CHALLENGES IN THE PROVISION OF MENTAL HEALTH SERVICES IN UNDERSERVICED AREAS

Dr. Lois Hutchinson

TWELVE MONTH PREVALENCE OF MENTAL DISORDERS Disorder NCS Data ECA Data

Any affective disorder 11.3 9.5

Major depressive episode 10.3 5.0

Manic episode (bipolar) 1.3 1.2

Dysthymia 2.5 5.4

Any anxiety disorder 17.2 12.6

Panic disorder 2.3 1.3

Agoraphobia without panic 2.8 -

Social phobia 7.9 4.2

Simple phobia 8.8 9.1

Any phobia - 10.9

Generalized anxiety disorder 3.1 -

Obsessive-compulsive disorder - 2.1

Any substance-use disorder 11.3 9.5

Alcohol dependence or abuse 9.7 7.4

Drug dependence or abuse 3.6 3.1

Schizophrenia 0.5 1.0

Any mental disorder 29.5 28.1

(NCS: National Comorbidity Survey; ECA: Epidemiologic Catchment Area Study)

Unscheduled ED Visits by North West LHIN residents for fiscal year 2007

For ICD-10-CA Chapter V Diagnoses (F00-F99): Mental Health and Behavioural Disorders

NW LHIN Residents Ontario

MOST RESPONSIBLE DIAGNOSIS# ED Visits % of ALL ED

Visits% ED Visits for

MRDx of F00-F99% of ALL ED

Visits% ED Visits for MRDx of

F00-F99

(F10-F19) Mental and Behavioural Disorders Due to Psychoactive Substance Use 3220 1.6% 45.0% 0.9% 27.5%

(F40-F48) Neurotic, Stress Related and Somatoform Disorders 2044 1.0% 28.5% 1.1% 33.1%

(F30-F39) Mood(affective) Disorders 1016 0.5% 14.2% 0.7% 21.0%

(F20-F29) Schizophrenia Schizotypal and Delusional Disorders 463 0.2% 6.5% 0.4% 11.1%

(F00-F09) Organic, including Symptomatic, Mental Disorders 140 0.1% 2.0% 0.1% 3.1%

(F60-F69) Disorders of Adult Personality and Behavior 101 0.0% 1.4% 0.1% 1.7%

(F90-F89) Behavioural and Emotional Disorders with onset usually occurring in Childhood and Adolescence 87 0.0% 1.2% 0.0% 0.3%

(F50-F59) Behavioural Syndromes Associated with Physiological Disturbances & Physical Factors 45 0.0% 0.6% 0.0% 0.8%

(F99-F99) Unspecified Mental Disorder 33 0.0% 0.5% 0.0% 0.0%

(F70-F79) Mental Retardation 7 0.0% 0.1% 0.0% 0.2%

(F80-F89) Disorders of Psychological Development 7 0.0% 0.1% 0.0% 1.3%

Ambulatory Care Main Table, intelliHEALTH, June 2009

COMMON MENTAL DISORDERS

♦ Alcohol and Substance Abuse/Dependence♦ Anxiety Disorders♦ Mood Disorders

ABORIGINAL MENTAL HEALTH♦ Higher rates of substance use/dependence as well as

depression♦ Violence and trauma♦ Socio-economic factors

■ Poverty

■ Lack of education

■ isolation

♦ WHAT IS NEEDED?

CURRENT SITUATION

♦ FORMAL MENTAL HEALTH PROVIDERS■ Primary Care Practitioners

■ Community Mental Health Workers

■ Private Practice Counselors

■ Specialists

♦ OTHERS■ Social Service Agency Workers

■ School Counselors

■ Spiritual Advisors – ministers, elders

■ Alternate Medicine Practitioners

■ Self Help Groups / Peer Support

STRENGTHS AND WEAKNESSES OF CURRENT SITUATION♦ PRIMARY CARE PRACTITIONERS

■ Lack of a Primary Care Provider

■ Primary Care Providers feeling ill-equipped to deal with mental health problems, e.g. making diagnoses, instituting appropriate treatment

■ “One Problem Approach” – failure to enquire whether there are mental health issues

■ Locum based care in many communities with no continuity in situations where continuity of care by a single provider enhances care

♦ COMMUNITY MENTAL HEALTH PROVIDERS■ Inadequate training to meet multiple demands and the need

to be “experts” in addictions, mood and anxiety disorders, trauma and psychoses

■ Inconsistent partnerships with primary physicians who could assist in making diagnoses and providing pharmacotherapy

■ Inconsistent use of evidence based guidelines in providing therapy

■ Stigma/fears of lack of confidentiality in smaller communities

♦ SPECIALISTS■ Diversion of specialist resource to primary care psychiatry

(due to lack of family physicians) or to subspecialty services – ACT, rehabilitation, forensics

■ Slow responsiveness of specialist to primary care requests for consultation – infrequent visits to communities or inconsistent provision of telehealth services

POTENTIAL FOR IMPROVEMENTS♦ PRIMARY CARE PROVIDERS

■ Ensure family physicians are trained to assess and manage common psychiatric conditions

■ Identify a specialist/specialist service that can be consulted in difficult cases

■ Promote “shared care model” to work with family physicians that have longevity in the community

■ In communities largely served by locum family physicians, identify a nurse or nurse practitioner that can assist in monitoring patients on an ongoing basis to provide continuity of care

■ Develop partnerships with community mental health programs to assist in making diagnoses so appropriate counseling can take place and optimizing care by providing adjunctive pharmacotherapy

♦ COMMUNITY MENTAL HEALTH PROVIDERS■ Develop partnerships with primary care physicians to aid in

diagnoses and provision of appropriate psychotherapy and counseling

■ Provide therapy that is evidence based. This may require more dollars spent on education and training.

■ In some communities, there may not be sufficient clinicians to meet the multiple demands that are made

♦ SPECIALISTS■ Develop a more coordinated response to consultation

requests from primary care physicians

■ Participate in “shared care” initiatives with primary care physicians where there are family health teams

■ Enhance the skill set of primary care physicians to manage common psychiatric disorders

■ Reduce the number of patients seen for primary care psychiatry by developing relationships with new family health teams

■ Provide education and training to community mental health providers so evidence based care can be delivered

OPPORTUNITIES FOR PREVENTION♦ Family support and parenting intervention decreasing child

abuse and reducing oppositional behavior and conduct problems in high risk populations

♦ Identification of maternal depression either pre or post delivery and effective treatment can mitigate negative effects on children

♦ Teaching of coping skills in stressful life situations – divorce, bereavement, bullying

♦ Early identification of anxiety and depression in children and intervening with cognitive behavior strategies

♦ Early intervention for substance use problems prior to onset of significant abuse or dependence

♦ Closer follow-up of persons making a serious suicide attempt

SUMMARY

1) Adequate Resources Need planning data to assist in funding applications

2) Partnerships More Effective and Coordinated Care Enhance Opportunities for Prevention

3) Effective Interventions Education and Training Accountability

“OVERPRACTITIONERED BUT UNDERCARED FOR”