Psychiatry, today more than ever, is faced with great challenges and pressures. Social forces and society’s needs play a tremendous role in creating and channelling these pressures,1–4 and it is important to examine these needs to determine what is required for optimal functioning of the system.
A definition is in order here: “Psychiatry is the medical specialty which detects, diagnoses through a medical examination, treats, follows up partially treated patients, and, where possible, prevents diseases (disorders) of the mind (psyche) and brain and all organ systems which interrelate to these.”5 This definition cites the trail from a patient’s admission to being a psychiatric patient (the mentally ill “sick role”) and stresses the medical examination — the gatekeeper for individual diagnosis and treatment plans.6–8
The University of Ottawa model for obtaining the spectrum of psychiatric services needed for a defined population
On joining the department of psychiatry of the then-young University of Ottawa faculty of health sciences on Jan. 1, 1972, the inadequacies and absence of both vital and desirable psychiatric services and the small number of personnel were all too evident. The services were very small relative to the size, nature and demand of the population. Many services were token (e.g., staffed by 1 psychiatrist) or non-existent. The psychiatrists and services were funded by Ontario’s Health Insurance Program (OHIP), which provides universal coverage to all.
Chiefs of Psychiatry Committee
Dr. Charles Roberts had already formed a small committee of the heads of each psychiatric teaching unit to assess their needs. Ottawa, Canada’s capital, is the second largest city in Ontario and sits on the Ontario–Quebec border. It has a bilingual population (one-third French speaking) and excellent relations with the city of Hull, Que., across the Ottawa River. At the time, federal government employees accounted for 40% of the working population, and Ottawa possessed a large percentage of middle class, university-educated people who were used to and expected individual and personalized medical services. In collaboration with Dr. Roberts, I chaired this committee after 1972, with a much expanded philosophy and objectives.9–12 When I succeeded him as chairman of the Department of Psychiatry in 1974, and with the dean of the medical school’s approval, I oversaw the development of the psychiatric health services delivery system for the entire region, as well as the needed complements of the medical school for this purpose.
As chair of the Department of Psychiatry, I recruited massively to create and staff the departments needed to function properly. The vision was to have every subspecialty of psychiatry filled with adequate numbers of clinical, investigative, research and rehabilitative psychiatrists and research and teaching personnel.9–24 Eighty percent of the recruits were graduates of Canadian universities. Twenty percent were excellent foreign clinicians and research personnel, several of international repute. They came from the United States, Great Britain, Ireland and many European countries. Many Spanish-speaking colleagues were from South and Central America, as well as Spain. A strong group came from Australia, New Zealand and the Far East, as well as from the Middle East. The Royal College of Physicians and Surgeons of Canada granted specialty status in psychiatry for the senior, highly qualified university professors, and the College of Physicians and Surgeons of Ontario granted licences to our foreign professors to practise medicine in university teaching hospitals. Our catchment area of more than 2 million people, from Brockville to James Bay in the North and Quebec in the East, needed these specialists, particularly for individual psychotherapy.
The Pierre Janet Hospital in Hull was an integral French-language part of our 4-year Psychiatry Residency Program. We obtained needed special funding for French-language psychiatric services. For the “one-of-a-kind services,” a unique, expert Forensic Psychiatry Unit was formed in a university hospital with 16 full-time forensic psychiatrists.12 We also established the Family Court Clinic; at the opening on July 28, 1978, I spoke, along with the then Minister of Health Keith C. Norton and the President of the Board of the Royal Ottawa Hospital, Mrs. Jacqueline Holtzman. The Child Psychiatric Department’s 32-bed housing unit (planned by Dr. Roberts) was now built,11 and the Alcoholic and Addictions Unit was fully staffed from its previous 1 psychiatric consultant.9,10 The only Inpatient Geriatric Psychiatric Unit was developed at the Royal Ottawa Hospital and fully staffed with geriatric psychiatrists, nurses and specialized personnel.25
Later, a special intermediate-length psychiatric treatment program for schizophrenia, with 29 long-term beds, was formed.
At the Ottawa General Hospital (my university department headquarters) within the new Health Sciences complex, we developed a modern, strikingly beautiful panoply of psychiatric services,9 including inpatient,26 day and night beds, as well as the most elaborate and structured treatment, research and teaching psychiatric outpatient clinics.27–30 Our Psychophysiology and Sleep Research Unit was developed,1 and a specialized Bilingual Outpatient Psychogeriatric Program was established in some older renovated houses in the downtown area. The Outpatient Bilingual (English–French) Family and Child Program, in an adjacent house,9–11 offered a French Day Hospital and School Treatment Program for French-speaking adolescents, too ill for normal schooling, who received their education and therapy there.
The Civic Hospital Psychiatric Unit had only 1 or 2 full-time psychiatric teachers and depended on its voluntary teachers for the rest. I added 5 full-time positions to this and increased the number of residents significantly. This enhanced the excellent work that had always been done there and enabled clinical and basic research to thrive.
The building of the new children’s hospital in Ottawa, the Children’s Hospital of Eastern Ontario, permitted the completion of the rest of our child psychiatry plan with the opening of the Child Psychiatry Unit and new inpatient child psychiatry beds and outpatient clinics. We moved from 3 to 15 full-time and many part-time child psychiatrists.
A division of child and adolescent psychiatry, the first division in psychiatry in this medical school, was formed to unite the work and research of the 4 child and adolescent units in the Department of Psychiatry (i.e., those of the Royal Ottawa Hospital, the Children’s Hospital of Eastern Ontario, the Outpatient Child and the French Adolescent Day Hospital of the Ottawa General Hospital and the French-language Pierre Janet Hospital in Hull).2,11 Over time, the number of child psychiatrists went from 3 to some 85, of whom 65 were in university departments and 15 plus worked in the community.
From an original number of approximately 26, we were training up to 65 residents and fellows in our fourth-year residency and fifth-year specialized fellowships (research, psychopharmacology, child psychiatry, forensic psychiatry, psychogeriatrics, alcohol and addictions, psychotherapy, and psychoanalysis, the latter through the Ottawa branch of the Canadian Psychoanalytic Institute).
It was our accurate boast that all patients with schizophrenia in the Ottawa area,3,4,6,11,12,16,20–22 along with patients suffering from other psychoses, had an individual psychiatrist responsible for their treatment and follow-up. These resources were largely the result of our University of Ottawa model.
Footnotes
This text is an abbreviated version of a presentation given at a symposium on Health Care Systems of Management, Chair, G.J. Sarwer-Foner, at the 16th meeting of the World Association of Social Psychiatry, Aug. 18, 1998, Vancouver, BC. The complete unedited version of the presentation may be found at www.cma.ca/jpn
Medical subject headings: health facilities; health personnel; health services; health services needs and demands; history of medicine, 20th century; hospitals, psychiatric; mental health services; psychiatry.
Competing interests: None declared.