Gold Award: Confronting Mood Disorders Through Clinical Care, Research, and Education

In facing the challenge to grow beyond their traditional role of custodial care, psychiatric hospitals supported by states or provinces have found many creative ways to broaden their mission and extend their services to a wider community. The McMaster Regional Mood Disorders Program of Hamilton Psychiatric Hospital in Hamilton, Ontario, provides an excellent example of success in this continuing process of development. In the relatively short period since its inception in 1994, the program has brought together public and private resources to shift the treatment of mood disorders from an inpatient focus to a comprehensive approach that blends a continuum of treatment services with the academic enterprises of research and education.

The McMaster Regional Mood Disorders Program provides comprehensive and individualized assessment, treatment, and rehabilitation for patients with mood disorders across the Central West region of Ontario. The program is affiliated with the department of psychiatry and behavioral neurosciences at McMaster University Faculty of Health Sciences in Hamilton, Ontario, and is based at the 211-bed Hamilton Psychiatric Hospital, a provincially owned and operated facility.

The program's core service components—a 14-bed inpatient unit and extensive outpatient services, including a day hospital-community integration program and several outpatient clinics located at the hospital and at satellite sites in the community—are built on a strong academic foundation of research and education. The program's research component ranges from basic sciences to investigation of novel treatment and service delivery models. The nationally recognized education component includes a toll-free telephone line that provides expert information on mood disorders to health care professionals and the general public. The program provides consultation services to community psychiatrists, family physicians, and other health care providers and fosters the relationship between academic health care and practice through its ongoing commitment to education, research, and evaluation.

In recognition of its achievement in melding academic enterprise with clinical services, which has resulted in enhanced quality of care for patients with mood disorders, the McMaster Regional Mood Disorders Program was selected as one of two winners of the Gold Achievement Award for 1998. The award is presented annually by the American Psychiatric Association to recognize outstanding programs for mentally ill and developmentally disabled persons. It includes a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals Group.

The McMaster Regional Mood Disorders Program was selected as the award winner in the category of large academically or institutionally sponsored programs. The winner of the award for small community-based programs is described in a separate article on page 1338. The awards were presented on October 2 during the opening session of the Institute on Psychiatric Services in Los Angeles.

Program development and organization

In 1993 the affective disorders program of Hamilton Psychiatric Hospital consisted of a 32-bed inpatient unit with a small outpatient service and limited linkages to the surrounding community. The service had limited academic productivity and potential for attracting, training, and retaining expert health care professionals.

In the fall of 1994 Russell T. Joffe, M.D., F.R.C.P.(C.), then chairman of the department of psychiatry at McMaster University Faculty of Health Sciences, who had recently been appointed chief of psychiatry at Hamilton Psychiatric Hospital, initiated a substantial restructuring of the affective disorders program on an academic foundation to form the Regional Mood Disorders Program.

During 1994-1995 a multidisciplinary treatment model was adopted and an outpatient clinic was developed at the hospital. Effort was increased to strengthen the program's academic orientation by developing an infrastructure for research at the hospital, whose nonmedical staff had limited background in research.

The following year, outpatient clinics were established at satellite sites in the community. A day hospital and transition team were established to assist in bridging patients back to their communities. Public and private industry funding was secured to develop the program's telephone information line, DIRECT (Depression Information Resource and Education Centre, Toll-Free). In May 1996, the information line was launched and received a flood of more than 12,000 calls from across Ontario in the first month alone.

During 1996-1997 the satellite clinics expanded services to underserved areas, and the information line was expanded to be toll-free nationwide.

A community advisory committee of family members was actively involved in planning during the program's development and continues to meet as a resource for further development.

Service delivery

The program's service delivery model has three main thrusts: clinical care, education, and research. Activities in these three areas are overseen by program director L. Trevor Young, M.D., Ph.D., F.R.C.P.(C.).

Clinical care

Assessment and treatment follow a broad-based biopsychosocial model driven by consumers' needs. Program manager Ron Dolson, B.A., a social worker, ensures that the program is easily accessible to practitioners, social agencies, and consumers. The service components have strategies in place for ongoing program evaluation. Referral sources and clients are asked to rate their satisfaction with treatment. In awarding the program full accreditation, the Canadian Council of Health Services Accreditation recognized its client-centered approach and use of rigorous quality improvement techniques in its everyday work.

The program offers a full range of services, including inpatient psychiatric hospital care, outpatient services provided at the hospital mood disorders clinic, and consultation to community psychiatrists, family physicians, and other health care providers.

The day hospital-community integration program has the capacity to serve 80 clients who stay with the program an average of six months. Satellite outpatient clinics are available at four sites in Hamilton, Haldimand County, and Niagara County. Case management services are provided for a selected group of clients.

Before the hospital's affective disorders program was restructured as the mood disorders program, referrals came almost exclusively from psychiatrists or other psychiatric institutions within the Hamilton-Wentworth district. The program now receives referrals from a network of providers, including primary care providers, outpatient clinics, and social agencies and from clients themselves from across the Central West Ontario region, which has a population of 1.6 million.

Staff roles that were in place before the program started have been restructured such that the same number of staff are able to treat many more patients more efficiently. Services are provided by 53 full-time-equivalent staff members, including representatives of the major treatment disciplines of psychiatry, nursing, social work, psychology, occupational therapy, vocational rehabilitation, and recreation therapy, as well as clerical support and data management staff.

The program's success in shifting from the traditional custodial model of care to a progressive and academically grounded service delivery system is reflected in changes in service utilization data between 1993 and 1997. Hospital staff provided 2,451 new consultations for community providers in 1996-1997, compared with 50 in 1993-1994. The number of registered and active outpatients increased from 137 in 1993-1994 to 654 in 1996-1997, and the number of inpatient beds decreased from 32 to 12. Inpatient length of stay decreased from 730 days in 1993-1994 to only 49 days in 1996-1997.

Research

The McMaster Regional Mood Disorders Program has developed an infrastructure to support high-productivity research within its clinical units and has fostered an organizational culture in which representatives of the many clinical disciplines are involved in research. The overall objectives of the research component are to define the basic pathophysiology of mood disorders, to delineate the clinical course and outcome in both unipolar and bipolar disorders, and to identify treatment strategies that benefit individuals with mood disorders.

The research component represents a strong integration of biological and clinical research. The research manager, Janine Robb, R.N., B.Sc.N., in collaboration with Dr. Young, program director, and Dr. Joffe, senior consultant, is responsible for the development, implementation, and evaluation of program-based research projects. Molecular biologists interact with psychosocial researchers within a collaborative model that encompasses a full spectrum of investigation from laboratory work to bedside process.

Recent projects have included inpatient and outpatient pharmaceutical trials, psychotherapeutic trials, a study of rapid transcranial magnetic stimulation, and a study of patients' quality of life. Longitudinal follow-up studies use psychosocial, psychological, and biological outcome measures. The extensive research component has fostered community awareness of the mandate of the mood disorders program, resulting in a steady availability of clients for particular studies.

Information from the research component has been regularly presented at major psychiatric meetings in both Canada and the United States and has been published in several psychiatric journals. Recently the Stanley Foundation recognized the McMaster Regional Mood Disorders Program as one of its international research centers. The program is the first Canadian site to be so designated.

Education

Education of health care providers and consumers is an integral part of the McMaster Regional Mood Disorders Program. The education component's major feature is the toll-free telephone line, DIRECT, which connects callers to recorded messages providing expert medical information on mood disorders. The information line was founded by Dr. Joffe, now dean of McMaster University Faculty of Health Sciences, and Anthony Levitt, M.B.B.S., F.R.C.P.(C.), now of the University of Toronto. The line was developed by Gloria O. Kain, M.H.A., and was launched in the spring of 1996 to deal with ongoing requests from physicians and the general public for information about the constantly changing field of mood disorders. The coordinator of the program since its inception is Michael Quinn, M.H.A.

The goal of this component is to improve the rate of early diagnosis and effective treatment of mood disorders through the provision of immediate access to expert information. The information line is funded with a combination of public and private industry resources. The Canadian toll-free number to gain access to the public line is 888-557-5051, extension 8000. The line for physicians is reached by calling 888-557-5050, extension 800. DIRECT's Web site is located at http://www-fhs.mcmaster.ca/direct.

The physicians' phone line offers three and a half hours of recorded information about features of mood disorders and medication and treatments issues. An information officer is available to answer questions about the recorded messages and record comments and questions.

The phone line for the public provides information about self-assessment for depression, detailed information on treatment, drug profiles, and available resources. A recorded message for the public emphasizes that the service is an information line rather than a referral or crisis support line and directs people in need of emergency help to contact their family physician, go to the nearest hospital emergency room, or call 911.

DIRECT has compiled a resource directory that lists 950 programs and services providing care to people with mood disorders in Ontario. DIRECT has also prepared and distributed information packages on mood disorders to 15,000 mental health centers, health care professionals, and health services locations. Other educational activities include community presentations on how to interpret the DIRECT mood disorders self-assessment.

DIRECT is assisted by a nine-member advisory board representing a cross-section of people in the community, including consumers, family members, and providers. A panel of leading medical experts from across Canada helps shape the information content for the physician line.

As an academic program, the Regional Mood Disorders Program has been identified as a center of excellence for training psychiatric residents and other health care trainees from a local and international network. Professional educational activities include weekly rounds, medical student teaching rounds, research rounds, and a journal club.

Funding

The McMaster Regional Mood Disorders Program augmented limited funding from the provincial mental health system by developing partnerships with private-sector and academic organizations to increase clinical and scholarly activities. Funding is derived from separate sources for the various program components. The clinical care component is funded by the Ontario Ministry of Health. The budget for 1996-1997 totaled $2,119,000 (Canadian dollars) for inpatient services and nearly $1 million for outpatient services.

The program's research component has flourished despite the Canadian environment in which granting agencies' awards are relatively small—about $50,000 each—and difficult to obtain. Research funds, which totaled $1.6 million in 1996-1997, included provincial and federal grants and awards as well as funds from pharmaceutical companies and awards to individual researchers.

The $380,000 budget of the education component is funded through grants from five pharmaceutical companies, the Ministry of Health, and private donations.

Future plans

As the program continues its evolution, there has been an increased focus on the development and dissemination of best practices in the treatment of mood disorders across disciplinary and geographic boundaries. Services are provided through a multidisciplinary approach throughout the program's institutional and community-based settings. Information provided by the program flows across the nation via the toll-free lines and the Internet.

As the provincial hospital system in Ontario continues restructuring and downsizing, the Ministry of Health is watching McMaster Regional Mood Disorders Program as an example for other hospitals in the province. Its model of evolution from a purely inpatient program to a comprehensive regional program could well be fostered in the other hospitals that are slated for restructuring and are situated close to a university center.

For more information, contact Gloria Kain, M.H.A., Department of Psychiatry and Behavioral Neurosciences, Faculty of Health Sciences, McMaster University, Room 3G48, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5; phone, 905-521-2100 (extension 6428); fax, 905-521-5083; e-mail, [email protected].