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Guest Editorial
Training Issues in Psychiatry in Canada
Emmanuel Persad, John Leverette
(PDF)

In Review
The Implications of Core Competencies for Psychiatric Education and Practice in the US
Stephen C Scheiber, Thomas AM Kramer, Susan E Adamowski
(PDF)

Mastering CanMEDS Roles in Psychiatric Residency: A Resident’s Perspective
Isolda Tuhan
(PDF)

Residency Training: Challenges and Opportunities in Preparing Trainees for the 21st Century
Lawrence Martin, Karen Saperson, Barbara Maddigan
(PDF)

Original Research
Patient Characteristics Associated With Nonprescription Drug Use in Intentional Overdose Andre Lo, Stephen Shalansky, Marianna Leung, Yitzchak Hollander, Janet Raboud
(PDF)

The Canadian Psychiatric Association Practice Profile Survey: I. Methods and General Sample Characteristics
Elizabeth Lin, D Blake Woodside, Anne Rhodes
(PDF)

The Canadian Psychiatric Association Practice Profile Survey: II. General Description of Results
D Blake Woodside, Elizabeth Lin
(PDF)

Effect of Depression on Stroke Morbidity and Mortality
Rajamannar Ramasubbu, Scott B Patten
(PDF)

Switch to Mania Upon Discontinuation of Antidepressants in Patients With Mood Disorders: A Review of the Literature
Sherese Ali, Roumen Milev
(PDF)

Acute Neuroendocrine Response to Sexual Stimulation in Sexual Offenders
Philip Haake, Manfred Schedlowski, Michael S Exton, Christoph Giepen, Uwe Hartmann, Michael Osterheider, Martin Flesch, Onno E Janssen, Norbert Leygraf, Tillmann HC Krüger
(PDF)

Brief Communication
Weight Gain in First-Episode Psychosis
Jean Addington, Chrystal Mansley, Donald Addington
(PDF)

Influence of Season and Latitude in a Community Sample of Subjects With Bipolar Disorder
Ayal Schaffer, Anthony J Levitt, Michael Boyle
(PDF)

Book Reviews
(PDF)

Overcoming Resistance in Cognitive Therapy.
Reviewed by
Nancy L Kocovski, MA; Zindel V Segal, PhD, C Psych

Media Violence and Its Effect on Aggression: Assessing the Scientific Evidence.
Reviewed by
Jan Volavka, MD, PhD

Letters to the Editor
(PDF)

Biological Factors and Adolescent Alcohol Use

Minor Strokes Related to Paroxetine Discontinuation in an Elderly Subject: Emergent Adverse Events

Quetiapine Reduces Flashbacks in Chronic Posttraumatic Stress Disorder

Behaviour Therapy for Dizziness?

Involuntary Treatment of a Patient with Factitious Disorder: A Paradox?

Original Research

The Canadian Psychiatric Association Practice Profile Survey: II. General Description of Results

D Blake Woodside, MD, FRCPC¹, Elizabeth Lin, PhD²

In the companion report to this paper (1), we described the development, general methodology, and sample characteristics for the Canadian Psychiatric Association (CPA) practice profile survey (PPS). This paper presents an overview of the results pertaining to professional activity and the nature of the patients seen by Canadian psychiatrists.

Despite a rapid and significant change in the nature of psychiatric practice over the last few decades, little attention has been paid to the nature of this practice. Deinstitutionalization, innovations in biological treatments, and an increasing presence by government decision makers have all produced the perception that shifts are occurring in the nature of psychiatric practice.

A Medline search performed from 1986 to 2000 revealed no significant literature on the practice patterns of Canadian psychiatrists. However, some information is available from internal surveys performed by the CPA.

In 1993, the CPA commissioned the Canadian Psychiatric Survey (CPS; 2,3). This survey was methodologically straightforward and attempted to compile basic information about the psychiatrists who provided service to those with mental illness and the nature of the services provided. The survey was circulated to the whole membership (3090 psychiatrists), of whom 62% responded (2,3). At that time, the profession included 27% women, and the average number of hours worked weekly was similar for men and women (52 hours weekly for men and 50 hours weekly for women). About 50% of the profession indicated that their primary location of work was a hospital, and 66% of their time was spent in providing direct patient care services. Indirect care, teaching, and research accounted for 16%, 9%, and 5% of hours worked, respectively.

The only other report of Canadian psychiatric practice is a local survey of office practitioners in Ottawa performed by Anderson and colleagues in 1995 (4). This survey of 107 practitioners provides information with complex generalizability, given that only private office practitioners were surveyed. This report showed that psychiatrists in the sample were seeing a wide variety of patients from mainly lower socioeconomic groups, suffering from many different psychiatric illnesses.

Limited information is available from other jurisdictions. In 1996, the Office of Research of the American Psychiatric Association (APA) undertook a survey of practice patterns (5). The survey methodology included a random sample of 1375 APA members. A wide variety of demographic and work-related variables were assessed. The key findings from this study showed that the profession in the US is gradually including more female practitioners: 25% in 1996, compared with 14% in 1982. The average number of hours worked weekly was 46, of which 27 (59%) were direct patient care hours. Female practitioners reported working about 90% of the hours of male practitioners. Forty percent of practitioners worked in a solo office setting, and mood disorders, anxiety disorders, and schizophrenia were the most common diagnoses seen. A follow-up paper compared the practice patterns of international medical graduates (IMGs) to graduates of US schools, demonstrating that IMGs worked longer hours, saw more patients, and treated larger numbers of patients with psychotic disorders (6).

In summary, very little data are available, either cross-sectional or longitudinal, about the practice patterns of psychiatrists. This lack of data impairs planning for the provision of psychiatric services and for the education of psychiatric practitioners.

Table 1  Global activities during the designated daya
Activity	Mean (SD) n = 1182	Range	% psychiatrists
Personal hours	13.9 (2.6)	0–22	98.0
Working hours	10.0 (2.8)	0–24	97.3
Clinical	8.2 (3.1)	0–24	95.5
Administrative	1.1 (1.8)	0–12	41.9
Teaching	0.4 (1.1)	0–12	19.9
Research	0.4 (1.1)	0–10	14.1
On-call hours	5.1 (8.5)	0–24	33.0
Direct care	0.9 (2.4)	0–14	17.1
Indirect care	0.2 (1.1)	0–24	11.2
aMean hours and range are calculated based on all psychiatrists (including those reporting zero hours for that activity). Percent psychiatrists is the percentage reporting 1 or more hours for that activity.

Method

The methodology employed in this study is described in the companion paper (1). Professional activity results (Tables 1 to 3) are based on all psychiatrists responding for the “designated day” (n = 1182), as defined in the companion paper. Details of the sample’s clinical activities and information on the patient profiles (n = 1141) are based on those responding for both the correct day and hour.

Results

Designated Day
Table 1 presents the global activities as recorded in the 24-hour designated day. The average number of hours worked was 10.0, and most of this time was spent in clinical activities (82%). Teaching, research, and administration made up for the remaining 18% of working hours. While over 40% of psychiatrists reported at least 1 hour of administration work on the designated day, only 1 in 5 reported a teaching hour, and 1 in 7 reported an hour of research. These latter 2 activities made up 8% of the working day.

One-third of psychiatrists who responded to the survey were on call, with about one-half providing either direct or indirect patient care. Within the on-call group (not shown) the mean number of hours on call (15.3 hours) included 3.5 hours of direct or indirect patient care

Table 2  Payment source, location, and clinical activity during the designated day
	Hours (n = 1182)
	Mean (SD)	Range	% of working hours
Payment source
Fee-for-service	5.3 (3.7)	0–15	54.6
Sessional	1.4 (2.6)	0–14	14.7
Salary	0.9 (2.5)	0–18	9.4
Other	0.2 (1.2)	0–12	2.3
Unpaid	1.2 (1.8)	0–15	11.5
Location
Private office	3.3 (4.1)	0–18	33.9
Hospital inpatient	1.5 (2.6)	0–15	15.7
Hospital outpatient	2.5 (3.5)	0–15	25.2
Agency	0.6 (1.8)	0–15	5.9
Other	1.0 (2.2)	0–16	9.8
Clinical activity
Direct patient care	5.8 (3.3)	0–14	59.5
Indirect patient care	0.7 (1.3)	0–10	7.0
Telephone work	0.3 (0.9)	0–12	2.7
Record keeping	0.4 (0.8)	0–8	4.2
Supervision	0.2 (0.6)	0–8	1.6
Other clinical work	0.1 (0.9)	0–15	7.0

Table 2 displays information related to clinical activities that were performed on the designated day. The payment, location, and type of clinical activity are recorded. The dominant method of remuneration is fee-for-service, accounting for 55% of hours worked. Sessional funding and other types of salary accounted for 24% of hours worked. Of the hours worked, 11.5% were unpaid.

The hospital is the most common location of practice, with 41% of clinical hours occurring in a hospital inpatient or outpatient setting. Just over one-third (33.9%) of hours worked were in private offices. Only 1 hour in 20 (5.9%) was provided in an agency setting. The type of work is generally direct patient care (59.5%), with various types of indirect services totalling 15.3% of hours worked.

Table 3 Total numbers of patients seen during the designated day
Total number of patients seen	Number (%) of psychiatristsa
0–4	217 (20.5)
5–8	309 (29.2)
9–12	322 (30.5)
13–16	119 (11.3)
> 16	90 ( 8.5)
aSum is less than 1182 because of missing data

Psychiatrists participating in the survey saw varying numbers of patients in the designated day, the most common numbers being 5 to 8 daily and 9 to 12 daily, accounting for 60% of psychiatrists (Table 3). Fewer psychiatrists saw 4 patients or less (20.5%) or larger numbers (19.8%).

Random-Hour Results
Table 4 presents data on the activities of the 80% of psychiatrists who performed clinical work during the random hour. These data do not include results from psychiatrists who were performing other tasks, such as teaching or research. Because the questionnaire was set up for respondents to indicate a range of minutes (for example, 1 to 10 or 11 to 20), the total number of minutes in this table does not equal 60. Numbers of minutes in subcategories (for example, family therapy) are the average number of minutes for that activity if it occurred.

The average number of minutes spent in clinical activities during the hour was 49. Of this, 40% was direct care, 11% was telephone work, 22% was indirect care, 10% was record keeping, and 17% was supervision. Most services were comparatively brief, with only individual and family therapy lasting over 30 minutes on average.

Table 4  Number of minutes spent on specific clinical activities during the random hour of the designated day
Activity	Mean (SD)a (n = 946)	% of psychiatrists
Total clinical time	49.1 (11.8)	80.0
Direct care	36.2 (14.3)	65.4
Individual psychotherapy	34.3 (14.3)	44.2
Family therapy	32.3 (15.7)	5.6
Group therapy	23.5 (10.7)	1.1
Medication or prescription	7.6 (7.1)	20.9
General assessment	24.9 (16.1)	18.6
Crisis intervention	18.0 (14.4)	3.5
Telephone work	10.0 (8.7)	23.5
With patient	7.4 (6.1)	12.4
With family	6.4 (4.2)	6.4
With health professional	7.3 (6.9)	12.0
With other professional	6.0 (4.0)	2.6
Indirect care	20.3 (19.1)	18.3
Rounds or case conference	23.4 (18.9)	8.1
Consulting with other health care professionals	12.5 (14.5)	8.9
Record keeping	9.2 (10.4)	43.5
Supervision	15.3 (15.1)	5.4
aMeans and standard deviations calculated based on psychiatrists spending at least 1 minute on that activity.

Patient Characteristics
Table 5 displays information on the characteristics of the patients, comparing random-hour to most seriously ill patients. The average patient age is about 40 years in both groups. Most patients are female, nearly 55% to 60% in both groups. Substantial numbers in both groups have never been married, with about one-half of those who are or have been married suffering disruptions in their marital status (for example, divorces or separations).

One-fifth of patients seen are new patients, many (43.7%) of whom are referred by their family physician. Other physicians are the referral source in about one-quarter (27.8%) of cases. Most of the patients seen will receive ongoing care from the psychiatrist (74%), with about 1 in 7 referred to hospital and the remainder to other forms of care.

Table 5  Demographic profile, referral source, and disposition of patients seen during the designated day
Demographic variable	Random-hour patienta (n = 812)	Most seriously ill patientb (n = 1078)
Mean age (SD) in years	40.1 (17.3)	39.6 (17.5)
Male (%)	42.1	44.3
Marital status (%)
Never married	42.1	48.6
Married	31.9	24.9
Disrupted marital status	25.1	25.2
New patients (%)	20.9	22.1
Referral source (%)
Self	6.7	5.8
Family or friends	6.2	6.5
General practitioner or family doctor	43.7	41.0
Other MD	27.8	32.5
Other professional	12.6	9.3
Disposition (%)
Hospitalized	14.3	24.5
Ongoing care	74.0	64.8
Discharged	1.9	0.7
Referred	4.6	4.0
Other	3.5	3.0
aBased on 1141 psychiatrists completing questionnaire for correct day and hour. Percentages may total less than 100% because of missing values. bBased on 1182 psychiatrists completing questionnaire for correct day. Percentages may total less than 100% because of missing values.

Table 6 shows some data related to disability and dangerousness. One-eighth of the random-hour and one-fifth of the most seriously ill patients were reported to have had a suicide attempt in the last 6 months, and similar proportions reported nonlethal self-harm. One-tenth of the random-hour and one-seventh of the most seriously ill patients were reported to have been a danger to others in the previous 6 months. One-third of the most seriously ill group was thought to be a serious suicide or self-harm risk at the time of the survey, and one-fifth was regarded as a serious risk to others.

Rates of disability (for example, work or school) were significant for the most seriously ill group, with over one-half of this group being reported as having either quite a bit of difficulty or being unable to function in the domains of work, family, leisure, and relationships. For the random-hour patient, one-third to two-thirds of patients reported the same level of disability in these domains of function. While smaller percentages of subjects reported difficulties at school, this likely represents the overall ages of the participants.

Table 6  Disability and dangerousness to self and others of patients seen during the designated day
Characteristic	Random-hour patient (%) (n = 812)	Most seriously ill patient (%) (n = 1078)
Past-week disabilitya
Work	36.5	50.7
School	15.6	25.1
Household or family	44.7	69.2
Leisure	46.4	70.2
Relationships	61.7	81.3
Dangerous behaviour (past 6 months)
Suicide attempt	12.6	21.1
Physical self-harm	13.9	27.2
Physical harm of others	9.2	14.8
Current serious riskb
Suicide attempt	15.3	31.5
Physical self-harm	17.6	34.3
Physical harm of others	10.2	19.7
aDefined as “quite a bit of difficulty” or “unable to function” in domain within the past week. bDefined as “moderate” or “high” present risk.

Table 7 shows the most common primary Axes I, II , and III diagnoses in the random-hour and most seriously ill group. Serious psychotic and bipolar illness accounted for 26% of the random-hour and 39% of the most seriously ill groups. Depression was reported to be present in 21% of both groups. Anxiety and adjustment disorders were reported as the primary diagnosis in 17% of the random-hour group and 12% of the most seriously ill group. Alcohol and drug use problems were reported as primary for only a small number of those seen on the study day.

Table 7  Pimary diagnoses of patients seen during the designated day
Diagnosis	Random-hour patient (%)a (n = 812)	Most seriously ill patient (%)a (n = 1078)
Primary Axis I
Depression	21.9	21.5
Schizophrenia and psychotic disorders	13.7	25.0
Bipolar disorder	12.1	13.9
Dysthymia	8.6	3.4
Anxiety	13.1	9.2
Adjustment disorder	4.3	2.7
Attention deficit and    disruptive disorders	3.7	2.1
Alcohol or drug	3.0	2.2
Medical psychiatry	2.7	2.8
Eating disorders	1.9	1.6
Dementia, delirium	1.7	2.3
V-code conditions	2.2	0.9
Other DSM-IV disorders	7.0	8.1
Primary Axis II
Schizoid	0.3	1.5
Schizotypal	0.7	1.3
Avoidant	2.5	2.4
Paranoid	2.1	2.8
Dependent	4.8	3.6
Obsessive–compulsive	4.1	2.2
Histrionic	1.6	1.6
Narcissistic	3.6	2.8
Borderline	7.8	11.9
Antisocial	0.6	1.8
Mental retardation	1.2	2.2
Not otherwise specified	5.2	4.7
Primary Axis III
Cancer	0.9	0.7
Cardiovascular	3.3	3.0
Dermatologic	0.3	0.1
Endocrinologic	2.6	1.9
Gastrointestinal	1.6	2.2
Genitourinary	0	0.1
Hematologic	0.3	0.1
Infectious	0.6	0.7
Musculoskeletal	3.0	3.0
Neurological	4.3	4.0
Renal	0.3	0.3
Respiratory	0.5	1.5
Other Axis III	—	0.4
aPercentages do not total 100 because of missing values

Table 8  Comorbidity of patients seen during the designated day
Comorbidity	Random- hour patient (%)a	Most seriously ill patient (%)a
Psychiatric comorbidity
2 or more Axis I diagnoses	37.7	37.2
Axis I plus any Axis II diagnoses	33.0	36.6
Psychiatric and medical comorbidity
Axis I plus single Axis III diagnosis	14.2	13.5
Axis I plus 2 or more Axis III diagnoses	4.3	5.3
aPercentages may not total 100 because of missing values.

One-third of both groups were reported to have an Axis II diagnosis, with borderline personality the most common diagnosis in both the random-hour and most seriously ill groups. Table 8 presents data on comorbidity, showing that 37% of each group (random-hour and most seriously ill) have at least 1 comorbid Axis I diagnosis, and 33% have a comorbid Axis II diagnosis.

Comorbid Axis III diagnoses occurred in 14.2% of the random-hour and 13.5% of the most seriously ill group; less than 6% of each group had multiple Axis II comorbidity. The most common comorbid Axis III diagnoses were neuro- logical, cardiac, musculoskeletal, and endocrine.

Discussion

This paper represents the first attempt to review the activities of Canadian psychiatrists in a comprehensive fashion. The strengths and weaknesses of this study have been discussed in the companion paper (1). Briefly, the strengths of this study relate to the careful design and field testing of the questionnaire and having access to the entire population of psychiatrists practicing in the country. The main weaknesses of the study relate to the response rate of 45%, which may make it difficult to generalize the results.

Results focusing on a 24-hour period suggest that psychiatrists are working just over 10 hours daily on average and performing significant hours carrying a pager on call (an additional 5 hours daily on average) of which 1 hour involves patient care. This amounts to an average workday of 15 hours. Most of the time spent by psychiatrists is clinical, with administration being the second greatest investment of time. Of the clinical activity, 70% is direct patient care, with the remainder being various types of indirect patient care, such as record keeping and telephone work. Psychiatry appears to be low-volume work, with most practitioners seeing relatively small numbers of patients daily, the range being 5 to 12. It would be interesting to examine the practice patterns of the 20% who see larger numbers of patients daily in more detail to understand the nature of their practice more fully.

The fee-for-service paid hours seem to correspond closely to the direct patient care hours (59% of clinical time, 55% of hours paid). It would seem that some remuneration is being paid for indirect care—while 30% of the clinical hours are indirect, only 11% of the clinical hours are unpaid. A more detailed examination of the nature of these unpaid hours might help to understand what activities are occurring during this time.

Whether the 8% of time spent on teaching or research is too much, too little, or just right is a difficult question to answer: in this regard a future comparison of teaching to nonteaching hospital practitioners would be helpful. This matter requires further study.

A related issue is the relatively small number of hours provided in agencies—about 6% in this survey. It is not possible to say from this survey what factors might affect a choice to work in a community agency. Widespread implementation of assertive community treatment teams since the survey was performed might alter these results in a repeat survey.

Results from the random hour have similarities to and differences from the pattern of the full 24-hour day. The percentage of minutes attributed to direct patient care in the random hour is 40%, compared with 70% for the full day. The difference is attributable to more indirect care, record-keeping, and consultative activities being identified in the random hour.

The profiles of the patients seen in the random hour and the most seriously ill patients seen on the study day provide a clear picture of the nature of psychiatric practice. The modal patient is female, middle-aged, not presently married, and severely disabled in virtually all aspects of functioning. She is suffering from a serious psychotic disorder or a depression. A significant minority of these modal patients have harmed themselves recently or have a comorbid diagnosis of a personality disorder or other Axis I disorder. It is interesting to note that most psychiatrists practise at least part-time in a hospital setting.

It is puzzling that so few patients are identified as having a primary diagnosis of a substance use disorder. This may reflect a bias on the part of psychiatrists to diagnose these conditions as secondary or to underdiagnose them all together. A closer examination of the data on comorbidity may shed some light on this issue.

These data provide an intriguing glance into the practice patterns of Canadian psychiatrists. Repeated focused surveying would be useful in identifying trends in the data and in providing answers to some of the questions raised above.

Funding and Support

The CPA practice profile survey was funded by a grant from the Canadian Psychiatric Association. All opinions expressed herein are those of the authors and may or may not coincide with those of the granting agency.

References

1. Lin E, Woodside DB, Rhodes A. The Canadian Psychiatric Association practice profile survey: I. Methods and general sample characteristics. Can J Psychiatry 2003;48(4):237–43.

2. Bebchuk W. 1993 Human resource survey. Internal document. Ottawa (ON); Canadian Psychiatric Association; 1994.

3. Angus Reid Group. 1993 Human resource survey: detailed tables. Internal document. Ottawa (ON); Canadian Psychiatric Association; 1993.

4. Anderson K, Catterson A, Gaudet M, Gautam M, Kerr PJ, Pecher M, Waiser D. The contribution of private psychiatrists to the delivery of psychiatric care. Internal report. Ottawa (ON); Canadian Psychiatric Association; 1993.

5. Zarin DA, Pincus HA, Peterson BD, West JC, Suarez AP, Marcus SC, McIntyre JS. Characterizing psychiatry with findings from the 1996 national survey of psychiatric practice. Am J Psychiatry 1998;155:397–404.

6. Blanco C, Carvalho C, Olfson M, Finnerty M, Pincus HA. Practice patterns of international and US medical graduate psychiatrists. Am J Psychiatry 1999;156:445–50

Author(s)

Manuscript received June 2002, revised, and accepted September 2002.

1Director, Inpatient Eating Disorders Program, Toronto General Hospital, and Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.

2Research Scientist, Health Systems Research and Consulting Unit, Clarke Site, Centre for Addiction and Mental Health; Assistant Professor, Department of Psychiatry, University of Toronto; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario.

Address for correspondence: Dr DB Woodside, 8EN-219, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON M5G 2C4

e-mail: b.woodside@utoronto.ca

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