Our study found that the eConsult psychiatry service is a useful and valued tool to assist in addressing the significant treatment gap for mental illness in primary care settings. In keeping with the evidence for prevalence of mental illness, this study found that depression was the most common clinic topic for which clinical assistance was requested, followed by anxiety, neurodevelopment, bipolar, and schizophrenia spectrum disorders. MDD is the second leading cause of disability worldwide [18], more than breast, colorectal, lung, and prostate cancers [19]. Thus, timely access to care is paramount.
By far the most common questions asked pertained to pharmacotherapy recommendations around how to choose, augment and switch between commonly used psychotropic medications. These included, but were not limited to, frequently prescribed Selective Serotonin Reuptake Inhibitors, Selective Norepinephrine Reuptake Inhibitors, and First and Second Generation Antipsychotics. Questions regarding dosing and side effect profiles were more often asked about Methylphenidate and Amphetamine based Stimulants, Mood Stabilizers and Anticonvulsants. Polypharmacy concerns and medical monitoring were commonly asked across all classes. A possible explanation why there are more treatment type questions than diagnosis questions is that it is harder to easily diagnose patients in psychiatry as specialists do not have investigations to rely upon. Furthermore, PCPs may be able to diagnose cases more easily but need more assistance with treatment options.
In a similar study by Lowenstein et al. [20], the authors describe the implementation of eConsults specifically for psychiatric services. The authors evaluated 50 psychiatry eConsults, which revealed that PCPs most commonly asked questions about depressive disorders (20/50, 40%). (49/50, 98%) were related to the management of the disease, most often for managing medications. The average response time for specialists reported in the Lowenstein study was 1.4 days, slightly lower than the response time reported here, 2.3 days.
In another specialist classification study using eConsult data, Wren et al. [21] found that 46% of PCP cases were related to treatment compared to almost 76% in our analysis. However, the Wren study included nine specialties but no psychiatry questions. Goberstein et al. [22] recently published a study exploring the effects of electronic psychiatric consultations of mental health care. They found that PCPs reported high levels of confidence in treating depression with medication, through referral. However, there is no indication of how many consults were related to treatment.
Analysis of results indicates that the eConsult service had a significant impact on PCPs course of action, as it provided them with advice and/or information that they anticipated would lead to a more effective visit with their patient in a majority of cases. In the study by Lowenstein et al. [20], 38/50 (76%) of PCPs implements the specialists’ recommendation. Although we did not directly ask this question it can be assumed that the vast majority of PCPs implemented the specialist’s advice as it was either new or confirming information (95.3%).This transmission of clinical knowledge may have the potential for capacity building when PCPs encounter similar cases in their practice.
Moreover, if eConsults continue to reduce referrals to specialty services, this has important implications for both patients and the health care system. Benefits could include decreased wait times for patients who require face-to-face specialist care, and cost savings as an alternative model for the delivery of specialty services within the health care system. The service proved to be highly valued by PCPs for its high-quality advice and provision of rapid access to specialist knowledge and recommendations.
Although not the only solution to the treatment gap in the provision of mental health care in the primary care setting, eConsult has demonstrated clinical utility in narrowing the gaps for both patients and providers in Eastern Ontario. Therefore, expanding the service to other healthcare regions in Ontario and across Canada, which our group is currently doing, could yield similar success. Future research analyzing and comparing eConsult analysis between different jurisdictions to identify patterns in the healthcare needs of the population would help to identify gaps in healthcare services.
The findings of this study are susceptible to several limitations. First, as a study completed at a single center in Eastern Ontario, Canada, the result may not be generable to other health urban or rural centers with varying infrastructures. However, the results of the study align with similar studies in other health regions [20]. The data were analyzed retrospectively which also poses as a limitation as some of the consults dated back to 2011. The sample analyzed was a convenience sample, and thus might not have been representative of the population being examined.
