Challenges in the Provision of Mental Health Services in Underserviced Areas

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Challenges in the Provision of Mental Health
Services in Underserviced Areas

• Dr. Lois Hutchinson

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(No Transcript)
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• 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

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Unscheduled ED Visits by North West LHIN residents for fiscal year 2007 Unscheduled ED Visits by North West LHIN residents for fiscal year 2007 Unscheduled ED Visits by North West LHIN residents for fiscal year 2007 Unscheduled ED Visits by North West LHIN residents for fiscal year 2007 Unscheduled ED Visits by North West LHIN residents for fiscal year 2007 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 For ICD-10-CA Chapter V Diagnoses (F00-F99) Mental Health and Behavioural Disorders For ICD-10-CA Chapter V Diagnoses (F00-F99) Mental Health and Behavioural Disorders For ICD-10-CA Chapter V Diagnoses (F00-F99) Mental Health and Behavioural Disorders For ICD-10-CA Chapter V Diagnoses (F00-F99) Mental Health and Behavioural Disorders For ICD-10-CA Chapter V Diagnoses (F00-F99) Mental Health and Behavioural Disorders
NW LHIN Residents NW LHIN Residents NW LHIN Residents Ontario 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 Ambulatory Care Main Table, intelliHEALTH, June 2009 Ambulatory Care Main Table, intelliHEALTH, June 2009 Ambulatory Care Main Table, intelliHEALTH, June 2009 Ambulatory Care Main Table, intelliHEALTH, June 2009 Ambulatory Care Main Table, intelliHEALTH, June 2009
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Common Mental Disorders

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

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Aboriginal Mental Health

• Higher rates of substance use/dependence as well
  as depression
• Violence and trauma
• Socio-economic factors
• Poverty
• Lack of education
• isolation

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• What is Needed?

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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

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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

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• 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

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• 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

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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

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• 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

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• 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

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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

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SUMMARY

• Adequate Resources
• Need planning data to assist in funding
  applications
• Partnerships
• More Effective and Coordinated Care
• Enhance Opportunities for Prevention
• Effective Interventions
• Education and Training
• Accountability
• Overpractitionered but Undercared For