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Shared Mental HealthCare in Canada
Current status, commentary andrecommendationsA Report of The Collaborative Working Group onShared Mental Health Care
December 2000
Members of the Collaborative Working Group on Shared Mental Health Care (1998–2000)
College of Family Physicians of Canada Canadian Psychiatric Association
Co-Chair Co-ChairDr. Marilyn Craven, Hamilton, ON Dr. Nick Kates, Hamilton, ON
Members MembersDr. Sophie Galarneau, Montreal, QC Dr. Jean-Marie Albert, Montreal, QCDr. David Ross, Moncton, NB Dr. Roger Bland, Edmonton, ABDr. Kathy Kisil, Winnipeg, MN Dr. Joseph Burley, Halifax, NSDr. André Piver, Nelson, BC Dr. Mark Tapper, Comox, BC
Staff StaffDr. Richard Handfield-Jones, Mississauga, ON Ms. Francine Knoops, Ottawa, ONMs. Catherine Hunt, Mississauga, ON
____________________________
©Copyright 2000, Canadian Psychiatric Association and the College of Family Physicians of Canada.
ISBN 0-9699992-5-9
Executive Summary
In 1996, the College of Family Physicians of Canada (CFPC) and the Canadian Psychiatric Association (CPA)identified a need for increased collaboration between family physicians and psychiatrists. In order to address thisissue, the CFPC and the CPA struck a task force whose mandate was to examine problems in the relationshipbetween psychiatry and family medicine, and identify ways in which the relationship could be improved. In 1997,the task force produced a position paper which identified shared mental health care as a solution which wouldsupport both family physicians and psychiatrists, and would be likely to lead to better outcomes for patients. Thisposition paper, Shared Mental Health Care in Canada was endorsed by the boards of the CFPC and the CPA and wasjointly published in October 1997.
Shared mental health care is based on the following principles:
• Family physicians and psychiatrists are part of a single mental health care delivery system.
• The family physician has an enduring relationship with a patient that the psychiatrist should aim to support andstrengthen.
• No single provider can be expected to have the time and skills to provide all the necessary care a patient mayrequire.
• Professional relationships must be based upon mutual respect and trust.
• Roles and activities of family physicians and psychiatrists should be defined, coordinated, complementary andresponsive to the changing needs of patients, their families and other caregivers, as well as to resourceavailability.
• The patient must be an active participant in this process, understanding that both the family physician andpsychiatrist will remain involved in his or her care, and knowing who to contact when a particular problemarises.
• Shared care should be sensitive to the community context in which such care takes place.
To further this work and to facilitate the implementation of recommendations made in the joint position paper,the CFPC and the CPA established the Collaborative Working Group on Shared Mental Health Care in 1998. The ultimate purpose of the Working Group was to enhance the quality of care for Canadians with mental healthproblems through better collaboration between family physicians and psychiatrists.
The Working Group started its work by reviewing the current status of collaboration between family physiciansand psychiatrists across Canada. An extensive survey of clinicians, educators, researchers, heads of academicdepartments, and health system planners and policy makers identified more than 350 individuals interested orinvolved in shared mental health care. The list now forms the basis of a national network of colleagues who areable to share their experiences with shared mental health care strategies, and who will constitute an importantresource for others who wish to explore collaborative care.
A second survey of residency program directors in both family medicine and psychiatry provided the WorkingGroup with important information about the status of shared mental health care as a curriculum component,about obstacles to the teaching of shared mental health care principles and practices, and about resources whichare needed to support shared mental health care as a curriculum component. Work on these resources and ontraining objectives has already begun.
A review of continuing medical education programs across Canada (CME) was conducted to determine how wellthese programs meet the needs of family physicians for up to date psychiatric knowledge and whether they provide family physicians with the skills necessary to work collaboratively with psychiatrists. A number of deficits were
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identified. These will be shared with CME planners, and the Working Group will develop resources to help CMEprogram planners incorporate topics relevant to shared mental health care.
The Working Group reviewed provincial fee structures for family physicians. Non-supportive features of each ofthese often weighed on the side of discouraging family physicians from providing effective mental health care. Appropriately structured remuneration systems must be in place if shared mental health care is to be implementedsuccessfully. Psychiatrist remuneration issues will be reviewed in the next phase of the Working Group’s mandate.
As health care reform is likely to have a significant impact on how family physicians and psychiatrists practice andon opportunities for collaboration, the Working Group conducted a review of selected federal and provincialplanning documents related to primary care reform and mental health care reform. The findings of this review willbe circulated widely to planners and policy makers. The Working Group will actively pursue opportunities toencourage and support greater integration in planning, and greater support for collaborative care in policydevelopment.
Finally, the Working Group searched the literature and has created a bibliography of 165 references which dealwith the interface between psychiatry and family medicine. These references are appended to the report and willform the basis for the annotated bibliography. It is intended that the annotated bibliography will support thedevelopment of a national research agenda.
Building on this foundation, the Working Group is now in a position to propose an agenda for completion of itsmandate. This will involve:
• Development of more extensive processes to disseminate the findings of the group’s reviews and analyses.
• Expansion of the network of individuals interested/involved in shared mental health care and creation of adetailed registry of projects and activities across Canada.
• Development of local and provincial infrastructures to enhance and extend the work of the Working Group.
• Development of resources and ‘tool kits’ for residency program directors and CME program planners.
• Development of an annotated bibliography and critical overview of the literature on shared mental health care.
• Development of a process to create a national research agenda.
• Strengthening of liaisons with Ministries and other funding sources to advocate for policy and funding changeswhich will support shared mental health care.
• Development of a process to work with those who are responsible for providing mental health care to ruraland other underserved populations, to identify ways in which shared mental health care could help to meettheir needs.
• Strengthening of links with other professional provider groups who have an interest in collaborative mentalhealth care.
The Working Group has set an ambitious agenda, but with the continued support of the boards and staff of theCFPC and the CPA, it looks forward to the achievement of these goals.
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Table of Contents
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Background · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · 2
Health care policy and planning · · · · · · · · · · · · · · · · · · · · · 5
The current status of shared mental health care in Canada · · · · · · · 8
Residency training · · · · · · · · · · · · · · · · · · · · · · · · · · · · 10
Continuing medical education · · · · · · · · · · · · · · · · · · · · · 12
Opportunities and barriers · · · · · · · · · · · · · · · · · · · · · · · 14
Underserved populations · · · · · · · · · · · · · · · · · · · · · · · · 17
Research and evaluation· · · · · · · · · · · · · · · · · · · · · · · · · 18
Advocating for shared mental health care · · · · · · · · · · · · · · · 20
Plans for the future · · · · · · · · · · · · · · · · · · · · · · · · · · · 22
Supporting documents · · · · · · · · · · · · · · · · · · · · · · · · · 23
Appendix: Literature on shared mental health care · · · · · · · · · · · · · · · · 24
Background
In 1996, the Canadian Psychiatric Association(CPA) and the College of Family Physicians ofCanada (CFPC) identified a need for increasedcollaboration between family physicians andpsychiatrists.
The prevalence of mental health problems inprimary care settings is high. Approximately onethird of all family practice patients have identifiablemental health problems1,2,3,, and up to 25% of
patients who visittheir familyphysician have adiagnosable mentaldisorder4,5,6. Thefamily physician is in an ideal position toidentify and treatmental healthproblems at an earlystage: up to 97% ofCanadians have afamily physician andmore than 80% visittheir familyphysician in thecourse of the year7. Moreover, the family physician is usuallythe first, and may bethe only contact with
a health care provider for individuals with mentalhealth problems.8
It is not surprising, therefore, that family physicians report spending a large proportion of their timediagnosing and treating individuals who have
emotional or psychiatric problems9. Unfortunately,many feel unsupported in this role. Studies offamily physicians in Canada and in other countrieshave consistently reported problems in familyphysicians’ relationship with psychiatrists, includingproblems in communication, difficulty in accessingconsultation and treatment services, and a lack ofrespect and support10,11,12.
Psychiatrists echo some of these complaints andreport additional ones: poor communication andinadequate information from family physicians atthe time of referral, reluctance on the part of family physicians to take responsibility for the continuingmental health care of patients once an acute episode has been stabilized, and frustration with familyphysicians’ lack of understanding of mental healthlegislation13.
Compounding these problems are resource issuesand health care policy changes which placeadditional pressures on the psychiatry/ familymedicine interface. Shortages of psychiatrists inmany areas, particularly rural areas, increasingemphasis on community-based care, and decreasing lengths of stay in hospital mean that familyphysicians and community psychiatrists arefrequently being asked to care for more acutely illpatients. In the face of these pressures, continuityof care, comprehensive, integrated care,collaborative care planning and the holisticapproach to the individual are values, which areincreasingly difficult to maintain.
In order to address these issues, the CFPC andCPA struck a task force whose mandate was toexamine problems in the relationship between
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“Shared mental health care is a
process of collaboration between
the family physician and the
psychiatrist that enables
responsibilities for care to be
apportioned according to the
treatment needs of the patient at
different points in time in the course
of a mental health problem and the
respective skills of the psychiatrist
and the family physician. ”
The 1997 CFPC - CPA joint position paper:
“Shared mental health care in Canada”
1Surtees PG. Psychiatric disorder in the community and the General Health questionnaire. Br J Psychiatry 1987;150:828-35.2Verhaak PF, Tijhuis MA. Psychosocial problems in primary care: some results from the Dutch national study of morbidity and interventions in general practice. Soc Sci Med 1992;35:105-10.3Finlay-Jones R, Brown GW, Duncan-Jones P et al. Depression and anxiety in the community: replicating the diagnosis of a case. Psychol Med 1980;10:445-54.4Barrett JE, Barrett JA, Oxman TE Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry1988;45:1100-6.5Kessler L, Cleary P, Burke J. Psychiatric disorders in primary care. Arch Fen Psychiatry 1985;583-7.6Van den Brink W, Koeter MWJ, Ormel et al. Psychiatric diagnosis in an outpatient population: a comparative study of PSE-Catego andDSM-III. Arch Gen Psychiatry 1989;46:369-72.7College of Family Physicians of Canada. Decima Research Report to the College of Family Physicians of Canada. Toronto: DecimaResearch 1993. 8Goldberg D, Huxley P. Mental illness in the community: the pathway to psychiatric care. London: Tavistock 1980. 9Craven MA, Cohen M, Campbell D, Kates N, Williams JI. Mental health practices of Ontario family physicians: a study using qualitativemethodology. North York, Ontario. Institute for Clinical Evaluative Sciences in Ontario. , 1996. 10Watters L. Attitudes of general practitioners to the psychiatric services. Irish J Psychological Med 1994;11:44-6.11Mezey AG, Kellett JM. Reasons against referral to the psychiatrist. Postgrad Med J;47:315-9.12Orleans CT, George LK, Houpt JL, Brodie HKH. How primary care physicians treat psychiatric disorders: a national survey of familypractitioners. Am J Psychiatry 1985;142:52-7.13Williams P, Wallace B. General practitioners and psychiatrists – do they communicate? BMJ 1974;1:505-7.
psychiatry and family medicine and identify waysin which the relationship could be improved. In1997 the task force produced a position paperwhich identified shared mental health care as asolution which would support both familyphysicians and psychiatrists, and would be likelyto lead to better outcomes for patients. Thisposition paper Shared Mental Health Care inCanada14 was endorsed by the boards of the CPAand the CFPC and was jointly published inOctober 1997.
Shared mental health care is based on the followingprinciples:
• Family physicians and psychiatrists are part of asingle mental The family physician has anenduring relationship with a patient that thepsychiatrist should aim to support andstrengthen.
• No single provider can be expected to have thetime and skills to provide all the necessary care a patient may require.
• Professional relationships must be based uponmutual respect and trust.
• Roles and activities of family physicians andpsychiatrists should be defined, coordinated,complementary and responsive to the changingneeds of patients, their families and othercaregivers, as well as to resource availability.
• The patient must be an active participant in thisprocess, understanding that both the familyphysician and psychiatrist will remain involved in his or her care, and knowing who to contactwhen a particular problem arises.
• Shared care should be sensitive to thecommunity context in which such care takesplace.
Shared care covers a broad spectrum ofcollaborative treatment possibilities. No singlemodel or approach will be applicable in everycommunity or clinical context. At the very least, itinvolves clear, helpful, two-way communicationbetween the family physician and psychiatrist orpsychiatric service. At the other end of thespectrum, it may involve psychiatrists and/or othermental health workers providing consultation andtreatment in the family physician’s office, anddeveloping collaborative management plans withfamily physicians. Shared mental health care should lead to improved patient outcomes and quality oflife; a more efficient use of resources; optimal useof the time and skills of family physicians,psychiatrists and other providers; improvement inthe ability of family physicians to access timely and
appropriate psychiatric consultation and backup;and enhanced morale on the part of the providers.
The CPA/CFPC position paper outlinedsystem-wide changes required to support theimplementation of shared mental health care andsuggested recommendations for changes inresidency training programs, relationships betweenacademic departments of family medicine andpsychiatry, and continuing medical educationprograms. It also outlined potential barriers toimplementation and identified special issuesrelevant to shared mental health care in underserved populations.
The Collaborative Working Group on Shared Mental Health Care
To further this work and to facilitate theimplementation of recommendations made in thejoint position paper, the CPA and CFPCestablished the Collaborative Working Group onShared Mental Health Care in 1998. The WorkingGroup consisted of 5 members from eachorganization with a co-chair from each. Each ofthe major regions of Canada was represented.
The ultimate purpose of the Working Groupwas to enhance the quality of care forCanadians with mental health problemsthrough better collaboration between familyphysicians and psychiatrists.
The specific objectives of the Working Group were:
• To facilitate implementation ofrecommendations made in the joint positionpaper.
• To introduce a national agenda for collaboration in order to facilitate the implementation andevaluation of this agenda, and to identify areaswhere increased collaboration is needed.
• To further our knowledge and understanding ofthe impact and benefits of shared mental healthcare.
• To strengthen personal contacts and improvecommunication between family physicians andpsychiatrists.
• To improve the skills of family physicians andpsychiatrists in working collaboratively in orderto enhance the mental health care received bytheir patients.
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14Kates N, Craven M, Bishop J, et al. Shared mental health care in Canada. Can J Psychiatry 1997;42(8):suppl 12 pp.
• To advocate for changes within health caresystems that will lead to greater collaborationbetween family physicians and psychiatrists andto improved mental health care for patients.
• To serve as a resource on issues related tomental health care delivery to the boards of theCanadian Psychiatric Association and theCollege of Family Physicians of Canada.
In order to meet these objectives, the WorkingGroup defined a series of questions which helpeddirect its work.
• How do health care policy and planninginfluence shared mental health care?
• What are the current activities in shared mentalhealth care in Canada? Who is involved? Whatprojects and initiativesare already underway?
• Are we training our residents in shared mentalhealth care?
• Do current continuing medical educationopportunities for family physicians supportshared mental health care?
• Are there barriers and/or incentives to sharedmental health care? How does physician
remuneration influence mental health caredelivery?
• How could the needs of underservedpopulations be addressed by shared mentalhealth care?
• What research has been published on sharedmental health care and its effectiveness? Whatshould the research priorities be?
• How can we share this information? And withwhom?
• How can we advocate for shared mental healthcare?
This report describes the activities of the WorkingGroup during its 3-year mandate, summarizes theinformation it has gathered, and provides initialanalysis of its implications. Based on this, theWorking Group proposes recommendations itbelieves will help lead to more effective mentalhealth care by supporting the concept of sharedmental health care. Detailed backgrounddocuments on specific activities of the WorkingGroup may be obtained from the CFPC or CPA(see page 23).
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Health care policy and planning
As health care reform is likely to have a significantimpact on how family physicians and psychiatristspractice and on opportunities for collaboration, theWorking Group conducted a review of selectedfederal and provincial planning documents relatedto primary care reform and mental health carereform. Both the CFPC and CPA submitteddocuments from their files, and provincial andfederal ministries were approached to provide whatthey believed to be their key planning documents. The goals of the review were to improve ourunderstanding of the policy and planning contextand to identify policies or initiatives that might have an impact on shared mental health care.
A number of recurring themes emerged from theplanning documents. Policy makers and planners in every province in both mental health reform andprimary care reform identified and expressed similar goals. They proposed health services goals (seeTable 1).
These goals are consistent with the goals of sharedmental health care. Moreover, shared mental health care has the potential to facilitate their achievement.
Mental health care reform
Many of the mental health planning documentsacknowledge the role of the family physician as a provider of mental health care. The Manitobadocument15 states: “General practitioners alreadyplay a key role in mental health services inManitoba. Recently, of the 110,000 individuals who received mental health services in the province,more than 80,000 were seen by general practitioners (20,000 were seen by psychiatrists and 9,000 bycommunity mental health workers - usually RPN or Social Workers).” The British Columbiadocument16 states: “For many people with mentalillness, the general practitioner is the primaryprovider of treatment.” In Nova Scotia: “Generalpractitioners... already play a significant role in
providing crisis services.”17 And in a letteraccompanying the Saskatchewan mental healthreform document18: “In Saskatchewan, the generalpractitioners see about 100,000 people each year for mental health reasons and collaborate to aconsiderable degree with psychiatrists around theprovince.”
Several mental health reform documents alsoidentified a need for more collaboration betweenfamily medicine and psychiatry. The federal
“Best Practices” document19 states “New service
delivery models are needed that can link familyphysicians with mental health professionals.” The
Ontario document20 calls for “New service deliverymodels that link family physicians with mentalhealth specialists... ” In Nova Scotia, planners
stated that “General practitioners ... should be
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Table 1. Goals for health services reform
Mental health care Primary care
Comprehensive Comprehensive
Continuous Continuous
More accessible More accessible
Patient centred Patient centred
Better coordinated Better coordinated
Better integrated Better integrated
More collaborative More collaborative
Community based Community based
Based on best practices Based on best practices
Evaluated and accountable Evaluated and accountable
Flexible Population based
Focused on serious mental illness Utilizes technology
High quality services
15Building the Future of Mental Health Services in Manitoba. A “Partners for Health” Consultation Paper. Manitoba Ministry of Health,1992. 16Revitalizing and Rebalancing British Columbia’s Mental Health System. The 1998 Mental Health Plan. British Columbia Ministry ofHealth and Ministry Responsible for Seniors, 1998. 17A Vision for the Future: A Report of the Working Group on Mental Health. Nova Scotia Department of Health, 1992. 18Working Together Toward Wellness: A Guide To Core Services for Saskatchewan Health Districts. District Support Branch,Saskatchewan Health, 1993. 19Best Practices in Mental Health Reform. Discussion Paper. Health Systems Research Unit, Clarke Institute of Psychiatry, 1997. 20Making It Happen: Framework for the Delivery of Mental Health Services and Supports. Integrated Policy and Planning Division andMental Health System Management Division. Ontario Ministry of Health, 1998.
provided with education to enable them to play alarger role in mental health emergency crisisservices.” The British Columbia document statesthat “Because recruiting sufficient numbers ofpsychiatrists to rural communities is a challenge,providing adequate training and support to generalpractitioners is key to ensuring that effectivediagnosis and treatment of mental illness is madeavailable in all communities.” And finally, theNorth West Territories document21 emphasizes that “strong links between family physicians ... andmental health specialists or psychiatrists are vital toensure that (people diagnosed with mental illness)receive consistent and timely treatment.”
Primary care reform
While the prevalence of mental health problems inprimary care is high and managing these problemsoccupies significant amounts of the familyphysician’s time, to date, primary care reformdocuments have placed little emphasis on supportsfor mental health care in primary care.
The 1996 Report of the Advisory Committee onHealth Services suggested principles on whichprimary care reform could be based. Amongst itsspecific recommendations were that “ in urban andsome rural areas, primary care organizations willhave available a spectrum of professionals including physicians, nurses, psychologists, midwives,physical therapists, dieticians, counsellors and social workers”22.
Since then, as most provinces have embarked onprimary care reform, a number of provincialplanning documents, such as the Nova Scotiadocument, have focused on local pilot projectswhich did not include a major mental healthcomponent. Others have suggested one of twogeneral approaches to supporting provision ofmental health care in primary care. The first hasbeen to integrate a broader range of services intoprimary care settings and the second is to linkprimary care services more closely with other health and social services. Both of these approaches areconsistent with the goals of shared mental healthcare.
Ontario’s report makes perhaps the cleareststatement in this regard, seeing mental health careas a “mandatory function” of primary care while
also stressing the value of “special attachments with mental health workers”. Saskatchewan sees thevalue of “community therapist and social workers”in “larger primary care sites” and discusses possibleroles for these individuals such as “supportingfamilies” and “addressing health risks for youngpeople”. The Saskatchewan document also talksabout integration of primary care services with avariety of other health services such as “publichealth, mental health and drug services within thehost district”.
Problems
While it is encouraging to find the need for greatercollaboration between family medicine andpsychiatry emphasized in some of these documents, a number of problems remain.
Despite their similar goals, the primary care andmental health care planning processes appear to beoccurring in parallel with little integration or crossconsultation. There were no indications indocuments reviewed to suggest that there were anyformal linkages between the two processes. Thisraises serious issues regarding coordination andefficient use of resources and encourages separation of the constituencies which serve the chronic,persistent and severely mentally ill and those whereepisodic disorders, phase of life problems, andcomplex psychosocial difficulties are the primaryfocus of care.
Although a number of mental health planningdocuments acknowledge the role of the familyphysician as an important provider of mental health care, few actually incorporate the role of the familyphysician into the design of the mental health caredelivery system. The primary care component ofmental health is not described or defined, is notidentified as part of the continuum of mental health care, rarely appears on organizational charts andsystem diagrams, and is usually conceptualised asbeginning with entry into the formal mental healthcare system. Few documents address the physicalhealth care needs of individuals with mental healthproblems and the need for integration of physicaland mental care.
The role of the family physician in providing mental health promotion, screening, early detection andtreatment and appropriate referral to specialized
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21Mental Health Sevices in the NWT: A Framework for Discussion. Department of Health and Social Services, North West Territories,November 1998.22What We Heard: A National Consultation on Primary Health Care. Federal, Provincial and Territorial Advisory Committee on HealthServices. Publications Unit, Health Canada, 1996.
services is not discussed in these documents. Similarly, a number of documents discuss the issueof discharge from specialized, often regionallybased services, back into the community but fail tooutline the role of the family physician in providingfollow-up care. These activities are critical to thesuccessful care of individuals and to the successfulfunctioning of the mental health care system.
The fact that mental health services do not figureprominently in reform planning is concerning, inlight of the high prevalence of mental health
problems in primary care and the amount of timefamily physicians spend managing them.
At the same time, our review of planningdocuments has revealed a high level of consistencybetween the goals of primary care and mentalhealth care reform and the goals of shared mentalhealth care. Shared mental health care could beseen, therefore, not only as a key component ofboth of these processes but also as a bridge to helplink them.
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Recommendations• Provide feedback of the results of the Working Group’s policy review to health policy
makers and planners.
• Continue exchanges with health policy makers and planners to facilitate theimplementation of shared mental health care by
• monitoring and reporting on health policy/planning initiatives as they impact onshared care
• identifying and communicating with key committees that may have an influenceon the interface between mental health planning and primary care reform anddeveloping recommendations to facilitate the integration of these two processes
• extending this review to other policy areas and analysing their implications forshared mental health care (e.g. hospital restructuring, the continued shift tocommunity care, rural health strategies, etc.).
• Identify, review, and report on areas where governments are investing resources fordemonstration projects, research and evaluation of shared mental health care.
• Develop collaborative linkages with advocacy groups such as the newly formedCanadian Alliance on Mental Illness and Mental Health (CAMIMH).
The current status ofshared mental health care in Canada
An important task for the Working Group was todevelop a comprehensive list of individuals with aninterest in shared mental health care across Canada. A “fanout” technique was used, beginning with themembers of the Working Group and theircolleagues. Heads of provincial medical andpsychiatric associations and CFPC chapters wereapproached and asked to provide the names ofindividuals who are either currently active in, orwho had expressed an interest in, shared mentalhealth care. Similarly, heads of academicdepartments of family medicine and psychiatry were also contacted.
The people identified were surveyed to gatherinformation about collaborative projects takingplace across Canada. These “key informants” weresent a questionnaire asking them aboutcollaborative shared mental health care activities,projects or activities in their areas, local government initiatives relevant to shared mental health care, and what they considered to be barriers or obstacles toshared mental health care in their community.
To date, the Working Group has collected thenames of more then 350 individuals who areinterested and/or involved in shared mental healthcare across Canada. Those who responded to thesurvey described and identified a broad range ofshared mental health care projects and activities.The following are examples:
Service projects
• telemedicine consultation and backup to familyphysicians
• outreach to underserved populations,particularly in rural areas
• family physicians providing mental healthservices in psychiatric settings, includingspecialized clinics, inpatient wards and generaloutpatient clinics
• community psychiatrists providing consultations in the primary care setting for a wide range ofproblems, including specialized consultation forpaediatric and geriatric age groups
• mental health services provided by psychiatristsand other mental health workers integratedwithin the primary care setting
• psychiatrists providing telephone backup tofamily physicians
Educational resources forfamily physicians
• treatment guidelines produced specifically forprimary care physicians, such as the WHODiagnosis and Management of CommonDisorders in Primary Care, the Prime MD, andthe Clarke Institute for Psychiatry’s Guidelinesfor Depression
• McMaster University’s Depression InformationResource and Education Centre (DIRECT)
Continuing medical educationactivities
• Balint-type groups
• single and multi-session courses for familyphysicians
• Practice-Based Small Group Learning modules
• single issue initiatives such as the “AccessProgram” to train family physicians acrossCanada about schizophrenia
Residency training programinitiatives
• family medicine third year training opportunitiesin psychiatry
• adult and child psychiatry training opportunitiesin the primary care setting
• behavioural science training which is integratedinto family residency training programs
Collaborative activities between academic departments
• reported less frequently, but included crossappointments, joint administrative projects,
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regular meetings of department heads, and crossrepresentation on department committees
Research activities
• collaborative research involving familyphysicians and psychiatrists
• research sponsored by psychiatrists about familyphysicians’ needs
• evaluation of shared mental health care strategies and their effectiveness
The number and scope of these activities andprojects is exciting and encouraging. A significantproblem, however, is that many are occurring inisolation without much dialogue with colleagues inother parts of Canada who may share theseinterests.
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Recommendations• Develop a web site, Listserve, and other approaches to disseminate this information
and encourage networking.
• Maintain and expand the current network of clinicians, teachers, planners andresearchers using the Internet, local and national meetings, and other formats fordisseminating information.
• Develop a standardised descriptive inventory of shared mental health care projects oractivities taking place across Canada, to publicise what is currently taking placenationally and serve as a resource for others wishing to implement shared mentalhealth care strategies.
Residency training
The joint position paper stated that many problemsin the relationship between family physicians andpsychiatrists reflect the fact that little attention ispaid to collaborative models of practice in residency training programs.
The Working Group conducted a survey of theprogram directors of all Canadian family medicineand psychiatry residency programs to determine the current training experience of residents in sharedmental health care. The specific objectives were:
• To assess the awareness of shared mental healthcare in family medicine and psychiatry residencyprograms.
• To determine the extent to which the jointposition paper was influencing training.
• To identify the types of interactions between the two groups of residents.
• To identify obstacles to the implementation ofshared mental health care principles andpractices.
• To list and rank resources which would behelpful to family medicine and psychiatryresidency programs in implementing sharedmental health care.
• To determine to what extent psychiatryresidency programs are responsible for theteaching of psychiatry/behavioural medicine tofamily medicine residents and vice versa.
The questionnaires sent to the family medicine andpsychiatry programs were similar enough to permitdirect comparison of the results. 14 out of 16 ofthe psychiatry surveys and 15 out of 16 of thefamily medicine surveys were returned. Somefamily medicine program directors commented thatit was difficult to make general statements abouttheir programs because of the variation among their teaching sites.
The principal results of the surveys were:
• Most program directors in both departmentswere aware of the joint position paper. In manyfamily medicine programs it had been used todevelop goals and objectives.
• The majority rated shared mental health care asbeing important in training.
• The document had not been discussed as muchin postgraduate education committees inpsychiatry as in family medicine.
• The majority of family medicine teaching unitshave a visiting psychiatrist to assess/discusscases. Some commented that this does nothappen frequently enough. Some psychiatryresidents participate in this at some point in their training. There is considerable variation in thetype of experiences available.
• There appears to be limited contact betweenfamily physicians and psychiatrists in theirrespective practice settings.
• Few programs offered joint educational sessionsfor family medicine and psychiatry residents.
• Neither department identified major obstacles to teaching the principles and practice of sharedmental health care.
• Programs indicated that improved relationshipsbetween departments would facilitate theteaching of shared mental health care.
• Program directors in both disciplines identifiedthe need for influential role models and leadersin theory and practice of shared mental healthcare.
• Program directors in both disciplines identifiedthe need for teaching materials, trainingobjectives and additional human resources toteach shared mental health care in theirprograms.
Separate meetings have been held with familymedicine and psychiatry program directors todiscuss these findings, and program directors havereceived copies of the findings andrecommendations of both surveys. The WorkingGroup has developed draft training objectives inpsychiatry for family medicine residents and infamily medicine for psychiatry residents. Thesehave been circulated to program directors for theirfeedback.
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Recommendations• Continue to collaborate with program directors to finalise the learning objectives and
to assist in their implementation.
• Further explore ways in which university departments of family medicine andpsychiatry could increase contacts among faculty members and learners from eachdepartment and facilitate the collaborative development of educational (and other)programs.
• Develop strategies to assist residency program directors in meeting the needsidentified in the surveys e.g.
• provide suggestions for topics for tutorials and seminars
• provide a current list of references on shared mental health care anddescriptions of existing collaborative programs
• identify potential opportunities for activities that bring psychiatry and familymedicine residents together, such as educational rounds, tutorials and jointclinical placements.
• Promote and encourage the participation of residents in shared careprojects/programs throughout their training.
• Create a registry (from the national database) of educators with an interest in sharedmental health care.
• Continue liaison with the CFPC and the Royal College of Physicians and Surgeons ofCanada to incorporate concepts of shared mental health care in family medicine andpsychiatry residency training requirements, respectively.
Continuing medical education
Family physicians are more likely to be comfortable participating in the mental health care of patientswith psychiatric disorders if they have adequateknowledge about these disorders, and the skills towork collaboratively with psychiatrists. Consequently, the Working Group identifiedcontinuing medical education (CME) as animportant factor in the successful implementationof shared mental health care. A review of recentCME programs across Canada was conducted todetermine how well these programs meet the needsof family physicians for up to date psychiatricknowledge and whether they provide familyphysicians with the skills necessary to workcollaboratively with psychiatrists and other mentalhealth professionals.
Three sources of CME programs for familyphysicians were reviewed – the annual scientificassemblies of the CFPC, the programs offered bythe university CME offices, and other programsaccredited by the CFPC. Unaccredited CME andspecially CME were not renewed, nor was aliterature search undertaken.
CFPC annual scientific assemblies: All CFPCchapters and the national office were asked tosubmit their ASA programs for the years1994-1998. All but one of the chapters were able to provide all of the programs. These were reviewedin detail, and each topic was classified under abroader subject category heading (e.g., cardiology,endocrinology, office management, ethics and legalissues). Topics were classified under psychiatry and mental health if they dealt with a DSM-IVdiagnosis, psychopharmacology, psychotherapy, orfell under the broader heading of psychosocialproblems (e.g., parenting techniques, coping withan alcoholic family member, phase of life issues,etc.).
Thirteen percent of all presentations were on topics relevant to mental health care. This comparesfavourably to other areas, such as respirology (3%)and infectious diseases (5%). The frequency ofmental health topics varied widely, however, fromprovince to province. Ontario had 42 mentalhealth CME topics over 5 years, and the combined
Maritime Provinces had 11. The mean for allprovinces was 21.
Of the mental health care topics, depression wasthe most common topic (14%), followed bycounselling/psychotherapy (11%), alcohol abuse(11%) and family violence (10%). Other topicswere anxiety disorders (5%), personality disorders(3%), bipolar affective disorder (1%), andschizophrenia (1%). There was one presentationon suicide risk assessment in five years acrossCanada.
None of the topics specifically addressed sharedmental health care or the skills and knowledgenecessary for co-management of the seriouslymentally ill.
University CME offices’ programs: All sixteenCanadian medical schools have offices that provideCME for family physicians. They were asked toprovide statistics on the activities they plannedduring a 12-month period (October 1998 toSeptember 1999). Ten universities responded. Across these universities, there were a total of 553activities. Of these, 43 (7.8%) were on mentalhealth topics, and a further 95 (17.2%) were general programs which included at least some mentalhealth content.
CFPC database of accredited CME: The centralCFPC database for other accredited CME eventswas reviewed for a 12-month period from1998-1999. The data for the CFPC ASA’s wasexcluded. Mental health care topics, as definedabove, were extracted and analysed. Review of thisdata produced results similar to the ASA’s: 12% ofall topics were categorized as mental health.
The overall frequency of psychiatry/mental healthtopics in family medicine CME (8-17%) activities isencouraging. But the low frequency ofpresentations on some common and seriouspsychiatric problems (such as anxiety disorders,bipolar affective disorder, and schizophrenia) isconcerning. Similarly, the absence of any topics infamily medicine CME dealing with the skillsnecessary to co-manage patients with mental healthdisorders is a potential barrier to the disseminationof the shared mental health care model.
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Recommendations
• Disseminate the findings of these reviews, which highlight the relative lack of certainimportant topics to CME providers. CME opportunities for family physicians andpsychiatrists reflect local practice contexts and community needs and place increased focus on the diagnostic, management and inter-professional skills needed for collaborative care. Disseminate these results to psychiatrists involved in delivering CME to family physicians.
• Prepare a list of core topics and background materials relevant to shared mental healthcare in conjunction with organisers of CME events and national groups such as the Councilof Psychiatry Continuing Education (COPCE).
Opportunities and barriers
Opportunities and barriers were identified in anumber of ways including: the survey of keyinformants, the surveys of residency programdirectors, and a review of provincial fee schedulesfor family physicians. The Working Group wasalso invited to contribute questions on therelationships between psychiatrists and familyphysicians to the 1999 survey of the CanadianPsychiatric Association Research Network(CPARN). This survey was sent to 160(self-selected) psychiatrists across Canada. Thefollowing issues arose from one or more of thesesources.
Health care system restructuring was mentioned bysome of the respondents of the key informantsurvey as offering many opportunities forcollaborative projects, as many of the goals wereconsistent with those of shared mental health care. Specific factors mentioned included:
• the increasing emphasis on primary care as thecornerstone of health delivery systems
• hospital restructuring, which stressed the needfor closer links between hospitals andcommunity services
• primary care reform, which aims to integratespecialised services within primary care
• planning for enhanced rural services taking place in many provinces
There was broad agreement on the following majorbarriers to shared mental health care:
• time constraints
• limited personal contacts and poorcommunication between family physicians andpsychiatrists
• physician remuneration for collaborativeactivities
• lack of funding for collaborative projects
• attitudinal barriers
Time Constraints
Many respondents identified this as an issue. Psychiatrists and family physicians both felt that itwould be difficult to take time from their clinicalactivities to devote to activities for which there isno remuneration. This was not identified as amajor problem for those physicians already
involved in shared mental health care projects. The CPARN survey, however, suggested thatpsychiatrists would be willing to devote someadditional time to joint clinical or educationalactivities or providing telephone backup.
Limited personal contacts /communications
A consistent theme was the need for improvedcommunication and increased personal contactsbetween psychiatrists and family physicians. Thisapplied to contacts between family medicine andpsychiatry educators and educational programplanners, between academic departments, betweenhealth planners responsible for mental health andprimary care reform, and between cliniciansworking in different settings. Improvedcommunication and closer personal contacts wereseen as essential for effective collaboration and theimplementation of shared mental health care.
According to the CPARN survey, the main contactbetween psychiatrists and family physicians tookplace over the phone (usually discussing cases). Psychiatrists felt that this was likely to be the mosteffective way of linking psychiatrists and familyphysicians. They also saw increased participation in joint rounds or education activities to be bothdesirable and achievable.
Physician remuneration issues
The Working Group reviewed the billing codesavailable to family physicians across Canada inorder to determine how payment options eithersupport or discourage effective mental health care.Notwithstanding the fact that some provincesprovide a salary to family physicians in somesettings (e.g. CLSC’s in Quebec and CHC’s inOntario), and though the details vary considerably,the billing systems of all provinces are based on asimilar fee-for-service model. In general, there aretwo kinds of codes: fees for office visits (usually for medical problems) which are defined according tothe type of service performed; and fees forcounselling or psychotherapy which are definedaccording to the amount of time spent with thepatient.
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Analysis of the various provincial fee systemsrevealed that they all have both strengths andweakness in terms of how well they support theprovision of mental health care.
Examples of billing codes, which support theprovision of mental health care by familyphysicians, include:
• health promotion counselling
• phone calls
• group counselling
• interviews with relative
• interviews with other health care professional
• complete “physicals” for mental illness
• case conferences
• psychotherapy and family therapy
• short time intervals forcounselling/psychotherapy
But there were also features of the fee schedulesthat are likely to discourage the provision of mentalhealth care by family physicians. Whereas mostmental health care is billed using time-based codes,almost all uncomplicated non-psychiatric problemsare billed using codes that are not time-based. Thefollowing specific barriers exist in at least oneprovince.:
• low rates for mental health care compared togeneral medical assessments and care
• no psychiatric care codes
• restricted number of annual visits billable forcounselling
• requirement to pre-book visits for counselling or psychotherapy
• complex fee code systems
• fixed fee for psychotherapy regardless of timespent
• although some provinces have special codes forserious or catastrophic situations (e.g. rape, acute psychosis), none have any for common butdisabling mental illness
The particular combination of these supportive and non-supportive features of the fee structures ineach province often weigh on the side ofdiscouraging family physicians to provide effectivemental health care. Appropriately structured
systems of remuneration must be in place if sharedmental health care is to be implementedsuccessfully. Codes that adequately remunerateboth family physicians and psychiatrists for casediscussions and telephone advice, in particular, areneeded.
Limited funding forcollaborative projects
Many respondents commented that even when thedesire to implement shared mental health carestrategies existed and the planning had beencompleted, it was often difficult to obtain newfunding. This was often reinforced by localplanning authorities that did not give a high priority to collaborative projects, or where funding wasprovided by different sources and was hard tointegrate. While there is evidence that this is slowlychanging, most projects had started by reallocatingexisting funding, or by pursuing non-traditionalsources of funding such as the Health CanadaTransition Fund.
Attitudinal barriers
Despite acceptance of the value of shared care bymany psychiatrists and family physicians, attitudinalbarriers still need to be overcome. These includestereotyped (and usually inaccurate) views of thework of the other discipline and a lack of respectfor the role each could play. In part this stemsfrom the lack of personal contacts betweenpsychiatrists and family physicians and can bereinforced by a poor understanding of what takesplace in the clinical settings of the other disciplineand different conceptual frameworks regarding theaetiology of mental health problems.
There appeared to be agreement that the mosteffective way to change these attitudes would be tofind clinical, educational and planning settingswhich would bring family physicians andpsychiatrists into contact with each other, andenable them to learn about each other’s practice. Itwas suggested that this needs to start duringresidency training.
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Recommendations
• Continue to develop strategies to enhance communication between family physiciansand psychiatrists, including
• further exploration of opportunities for hospital departments of family medicineand psychiatry to increase contacts among their members (including residents)by joint clinical rounds and educational activities, and the development ofcollaborative programs and evaluation processes
• compiling and circulating examples of clinical forms and communicationprocesses that significantly improve the exchange of clinical information betweenthe two specialties.
• Request provincial medical associations and health insurance plans to review feeschedules for mental health services by family physicians to ensure that they do notundermine the role of the family physician as a provider of mental health care. Feesfor activities that would support collaborative activities such as case discussions,telephone advice and conjoint assessments, should be considered. Conduct a similarreview for psychiatry.
• Work with Government and other funding sources to advocate for resources for theimplementation and evaluation of collaborative projects.
• The Working Group act as a clearinghouse for the compilation and dissemination ofevaluation materials and strategies in shared care, to enable individuals embarking onnew projects to learn from the experiences of colleagues.
• Further assess psychiatrists’ attitudes towards shared care and the types of supportsand resources they feel are necessary to facilitate implementation.
Underserved populations
Rural / isolated communities
Many of Canada’s rural or more isolatedcommunities have shortages of medical specialists,including psychiatrists and other specialized mentalhealth care providers. Attracting and retainingpsychiatrists to these communities remains apriority, but because of the relative lack of successthat many communities have had in this regard,alternate models for delivering mental health carehave been developed.
Many of the models are based upon anacknowledgement of the central role that a familyphysician plays in delivering mental health servicesin these communities. Examples of these includeoutreach by psychiatrists who visit communitiesperiodically to deliver clinical and educationalservices; telephone backup to family physicians; theuse of new technologies for video consultations and case conferences and educational sessions;Web-based clinical and educational trainingactivities; CME events; and specialized training forfamily physicians as mental health providers.
In addition to individual projects, there areexamples of academic centres and provinces that
have launched major initiatives to coordinateactivities to outlying communities in theircatchment area.
Shared mental health care offers manyopportunities for innovative projects which couldenhance the mental health care received byindividuals in these communities.
Other underserved populations
Shared mental health care has been utilized todeliver mental health care to the homeless,immigrant and specific cultural groups, the elderly,individuals with co-existing medical and emotionalproblems, and native populations.
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Recommendations
• Collaborate with organizations, health planners and providers working in more isolated or underserved communities to explore the role that shared mental health care canplay in increasing access to mental health/psychiatric services. Steps towardsachieving this will include
• an overview of the types of unmet mental health needs in these communities
• a review of existing projects that have successfully linked mental health andprimary care services in isolated/underserved communities
• Liase with rural health organizations and ministry planners to assist in the development and evaluation of new/demonstration shared mental health care projects forcollaborative activities in rural communities.
• Develop additional training opportunities in mental health care for rural-based familyphysicians in conjunction with academic departments.
• Document and describe successful strategies for providing service to otherunderserved populations and broad dissemination of these findings.
Research and evaluation
An annotated bibliography ofshared mental health care
An important part of the Working Group’s strategy for supporting the implementation of shared mental health care is the development of an annotatedbibliography and overview of the literature onshared mental health care. Together, these willcomprise a reference document for individuals andgroups interested in the experience with sharedmental health care to date. In addition, they willsupport the development of a national researchagenda and, hopefully, stimulate innovative newprograms and activities.
The first step in this process, a Medline review ofthe English language literature for the years1980-1998, has been completed. References wereincluded if they dealt primarily with the interfacebetween family medicine and psychiatry. Onehundred and sixty-five references were selected(Appendix). These are also available, includingtheir abstracts, in a separate document.
Interest in the relationship between family medicine and psychiatry, as demonstrated by the number ofarticles dealing with it, has grown rapidly in the 18years covered by the search. Between 1980 and1984, 12 articles dealing with the interface betweenfamily medicine and psychiatry were published. For the five-year period from 1994 and 1998, 80references were found.
The majority of articles included are British inorigin. However, work by groups in Australia, theU.S. and Canada is now being published withincreasing frequency.
The references generated by this search includedescriptive studies, intervention studies, discussionpapers, editorials, letters, and position paperspublished by professional bodies, all dealing withthe relationship between family medicine andpsychiatry. The content of these referencesincludes, among others, the following topics:
• the current role(s) of the family physician in thedelivery of mental health care and what familyphysicians need from psychiatrists to help themoptimise their care
• communication between family physicians andpsychiatrists, and how it could be improved
• family physicians’ attitudes toward increasedcollaboration with psychiatrists
• the prevalence of formal links and collaborativearrangements between family physicians andpsychiatrists and other mental healthprofessionals
• models of collaboration, their advantages anddisadvantages
• descriptions of specific collaborative programsand services in Canada, the United Kingdom,Australia, the U.S., the Netherlands, and Israel
• family physician and patient responses to theseprograms
• program costs
• impact of collaborative programs on the existing network of psychiatric services
• impact of collaborative programs on familyphysician knowledge, skill, and mental healthcare practices
• suitability of collaborative models for specialpopulations and settings (e.g. children andadolescents, rural settings, substance abusers, the military)
• the seriously mentally ill, and the issues relatedto serving this population
Initially, much of the literature on shared mentalhealth care was descriptive or conceptual in nature. In more recent years, well-designed outcomestudies are beginning to demonstrate what workswell, with what populations, and what does not. Of particular interest is the growing number ofreferences which deal with shared mental healthcare in relation to the seriously mentally ill. Manyof these articles, letters and editorials raise questions about resources and the need to ensure that theyare not diverted from this population.
Research strategy
At present, there is not a substantial body ofCanadian literature about shared mental health careand its implementation, despite the increasingnumber of individuals involved in collaborativepractice. The results of the surveys of keyinformants and academic departments suggest thatthere is little funded research currently taking placein Canada that examines different facets of therelationship between psychiatry and primary care. Many of the investigative activities that are taking
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place fall under the category of program evaluationor are funded through resources already allocated to specific programs.
The Working Group recognises the importance offacilitating both effective evaluation and welldesigned research projects. The demonstration ofthe benefits of collaborative care will be a crucialfactor in negotiations for funding for furtherresearch, as well as providing support and guidancefor practitioners working in the field.
Because of limitations in resource availability, themore that individuals in different parts of thecountry can collaborate and draw on their collective experiences, the more efficient research activitiesare likely to be. At the same time, if differentgroups are addressing common or complimentaryquestions, they have the opportunity to build uponeach other’s work.
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Recommendations• Complete the annotated bibliography with a critical overview and with references
organized under content headings. Circulate the resulting document widely toeducators, learners, planners and service providers.
• Establish a representative national group of persons who research and evaluateactivities in shared mental health care by
• linking individuals across the country who are interested in research andevaluation
• compiling, maintaining and distributing a list of current research, evaluativeactivities, and related publications.
• Develop a national research and evaluation strategy that includes, among others, thefollowing issues
• sponsoring a process to develop a national research agenda and a framework toensure a coordinated approach to research and evaluation
• the most effective use of resources including cost-benefit analyses of sharedmental health care strategies
• the optimal roles for family physicians and psychiatrists working together todeliver mental health care
• which interventions/strategies are most likely to result in improved patientoutcomes
• how to use shared care strategies to improve the care provided for hard to servepopulations
• how to implement shared care strategies on a large scale
• impact of shared mental health care on the health of the population.
• Advocate for increased funding for research and evaluation.
Advocating for shared mental health care
Information about shared mental health care andthe collaboration between the CFPC and CPA wasdisseminated widely after the release of the jointposition paper using a variety of communicationsvehicles. Communications and advocacy activitiesfocused on reaching the following audiences:members and the governing bodies of the twosponsoring organizations, officials who influenceand are responsible for policy, planning, andfunding of the primary and mental health caresystems, medical educators, and allied professionalorganizations.
The objectives were to inform audiences about theactivities of the Working Group and to foster aclimate that encouraged individuals and groupsinvolved or interested in shared care to share ideasor successful strategies and to discuss theirexperience. At the policy level, the objective was to begin to engage decision makers in a dialoguearound the policy and funding issues in order tooptimise the contextual framework for sharedmental health care.
The key messages were:
• that physicians involved in mental health carewere taking steps to improve patient care at theprimary care level
• that the initial focus of the Working Groupwould be on gathering information about outhow shared mental health care is beingimplemented in different communities and onissues and barriers that need to be addressed
The public release of the joint position paper in1997 at a press conference held in Toronto andjoint publication in each of the two organizations’major publications, was followed by writtencommunication to a wide range of medical andallied professional and consumer organizations andto senior health officials at the federal andprovincial levels. Many supportive and encouraging responses were received.
While the Working Group recognised it needed tolimit its discussions to collaboration betweenpsychiatrists and family physicians – as the grouphad no mandate to speak on behalf of any otherhealth care providers – most non-physicianorganisations contacted saw this activity as apositive step. They initiated independentdiscussions to explore how they could address
shared care issues in mental health care within other domains. Two examples are discussions betweensocial work and psychiatry around working with the homeless mentally ill population, and initialdiscussions around shared care in child mentalhealth. Over the next three years it is hoped thatthese discussions will lead to more formal linkageswith other mental health care providers.
In addition, the Canadian Alliance on Mental Illness and Mental Health (CAMIMH) has invitedrepresentation from the Working Group toparticipate in planning a nation-wide system formonitoring mental disorders and developing anaction plan to support mental health promotion and the treatment of mental disorders.
Throughout the 3-year mandate of the WorkingGroup, information about its mandate, activitiesand progress has been disseminated in a variety ofways including national and international meetings,published articles, and media presentations. Progress was communicated regularly to membersand governing bodies of the CPFC and CPAthrough Board presentations and news articles ineach of the two organizations publications.
In addition, the surveys of academic centres and the network building among those already involved orinterested in shared mental health care served toimprove understanding within the two spheres ofpractice about the Working Group’s activities.
Some press relations work was undertaken, with the medical media producing a number of stories onshared mental health care activities suchpublications as the Medical Post and the AmericanPsychiatric Association News.
Efforts were also made to foster communicationsand information-sharing mechanisms at theprovincial level, often facilitated by representativeson the Working Group within their province. Oneprovince (Alberta) held a number of meetingsbetween parties at the provincial level and reportedback to the committee with a series ofrecommendations and issues it felt should beaddressed.
Governments have responded extremely positivelyto the communications about the shared mentalhealth care initiative. A series of follow-up writtenexchanges resulted from the original
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communications between the Working Group andthe Deputy Minister of Health Canada as well asthe Chair of the Federal/ Provincial/TerritorialHealth Services Advisory Board. As a result, theWorking Group met with the Federal ProvincialTerritorial Advisory Network on Mental Health inApril 1999. During that meeting, background onthe current situation, an initial analysis of the extent to which primary care and mental health reformplanning documents support shared mental healthcare in Canada, and the work of the committeewere presented and discussed.
Subsequently, a co-chair of the Working Groupmade a presentation to a broad range of officials
within Health Canada, which resulted in acommitment for some limited financial support forinformation dissemination. Communications to theCPA from the government generally point toshared mental health care as an illustration of thework they find encouraging. This has set the stagefor potentially positive ongoing dialogue aroundpolicy changes needed to address some of thesystemic barriers to the practice of shared mentalhealth care.
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Recommendations
• Develop a process to facilitate regular, ongoing dialogue with CFPC and CPA members, other physiciansand other health care providers, educators, health care policy makers and planners and other medical and allied health care organizations.
• The objectives of this dialogue would be to
• advance the understanding of shared mental health care and its potential benefits
• facilitate the implementation of the recommendations of the position paper especially as theyrelate to human resources, system planning, funding, training, and research.
• Strategies could include
• continued development and expansion of a web-site containing information available tomembers and others with an interest in shared mental health care
• regular publication of the work of the Working Group in appropriate journals and other media
• wide and targeted distribution of this report, including a press conference around its release
• regular presentations at professional and CME meetings
• periodic meetings and ongoing dialogue with medical training, accrediting, and CME bodies toshare the results of surveys and explore strategies to improve shared care training as well as to find solutions to identified barriers
• continued ongoing information exchange meetings with national governmental bodies (Federalprovincial territorial committees) and Health Canada officials.
• Explore linkages with allied groups (including other professions and CAMIMH) through either a multistakeholder meeting or a series of one-to-one meetings with key organizations. The purpose of suchmeetings would be to foster broader collaboration and integrate the multi-disciplinary nature of mentalhealth care.
• Develop a comprehensive list of policy issues and strategies (research, funding, human resources, etc.)which both sponsoring organizations can jointly bring to the attention of governments to fostercollaboration between primary care and mental health care reform initiatives.
• Establish provincial and local ‘shadow’ committees to advocate for policy and funding changes at theprovincial level and to share information at a local level.
Plans for the future
The initial task of the Working Group was to gather as much information as possible on the currentstate of shared mental health care across Canada,on obstacles that might interfere with collaborationbetween family physicians and psychiatrists, andopportunities that might facilitate collaborativeactivities. Future plans of the Working Groupinclude:
• Development of more extensive processes todisseminate the findings of the group’s reviewsand analyses.
• Expansion of the network of individualsinterested/involved in shared mental health careand creation of a detailed registry of projects and activities across Canada.
• Development of local and provincialinfrastructures to enhance and extend the workof the Working Group.
• Development of resources and ‘tool kits’ forresidency program directors and CME programplanners.
• Development of an annotated bibliography andcritical overview of the literature on sharedmental health care.
• Development of a process to create a nationalresearch agenda.
• Strengthening of liaisons with Ministries andother funding sources to advocate for policy and funding changes which will support sharedmental health care.
• Development of a process to work with thosewho are responsible for providing mental healthcare to rural and other underserved populations,to identify ways in which shared mental healthcare could help to meet their needs.
• Strengthening of links with other professionalprovider groups who have an interest incollaborative mental health care.
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Supporting documents
These documents may be obtained from the College of Family Physicians of Canada or the CanadianPsychiatric Association.
1. Position Paper on Shared Mental Health Care in Canada. Canadian Psychiatric Association and College of Family Physicians of Canada.
2. Detailed results of the surveys of family medicine residency program directors
and of the survey of psychiatry residency program directors.
3. List of Canadian continuing medical education on mental health care for
family physicians.
4. Review and summary analysis of Canadian federal and provincial primary care and mental health care reform planning documents.
5. Provincial billing codes pertinent tomental health care for family physicians.
6. Psychiatry and Primary Care: Interface Issues and Models of Shared Mental
Health Care—An annotated bibliography(in progress).
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Appendix: Literature on shared mental health care
1. Aldrich CK. Psychiatry in 2001. J Fam Pract1993;36(3):323-8.
2. Arreghini E, Agostini C, Wilkinson G. General practitioner referral to specialist psychiatric services: a comparison ofpractices in north-and-south-Verona. Psychol Med 1991;21:485-94.
3. Bailey JJ, Black ME, Wilkin D. Specialist outreach clinics in general practice. BMJ 1994;308(6936):1083-6.
4. Balestrieri M, Williams P, Wilkinson G. Specialist mentalhealth treatment in general practice: a meta-analysis.Psychol Med 1988;18(3):711-7.
5. Barber R, Williams AS. Psychiatrists working in primarycare: a survey of general practitioners’ attitudes. Aust N Z J Psychiatry 1996;30(2):278-86.
6. Bindman J, Johnson S, Wright S, Szmukler G, BebbingtonP, Kuipers E, et al. Integration between primary andsecondary services in the care of the severely mentally ill:patients’ and general practitioners’ views. Br J Psychiatry1997;171:169-74.
7. Bird DC, Lambert D, Hartley D, Beeson PG, Coburn AF.Rural models for integrating primary care and mentalhealth services. Adm Policy Ment Health1998;25(3):287-308.
8. Blaney D, Pullen I. Communication between psychiatristsand general practitioners: what style of letters dopsychiatrists prefer? J R Coll Gen Pract 1989;39(319):67.
9. Bloom JD. Psychiatry: three models in search of a future.Psychiatr Serv 1996;47(8):874-5.
10. Bouras N, Tufnell G, Brough DI, Watson JP. Model forthe integration of community psychiatry and primary care.J R Coll Gen Pract 1986;36(283):62-6.
11. Broome AK, Kat BJ. Would more mental illness helpgeneral practitioners manage their difficult patients? J RColl Gen Pract 1981;31:303-7.
12. Brown LM, Tower JE. Psychiatrists in primary care: wouldgeneral practitioners welcome them? Br J Gen Pract1990;40(338):369-71.
13. Burbach FR, Harding S. GP referral letters to a communitymental health team: an analysis of the quality and quantityof information. Int J Health Care Qual Assur Inc Leadersh Health Serv 1997;10(2-3):67-72.
14. Burns T, Kendrick T. Care of long-term mentally illpatients by British general practitioners. Psychiatr Serv1997;48(12):1586-8.
15. Carr VJ, Donovan P. Psychiatry in general practice. A pilotscheme using the liaison- attachment model. Med J Aust1992;156(6):379-82.
16. Carr VJ, Faehrmann C, Lewin TJ, Walton JM, Reid AA.Determining the effect that consultation-liaison psychiatryin primary care has on family physicians’ psychiatricknowledge and practice. Psychosomatics1997;38(3):217-29.
17. Carr VJ, Reid AL. Seeking solutions for mental healthproblems in general practice. Med J Aust1996;165(8):435-6.
18. Clare AW. Psychiatry in general practice [editorial]. J R Coll Gen Pract 1983;33(249):195-8.
19. College of Family Physicians of Canada. The relationshipbetween family physicians and specialists/consultants.Toronto: College of Family Physicians of Canada incollaboration with Royal College of Physicians andSurgeons of Canada; 1993.
20. Corney R. Developing mental health services in thecommunity: current evidence of the role of general practice teams. J R Soc Med 1994;87(7):408-10.
21. Corney RH. Links between mental health care professionals and general practices in England and Wales: the impact ofGP fundholding. Br J Gen Pract 1996;46(405):221-4.
22. Cornwall PL. Communication between generalpractitioners and child psychiatrists. BMJ1993;306(6879):692-3.
23. Craven MA, Allen CJ, Kates N. Community resources forpsychiatric and psychosocial problems. Family physicians’referral patterns in urban Ontario. Can Fam Physician1995;41:1325-35.
24. Craven MA, Cohen M, Campbell D, Kates N, Williams JI.Mental health practices of Ontario family physicians: astudy using qualitative methodology. North York, Ont:Institute for Clinical Evaluative Sciences in Ontario; 1996.
25. Craven MA, Handfield-Jones R. Shared mental health carein Canada. Making a joint effort to define our roles. CanFam Physician 1997;43:1785-6 (Eng); 1786-7 (Fr).
26. Creed F, Goldberg D. Students’ attitudes towardspsychiatry. Med Educ 1987;21:227-34.
27. Creed F, Gowrisunkur J, Russell E, Kincey J. Generalpractitioner referral rates to district psychiatry andpsychology services. Br J Gen Pract 1990;40:450-4.
28. Creed F, Marks B. Liaison psychiatry in general practice: acomparison of the liaison- attachment scheme and shiftedoutpatient clinic models. J R Coll Gen Pract1989;39(329):514-7.
29. Crews C, Batal H, Elasy T, Casper E, Mehler PS. Primarycare for those with severe and persistent mental illness.West J Med 1998;169(4):245-50.
30. Cummins RO, Smith RW, Inui TS. Communication failurein primary care. Failure of consultants to provide follow-up information. JAMA 1980;243:1650-2.
31. Davies JW, Ward WK, Groom GL, Wild AJ, Wild S. Thecase-conferencing project: a first step towards shared carebetween general practitioners and a mental health service.Aust N Z J Psychiatry 1997;31(5):751-5.
32. deGruy FVr. Coordinating mental health care: what matters most? [editorial; comment]. Gen Hosp Psychiatry1997;19(6):391-4.
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33. Dowrick C. Improving mental health through primary care. Br J Gen Pract 1992;42(362):382-6.
34. Engel CC, Kroenke K, Katon WJ. Mental health services in Army primary care: the need for a collaborative health care agenda. Mil Med 1994;159(3):203-9.
35. Falloon IR, Shanahan W, Laporta M, Krekorian HA.Integrated family, general practice and mental health carein the management of schizophrenia. J R Soc Med1990;83(4):225-8.
36. Ferguson B, Cooper S, Brothwell J, Markantonakis A, Tyrer P. The clinical evaluation of a new community psychiatricservice based on general practice psychiatric clinics. Br JPsychiatry 1992;160:493-7.
37. Ferguson BG, Varnam MA. The relationship betweenprimary care and psychiatry: an opportunity for change. BrJ Gen Pract 1994;44(388):527-30.
38. Fink PJ. Psychiatry and primary care: can a workingrelationship develop? Gen Hosp Psychiatry1985;7(3):205-9.
39. Fink PJ. Psychiatry and the primary care physician. HospCommunity Psychiatry 1985;36(8):870-5.
40. Fisher JV. Family practice, psychiatry, and psychosomaticmedicine: Quo vadis? [editorial]. Psychosomatics1980;21(1):6-7.
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