Background: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related str... more Background: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related stressors and experiences, and coping styles on the mental health trajectory of employed individuals during the lockdown are limited. The study examined the mental health trajectories of a sample of employed adults in Hamilton, Ontario during the initial lockdown and after the reopening following the first wave in Canada. Further, this study also identified the pandemic-related stressors and coping strategies associated with changes in depressive symptoms in employed adults during the COVID-19 pandemic. Methods: The InHamilton COVID-19 longitudinal study involved 579 employees aged 22-88 years from a large public university in an urban area of Hamilton, Ontario at baseline (April 2020). Participants were followed monthly with 6 waves of data collected between April and November 2020. A growth mixture modeling approach was used to identify distinct groups of adults who followed a similar pattern of depressive symptoms over time and to describe the longitudinal change in the outcome within and among the identified subgroups. Results: Our results showed two distinct trajectories of change with 66.2% of participants displaying low-consistent patterns of depressive symptoms, and 33.8% of participants displaying high-increasing depressive symptom patterns. COVID-19 pandemic-related experiences including health concerns, caregiving burden, and lack of access to resources were associated with worsening of the depressive symptom trajectories. Frequent use of dysfunctional coping strategies and less frequent use of emotion-focused coping strategies were associated with the high and increasing depressive symptom pattern.
This paper reviews the current state of Israel's mental health system during a period when it may... more This paper reviews the current state of Israel's mental health system during a period when it may be possible to bring about significant change. It analyses its strengths and weaknesses, including the heavy influence of the psychiatric hospital and the lack of necessary community programs. The author stresses the need for an integrated planning process, based upon a vision of what the mental health system should look like and who it should be serving, and discusses how this process could occur.
Objective: To document the number and pattern of psychiatric and psychosocial referrals to commun... more Objective: To document the number and pattern of psychiatric and psychosocial referrals to community resources by family physicians (FPs) and to determine whether referral practices correlate with physician variables. Design: Cross-sectional survey of referrals by FPs to 34 key psychiatric and psychosocial community resources identified by a panel of FPs, psychiatric social workers, psychiatric nurses, public health nurses, and the local community information service. Setting: Regional municipality of 434,000 persons in Ontario. Participants: Twenty-seven of 34 (79%) community agencies identified 261 FPs who made 4487 referrals to participating agencies (range 0 to 65, median 15, mean 17.19 +/- 13.42). Main outcome measures: Number of referrals to all agencies; variables, such as physician sex, school of graduation, year of graduation, and certificate status in the College of Family Physicians of Canada, related to referral patterns. Results: Referrals to outpatient psychiatric clinics, support services, and general counseling services accounted for 96% of all referrals. Physicians' average annual referral profile was as follows: 8.6 patients to a support service, 6.3 to an outpatient psychiatric service, 1.6 to a counseling service, and 0.46 to a substance abuse service. Referral profiles of individual physicians varied greatly. Female FPs made fewer referrals than male FPs to support services, but both made similar numbers of referrals to psychiatric, counseling, and substance abuse services. The more recent the year of graduation, the greater the number of referrals to psychiatric (r = 0.158, P = 0.0107) and counseling services (r = 0.137, P = 0.0272) and the higher the fraction of referrals to psychiatric services (r = 0.286, P = 0.0001). Conclusions: Family physicians in Hamilton-Wentworth made few referrals to psychiatric and psychosocial services. Only physician sex and year of graduation correlated significantly with numbers of referrals made. Recent graduates of both sexes made significantly more referrals to psychiatric clinics and counseling services than their older colleagues.
This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health ... more This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.
... Nick Kates, MB, FRCPC Marilyn Craven, MD, PHD, CCFP P resque deux ans apres la publication de... more ... Nick Kates, MB, FRCPC Marilyn Craven, MD, PHD, CCFP P resque deux ans apres la publication de l'enonce de prin-cipes conjoint de l'Association des psychiatres du Canada (APC) et du College des medecins de famille du Canada (CMFC) sur les soins de santementale ...
Objective: To review the ways attention deficit disorder (ADD) presents in adults in primary care... more Objective: To review the ways attention deficit disorder (ADD) presents in adults in primary care and to suggest treatment approaches. Sources of information: PsycINFO, PubMed, and Academic Search Elite databases were searched. Level I evidence supports the effectiveness of stimulants for treating ADD in adults, and mixed evidence (levels I and II) supports the effectiveness of antidepressants. Main message: Attention deficit disorder is a prevalent but often unrecognized disorder in adults. The diagnosis, which must include onset of symptoms before age 7, is often missed. This could be because family physicians are not always familiar with the presentation in adults, because it frequently presents with comorbid problems, or because specific questions are not asked to elicit the diagnosis. Diagnosis is based on clinical assessment often assisted by self-rating scales. Management includes support and education, helping patients develop additional structure in their lives and make necessary behavioural changes, enhancing self-esteem, supporting and educating families, and prescribing medication. Medication choices include stimulants and antidepressants; medication can benefit up to 60% of people with ADD. Conclusion: It is crucial for primary care physicians to identify ADD in adults and to initiate treatment or referral. Several simple interventions can be employed.
Canadian Journal of Dietetic Practice and Research, Jul 1, 2007
The Hamilton Health Service Organization Nutrition Program integrates nine registered dietitians ... more The Hamilton Health Service Organization Nutrition Program integrates nine registered dietitians (RDs) into the offices of 80 family physicians (FPs) at 50 sites in Hamilton, Ontario. The program is based on a shared care model, in which FPs and RDs work collaboratively to provide nutrition services aimed at prevention, treatment, and management of nutrition-related problems. In addition to their clinical role, dietitians in the program are involved in health promotion, disease prevention and early intervention strategies, interdisciplinary collaboration, building links with community services, and research. The RDs’ specialized knowledge, skills, and experience allow them to provide a wide range of services that complement and augment those of the FP. This model is consistent with Canadian health care reform recommendations and offers significant benefits for both health care providers and consumers.
A survey of 255 family physicians and general practitioners in the Hamilton-Wentworth area, revea... more A survey of 255 family physicians and general practitioners in the Hamilton-Wentworth area, revealed that knowledge of social services and community treatment programs was often poor: 65% of 122 respondents did not know about one or more points of access to social services information, and 26% reported that they knew of appropriate social services for less than half of 13 psychosocial problems commonly encountered in family practice. Although 43% indicated that they preferred to treat patients themselves, 47% agreed that lack of information precluded referral, and 75% agreed that opportunities to increase their knowledge of community services would be helpful.
Canadian Journal of Disability Studies, Jan 18, 2013
The debate persists in disability studies about the best ways to learn more about the experience ... more The debate persists in disability studies about the best ways to learn more about the experience and consequences of disability. Various research approaches have held sway over the years, but a favoured approach at present appears to be emancipatory research. Due to numerous critiques and caveats, emancipatory research has been referred to as an "impossible dream". In this paper we offer a way of satisfying the ideological principles of emancipatory research that upholds the highest standards of evidence and policy relevance. It is derived from continuing quality improvement in health care, and is referred to as the Learning Collaborative. We offer an example of the Learning Collaborative approach as it was used in Ontario Canada to improve accessibility in primary care settings. The Learning Collaborative approach is evaluated against criteria for collaboration in disability studies, and found to embrace many of the principles of emancipatory research, specifically: a focus on barrier removal, consumer-researcher collaborations at every stage, and a focus on the priorities of the disability community. In addition, it adds a level of scientific rigour through the use of evidence-based policy analysis and scoping methodology.
Objective: To determine whether health care providers are satisfied with an integrated program of... more Objective: To determine whether health care providers are satisfied with an integrated program of mental health care. Design: Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions. Setting: Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization's Mental Health Program. Participants: Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings. Main outcome measure: Satisfaction as shown on 5-point Likert scales. Results: High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication. Conclusion: Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.
International Journal of Integrated Care, May 16, 2022
Background: Patients and families are often referred to as important partners in collaborative me... more Background: Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders. Methods: We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings. Findings: We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs. Limitations: Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed. Conclusion: Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient-and family-centeredness of collaborative care.
Background: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related str... more Background: Longitudinal studies examining the impact of changes in COVID-19 pandemic-related stressors and experiences, and coping styles on the mental health trajectory of employed individuals during the lockdown are limited. The study examined the mental health trajectories of a sample of employed adults in Hamilton, Ontario during the initial lockdown and after the reopening following the first wave in Canada. Further, this study also identified the pandemic-related stressors and coping strategies associated with changes in depressive symptoms in employed adults during the COVID-19 pandemic. Methods: The InHamilton COVID-19 longitudinal study involved 579 employees aged 22-88 years from a large public university in an urban area of Hamilton, Ontario at baseline (April 2020). Participants were followed monthly with 6 waves of data collected between April and November 2020. A growth mixture modeling approach was used to identify distinct groups of adults who followed a similar pattern of depressive symptoms over time and to describe the longitudinal change in the outcome within and among the identified subgroups. Results: Our results showed two distinct trajectories of change with 66.2% of participants displaying low-consistent patterns of depressive symptoms, and 33.8% of participants displaying high-increasing depressive symptom patterns. COVID-19 pandemic-related experiences including health concerns, caregiving burden, and lack of access to resources were associated with worsening of the depressive symptom trajectories. Frequent use of dysfunctional coping strategies and less frequent use of emotion-focused coping strategies were associated with the high and increasing depressive symptom pattern.
This paper reviews the current state of Israel's mental health system during a period when it may... more This paper reviews the current state of Israel's mental health system during a period when it may be possible to bring about significant change. It analyses its strengths and weaknesses, including the heavy influence of the psychiatric hospital and the lack of necessary community programs. The author stresses the need for an integrated planning process, based upon a vision of what the mental health system should look like and who it should be serving, and discusses how this process could occur.
Objective: To document the number and pattern of psychiatric and psychosocial referrals to commun... more Objective: To document the number and pattern of psychiatric and psychosocial referrals to community resources by family physicians (FPs) and to determine whether referral practices correlate with physician variables. Design: Cross-sectional survey of referrals by FPs to 34 key psychiatric and psychosocial community resources identified by a panel of FPs, psychiatric social workers, psychiatric nurses, public health nurses, and the local community information service. Setting: Regional municipality of 434,000 persons in Ontario. Participants: Twenty-seven of 34 (79%) community agencies identified 261 FPs who made 4487 referrals to participating agencies (range 0 to 65, median 15, mean 17.19 +/- 13.42). Main outcome measures: Number of referrals to all agencies; variables, such as physician sex, school of graduation, year of graduation, and certificate status in the College of Family Physicians of Canada, related to referral patterns. Results: Referrals to outpatient psychiatric clinics, support services, and general counseling services accounted for 96% of all referrals. Physicians' average annual referral profile was as follows: 8.6 patients to a support service, 6.3 to an outpatient psychiatric service, 1.6 to a counseling service, and 0.46 to a substance abuse service. Referral profiles of individual physicians varied greatly. Female FPs made fewer referrals than male FPs to support services, but both made similar numbers of referrals to psychiatric, counseling, and substance abuse services. The more recent the year of graduation, the greater the number of referrals to psychiatric (r = 0.158, P = 0.0107) and counseling services (r = 0.137, P = 0.0272) and the higher the fraction of referrals to psychiatric services (r = 0.286, P = 0.0001). Conclusions: Family physicians in Hamilton-Wentworth made few referrals to psychiatric and psychosocial services. Only physician sex and year of graduation correlated significantly with numbers of referrals made. Recent graduates of both sexes made significantly more referrals to psychiatric clinics and counseling services than their older colleagues.
This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health ... more This paper describes a program in Hamilton-Wentworth, Ontario, Canada, that brings mental health counselors and psychiatrists into the offices of 87 local family physicians, working in 35 practices serving 170,000 people. It outlines the organization of the mental health teams in the family physician's office and the way in which these teams are coordinated and discusses how this "shared care" approach can overcome many of the problems that traditionally bedevil the relationship between psychiatric services and family practices. It summarizes the benefits of this approach for patients providers and the health care system and looks at its implications for learners and for new approaches to continuing education. This model can be adapted to most communities.
... Nick Kates, MB, FRCPC Marilyn Craven, MD, PHD, CCFP P resque deux ans apres la publication de... more ... Nick Kates, MB, FRCPC Marilyn Craven, MD, PHD, CCFP P resque deux ans apres la publication de l'enonce de prin-cipes conjoint de l'Association des psychiatres du Canada (APC) et du College des medecins de famille du Canada (CMFC) sur les soins de santementale ...
Objective: To review the ways attention deficit disorder (ADD) presents in adults in primary care... more Objective: To review the ways attention deficit disorder (ADD) presents in adults in primary care and to suggest treatment approaches. Sources of information: PsycINFO, PubMed, and Academic Search Elite databases were searched. Level I evidence supports the effectiveness of stimulants for treating ADD in adults, and mixed evidence (levels I and II) supports the effectiveness of antidepressants. Main message: Attention deficit disorder is a prevalent but often unrecognized disorder in adults. The diagnosis, which must include onset of symptoms before age 7, is often missed. This could be because family physicians are not always familiar with the presentation in adults, because it frequently presents with comorbid problems, or because specific questions are not asked to elicit the diagnosis. Diagnosis is based on clinical assessment often assisted by self-rating scales. Management includes support and education, helping patients develop additional structure in their lives and make necessary behavioural changes, enhancing self-esteem, supporting and educating families, and prescribing medication. Medication choices include stimulants and antidepressants; medication can benefit up to 60% of people with ADD. Conclusion: It is crucial for primary care physicians to identify ADD in adults and to initiate treatment or referral. Several simple interventions can be employed.
Canadian Journal of Dietetic Practice and Research, Jul 1, 2007
The Hamilton Health Service Organization Nutrition Program integrates nine registered dietitians ... more The Hamilton Health Service Organization Nutrition Program integrates nine registered dietitians (RDs) into the offices of 80 family physicians (FPs) at 50 sites in Hamilton, Ontario. The program is based on a shared care model, in which FPs and RDs work collaboratively to provide nutrition services aimed at prevention, treatment, and management of nutrition-related problems. In addition to their clinical role, dietitians in the program are involved in health promotion, disease prevention and early intervention strategies, interdisciplinary collaboration, building links with community services, and research. The RDs’ specialized knowledge, skills, and experience allow them to provide a wide range of services that complement and augment those of the FP. This model is consistent with Canadian health care reform recommendations and offers significant benefits for both health care providers and consumers.
A survey of 255 family physicians and general practitioners in the Hamilton-Wentworth area, revea... more A survey of 255 family physicians and general practitioners in the Hamilton-Wentworth area, revealed that knowledge of social services and community treatment programs was often poor: 65% of 122 respondents did not know about one or more points of access to social services information, and 26% reported that they knew of appropriate social services for less than half of 13 psychosocial problems commonly encountered in family practice. Although 43% indicated that they preferred to treat patients themselves, 47% agreed that lack of information precluded referral, and 75% agreed that opportunities to increase their knowledge of community services would be helpful.
Canadian Journal of Disability Studies, Jan 18, 2013
The debate persists in disability studies about the best ways to learn more about the experience ... more The debate persists in disability studies about the best ways to learn more about the experience and consequences of disability. Various research approaches have held sway over the years, but a favoured approach at present appears to be emancipatory research. Due to numerous critiques and caveats, emancipatory research has been referred to as an "impossible dream". In this paper we offer a way of satisfying the ideological principles of emancipatory research that upholds the highest standards of evidence and policy relevance. It is derived from continuing quality improvement in health care, and is referred to as the Learning Collaborative. We offer an example of the Learning Collaborative approach as it was used in Ontario Canada to improve accessibility in primary care settings. The Learning Collaborative approach is evaluated against criteria for collaboration in disability studies, and found to embrace many of the principles of emancipatory research, specifically: a focus on barrier removal, consumer-researcher collaborations at every stage, and a focus on the priorities of the disability community. In addition, it adds a level of scientific rigour through the use of evidence-based policy analysis and scoping methodology.
Objective: To determine whether health care providers are satisfied with an integrated program of... more Objective: To determine whether health care providers are satisfied with an integrated program of mental health care. Design: Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions. Setting: Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization's Mental Health Program. Participants: Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings. Main outcome measure: Satisfaction as shown on 5-point Likert scales. Results: High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication. Conclusion: Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.
International Journal of Integrated Care, May 16, 2022
Background: Patients and families are often referred to as important partners in collaborative me... more Background: Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders. Methods: We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings. Findings: We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs. Limitations: Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed. Conclusion: Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient-and family-centeredness of collaborative care.
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