Abstract
Aim: Esperance is a geographically isolated community of 17,000 individuals 780 kilometres SE of Perth. A visiting psychiatric service started 6 years ago and is based in the local Community Health Centre. The service uses the existing primary and community care infrastructure with GPs and community mental health nurses (CMHNs) largely providing psychiatric care. A CMHN usually assesses all patients referred to the service. Patients are then: 1) managed by the CMHN in liaison with the referring agency, usually the GP; 2) referred on to other agencies or; 3) booked in to see the visiting psychiatrist. This study describes the characteristics of patients seen by the visiting psychiatrist between 1993 and 1999, and assesses GP's satisfaction with the service in the first year of operation.
Method: The following data were collected on all patients referred to the visiting psychiatrist from 1993 to 1999: social/demographic characteristics, DSM diagnosis, ICD code, referrer, management and the number of missed appointments. Data were collected prospectively and diagnoses made according to DSM criteria by a single rater to ensure consistency. In the first year, a questionnaire was sent to all local GPs asking about their satisfaction with the service.
Results: Data were collected on 360 individuals, two-thirds being female (N = 224). Ages ranged from 15 to 79 with an average of 39 years. Just under a one third of patients had a primary diagnosis of affective disorder (N = 110), followed by 22% with schizophrenia (N = 79). Adjustment disorders, V codes and other diagnoses accounted for just under 20%. Other conditions were much less common and included personality disorder (11%), anxiety disorder (8%), substance use (4%) and organic mental disorder (4%). 30% were prescribed no medication. Of the rest, 40% of the sample were prescribed a new antidepressant such as an SSRI, SNRI, or reversible monoamine oxidase inhibitor. Only 8% were prescribed a tricyclic antidepressant. In 7%, antidepressant therapy was augmented with a mood stabiliser, most commonly Lithium. 10% were receiving an antipsychotic, being a conventional oral or depot preparation in the vast majority of cases. Only 2% were receiving an atypical neuroleptic. Of other interventions, 40% were seen for assessment, one third for supportive psychotherapy or counselling, and 7% were referred for cognitive behavioural therapy. Another 7% were offered family or marital interventions. Only 10% failed to attend for their appointment. GPs were highly satisfied with their access to the service, as well as the promptness and usefulness of information provided.
Conclusions: A consultation-liaison service by a visiting psychiatrist is highly effective for delivering specialist services. Case-mix was similar to Broken Hill in NSW, but in contrast to metropolitan services in Perth, affective disorders were more common than schizophrenia. The wide range of diagnoses and ages seen suggests that such settings may be particularly appropriate for psychiatric training and that the growing sub-specialisation of psychiatry in metropolitan practice may be inappropriate for rural and regional settings. The small number of patients on an atypical antipsychotic in comparison to those on conventional agents may be of concern.