There is a need for increased policies and public health programmes to reduce alcohol related harm, and evaluation of outpatient treatment potential.

OBJECTIVES: This study describes the mental health status, disability, physical health, and mental health service utilization of informal care-givers under the age of 65 in the province of Ontario. METHODS: The study analyzed data collected in the 1991 province-wide, population-based mental health supplement to the Ontario Health Survey. Diagnoses from the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised, were generated on the basis of a structured diagnostic interview. Caregivers and noncaregivers are compared here on past-year prevalence of psychiatric disorder, physical illness, disability, and utilization of mental health services. The possible confounding effects of age, sex, employment status, and economic disadvantage are explored. RESULTS: Informal caregivers (n = 1219) constituted 15.0% of the sample. Caregivers had higher rates of affective (6.3% vs 4.2%) and anxiety (17.5% vs 10.9%) disorders than noncaregivers and used health services for mental health problems at nearly twice the rate. CONCLUSIONS: Documentation of the prevalence of caregiving and the increased prevalence of psychiatric disorders, disability, and service utilization among caregivers is of critical importance as governments continue to move toward community-based care. To accomplish this goal, the needs of caregivers must be acknowledged and met by the establishment of appropriate and readily accessible support services.

With the closure of a number of provincial psychiatric hospitals planned, the Ministry of Health of Ontario has commissioned a series of planning projects to identify alternative placements for current hospital patients. The goal is to match need to care in the least restrictive setting. A systematic, clinically driven planning process was implemented that involved three steps: development of a continuum of levels of care representing increasingly intensive and more restrictive supports, development of criteria and decision rules for placement, and comprehensive needs assessment of current patients using the Colorado Client Assessment Record. Results showed that only 10% of current inpatients need to remain in the hospital, and over 60% could live independently in the community with appropriate supports. Evidence supports concurrent validity of the planning model, but further work is needed to assess whether recommended levels of care effectively meet consumer needs in the least restrictive setting.

There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or time frames, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.