General Psychiatry
General Psychiatric Services
Little has been written about the distinction between general and
subspecialty psychiatric services. Rich and Associates reported
a review of 100 patients assigned to a general psychiatric outpatient
clinic after they were unable to be assigned to distinct subspecialty
clinics, based on diagnosis, therapeutic approaches, or certain
patient characteristics (11). Patients assigned to the general psychiatry
clinic were found to belong to 1 or more of the following categories:
unclear diagnoses, more than 1 diagnosis, complicating medical illness,
extensive evaluation requirement, and illnesses for which no subspecialty
clinics were set up (that is, somatoform disorders, personality
disorders, and anxiety disorders). Yager and Langsley discussed
the evolution of subspecialization in psychiatry and suggested that
emerging subspecialties were being defined naturalistically by psychiatrists’
affiliations, converging around specific issues such as child psychiatry,
geriatric psychiatry, forensic psychiatry, consultation–liaison
psychiatry, clinical psychopharmacology, administrative psychiatry,
substance abuse, psychoanalysis, and family, group, or individual
psychotherapy (12). Rather than defining general psychiatry’s
role as assessing and treating patients who do not “fit”
with subspecialty psychiatry services, recent papers suggest that
general psychiatry is a distinct entity, and the general psychiatrist
has a specific role, skills, and values (6,7).
Although psychiatrists’ interests may drive the evolution
of some psychiatric subspecialties, mental health reform may help
define and promote general psychiatry according to the “level-of-need”
model of patient care. We believe that general psychiatric services
logically correspond to first-line and intensive services found
in the community and general hospitals. These are the psychiatric
services that are not targeted toward patients with specific psychiatric
diagnoses but rather toward the broad range of acute psychiatric
problems of moderate or serious nature. Moderate mental illness
includes such problems as anxiety disorders, mood disorders, or
personality disorders that are severe enough to impair functional
ability—with respect to maintaining relationships or continuing
to work—and severe enough to require treatment (13). Serious
mental illness has been characterized as causing significant disability
in capacity to function in major life activities and as persisting
over time or causing high service utilization. It includes such
diagnoses as schizophrenia, mood disorders, organic brain disorders,
and other psychotic illnesses (14).
Table 1 compares general psychiatric
services with tertiary psychiatric services. General psychiatric
services focus on patients with a broad range of ages and psychiatric
diagnoses and usually provide short-term care for patients with
acute psychiatric illnesses. Central to the distinction between
general and tertiary psychiatric services is the point of access.
Access to general psychiatric services occurs via family physicians,
community health agencies, the emergency room, and community-based
mental health services, specifically, crisis intervention outreach
services. Patients are usually referred to tertiary psychiatric
services by general psychiatrists and most often have complex, recurrent,
or treatment-resistant psychiatric illnesses. Specific populations
(that is children, the elderly, or forensic patients) are often
referred directly to specialty services, if available; however,
general psychiatrists often provide front-line services for these
patients, particularly in rural areas. For this reason, the required
expertise is essential.
Because general psychiatry encompasses community-based, first-line
mental health services, psychiatric emergency services, and general
hospital psychiatric services, coordination among these services
becomes especially important to achieve quality patient care. Integral
to general psychiatry will be service coordination that allows tracking
of patients throughout the system and service agreements that facilitate
timely referral from first-line services, such as community-based
crisis intervention services, to intensive-level services that are
based in general hospitals (15). Another critical link will be coordinating
general psychiatric services with mental health services provided
by family physicians. In a recent position paper, both the CPA and
the College of Family Physicians of Canada endorsed formalized shared
care between family physicians and psychiatrists as desirable. In
most areas, however, funding is not in place to allow for establishment
of these services (16,17).
Relation with Tertiary Psychiatric
Services
Wasylenki and others defined tertiary psychiatric care as “specialized
interventions delivered by highly trained staff to individuals with
problems that are complex and refractory to primary and secondary
care” (18). Tertiary care requires referral from secondary
care and involves a greater degree of staff expertise, greater program
and staff resources, and with more extensive and specialized assessment
and treatment. Wasylenki points out that long-term care is not synonymous
with tertiary care and that tertiary care is not necessarily provided
in a particular setting (that is, a hospital) (18). Patient characteristics
that may indicate a need for tertiary care include aggressive behaviour,
noncompliance with medication, danger to self or others, inappropriate
sexual behaviour, cognitive impairment resulting in poor orientation
or wandering and becoming lost, and coexisting medical problems
that interact with serious psychiatric illness. The following diagnostic
groups have been identified as ones in which tertiary psychiatric
services may benefit and may require residential care: elderly patients
suffering from dementia; patients with psychosis or medical illness;
developmentally handicapped patients with psychiatric disorders;
brain-damaged patients with loss of impulse control; patients with
schizophrenia who are chronically psychotic, assaultive or suicidal;
and patients with schizophrenia who are severely regressed (19,20).
Programs providing tertiary psychiatric care and demonstrating best
practices should be based on principles of psychosocial rehabilitation,
offer sophisticated medication management, and provide behavioural
approaches to care (18). Examples of such programs include ACT teams,
outreach teams, residential care, and specialized inpatient psychiatric
units.
General Psychiatrist Education
Discussing Canadian psychiatry in the new millennium, Garfinkel
and Dorion suggest that the academic system has a social responsibility
to educate and train the necessary types of physicians. Further,
the system should specify that future psychiatrists must commit
to providing care for patients with serious mental illnesses, to
working in mental hospitals and general hospitals, to providing
care in smaller communities, and to working within community care
organizations (21). Several factors have prompted renewed interest
in developing strong programs to train general psychiatrists; specifically,
the need for particular types of psychiatric services, the trend
to increase subspecialization in psychiatry, and the concern that
many recent graduates end up practising office-based psychiatry
in urban centres, which focus on the psychotherapeutic treatment
of patients with personality disorders (6). Psychiatrists willing
to work full-time on general psychiatry inpatient units are increasingly
difficult to recruit and, in academic settings, they may have particular
difficulties developing satisfying academic careers (3,22).
Outside Canada, psychiatrists have also called for changes in psychiatric
education to meet the demands of a reformed mental health system.
Borus described changes in mental health service delivery in the
US as changes that are driven by economic forces and suggested that
psychiatric training must respond to these forces by preparing residents
for these realities in several ways (10). He suggested training
residents to work in emergency and crisis intervention units, in
partial hospitalization programs, in community-based residences,
in managed care settings, and in primary care medical settings.
Similarly, he suggested that residents train to act as consultants
to general physicians and be highly conversant with general medicine.
Beigel and Santiago have described fundamental values and key characteristics
of future general psychiatrists, which they believe must influence
and shape training programs (7). These include working in a multidisciplinary
team, having unique expertise in the management of patients with
severe mental illness associated with physical symptoms or disease,
using psychotherapy as part of a total treatment plan and, in some
cases, delegating psychotherapy provision to nonmedical mental health
professionals. In addition, values include integrating the patient
as an active participant in the treatment process and appreciating
financial aspects of patient care program delivery (7).
Goldbloom described the development of a general psychiatry training
program in the early 1990s at the University of Toronto—a program
designed to enhance the core year of training in general hospital
psychiatry; to create “career-track” positions in general
psychiatry for senior residents; to establish postresidency fellowship
positions in general psychiatry; to provide community-based inpatient
and outpatient experiences during residency training outside the
major teaching hospitals; and to create a niche for academic general
psychiatrists as valued clinicians, teachers, and researchers (6).
Compared with psychiatrists graduating from 1980 to 1989 at the
University of Toronto before the program in general psychiatry was
in place, graduates from 1990 to 1995 spent less time in private
practice and more time working in general hospitals and as consultants
to family physicians. Services given to inpatient units and psychiatric
hospitals, however, did not change (8). Enhancing the training of
general psychiatrists therefore will likely influence practice patterns
and help promote mental health reform. Kates described a Canadian
curriculum for training psychiatry residents in shared mental health
care with family physicians (23). General psychiatrists also require
skills in short-term psychotherapy, because these evidence-based
psychotherapies are effective with a wide variety of psychiatric
illnesses that general psychiatrists manage and thus are clearly
best practices (24).
An Integrated Mental Health System
An IMHS would have defined access points, coordination of services,
efficiency, and lack of duplication of services; it would also be
accountable to government and the public for evidence-based treatment,
quality of care, and cost-effectiveness. As a result, an IMHS would
ensure a continuum of care, ranging from mental health care provided
in the community to psychiatric services provided by general hospitals
to specialized psychiatric services provided in the community and
by tertiary care psychiatric hospitals. Academic institutions must
promote the training of general psychiatrists, but mental health
reform must develop an IMHS to provide a framework for general psychiatry
to flourish. An IMHS coordinates services among family physicians,
community health centres, community psychiatrists, community mental
health agencies, general hospital psychiatric services, and tertiary
psychiatric services. Multidisciplinary mental health teams at various
levels of the IMHS, including psychiatric nurses, psychologists,
social workers, occupational therapists, addiction counsellors,
and case managers, are required.
Although psychiatrists working in community practices have sometimes
been characterized as treating the “worried well,” few
data exist on the psychiatric illness severity of patients attending
community psychiatrists. Anderson and others reported a survey of
107 community psychiatrists who completed a questionnaire about
their practice patterns and the sociodemographic and clinical characteristics
of their patients seen on a specific date (25). Their data have
the limitations of self-report and selection bias but suggest that
many community psychiatrists serve patients with major psychiatric
disorders and do not favour wealthier patients. Most patients were
seen weekly (or more often) and had been in treatment with the same
physician for 1 or more years, which suggests that community psychiatrists
often provide long-term and relatively intensive outpatient treatment.
Nevertheless, owing to the lack of formalized linkage to the larger
mental health system, most community psychiatrists are not accountable
in terms of readily accepting new patient referrals, regardless
of illness severity or diagnosis, and not accountable for coordinating
their service with other parts of the medical and mental health
system.
Integrating general psychiatrists in community practice into an
IMHS could include affiliation with, and provision of, acute care
services to groups of family physicians, community health agencies,
and general hospitals. Even so, psychiatrists already working in
community practice and billing the government insurance plan on
a fee-for-service basis may have little incentive to work within
an IMHS, particularly because this could involve some loss of control
over their pattern of psychiatric practice. Consequently, payment
structures to facilitate shared care programs with family physicians
or with community health agencies and fee-for-service incentives
to provide first-line or intensive-level psychiatric services for
patients with acute psychiatric illnesses may help with integration
(17). Government sponsorship of reentry positions for physicians
previously trained in other specialties but wanting to train in
general psychiatry and willing to work within an IMHS would provide
another mechanism to ensure integration of psychiatrists. Likewise,
licensing of well-trained foreign graduates obligated to work as
general psychiatrists within an IMHS would help.
Access to mental health care and patient referral among various
mental health agencies, patient services, and hospitals are often
poorly coordinated and difficult. Patients of family physicians,
community mental health agencies, or community psychiatrists may
have difficulty accessing more intensive level services, particularly
those based in general hospitals and specialty psychiatric hospitals.
At an administrative level, service agreements should be put in
place among community psychiatrists, mental health agencies, general
hospitals, specialized psychiatric hospitals, and tertiary community
mental health services; these should specify access points and ensure
continuity of care for patients according to their levels of need.
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