Peter Uhlmann is a semi-retired psychiatrist from Powell River, BC. He works as a locum consultant psychiatrist to several Northern communities.
In 2004 I started providing psychiatric locum service to Yellowknife, in the Northwest Territories. I worked in the local mental health centre and also on the psychiatric ward at Stanton Territorial Hospital. Later I travelled to three other communities; Hay River, Ft Smith, and Ft Simpson. For a few years I served those three communities on a regular basis every three to four months. As well as seeing patients, I would provide in service to health providers and education to community agencies. In 2006, I began working in four Inuit communities in Nunavut, specifically in the Kitikmeot region. I would service Taloyoak, Kugaaruk, Gjoa Haven, and Cambridge Bay. I still travel to these communities twice a year, and provide back up consultation via telehealth, telephone, or email. I work in the local health centre and always with a psychiatric nurse or counselor living in the community. Depending on the size of the community, I will visit for two to five days in each one. With travel, my biannual visits average a fortnight each.
For twenty years I worked as a psychiatrist in Powell River, BC, a community of 20,000 inhabitants. I was accustomed to rural practice, but working in Nunavut’s Kitikmeot is a unique experience. 95% of my patients are Inuit. I do see a few patients whose work brought them to the North, such as teachers, and government employees. Most patients speak English, but I have required translators on a few occasions. Now I spend most of my visits following prior patients. I do see a few new patients each visit.
People ask me how a typical patient might present. I found that the classic diagnostic categories described in the DSM versions are not helpful. My most chronic patients are young men from 15 to 35 years old. They often present with a diagnosis of “schizophrenia” or “drug induced psychosis”, but that is not the complete picture.
On taking a history, I learn there are often major family issues from birth, with dysfunction, illness, abuse, accidents, etc. early on in life. Many of these men have a very limited education, and many are functionally illiterate. Many are unemployed and have few skills. At an early age, even pre teen, they may have been exposed to solvents, and other inhalants, which can cause brain damage. Later they use marijuana, which affects the growing brain, and which they continue to use on a daily basis into adult life. A few will use harder drugs and/or alcohol, but marijuana is the main problem when trying to treat a psychosis.
Other factors are head injuries from accidents or altercations. Also involvement with illegal activities which result in prison time. Relationships are complicated by spousal assault, and infidelity. Cultural factors may also play a role and as a non Inuit, I may not even be aware of these influences. I have found that these men (and occasionally women) are very difficult to treat. First of all, many are unwilling to engage in traditional psychiatric counseling, and may only see me in a crisis, or under pressure from family or government. The territory lacks most of the usual mental health supports seen in the South. For example, as of this writing there is no proper treatment center for patients with major addiction issues. They have to be sent out of Nunavut, usually to Ontario or Alberta. This is very expensive and is limited to only a few patients. Also the Inuit patients often feel uncomfortable in programs away from Nunavut and will frequently drop out of the programs before completion.
My biggest frustration is trying to practice psychiatry with an outdated Mental Health Act. Both Nunavut and Northwest Territories are trying to bring their acts up to twenty first century standards. Currently a patient can be certified and sent for treatment in a facility (usually Stanton) against their will. However, once they are discharged, there is no legal way to force compliance to on going care. I have found that providing patients with long acting injectable antipsychotics every two or four weeks, can maintain them as functioning and productive individuals. However, most upon discharge from hospital refuse to come for injections, see the local psychiatric nurse, or refrain from using recreational drugs. They usually relapse and have to be evacuated from the community, back to Stanton. This is expensive, but also each “relapse” causes more brain damage from the psychosis.
Hopefully, the new Mental Health Act will address this concern.
Even though I am an outside visitor, I have felt blessed by my work in the North. The people are friendly and appreciative. They have opened up their world to me, and I have observed many cultural activities such as drum dances. I have met many wonderful people who work as nurses, social workers, doctors, counselors, etc. as well as carpenters, plumbers, pilots, teachers, and others who visit the North.
I have learned to be patient with flights being cancelled due to weather or “mechanical” issues. I have learned to adapt to situations beyond my control such as getting snowed in at Gjoa Haven, and setting up telehealth consults in Cambridge Bay, where I could not fly to. There is not enough communication between me and other psychiatrists working in Nunavut. There need to be more mental health workers willing to remain for a time in the community and not just provide a brief service of one month or less. It takes time to build up trust.
The pleasures of my work far outweigh the difficulties and frustrations. I plan to continue as long as my health and ability allow.