Canadian Rural/Remote Primary Care Physicians Perspectives on Child/Adolescent Mental Health Care Service Delivery.

INTRODUCTION: Primary Care Physicians (PCP) play a key role in the recognition and management of child/adolescent mental health struggles. In rural and under-serviced areas of Canada, there is a gap between child/adolescent mental health needs and service provision. METHODS: From a Canadian national needs assessment survey, PCPs' narrative comments were examined using quantitative and qualitative approaches. Using the phenomenological method, individual comments were drawn upon to illustrate the themes that emerged. These themes were further analyzed using chi-square to identify significant differences in the frequency in which they were reported. RESULTS: Out of 909 PCPs completing the survey, 39.38% (n = 358) wrote comments. Major themes that emerged were: 1) psychiatrist access, including issues such as long waiting lists, no child/adolescent psychiatrists available, no direct access to child/adolescent psychiatrists; 2) poor communication/continuity, need for more systemized/transparent referral processes, and need to rely on adult psychiatrists; and, 3) referral of patients to other mental health professionals such as paediatricians, psychologists, and social workers. CONCLUSIONS: Concerns that emerged across sites primarily revolved around lack of access to care and systems issues that interfere with effective service delivery. These concerns suggest potential opportunities for future improvement of service delivery. IMPLICATIONS: Although the survey only had one comment box located at the end, PCPs wrote their comments throughout the survey. Further research focusing on PCPs' expressed written concerns may give further insight into child/adolescent mental health care service delivery systems. A comparative study targeting urban versus rural regions in Canada may provide further valuable insights.

INTRODUCTION: Les médecins de soins de première ligne (MSPL) jouent un rôle essentiel dans la reconnaissance et la prise en charge des problèmes de santé mentale des enfants/adolescents. Dans les régions rurales et sous-desservies du Canada, il y a un écart entre les besoins de santé mentale des enfants/adolescents et la prestation de services. MÉTHODES: Tirés d'un sondage canadien national évaluant les besoins, les commentaires narratifs des MSPL ont été examinés à l'aide d'approches quantitatives et qualitatives. Au moyen de la méthode phénoménologique, les commentaires individuels ont servi à illustrer les thèmes dégagés. Ces thèmes ont ensuite été analysés avec le chi-carré afin d'identifier les différences significatives de la fréquence à laquelle ils étaient mentionnés. RÉSULTATS: Sur les 909 MSPL qui ont répondu au sondage, 39,38% (n = 358) ont écrit des commentaires. Les thèmes majeurs qui se sont dégagés étaient: 1) l'accès aux psychiatres, notamment des questions comme les longues listes d'attente, pas de pédopsychiatres disponibles, pas d'accès direct aux pédopsychiatres; 2) mauvaise communication/continuité, besoin de processus plus nombreux d'aiguillage systémique/transparent, et besoin de consulter des psychiatres pour adultes; 3) adresser les patients à d'autres professionnels de la santé comme les pédiatres, les psychologues et les travailleurs sociaux. CONCLUSIONS: Les préoccupations soulevées dans les divers centres s'articulaient autour de l'accès aux soins et des problèmes des systèmes qui empiètent sur la prestation efficace de services. Ces préoccupations suggèrent des possibilités pour l'amélioration future de la prestation de services. Implications: Bien que le sondage n'ait offert qu'un espace pour les commentaires à la fin, les MSPL ont écrit leurs commentaires sur tout le sondage. D'autres recherches portant sur les commentaires écrits des MSPL peuvent offrir d'autres idées sur les systèmes de prestation de services de santé mentale aux enfants/adolescents Une étude comparative ciblant les régions urbaines par rapport aux régions rurales du Canada peut fournir un apport valable.

Referral Patterns and Training Needs in Psychiatry among Primary Care Physicians in Canadian Rural/Remote Areas.

OBJECTIVES: This study examined the referral patterns of rural/remote primary care physicians (PCPs) as well as their needs and interests for further training in child/adolescent mental health. METHODS: Surveys were mailed to Canadian rural/remote PCPs requesting participants' demographic information, training and qualifications, referral patterns, and identification of needs and interests for continuing medical education (CME). RESULTS: PCPs were most likely to refer to mental health programs, and excessive wait times are the most common deterrent. Major reasons for referral were to obtain recommendations regarding medications and assessing non-responsive patients. While PCPs expressed higher levels of confidence in making appropriate referrals, they were much less confident in their knowledge and skills in managing mental health problems. Professional development in child/adolescent psychiatry is a moderate or highly perceived CME need. Overall, attention deficit/hyperactivity disorder (ADHD) was the most commonly chosen topic of interest and CME in the community was preferred, but some regional differences emerged. CONCLUSIONS: PCPs viewed limited community resources and self-identified gaps in skills as barriers to service provision. Professional development in child and adolescent mental health for PCPs by preferred modes appears desired.

Survey Comparing Criteria Used by Rural and Urban Primary Care Physicians for Referrals to Child and Adolescent Psychiatrists and Children's Mental Health Agencies in Ontario.

INTRODUCTION: Primary care physicians are the first-line assessors of children's mental health. Previous studies have shown a trend of over-reliance on referrals to child and adolescent psychiatrists and an underutilization of children's mental health agencies. A survey was conducted to a) examine the criteria used by family physicians and primary-care paediatricians in deciding how to refer youth to mental health services, and b) assess interest in developing a set of formal guidelines outlining when to consider referral to child and adolescent psychiatrists and children's mental health agencies. METHOD: A mail-out survey was conducted using elements of the Dillman method. Two regions in Ontario were surveyed, Northwestern Ontario and Middlesex County, allowing for comparison between rural and urban settings. RESULTS: Of the 266 physicians eligible for the study, 116 returned completed surveys, for a response rate of 40%. Awareness and utilization of children's mental health agencies was higher than predicted in both regions. A number of referral trends were identified. A majority of respondents in both regions indicated that they would like a standardized protocol and/or guidelines when referring to both psychiatrists and children mental health agencies. CONCLUSION: This study demonstrated that, in addition to referring to child and adolescent psychiatrists, the majority of primary care physicians are aware of and utilize children's mental health agencies in Ontario.

Teaching children's mental health to family physicians in rural and under serviced areas.

OBJECTIVE: To evaluate a curriculum for teaching family physicians (FPs) in rural and underserviced areas about children's mental health, and to evaluate a collaborative model of teaching using child psychiatrists and FPs. METHODS: A child psychiatrist and a rural FP provided training to rural FPs in attention-deficit/hyperactivity disorder (ADHD) and disruptive behaviour disorders (DBDs). Training consisted of a half-day workshop in 11 communities located in southwestern Ontario. Workshops included didactic teaching, observation of standardized videos demonstrating interviewing skills, and interactive discussion. Participants completed pre- and posttraining questionnaires about their confidence in managing these conditions, and completed standardized questionnaires on the effectiveness of the workshop and videos. One month after the training, participants were randomly assigned to receive individual interviews. Three months later 2 questionnaires were mailed to participants for evaluation of their confidence after their training and for evaluation of the impact on their practice. RESULTS: Fifty-six FPs attended the workshops and, of these, 80% completed the study. Family physicians reported improved confidence in their abilities to diagnose and treat ADHD and DBDs after the training. CONCLUSION: Didactic presentations by child psychiatrists and FPs, followed by video examples of interviewing skills, and informal discussions with small groups, was found to be an effective curriculum for teaching rural FPs about children's mental health.

Survey of rural family physician-obstetricians in Southwestern Ontario.

INTRODUCTION: The objectives of this paper are 1) to analyze the characteristics of rural physicians who currently practise obstetrics, their training background and the environment in which they work and 2) to develop strategies to sustain rural obstetrical services. METHODS: Information was gathered using both a survey and brief individual interviews. PARTICIPANTS: A survey was sent to 56 family physicians who currently practise obstetrics,as well as those who had stopped within the past 2 years, in the Southwestern Ontario communities of Clinton, Goderich, Hanover, Kincardine, Markdale, Mount Forest, Palmerston, Walkerton, Wiarton and Wingham. RESULTS: Forty-four physicians responded to the survey. Results indicate that current obstetrical training programs are lacking in the following areas: the provision of positive role models/mentors, rural placements, experience in complex decision-making, and instilling confidence in graduates. Physicians appear to be internally motivated to practise obstetrics, claiming it is important to their professional goals and personal values. Support systems of colleagues, nursing staff, administration, family and friends, were identified as vital components of a successful obstetrical program. CONCLUSION: Educators are advised to identify students with an internal motivation to practise rural obstetrics early in their medical training and provide them with mentors, rural placements, confidence and experience in complex decision-making.