. A total of 382 patients experiencing their first episode of mental disorder were enrolled. Among them, 157 patients primarily consulted general practitioners or general hospitals. We divided the 157 patients into 3 groups according to the kind of psycho-education given by general practitioners or physicians of general hospitals: those who were told nothing about their diagnosis nor mental condition (N = 74, 47.1%), those who were not given a direct diagnosis but were informed about their condition in some way (N = 55, 35.0%), and those who were directly informed of their diagnosis (N = 28, 17.8%). We found that almost half of the patients were told nothing about their diagnosis nor mental condition by general practitioners or physicians of general hospitals. Patients who were likely to be directly informed of their diagnosis were those who were recommended to see a doctor by someone, or those with a lower global psychosocial function. The patients who were told nothing about their diagnosis nor mental condition were mainly covered by national health insurance, and had decided to go to hospitals or clinics under their own volition. Sorted by ICD-10 F code, patients diagnosed as F0, F3, or F4 accounted for 89.9% of all subjects. We compared treatment delays among these 3 categories. The median treatment delay in patients diagnosed correctly as F0 by general practitioners or physicians of general hospitals was 50 weeks, that in patients diagnosed as F3 was 4 weeks, and that in patients diagnosed as F4 was 5 weeks. These findings suggest that patients might be treated in different ways according to their diagnosis by general practitioners or physicians in general hospitals. Our results suggest the importance of further educating general practitioners and physicians of general hospitals about mental disorders, in order to not only shorten the duration of untreated psychosis, but also for patients to be given proper primary care.     

Mexican Psychiatric Trainees’ Attitudes Towards People with Mental Illness: A Qualitative Study

Despite their training, psychiatrists have been found to have negative attitudes towards people with mental illness, including the patients they treat. Similarly, studies focused on service users have identified psychiatrists as a source of stigma. Even though negative attitudes in psychiatrists have been identified in different countries and settings, in Mexico the attitudes of these professionals have never been assessed. Because of this, we invited psychiatric trainees from a hospital in Mexico to participate in individual interviews to describe their opinions regarding mental health-related stigma, to evaluate their attitudes towards people with mental illness and to identify factors that could be influencing their attitudes. Interviews were audio recorded, transcribed and analysed using thematic analysis. A total of 29 trainees participated in the study. The results suggested that trainees recognised psychiatrists can have negative attitudes towards people with mental illness, such as poor empathy, judgement and labelling, and mainly towards patients considered difficult and with borderline personality disorder. Participants recognised these attitudes can influence their relationship with patients, and considered it is necessary to develop interventions to improve their own attitudes and reduce mental health stigma. From this study we concluded Mexican psychiatrists are not free from stigma towards people with mental illness. However, Mexican psychiatric trainees are interested in improving their attitudes and reactions towards their patients.

     

Recent developments in antitrust: challenges to medical autonomy

Once exemptions from antitrust scrutiny were removed, economic arguments have proved effective in dissolving the hegemony formerly held by psychiatrists over the provision of mental health services. A growing number of courts, legislatures, and insurance companies have been persuaded by psychologists that they can provide at least comparable services at lower costs than psychiatrists. The fact that psychotherapy is less obviously a "medical" procedure than surgery or other physical treatments has facilitated the establishment of the psychologists' position. After these gains, there are indications that other mental health providers will follow the paths established by psychologists. Cost-containment efforts in the mental health care industry, particularly through health maintenance organizations, have already led to increased utilization of nondoctoral providers for initial screening services, and psychiatrists have even filed countersuits alleging restraint of their trade through the exclusive use of lower-cost providers (State Medical Society of Wisconsin v. Schweiker et al., 1982). With the clear message from many courts and legislatures that profession will no longer serve to distinguish among mental health providers, it appears that the validity of psychiatrists' assertions that independent practice by nonmedical mental health professionals will result in lower quality of care for patients will be tested in the marketplace, with peer review and tort litigation serving as the barometer by which that quality will be measured. And, as other nonmedical professionals establish their credentials through licensure and recognition by consumers, we can expect that they will also seek recognition of their capacities to provide (and be reimbursed for) professional services through the courts. With this greater access to consumers of mental health care will also come, of course, greater public scrutiny and greater risk of malpractice liability.     

How do general practitioners deal with patients they do not consider to be depressed but who are classified as such according the PHQ-9?

OBJECTIVES How GPs describe their patients who they did not identify as suffering from depression but who were classified as such by PHQ-9? What conclusions can be drawn with regard to how depression is dealt with and the illness model in use? METHOD GPs who took part in a screening study were asked in interviews to talk about some of their patients - not being informed that these were those not identified as depressive by them. This study comprises 21 narrative interviews from 18 GPs. Analysis by Framework method by Lewis and Ritchie. RESULTS The low identification rate of depression is not the result of failed recognition of "psychological problems" but of other factors centring on GPs' particular way of working and their concepts about mental illness: making a diagnosis only in a contextual way of interpreting symptoms; using the time passing as a help for diagnosing; emphasis on the impairment rather the diagnosis; considering the therapeutic consequences before making a diagnosis; a tolerance concerning "deviation" respectively wider view on "normality". CONCLUSION Understanding the different ways of conceptionalizing mental illness by psychiatrists and general practitioners is basic for their cooperation.     

Recruitment of public psychiatrists: the impact of university and state collaboration on FMGs in Maryland

The current emphasis on university and state collaboration to recruit competent psychiatrists to the public sector may adversely affect foreign medical graduates (FMGs) working in state hospitals, many of whom received inadequate training in autonomous state hospital residency programs. In Maryland a joint initiative of the state university and the mental hygiene administration called the Maryland Plan has been successful in attracting university-trained psychiatrists, mostly U.S. medical graduates, to public hospitals, leaving fewer training and employment opportunities for FMGs. Most FMGs have retained their positions in the state hospitals, and 15 percent of the university-trained recruits have been FMGs. However, the authors predict that few FMGs will be able to compete with U.S. medical graduates for residency slots, and they call for continued recruitment of the most qualified FMGs into the public system.     

2014年四川省精神卫生服务机构、床位及精神科执业医师现状分析

目的了解四川省精神卫生机构和床位资源,以及精神科执业医师(含助理)分布情况。方法本调查由四川省精神卫生中心于2014年7月组织实施完成。首先编制"四川省精神卫生服务的机构调查表",下发各市州卫生局/精防机构填报;再编制"机构信息补充表"下发给被填报的相关机构人员填写;最后对全省开展精神卫生服务的机构,精神科核定床位及精神科执业医师(含助理)人数进行描述性分析。结果全省开展精神卫生临床服务的机构共138家,其中58.70%为专科医院,84.06%隶属于卫生系统。全省21个市州中阿坝藏族羌族自治州和甘孜藏族自治州尚无开展精神卫生服务的机构。全省181个区县中,50.83%的区县无精神卫生服务机构。全省编制床位19078张,每万人口编制床位2.37张;实际开放床位30241张,每万人实际开放3.76张。全省精神科执业医师(含助理)1756人,每10万人口2.18名精神科执业医师(含助理)。结论四川省各市州间精神卫生服务资源分布不合理。     

What you should know about physical evaluations in psychiatric patients. Results of a survey

Physical illness often initially manifests as a disturbance in thought, behavior, or mood; thus an important aspect of the psychiatric evaluation is differentiating organic disease from "functional" psychiatric disorders. A group of clinically oriented psychiatrists were surveyed about their attitudes and practices regarding medical evaluation in psychiatric patients. Thirty-seven percent of those surveyed performed physical examinations in 60%-100% of their inpatients whereas only 5% performed such examinations on outpatients. Of the 123 respondents, 63 did not perform physical examinations on any of their patients. Twenty-four percent of those who did not perform physicals also did not utilize internists or family practitioners to exclude the possibility of organic disease as a complicating factor in the psychiatric presentation. Those who considered themselves "biologically oriented" were twice as likely to include a physical examination in their inpatient evaluation as those who described themselves as "eclectic" psychiatrists; however, 30% still did no physical examinations in their practice. These findings suggest that though the ability to identify organic illness as a cause for psychiatric symptoms is considered important, psychiatrists often do not utilize the physical examination as a technique in uncovering physical disease.