Adult Mental Health

One in five Canadian adults experience a mental health or addiction problem. Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool is designed to assist primary care providers in identifying, assessing and managing risks in a patient with diagnosed, undiagnosed or changing mental health conditions.

Question #1: Which of the following is true?

Question #2: Examples of interventions that can be initiated for a patient at medium-high risk of harm to self or others are:

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Keeping Your Patients Safe Tool
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Primary care providers (PCPs) can face a high degree of uncertainty when it comes to identifying and acting upon risks associated with signs, symptoms or behaviours that are suggestive of a mental health condition. Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments tool aims to support and guide PCPs in appropriately assessing and managing a patient with risks or functional impairments, even in the absence of a diagnosis.

The tool gives primary care providers the ability to assess the type and severity of risk(s) through four main components:

  • Investigate and identify key signs, symptoms & behaviours associated with risks or functional impairments
  • Gauge the type, severity and time-sensitive nature of identified risk(s)
  • Initiate appropriate referral to emergency department for further psychiatric assessment
  • Initiate interventions, such as mandatory and permissive reporting, non-pharmacological interventions, or lifestyle modifications

Additional resources

To supplement the tool, we have developed additional resources for clarity and assistance. Click below to download each resource.

Assessing Functional Impairments: Discussion Aid [i]
Tips for completing a Form 1 [iii]
How to use computer-based Cognitive Behavioural Therapy (CBT) with your patients [xx]
Completed Form 1 samples

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Project Overview

Identifying mental health risk is important, even when the patient has not previously had a mental health risk diagnosis. The Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool is intended to help providers investigate, identify and assess the type, severity and time-sensitive nature of the risk(s) associated a mental health condition.

Development Process

Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool was developed using CEP’s integrated knowledge translation approach. The Centre for Effective Practice (CEP) ensures that primary care providers are engaged throughout the tool development process through the application of user-centered design methodology. Clinical leadership of the tool was provided by Dr. Jose Silveira, Dr. Patricia Rockman and Dr. Leah Skory, along with a clinical working group. Clinical experts were also engaged to provide feedback on key processes and components relevant to assessing and managing risks associated with mental health conditions.

The Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool is one of several resources developed as part of the 2014 to 2017 Knowledge Translation in Primary Care Initiative. This multi-year initiative was a collaboration between the Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supported primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, the CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey, providers identified the need for more effective resources to help identify and manage risks associated with mental health conditions.

Meet the Team

The project team conducted a comprehensive literature search, and developed evidence-based guidance in partnership with the clinical leads and working group. Health care providers and other stakeholders were also engaged throughout the development process.

Clinical Leads

Jose Silveira, MD, FRCPC, Dip, ABAM

Dr. Jose Silveira is an Assistant Professor in the Department of Psychiatry at the University of Toronto; Psychiatrist-in-Chief at St. Joseph’s Health Centre in Toronto as well as Medical Director of Mental Health and Addiction Programs. He works closely with primary care physicians and has been on the steering committee of Ontario College of Family Physicians Collaborative Mental Health Network since 2000. He has been providing indirect consultation and support to them across the province of Ontario throughout this time as well. In addition, Dr. Silveira has served as a psychiatrist providing shared care with numerous Community Health Centres and Family Health Teams throughout his career.


Patricia Rockman, MD, CCFP, FCFP

Dr. Patricia Rockman is Director of Education and Clinical Services at the Centre for Mindfulness Studies in Toronto and is also Associate Professor in the Department of Family and Community Medicine at the University of Toronto with a cross appointment to Psychiatry at UHN. She has a focused practice in Mental Health, and was co-chair and founder of the Ontario College of Family Physicians Collaborative Mental Health Network. Dr. Rockman has also functioned as an educator, public speaker and resident supervisor for the last ten years.

 

Leah Skory, MD, CCFP

Dr. Leah Skory works as a family physician at the Barrie Community Health Centre, where she provides comprehensive primary care to all ages. She has practiced family medicine since 1997 and has worked in both private and group settings. She is a trained McMaster Problem Based Learning Facilitator, and is currently co-chair for the Ontario College of Family Physicians upcoming Mentoring Network annual conference.

Acknowledgements

In addition to clinical leads, a clinical working group comprised of a family physician, primary care nurse practitioners and a social worker oversaw the development of this tool. Members include:

  • Gwen Morgan, Social Worker
  • Joanna Dickinson, MSc, PHCNP, CPMHN
  • Jennifer Wyman, MD, CCFP, DABAM

Thank you to all providers who participated in the development of this clinical tool.

Supporting Material

Supporting Materials

External Resources

Below are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. The CEP will make every effort to keep these links up to date.

  1. Mandatory and Permissive Reporting
    The College of Physicians and Surgeons of Ontario (CPSO) have documented all instances of mandatory reporting (e.g., child abuse or neglect; impaired driving ability; safety related to pilots or air traffic controllers, railway workers and maritime workers; and occupational health and safety) and permissive reporting (e.g., disclosure to prevent harm, and health provider incapacity or incompetence) requirements.
    http://www.cpso.on.ca/policies-publications/policy/mandatory-and-permissive-reporting
    The Ontario College of Family Physicians also houses a useful CPSO guide on mandatory and permissive reporting for general practitioners:
    http://ocfp.on.ca/docs/collaborative-mental-health-carenetwork/cpso-policy-statement-on-mandatory-reporting.pdf?sfvrsn=2
  2. Identifying Potential Workplace Hazard
    If a health provider is concerned that a patient could pose a potential hazard to him-or herself or to others in the workplace, the health provider is advised to contact the Ontario Ministry of Labour to file a concern, which can be done anonymously should the health provider so choose.
    The number to contact the Ministry of Labour is: 1-877-202-0008, option #3, which will in turn forward the information to their investigation unit. It is important that the provider knows the employer and employment location of the patient to file a concern.
  3. Partner, Child & Elder Abuse & Neglect
    For an overview of the professional responsibilities of health care providers regarding the prevention of child abuse and neglect, please review the following link:
    http://www.children.gov.on.ca/htdocs/English/topics/childrensaid/reportingabuse/abuseandneglect/abuseandneglect.aspx
    Legally, healthcare providers are obligated to report suspected cases of child abuse or neglect to the Children’s Aid Society. To access the closest location to you, please visit the following link:
    http://www.children.gov.on.ca/htdocs/English/topics/childrensaid/reportingabuse/CASLocations.aspx
    The Advocacy Centre for the Elderly provides useful guidance on dealing with suspected or confirmed elder abuse or neglect.
    http://www.advocacycentreelderly.org/elder_abuse_-introduction.php
    The Ministry of the Attorney General provides an extensive list of options and resources for individuals who are being abused by their partners.
    https://www.attorneygeneral.jus.gov.on.ca/english/family/violence.php
  4. Reporting to Ministry of Transportation
    According to the Highway Traffic Act (s. 203 and 204), physicians must report to the Registrar of Motor Vehicles any patient aged 16 years or older who may be suffering from a medical condition that could impair his or her driving ability.
    http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/023-SR-LC-097~1/$File/SR-LC-097.pdf
    The Canadian Medical Association offers a guide to determine medical fitness to operate motor vehicles, which can be found here:
    https://www.cma.ca/En/Pages/drivers-guide.aspx
  5. Form 1 – Application by Physician for Psychiatric Assessment
    http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/CategoryDetail?OpenForm&ACT=RDR&TAB=PROFILE&ENV=WWE&NO=014-6427-41
    How to complete the Form 1 accurately
    http://ocfp.on.ca/docs/collaborative-mental-health-care-network/how-to-complete-a-form-1-.doc
  6. Form 2 – Order for Examination under Section 16
    If you cannot examine the patient and police arrest under the Mental Health Act is not appropriate, a Justice of the Peace can complete Form 2, which is then given to police. Make clear that voluntary efforts have not worked.
    http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-6428-41~1/$File/6428-41_.pdf
  7. Mental Health Act Forms
    http://ocfp.on.ca/cpd/collaborative-networks/cmhcn/medico-legal-issues
  8. Collaborative Mental Health Network
    The Collaborative Mental Health Network provides mentoring support and education to enhance the capacity of family physicians in providing comprehensive, quality care to patients with complex conditions involving mental illness or addictions.
    http://ocfp.on.ca/cpd/collaborative-networks/cmhn

References

  1. Perlman CM, Neufeld E, Martin L, Goy M, & Hirdes JP (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute.
  2. Allan CL, Behrman S, Ebmeier KP. Primary care management of patients who self-harm. Practitioner. 2012;256(1751):19-22, 2-3.
  3. National Institute for Health and Clinical Excellence (NICE). Self-harm: longer-term management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Nov. 41 p. (Clinical guideline; no. 133).
  4. U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 May 20;160(10):719-26.
  5. DiGregorio RV, Green-Hernandez C, Holzemer SP. Primary Care, Second Edition: An Interprofessional Perspective. 2015. Springer Publishing Company LLC.
  6. Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Child Abuse and Neglect: Risk and Protective Factors. [Internet]. 2016. Available from: http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html
  7. Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Suicide: Risk and Protective Factors. [Internet]. 2015. Available from: http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html
  8. Centres for Disease Control and Prevention, National Centre for Injury Prevention and Control, Division of Violence Prevention. Sexual Violence: Risk and Protective Factors [Internet]. 2016. Available from: http://www.cdc.gov/violenceprevention/sexualviolence/riskprotectivefactors.html
  9. National Institute for Health and Care Excellence. Depression in adults: the treatment and management of depression in adults (Update-NICE clinical guideline 90). London, UK: National Institute for Health and Clinical Excellence (NICE); 2009.
  10. Andrews G, Cuijpers P, Craske MG, McEvoy P, Titov N. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PloS ONE. 2010;5:e13196.
  11. Centre for Addiction and Mental Health. The CAMH Suicide Prevention and Assessment Handbook. [Internet]. 2011. Available from: https://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/suicide/Documents/sp_handbook_final_feb_2011.pdf
  12. Durbin S, Ker K, Rawal S, Chan J, Ho A, Au Billie, Lofchy J. Psychiatry–Toronto Notes. 2009.

Copyright & Disclaimer

The CEP fully supports the use of the Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool by providers, educators, decision-makers and others. Please read the following information prior to use of the Tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative CommonsKeeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool is a product of the Centre for Effective Practice.  Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation.  Use of the Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: [email protected])

For statistical and bibliographic purposes, please notify the Centre for Effective Practice ([email protected]) of any use or reprinting of the tool.

Please use this citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice (February 2017). Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool. Toronto: Centre for Effective Practice.

Disclaimer

Keeping Your Patients Safe: A Guide to Primary Care Management of Mental Health and Addictions-related Risks and Functional Impairments Tool (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations.  These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Third Party Resource(s).

This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice.  Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.