Mental Health Services in the Family Physician's Office: A Canadian Experiment
Kates, Nick, Craven, Marilyn, Crustolo, Anne-Marie, Nikoloau, Lambrina, The Israel Journal of Psychiatry and Related Sciences
Abstract: This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.
Family physicians are in an excellent position to provide mental health care for their patients; 80% of Canadians visit their family physician each year, and the family physician is often the first point of contact for an individual with a mental health problem (1).
Approximately a third of all family practice patients have identifiable mental health problems (2-4) and 25% of all patients who visit their family physician will have a diagnosable mental disorder (5-8). These problems are not always detected or treated. Studies suggest family physicians may identify just over 50% of the mental health problems presenting in their office (9-11). Even when a problem is detected, treatment rates are also low. Data from the 1990 U.S. National Ambulatory Care Medical Survey (12) found that 5% of all Family Physician visits involved some form of counseling while 5.9% involved the prescription of psychotropic medication. This rate is low despite the fact that many physical illnesses have an accompanying emotional component and that many appropriate treatments can be implemented effectively in Primary Care (13).
Referral rates to specialized mental health services are also low. Less than 5% of individuals with an identified psychiatric illness are referred to mental health services (1, 14) and less than 1% to a social agency such as a counselling service or child welfare agency (15). Part of the reason for low referral rates is the frustration many family physicians experience when trying to refer someone to a mental health service or psychiatrist (16).
To provide optimal mental health care, the family physician needs to work closely with, and be supported by local mental health services. Too often, however, family physicians and mental health care providers fail to establish the collaborative working relationship that would strengthen the role of the family physician and improve the quality of care their patients receive. This is unfortunate as, in theory, family physicians and psychiatrists are natural partners in the mental health care system, offering complementary services. Neither may be able to meet every need of a patient with a mental disorder, but each may play a key role at certain stages of an episode of illness and the subsequent period of recovery.
Studies of family physicians in different countries have identified common problems in the relationship between psychiatry and primary care (17-19). These include a lack of communication between psychiatrists and family physicians caring for the same individual, difficulty on the part of family physicians in accessing consultation and treatment services for their patients, and a lack of appreciation of the contributions that providers from different disciplines can make in delivering mental health care.
Overcoming these difficulties and establishing new productive partnerships between mental health services and family physicians requires new models of collaboration (19). Such models see family physicians and mental health services as part of an integrated mental health care system. Care is shared by providers whose roles are complementary, with the patient being able to move readily from one provider to another according to need with a minimum of impediment. …