3. Everyday Clinical Practice: From Initial Assessment to Treatment

Acute care and psychiatry in a general hospital

At Vancouver General Hospital, or VGH, the acute psychiatric pathway begins in Psychiatric Emergency Assessment & Triage, shared with the emergency department. After initial assessment, a person may return to outpatient care, remain for brief observation or move to an inpatient psychiatric unit. The Psychiatric Assessment Unit has 14 beds, with a typical stay of about three days. At the Segal Family Health Centre, 75 inpatient beds are distributed among brief intervention, mood disorders, general psychiatry and concurrent mental health and substance use disorders; the provider reports an approximate length of stay of 5 to 12 days. [2]

Consultation-liaison psychiatry serves patients on medical and surgical wards. The treating physician submits the request. The psychiatrist assesses mental state and clarifies diagnosis and treatment on the ward where the patient is receiving physical health care. This arrangement is particularly important in postoperative delirium, severe depression accompanying physical illness, or interactions between psychotropic and other medications. Medical interventions, nursing observation and psychiatric decisions are coordinated within a single admission. [2]

Alongside this hospital pathway, Vancouver has the Access and Assessment Centre, or AAC. It accepts city residents aged 17 and over with mental health and substance use concerns, in person daily from 7:30 a.m. to 9:30 p.m., and by telephone from 7:30 a.m. to 10 p.m. A nurse, social worker or another team clinician performs the initial assessment. Together with the patient and, when appropriate, relatives, the clinician identifies the next route: crisis support, a community service, addiction care or admission. When the need is urgent and admission is likely, a psychiatrist becomes involved at the first contact. Interpreters are available. [3]

A relative can telephone AAC, report changes in the person's condition and provide information relevant to assessment. Family physicians also have the RACE consultation line: psychiatric expertise is available on weekdays from 8 a.m. to 5 p.m. These two channels support different parts of the work: a person's request for help and professional discussion of their treatment. [3]

Psychotherapy: method, intensity and access

The 2023 CANMAT update on major depressive disorder, published in 2024, identifies cognitive behavioural therapy, interpersonal therapy and behavioural activation as first-line psychological treatments. The choice takes account of episode severity, previous response, patient preferences and availability. For severe and recurrent forms, combining or sequentially using psychotherapy and medication is important. [40]

Illustration (3. Everyday Clinical Practice)Zoom

Psychological care can have different intensities within a clinical pathway: independent work with materials, guided participation in a structured program, a group, or regular individual therapy. These involve different time commitments and different ways of working with symptoms. Behavioural activation restores specific activities to a day narrowed by depression; cognitive behavioural work adds examination of habitual interpretations; interpersonal therapy focuses on relationships, loss and changes in life roles. [40]

The free BounceBack program, delivered by CMHA BC, is intended for people aged 13 and over with mild to moderate depression, anxiety and stress. The telephone format offers 4 to 6 sessions with a trained coach, together with workbook exercises. Coaching is available in English, French, Cantonese and Punjabi. The referring primary care professional retains clinical responsibility and receives information about participation and risks. The online version contains 20 modules in English, with self-registration. [41]

Lau and Davis studied 25,338 closed referrals from 2008 to 2014. Of these, 10,903 participants reached the first standard session, and 7,203 completed the program. A further 8,100 declined or lost contact before proceeding, 8,104 discontinued after screening or starting coaching, and 1,931 were assessed as requiring another form of care. [42]

Among 5,537 participants with initial scores indicating clinically significant depression and/or anxiety, 3,794, or 68.5%, scored below the thresholds used on both scales after completion. Effect sizes for changes in PHQ-9 and GAD-7 were 1.13 and 1.08, respectively. Completers were older on average than those who discontinued: 48.2 versus 43.7 years.³ [42]

Medication treatment and the next appointment

The CANMAT/ISBD guideline for bipolar disorder organizes treatment by phase, including acute mania, bipolar depression and maintenance, and by a sequence of options that considers efficacy and tolerability. As acute symptoms subside, the work shifts to relapse prevention, monitoring adverse effects and restoring functioning. [43]

In practical care, the prescription is accompanied by a review date, a list of required tests and a named person responsible for reviewing them. After discharge, this may be an outpatient psychiatrist, family physician or team physician. The pharmacy receives the current prescription; the patient receives an understandable regimen and a contact for deterioration. After a change of dose or medication, the next appointment allows sleep, activity, mood, physical symptoms and tolerability to be considered together. In early psychosis, tolerability and return to education are especially important; in bipolar disorder, sleep and changes in activity; with clozapine, laboratory monitoring and physical health.

Who provides psychological treatment

A psychologist in BC is a regulated professional registered with the College of Health and Care Professionals of BC, or CHCPBC. Their work may include psychological diagnosis, psychometric assessment, psychotherapy and rehabilitation. In a hospital or community team, these activities are funded through the service's budget; in private practice, the fee is agreed with the patient. Registered Clinical Counsellor, or RCC, is a professional designation of the BC Association of Clinical Counsellors. Statutory regulation of psychotherapists through CHCPBC is scheduled to begin on 29 November 2027. [44, 45]

In 2026, BCACC recommends 140 to 175 CAD (approximately 41.8 to 52.2 CAD PPP) for 50 minutes of individual work, depending on the counsellor's experience; its upper benchmark for specialized services is 225 CAD (approximately 67.2 CAD PPP). For psychologists, BCPA has recommended 245 CAD (approximately 73.1 CAD PPP) per hour since 12 May 2025. An illustrative course of twelve sessions at 155 CAD (approximately 46.3 CAD PPP) would cost 1,860 CAD (approximately 555 CAD PPP); an employer insurance benefit or a place in a public program substantially changes the patient's share. [45, 46]

A distinct profession is the registered psychiatric nurse, or RPN, whose foundational education is specifically in psychiatric nursing. Alongside registered nurses, RPNs assess patients, monitor treatment response, sustain therapeutic engagement and work in hospital, community and outreach services. BCCNM regulates their practice. [47]

Electroconvulsive therapy

Modern electroconvulsive therapy, or ECT, is delivered under general anaesthesia with muscle relaxation. CANMAT considers it a particularly important option for the most severe depressive episodes, high suicide risk and physical depletion. Cognitive adverse effects and prevention of relapse after the acute course are part of treatment planning. [40]

The Neurostimulation Clinic in the Mental Health and Substance Use Wellness Centre at Royal Columbian Hospital in New Westminster can provide treatment to up to 14 patients per day. The pathway within the clinic includes nursing assessment and preparation, the procedure, monitored recovery in one of four spaces, and further time in a rest area before discharge. Referrals come from hospitals and community services; the regional ECT team coordinates access. [48]

At VGH's outpatient clinic, a psychiatrist submits the referral. An ECT psychiatrist and nurse assess the patient, reviewing previous treatments, physical illnesses and current medications. The program requires concurrent psychiatric follow-up throughout the course; procedures take place on Mondays, Wednesdays and Fridays. Patients must not drive on treatment days. Organizing a course therefore includes transport, support after anaesthesia, assessment of response and subsequent maintenance treatment.⁴ [49]

Five years of psychiatric training

The University of British Columbia residency lasts five years, with training sites in Vancouver, Fraser, Prince George, Vancouver Island and the southern interior. The first year includes general medicine, neurology, paediatrics, emergency care, addiction and psychiatry. The second focuses on adult inpatient and outpatient work; the third comprises six months each of child and geriatric psychiatry. Consultation-liaison psychiatry, addiction, acute and persistent disorders, elective placements and independent responsibility then take a greater role. [50]

Psychotherapy has protected time: two hours per week in the second year and four in the third and fourth years. Training includes two supervised cognitive behavioural therapy cases, six months of group work, at least eight family sessions, interpersonal therapy and a two-year psychodynamic case with weekly supervision. Psychotherapy practice thus develops alongside hospital rotations and continues long enough for the resident to observe the evolution of the therapeutic relationship. [50]

The resident's timetable calls this protected time. Learning to protect it from the rest of the timetable gradually becomes a professional skill of its own.

Electronic records, prescriptions and information transfer

Before a consultation, a psychiatrist may open several information sources. PharmaNet contains records of medications dispensed by community pharmacies across the province. The hospital electronic record contains orders, administrations, investigation results and the course of admission. Fraser Health has been introducing MEDITECH Expanse in stages since 2023; Vancouver Coastal Health, PHSA and Providence are developing the shared CST Cerner system. A patient transferred from Surrey to Vancouver moves between different hospital platforms. [51, 52]

CareConnect allows authorized staff to view laboratory results, imaging, selected clinical documents and pharmacy data from multiple sources. Practical reconciliation still occurs at the level of the individual treatment: the last methadone dose dispensed, medication administered in hospital, the reason lithium was stopped or the date of a long-acting antipsychotic injection. The patient and pharmacy help establish actual medication use, while the discharge summary explains the changes made. [52, 53]

Primary care offices and private medical practices have their own electronic systems. Referrals, consultation reports and discharge summaries pass through available channels, including fax and electronic fax. The provincial Digital Referrals and Orders program is introducing electronic referral with progress tracking. The clinical value of this exchange is concrete: the physician can see who accepted the request, and the patient receives a defined next contact. [52, 9]

How clinical work enters reporting systems

After an appointment, the physician submits an MSP claim with a service code and an ICD-9-based diagnostic code. The hospital separately codes the completed admission; BC data flow into the Discharge Abstract Database, or DAD, maintained by the Canadian Institute for Health Information, or CIHI. Diagnoses in this dataset use ICD-10-CA. These records support calculations of admission frequency, length of stay and service use. The clinical report, claim and statistical record describe the same episode at different levels of detail. [54]

The facility also retains Mental Health Act documents: certificates, treatment authorization, rights notifications and status renewals. Regional health authorities report service activity to the ministry. For example, the 2026/27 plan includes a target of 46% continuous retention in OAT for at least twelve months. For community bed-based addiction treatment and recovery programs, the forecast median wait in 2025/26 was 30.5 days, with a 30-day target for 2026/27. These times concern a defined group of programs, with acute withdrawal management counted separately. [1, 55]

Mandatory reporting beyond the treatment team

Under section 230 of the Motor Vehicle Act, a physician reports to RoadSafetyBC when a medical condition makes driving dangerous to the person or others and the patient continues to drive after being warned. The assessment connects diagnosis with function: attention, judgement, the risk of sudden loss of consciousness or marked sedation. The record retains the reasons for the conclusion and the substance of the discussion about driving. [56]

Section 14 of the Child, Family and Community Service Act requires everyone to report promptly to child protection services when there are reasonable grounds to suspect that a child needs protection. The Coroners Act requires reports of violent deaths, sudden unexplained deaths and other specified circumstances; the director of a designated psychiatric facility also has a specific duty to report a patient's death. Each report has a legally designated recipient and a specific basis. [56]