"I
just feel sad." "I want to kill my kids." "I don't know
what's wrong with me lately."
For primary care physicians like
Ottawa's Dr Barry Dworkin these types of statements
are common. Navigating the territory between these patients'
everyday stresses and mental health disorders can often
account for a large part of his day.
Many FPs across the country, like
Dr Dworkin, are expected to provide mental health counselling.
A shortage of psychiatrists, a fragmented system and
a lack of resources all contribute to the pressure placed
on family doctors to wear many different hats for their
patients. "The shortage of psychiatrists is a big problem,"
says Dr Dworkin. He believes that mental health counselling
has come to be expected of FPs as the scope of their
role is constantly stretched. With 8% of adults experiencing
major depression, 12% of the population being affected
by anxiety disorders and suicide accounting for 24%
of deaths among 15-to-24-year olds, the prevalence of
mental illness is unrelenting.
SHARE
THE (PATIENT) LOAD
It was in the face of this pressure that the term "shared
care" came into being in 1997 when the Canadian College
of Family Physicians and the Canadian Psychiatric Association
created the National Task Force on Shared Mental Health
Care. Their combined goal was to create a community
between FPs and psychiatrists to address the mental
health needs of patients. The shared care model is a
collaborative one that sees both primary care physicians
and psychiatrists working side-by-side. Another goal
was also to help lessen the load of expectations on
family physicians and increase patient access to mental
health services.
CLOSE
ENCOUNTERS
Approximately 40% of primary care patients have mental
health problems. FPs remain the first point of contact
for these patients and end up with the responsibility
of treating about 50% of all mental health problems.
FPs are often the first to notice
the signs of depression, anxiety, eating disorders,
bipolar disorders or suicidal behavior; usually because
of the close relationships they have with patients,
often established over a prolonged period of time.
Dr Dworkin knows this first hand.
He's been in practice for 15 years and has formed close
relationships with many of his patients. "I know a lot
of my patients, so I can tell when something is wrong,"
he says. "Other times they feel comfortable enough to
bring up the subject and talk to me about it."
The shame attached to mental health
disorders also prevents or delays patients from seeking
treatment. "There is definitely a stigma with mental
illness," says Dr Dworkin. "People feel they should
just suck it up and it goes untreated." But 87% of Canadians
visit their family doctor each year, putting the onus
on the physician to diagnose, as well as treat, the
problem.
The amount of time required by
family physicians to provide this extra service puts
added strain on their already tight schedules. Dr Dworkin
sees between 20 and 35 patients a day, but has made
it a policy to provide 30-minute appointments specifically
for counselling, when necessary. But he says that not
all doctors feel comfortable providing this service.
The shared care movement attempts
to create a network for doctors by improving communication
between the fields and providing mental health counsellors
to act as intermediaries. "Things aren't really changing,"
says Dr Dworkin. "We are still dealing with a healthcare
system that is unresponsive."
Long wait times are expected once
a family doctor does refer a patient to a psychiatrist,
creating further frustration on the part of both the
doctor and patient. Dr Dworkin thinks the most realistic
solution is to make psychiatrists available to FPs as
a resource or reference rather than referring their
patients.
"It comes down to a measure of
degree of the patient's disorder and the physician's
comfort in treating them," says Dr Dworkin. "It's always
in the back of your mind that there is no backup."
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