Psychiatrist Says Epidemiology More Than Just Numbers
Steve Kisely, M.D.: Nova Scotia offers “a fantastic psychiatric service database to work with.”
That’s how the meeting came to take place in the press room at the annual meeting of the Canadian Psychiatric Association in Halifax, Nova Scotia. Kisely grabbed a cup of coffee, sat down in an easy chair, crossed his legs, and began to discuss his professional life.
Kisely selected Australia for his medical education, he explained, because “I’ve always had a bit of wanderlust.” He decided to become a psychiatrist because “it is one of the few branches of medicine where you view patients as a whole.” However, he also became a public health physician as well so that he could work as a psychiatric epidemiologist.
“I’ve always been interested in dealing with people not just as individuals, but as populations,” he said. Yet his ultimate passion, he confessed, is researching psychiatric delivery outcomes—for instance, how well a service is organized, how accessible services are, and how patients fare with a particular service.
It’s About Making a Difference
So what turns him on about psychiatric delivery outcomes research? “Well, it certainly isn’t the money!” he chuckled. “I guess it might sound a bit trite, but at the end of the day, it is about making some sort of difference in the quality of life of individuals—to improve their outcome.”
He described one example of where he believes his research is making a difference—it involves compulsory outpatient treatment for seriously mentally ill patients. This concept has been introduced throughout the English-speaking world, although there is little scientific evidence that it leads to good outcomes, he said. Back when Kisely was still in Australia (he moved to Nova Scotia a year ago), he and his research colleagues reviewed the few trials that had been conducted on the effectiveness of compulsory outpatient treatment. They found that to avoid one arrest of a mentally ill patient for violence, you would need to treat 500 mentally ill people on a compulsory outpatient basis and that it would take 100 compulsory outpatient orders to prevent one admission.
“This is a blunderbuss treatment, incredibly ineffective,” he exclaimed. “The practical implication is that we need adequate community services for the seriously mentally ill, not compulsory outpatient treatment.”
Death Rates Higher: Why?
Still another example of where he believes his research is making a difference, he said, is a study he undertook after moving to Nova Scotia. He and his Dalhousie University colleagues compared the death rates of some 67,000 people who received psychiatric treatment in Nova Scotia from 1995 to 2000 with the death rates of the whole population of Nova Scotia during this time.
They found a 50 percent higher death rate for the psychiatric group compared with that for the general population.
“This finding has important public health implications,” Kisely declared. “Why is it that so many psychiatric patients are dying? Is it because of side effects of the psychotropic medications they are taking, or because they are socially isolated, or perhaps because they are pursuing different types of lifestyles than psychologically healthy people are? Or could it be due to the fact that they are less likely to receive specialist procedures? Work from Australia suggests that although people with psychological problems are more likely to die of cardiovascular disease, they are less likely to have received revascularization or coronary artery bypass grafts.”
Kisely plans to continue studying psychiatric service outcomes. “It taps into my interest as a psychiatrist and as an epidemiologist,” he observed. “All things being equal, I will not change.”
Lured by Databases
Why did he leave balmy Perth, Australia, to move to wet, cold Halifax, Nova Scotia?
“Well,” he avowed, “there isn’t a lot of research money in Canada these days. What’s more, the psychiatric research budget in Canada was slashed especially dramatically this year. Before, one-third of research grant applications were funded; now it’s only one-fifth. Also, psychiatric epidemiologists in Canada are in even poorer straits financially than are other kinds of psychiatric scientists because, frankly, our kind of work is not glamorous and high tech, and because people find it hard to get enthused about databases.
“On the other hand, the financial situation for psychiatric researchers in Australia these days isn’t any rosier than that for psychiatric researchers in Canada. What’s more, my Dalhousie colleagues and I are getting a lot of mileage out of the little research money we receive.
“And Nova Scotia offers me something that I would be hard-pressed to find in other areas of Canada, or even in Australia, for that matter—a fantastic psychiatric services database to work with. Inpatient visits, outpatient visits, community visits, and prescription-drug information for the entire province are all documented and easily and accessible.” ▪
