Primary care, provided that it is accessible and available, improves population health. Primary care includes but is not limited to family physicians. In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder. Of that 35%, 93% were seen by a family physician and had a major diagnoses of an anxiety disorder, mood disorder, substance use disorder, schizophrenia and psychosis or cognitive impairment.
The World Health Organization
has nevertheless drawn attention to this "treatment gap"; the high proportion of people even in developed countries who have a treatable disorder but do not get treatment. The severity of cases and the diagnoses of those seen in primary care differ from those seen in specialist care yet the diagnostic systems
and criteria are more oriented to specialist practice than to primary care. Family physicians in Canada have highlighted problems with the mental health system including lengthy delays for consultations, inaccessibility of psychiatrists and poor communication following referral.The Canadian Psychiatric Association
and the College of Family Physicians of Canada
have worked together to improve care for patients with a mental health disorder and have strongly advocated for shared care or collaborative care where psychiatrists and mental health practitioners work closely with primary care physicians and services. There are several goals associated with this which include facilitating early treatment, achieving better outcomes, reducing stigma and ensuring that patients are receiving the most appropriate service in a timely fashion in a setting that is congenial and avoids stigma. Considerable effort has gone into ensuring that specialists services support primary care and primary care physicians rather than meeting the needs of specialist programs.
"In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder."
Several different models have emerged. One model uses a relocated consultation service. Although it may perhaps be the simplest concept it has not necessarily proved to improve services or outcomes. Another type of service includes placing mental health workers into primary care practices. Reports on this are variable depending on whether the services are designed to collaboratively support primary care or just be embedded in primary care but doing their own thing.
One of the better models seems to be where a psychiatrist and/or other mental health professionals are attached on a full or part-time basis to a primary care practice or practices and provide ongoing formal and informal consultation and support along with other aspects of psychiatric patient care. Integral to any of these services is that the individuals involved need to get to know each other and build trust and confidence. It is clear that when the various components are well coordinated it is reflected in how the patients feel about the service with greater satisfaction.
Research evidence is available but limited. Where a particular disorder, for example depression, is being treated with a standardized protocol and ample supports it is clear that patient outcomes are improved. Often the research project ends and those involved do not continue to follow the same protocol. Where there is close collaboration patient satisfaction studies tend to show positive results which is also often the case when additional service availability (for example counseling or housing services) are built in to primary care setting. Clearly role definitions are important. Specialty mental health services will continue to play a significant role in the management of difficult cases--specifically those where patient needs are very high which are often associated with psychoses and dementias.
For cooperation to succeed there needs to be strong positive attitudes on the part of the practitioners involved and good administrative support including financial support from those bodies responsible for funding health care. The rapid growth of collaborative care arrangements in Canada suggests that there is a strong belief that this approach can help those with mental health problems.
Dr. Bland is Professor Emeritus and former Chair of the Department of Psychiatry at the University of Alberta. His research interests have included epidemiological studies, long term outcomes and mental healthcare utilization including collaborative care. He has served as a CPA member of the CWGSMHC for the last decade.