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The Contribution of Private Psychiatrists to the Delivery of Psychiatric Care

Keith Anderson, M.D.*, A. Catterson M.D., M. Gaudet M.D., M. Gautam M.D., P.J. Kerr M.D., M Pecher M.D., D. Waiser M.D. M Fava M.D.

*Ottawa Civic Hospital, Ottawa, Ontario, Canada

⁺Committee of Private Psychiatrists

Ottawa Academy of Medicine, Section on psychiatry

⁼Harvard Medical School

Introduction
Method
Results
Interpretation
Summary
References

Abstract

Mental Health Reform, as proposed by the Ontario Ministry of Health, suggests the closer integration of hospital and community based psychiatrists, with an increased number of severely ill patients being seen by psychiatrists in private office practice. This presupposes that private psychiatrists are not already seriously involved in dealing with such cases, and will be able to take them on. It is therefore essential for planning purposes to discover what private psychiatrists really do.

A questionnaire was mailed to all 134 psychiatrists in private practice in the Ottawa Carleton Region. The first part asked questions about practice patterns. The second part developed a profile of all the patients seen by all psychiatrists on a single day (Nov.10,1994). Information gathered included DSM IV multiaxial diagnosis, sociodemographic data, suicidal risk, history of physical and sexual abuse, drug abuse, and method of treatment.

Close to 80% of psychiatrists responded. A richly detailed picture of both practice patterns and the profile of the patients treated was produced. Among the findings were that although 300 was the most common diagnosis (36.4%), over 33% had diagnoses of either 295 or 296. Sociodemographic data showed a close correlation to the sociodemographic picture of the region. These results call into question some of the basic assumptions of Mental Health Reform. The results will be presented in detail and their interpretation discussed.

Introduction

The role of psychiatrists in private office practice has been controversial. They are often portrayed as treating mainly the rich worried well; providing a service of marginal importance to the mental health delivery system and representing a drain on "mental Health dollars" more needed by the severely mentally ill. Yet each of us in private practice knows that he or she has many patients who fit the criteria for severe mental illness. A review of the literature show that little is known about the role or contribution of non-hospital based psychiatrists.

Mental Health Reform, as proposed by the Ontario Ministry of Health, suggests, as part of a greater emphasis on community based care, that responsibility for treatment of the severely mentally ill be transferred from hospital based psychiatrists to those in private practice. This suggests that the Ministry’s planning has been influenced by the view outlined above. It is therefore necessary for planning purposes to find out what private psychiatrist really do. This study which was carried out by a group of psychiatrists all engaged wholly or in part in office based practice and all members of the Psychiatric Section of the Academy of Medicine, Ottawa, attempts to provide some answers to this problem.

Methodology

The method we chose to address these issues was to conduct a survey of private psychiatrists working in the Ottawa Carleton Region and all of the patients receiving outpatient psychiatric treatment by them on a particular census day, using the simple epidemiological method developed by Valbak et al. (1992). The Ottawa Carleton Region comprises the City of Ottawa and surrounding region and has a population of approximately 900,000 people. One hundred thirty four psychiatrists were identified as being involved in private practice in this area.

The survey was conducted by means of a questionnaire, which was composed of two distinct parts. The first part, called ‘A Survey of Private Psychiatrists" asked questions concerning practice patterns, work hours, sources of referral, frequency of visits, treatment modalities employed and case dispositions. The second part of the questionnaire called "A Day in the Life" concerned all patients seen by those psychiatrists on Nov. 10,1994. This date was chosen as it was part of a regular week. It was not a religious holiday, and there were no major conferences scheduled. This section asked specific questions about each patient’s DSM IV multiaxial profile, sociodemographic status, risk of suicide, history of suicide attempts, history of physical and/or sexual abuse, and of substance abuse. In addition information was gathered about treatment modalities, frequency of visits, and the length of time the patient had been in treatment. Each doctor was asked to complete one "Day in the Life" form for each patient he or she saw on that day. Information about the proposed survey was circulated through the Psychiatric Section, Academy of Medicine, Ottawa, about a month before the survey. Each psychiatrist was personally contacted by a member of the Committee who was personally acquainted with him or her two weeks before the survey forms were mailed to alert him or her as to what to expect.

In order to ensure familiarity with the multiaxial diagnostic assessment of DSM IV a complimentary copy of the Desk Reference to the Diagnostic Criteria from DSM IV was mailed to each participant. Finally during the week of Nov. 7- 13,1994, each psychiatrist was called a second time by the same person to remind him or her of the survey, and to offer assistance if it was needed. All surveys were returned anonymously and measures were taken to ensure confidentiality of patient data.

Results

Of the 134 psychiatrists, 107 (80%) filled in the questionnaire and returned it. Five respondents filled in the first part only, as they happened not to have seen any patients that day. Three filled in the second part but not the first. Nine respondents did not provide complete responses, so their responses were considered invalid and excluded from the results. Altogether 95 psychiatrists gave complete data on the first part of the questionnaire, and 99 gave complete data on the second. A total of 842 patients were seen by these 99 psychiatrists on Nov. 10,1994, but complete data were available for only 739 patients.

All data were collected as categorical variables. Descriptive statistical analyses (frequency distributions and modes) were obtained for all the variables assessed. A richly detailed picture of both psychiatrists practice patterns and the profile of the patients treated was produced. Time constraints permit only a few highlights here.

Table 1 addresses two questions. Most health planners assume that psychiatrists accept referrals only from family physicians. This survey supports the view that psychiatrists are willing to accept referrals from a broad range of sources. It also shows that in Ottawa Carleton two thirds of psychiatrists see one or more new patients per week.

Table 1. Possible sources and number of referrals
Referral sources
Acute care hospital	67%
Agencies	45%
Community clinics	64%
Family doctor	96%
Professionals	84%
Patients	71%
Self	66%
Schools	23%
Universities	49%

Number of referrals per month
fewer than 1	1%
1 to 2	2%
2 to 3	8%
3 to 4	8%
4 to 5	12%
5 to 6	13%
6 to 7	7%
7 to 8	6%
8 to 9	3%
9 to 10	6%
10 or more	33%
Urgent referrals seen faster?	85%

Table 2 demonstrates that the usual 2:1 Female: Male distribution of patients is reproduced. The survey suggests that children and seniors are under-represented.

Table 2
. Demographic information on 739 patients.
Sex
	male	37.75%
	female	62.25%

Age
	0-19	7.17%
	20-39	38.97%
	40-59	47.23%
	60-79	6.63%

Marital status
	Single	29.09%
	Married	35.59%
	Common law	6.63%
	Separated/divorced	21.11%
	Widowed	2.30%
	Single/gay	3.65%
	Coupled/gay	1.62%

% with dependent children at home		40.19%

Table 3 shows that only 9% of the patients seen on Nov. 10th 1994 had an income of $60,000 or more. It also shows that 22 % of patients seen that day were receiving social assistance. Another 25 % earned less than $30,000.

Table 3
Patients' employment status

Annual income/employment status
	No income	1.89%
	less than $15,000	7.17%
	$16,000-$30,000	18.40%
	$31,000-$60,000	22.19%
	$61,000-$100,000	7.31%
	$100,000+	1.49%
	Dependent child	5.95%
	Disability pension	11.10%
	FBA	2.57%
	Retired	3.79%
	Student	5.82%
	Unemployed on UI	2.17%
	Unpaid homemaker	5.28%
	Welfare	6.36%

Table 4 Shows that the most frequent diagnostic category was 300 (36.4%),. The next most common Axis I diagnosis was 296 (30.04%). While only 3.11% were diagnosed 295, adding 295 & 296 together indicates that 33.15% were suffering from potentially psychotic disorders.

Table 4
Any Axis I disorder		93.37%
Specific Axis I disorders
	Axis I-295	3.11%
	Axis I-296	30.04%
	Axis I-300	36.40%
	Axis I-302	2.03%
	Axis I-307	2.57%
	Axis I-309	10.56%
	Axis I-Other	10.42%

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