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.     

Australian psychiatrists today: proud of their profession but stressed and apprehensive about the future

OBJECTIVE: To examine the levels of satisfaction and stress of Australian psychiatrists. METHOD: A survey was mailed in December 2002 to all Fellows of the Royal Australian and New Zealand College of Psychiatrists residing in Australia; 1039 out of 2059 (50%) returned the questionnaire. RESULTS: The large majority of respondents (79%) were proud of being a psychiatrist. Most (88%) reported being satisfied with their work. Reasons for dissatisfaction varied between public and private psychiatrists. Private psychiatrists nominated litigation/indemnity issues as the most frequent (69%) while the most common for public psychiatrists was lack of beds (47%). The main reason for satisfaction was helping patients get better (72%). Sixty-two percent found their work in the previous 12 months to be stressful. Dissatisfied psychiatrists were 11 times as likely to report being stressed as those satisfied. In the previous 12 months, 34% reported having had a threat of legal action, 39% had to answer a formal complaint, 67% had been verbally or physically abused by patients or relatives and 29% had patients who had suicided. Overall, psychiatrists were more pessimistic about the future than optimistic and 15% said they would not do psychiatry again. There were few differences according to state of origin or type of practice. However, females differed from males in several areas. CONCLUSION: Helping patients was reported as the main source of satisfaction for Australian psychiatrists while not being able to provide the best care for patients was described as one of the main reasons for dissatisfaction. Although most Australian psychiatrists are satisfied and proud of their profession, they are stressed and often experience verbal or physical abuse and threats of legal action and complaints. They are apprehensive about the future. The increasing number of females in the profession, their higher levels of stress and dissatisfaction, and other differences from males must be taken into account as the profession reshapes its future. There is a need for regular surveys of this kind.     

Psychiatrists' experience and views regarding St John's Wort and 'alternative' treatments

OBJECTIVE: This study aims to ascertain the experience and views of psychiatrists in relation to St John's Wort and alternative treatments generally. METHOD: A questionnaire was posted to all members of the Royal Australian and New Zealand College of Psychiatrists living in Australia or New Zealand. RESULTS: Of the 1910 mailed questionnaires, 862 (45%) were returned. Eighty per cent of respondents had patients who had used the herb. Side-effects and drug interactions were reported by 28% and 8% respectively of these psychiatrists. Some adverse events were described as serious. Psychiatrist attitudes about St John's Wort and alternative treatments were positive overall and psychiatrists seemed willing to recommend St John's Wort despite limited evidence of its usefulness. CONCLUSIONS: Psychiatrists in Australia and New Zealand regularly manage patients who take St John's Wort and a considerable number actually recommend the treatment. However, they also report side-effects and drug interactions. Psychiatrists should routinely enquire about their patients' use of alternative treatments, be mindful of possible side-effects and in particular be aware of the dangers of combining St John's Wort with other psychotropics.     

Private psychiatry in Switzerland

INTRODUCTION: Two-thirds of Swiss psychiatrists are engaged, either exclusively or partially, in private practice, a proportion that is higher than in other countries. METHOD: A questionnaire survey of 1000 psychiatrists was carried out. RESULTS: Psychiatrists in private practice display a greater degree of clinical activity, mainly with individuals, than do psychiatrists employed by public institutions; and they work principally within two practice profiles, psychoanalytical and generalist, and much less in the biological profile. They show a preference for the psychological model, mostly in a psychoanalytical orientation. Psychiatrists who have a mixed privatepublic practice &#45 more than half of them &#45 are even more psychoanalytically oriented than psychiatrists working exclusively in private practice. They act as an interface between the public and private sectors, playing a pivotal role as guardians of psychoanalysis, proclaiming its principles to psychiatric residents. CONCLUSION: With the transformations taking place in the health care system, new care concepts are being developed, there is a wider variety of theoretical orientations, and the profession is therefore undergoing substantial changes. ( Int J Psych Clin Pract 2000; 4: 227 - 232)     

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.     

Are psychiatrists equipped for management roles in mental health services?

OBJECTIVES: To promote the discussion of leadership and management skills development among psychiatrists in Australia and New Zealand. METHOD: A key informant survey of fellows of the Royal Australian and New Zealand College of Psychiatrists was conducted via a semi-structured interview. This canvassed views about leadership and management issues including levels of confidence and needs for additional skills. RESULTS: There was widespread support for psychiatrists to be in management roles in mental health services; however, on entering management positions, psychiatrists often felt inadequately trained and prepared for their new role. Furthermore, many who had made the transition to management perceived a lack of support from their clinical colleagues. Clinicians appeared to believe that management was not difficult to learn and could be done by any experienced clinician. The provision of short courses and mentoring programmes is the preferred option for most psychiatrists seeking to acquire leadership and management skills. CONCLUSIONS: For psychiatrists to maximize their potential as leaders in Australian and New Zealand mental health services, greater attention to promoting the acquisition of relevant skills throughout training and in the post-fellowship years is required. Psychiatrists need to be supported and encouraged to pursue further education, training and research in this area. Failure to address this issue risks psychiatrists continuing to feel disadvantaged in management roles and hence reluctant to undertake the challenge.     

The Senior Psychiatrist Survey II: experience and psychiatric practice.

OBJECTIVE: The aim of this study is to determine the effects of experience 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: years of psychiatric experience; higher medical qualifications; location and type of psychiatric practice; attitudes about senior psychiatrists and mentorship; changes in work practices over the career; and the perceived benefits and drawbacks of experience on psychiatric practice and case selection. RESULTS: Of 1086 eligible subjects, 629 participated. Over 96% of respondents, particularly the younger and less experienced, believed that senior psychiatrists have wisdom to offer to junior colleagues. This wisdom principally related to mentorship/supervision. Increased 'respect and tolerance' of patients as a benefit of experience was more likely to be reported by respondents who were more experienced. Respondents more confident about treating younger patients and treating functional psychoses were more likely to be less experienced, as were those reluctant to take on psychotherapy cases. Those respondents reluctant to take on 'dangerous or acting-out patients' were more experienced. The field of psychiatric practice significantly influenced case selection. CONCLUSIONS: Senior psychiatrists have accumulated wisdom through experience that is sought by junior colleagues via mentorship. It is recommended that the RANZCP should specifically address the needs of early career and senior psychiatrists.     

Uses of Community Treatment Orders in New Zealand: early findings

OBJECTIVE: To assess the uses of Community Treatment Orders (CommTOs) in New Zealand. METHOD: A retrospective study of patients' records held by the regional administrator of mental health legislation and a survey of psychiatrists attending a conference in Dunedin. RESULTS: Males under Community Treatment Orders (CommTOs) outnumbered females 6:4; a high proportion were considered to have a major psychotic disorder; and one fifth remained under a CommTO for more than a year without inpatient care. Among the psychiatrists, there was a high level of agreement that, when used appropriately, the benefits of CommTOs outweigh their coercive impact on the patients; the most strongly supported indicator for use was the promotion of compliance with medication. The rate of use of CommTOs in Otago is remarkably similar to the rate in Victoria, Australia. CONCLUSIONS: Records suggest that a significant proportion of patients under CommTOs are not soon readmitted; and many clinicians in New Zealand consider CommTOs to be a useful strategy for managing the community care of long-term patients with schizophrenia and major affective disorders.     

Who treats in-patients with a primary psychiatric diagnosis?

Data are presented concerning all patients with a primary psychiatric diagnosis who were admitted to various hospitals in Western Australia during 1976-1978. Data were analysed, first, to ascertain the relative proportion of these patients who were admitted under psychiatrists and non-psychiatrists respectively; second, to compare the diagnoses of patients admitted under psychiatrists with those admitted under non-psychiatrists, and, third, to ascertain if there were any differences in terms of the first two measures between city and country patients. A high proportion of patients were admitted under non-psychiatrists. The majority of patients with a diagnosis of alcoholism, and a high proportion of patients with a diagnosis of neurosis, were admitted under non-psychiatrists. The majority of patients with a diagnosis of functional psychosis were admitted, under psychiatrists, to Mental Health Services hospitals and to psychiatric units at general teaching hospitals. Psychiatrists in private practice admitted mainly patients with a diagnosis of neurosis and personality disorder. The results are discussed in terms of the population distribution, the availability of psychiatric services and other factors which might influence the type of hospital to which patients are admitted and the type of doctor care they receive.     

Patients in the care of private psychiatric practitioners

Summary In Western societies, the number of psychiatric hospital beds has decreased markedly in the past decades. The reduction in hospital beds has resulted in a relatively large number of mentally ill individuals residing in the community. They experience varying degrees of success. One form of treatment available to such patients is private psychiatric consultation. In Denmark and England (two countries with public supported health care systems) the number of psychiatrists in private practice (PPPs) has increased in recent years. These private practioners may offer a mode of treatment which may meet the needs of a subgroup of the psychiatric patients in the community. The fees of the PPPs are paid by the National Health Service. In this study we report on the characteristics of the patients attending the consultation of private psychiatrists and the treatment which they are offered. We compare the patients of the PPPs with 1. psychiatric patients residing in the same disricts who are cared for by the public hospital system and 2. the background populations of these same districts. The results suggest that the patients in private psychiatric practice are distinct in a number of ways. Neurosis is the dominant diagnosis. Of the patients, 71% are women; the patients tend to be younger than the background districts population; after controlling for age, the marital status of the patients in PPPs' care does not differ significantly from that of the background population, and they are comparable to the background population in level of employment. These patients are more able to care for themselves than the psychiatric patients treated in the public hospital system. The results suggest that PPP is a means of caring for a subgroup of the psychiatric patients in urban settings.     

Psychiatry's future: Facing reality

U.S. public and private health care costs, including mental health treatment costs, continue to rise at unacceptably high annual rates of increase. "Basic" health insurance plans presently being developed by both public and private payers, in response to this crisis, will include: (1) severely limited coverage for psychiatric care; and (2) coverage for specific categories of serious mental illness. Psychiatrists must develop cost-effective goals and treatment standards that achieve satisfactory outcomes for these high-priority conditions. Treatment standards must be compatible with economic reality. Psychiatry as a profession (i.e., all psychiatrists) must accept cost-effective treatment responsibility for society's most seriously mentally ill individuals. We need to train psychiatrists who are biologically-, crisis-, and rehabilitation-oriented and who can practice effectively and comfortably within society's treatment expectations and funding constraints.     

New Zealand's psychiatrist workforce: profile, recruitment and retention

OBJECTIVE: New Zealand is suspected of sharing other countries' difficulties of having inadequate numbers of practising psychiatrists and attracting psychiatrists to work outside its main urban centres, but there is no contemporary data on the socio-demographic and professional practice profile of its psychiatrists. This paper highlights some interesting trends about New Zealand's psychiatric workforce. METHOD: A postal questionnaire was sent to all actively practising vocationally registered psychiatrists with a New Zealand mailing address requesting information about basic demographic data, professional training experiences, current professional status, practise intentions, why they chose to work where they do and what factors might influence them to leave for another region of New Zealand or overseas. RESULTS: Of the 277 doctors on the vocational register for psychiatry, 159 responded, giving a response rate of 59.8%. Most psychiatrists were male (n = 102; 64.2%), European (n = 144; 90.6%), aged between 41 and 60 (69.2%), born overseas (n = 90; 56%), had English as their primary language (n = 142; 89.3%) and were in a long-term relationship with dependent children (n = 99; 62.3%). Nearly all (n = 149; 95%) did their psychiatry training in a metropolitan area and most (n = 108; 67.9%) held the Fellowship of the Royal Australian and New Zealand College of Psychiatry (FRANZCP). Most worked in a metropolitan area (n = 136; 85.5%) and either wholly or partly in the public sector (n = 145; 93%). Nearly one-quarter expected to retire over the next decade. Professional factors were rated more important as a reason for staying by metropolitan psychiatrists compared with their non-metropolitan counterparts (p < 0.001). Psychiatrists who did not have an FRANZCP (57%vs. 27%, p = 0.05), those who had spent more than 50% of their professional life in New Zealand (86%vs. 74%, p = 0.02) or those who had obtained their primary medical degree outside New Zealand were more likely to be in non-metropolitan areas (81%vs. 49%, p = 0.04). Metropolitan psychiatrists rated personal and social reasons more highly than non-metropolitan psychiatrists did for factors which might induce them to leave for another area, whereas professional development was ranked lower. CONCLUSIONS: This is the first contemporary study of New Zealand's psychiatric workforce and it highlights some interesting trends and has significant implications for those concerned with the recruitment and retention of psychiatrists. Further investigation is suggested, as a more complete picture of New Zealand's specialist psychiatric workforce would be gained by including psychiatrists who are not vocationally registered.     

A survey of the distribution of psychiatrists in Australia and New Zealand in 1987

A survey is described of the number and distribution of all psychiatrists and trainee psychiatrists in Australia and in New Zealand in 1987, with estimates of available psychiatrists over the next decade. Australia as a whole is not short of psychiatrists or of trainee psychiatrists, but has a marked maldistribution between States and between city and rural areas which needs to be seriously addressed. In 1987 the ratio of psychiatrists to population in Australia was 1:11 290 and in New Zealand 1:21 440. It is estimated that by 1997 the corresponding ratios will be 1:9 130 and 1:12 440. There were 549 trainee psychiatrists in Australia and 103 in New Zealand. Relativity of human resources needs are emphasised. Those Australian States with the highest ratio of psychiatrists to population also have the highest ratio of trainees to population, a fact which has obvious implications.     

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.     

The Senior Psychiatrist Survey III: attitudes towards personal ageing, life experiences and psychiatric practice.

OBJECTIVE: The aim of this study is: to explore whether there is a relationship between the effects of gender, age and perceptions of personal health on psychiatrist's reactions to personal ageing; and to determine the effects of psychiatrist's reactions to personal ageing upon their approach to clinical practice, retirement planning and post-retirement activities. METHOD: A postal survey was conducted. Respondents were Fellows of the Royal Australian and New Zealand College of Psychiatrists resident in Australia or New Zealand. Of 1086 eligible subjects, 529 participated. The main outcome measures were: Reactions to Ageing Questionnaire (RAQ); self-rated health; location and type of psychiatric practice; the perceived benefits and drawbacks of age on psychiatric practice and case selection; and retirement plans. RESULTS: Positive attitudes towards personal ageing were significantly associated with old age, males and good or excellent self-rated health. Negative attitudes were associated with working in universities and anticipated retirement due to poor health. Field of practice, anticipated post-retirement activities and approach to clinical practice were not found to have a significant effect on attitudes towards personal ageing. CONCLUSIONS: The effects of life experiences on psychiatrists' attitudes towards personal ageing are complex. Attitudes towards personal ageing have little impact on psychiatric practice.     

Recruitment and training of psychiatrists in Hong Kong: What puts medical students off psychiatry – An international experience

Abstract

The Hospital Authority employs over 60,000 staff and manages 41 public hospitals and institutions, 47 specialist outpatient clinics and 74 general outpatient clinics throughout Hong Kong. It received HK$41.14 billion (£3.475 billion) of funding from the government in the year 2012 to 2013, which represented 92% of its funding income (). This public healthcare system uses 3% of the Hong Kong gross domestic product (GDP) to provide 88% of inpatient services and 28% outpatient services locally, while the private sector provides only 12% of inpatient services and 72% of outpatient services with 2.3% of GDP. There is a heavy reliance on the public sector to provide healthcare to most of the patients requiring more intensive hospitalization. Hong Kong currently only has about 280 specialists in psychiatry serving a population of over 7 million people, of whom 90 work in the private sector. According to the World Health Organization (WHO) Mental Health Atlas 2011 country profiles (), the number of psychiatrists per 100,000 population is 4.39, compared to 12.76 in Australia, 10.1 in Japan, 5.12 in Korea, and 2.81 in Singapore. There is a shortage of psychiatrists, especially in the public mental health sector, which urgently needs to be tackled. This article looks at the current trend in psychiatry teaching and recruitment from medical school and the training scheme provided by the Hong Kong College of Psychiatrists.     

Country of birth and hospital treatment for psychosis in New South Wales

Background

Migration has been found to be a risk factor for schizophrenia in several high-income countries.

Aim

To examine whether overseas migrants to New South Wales (NSW) have higher rates of admission to psychiatric hospitals for psychotic disorders, including schizophrenia and mania, compared to people born in Australia.

Methods

The country of birth of people admitted to public mental health units for the treatment of psychotic illness and for non-psychotic disorders between 2001 and 2010 was compared to the country of birth for the NSW population in the 2006 census. Meta-analysis was used to estimate the odds of being admitted for any psychotic disorder, for a schizophrenia-related psychosis and for mania compared to non-psychotic disorder, for those born in Australia, New Zealand and for nine global regions.

Results

Those born in Oceania (including Melanesia, Fiji, Samoa, Tonga and other Polynesian islands, but excluding Hawaii and New Zealand) had the highest odds of admission for the treatment of psychosis compared to a non-psychotic disorder and had the highest odds of being admitted with a diagnosis of schizophrenia or mania.

Conclusions

In the years 2001–2010, those born in Oceania were at an increased risk of admission to NSW psychiatric hospitals for the treatment of psychotic illness.     

Barriers and facilitators for psychiatrists in managing mental health patients in Hong Kong—Impact of Chinese culture and health system

Introduction

This study investigated the barriers and facilitators for psychiatrists in managing mental health patients under a Chinese context and a mixed private‐public health system.

Methods

Two focus group interviews were conducted to explore the in‐depth opinions of psychiatrists in Hong Kong. The themes identified from the focus groups were investigated in a questionnaire survey with data from 83 psychiatrists working in public and private sectors.

Results

No insurance coverage of mental health problems, patients' poor compliance of medication, and stigma of seeing psychiatrists were rated as the top barriers in the survey. Some psychiatrists mentioned in focus groups that they might write down the associated physical symptoms of the patients rather than the mental disorder diagnoses on the medical certificate. They observed some patients suspecting that psychiatric drugs were prescribed to control their behavior and make them more muddleheaded. The survey also found that consultation time constraint, long patient waiting list, and difficulty in discharging patients to primary care mostly affected public psychiatrists rather than private ones. However, they perceived similar facilitators, including public campaign to promote positive results of help‐seeking, adequate explanation by other health professionals to the patients before referrals, handling severe cases by casework approach, and having a regular primary care physician.

Discussion

The top barriers are related to insufficient public awareness and negative attitudes towards mental illness and its treatment. Major solutions include promoting positive results of help seeking, enhancing collaboration with primary care physicians, and follow‐up of severe cases by a casework approach.