Paul Kurdyak is a psychiatrist and clinician scientist at the Centre for Addiction and Mental Health (CAMH), lead of the Mental Health and Addiction Research Program at the Institute for Clinical Evaluative Sciences (ICES), and expert advisor with EvidenceNetwork.ca; David Goldbloom is a psychiatrist and senior medical advisor at CAMH and chair of the Mental Health Commission of Canada.
We are talking openly about mental illnesses and addictions now more than ever – and that’s a good thing. Efforts to address the stigma associated with mental illnesses have made it easier for people who have been suffering in silence to seek help. We have witnessed this first-hand at the Centre for Addiction and Mental Health (CAMH) in Toronto where we work. As a result of a campaign to raise awareness about mental illnesses in general, and CAMH’s services in particular, the number of people seeking help in both our Emergency Department and outpatient clinics has dramatically increased.
But it’s not all good news. We continue to witness public tragedies involving untreated mental illness – often with horrible repercussions for the individual, their families, and the communities where they live. While talk of reducing the stigma of mental illness seems to be everywhere in the media these days, there has been far less public discussion about how difficult it is to access services for mental health.
What the anti-stigma campaigns gloss over is that demand for mental health services already outstrips supply – and that this demand, for psychiatrists in particular, will only grow as barriers to acknowledging mental illnesses diminish. The problem of demand has led many to conclude that there are simply not enough psychiatrists, and that increasing the supply of psychiatrists will improve access – problem solved.
Unfortunately, it’s not that simple.
In a recent study published in Open Medicine, we explore the relationship between regional psychiatrist supply and access to care in Ontario. The idea for this project came from two related facts. First, there are a lot of psychiatrists in Ontario, and quite a few of them are concentrated in the two largest cities, Toronto and Ottawa. Second, finding a psychiatrist to accept new patients does not seem to be any easier in Toronto – with a large supply of psychiatrists and a lower patient to psychiatrist ratio – than in regions with far fewer psychiatrists, and a higher patient to psychiatrist ratio.
What we found, in fact, was that as the supply of psychiatrists increased, the total number of patients that each psychiatrist saw decreased. When supply is plentiful, psychiatrists opt for maintaining smaller practices of patients who are seen more frequently. Full-time Toronto psychiatrists, on average, saw half as many outpatients, and half as many new outpatients, per year compared to psychiatrists in regions with fewer psychiatrists. To put this in perspective, 40 per cent of Toronto-based psychiatrists saw fewer than 100 unique patients per year (and 10 per cent saw fewer than 40 patients), whereas only 10 per cent of psychiatrists in the lowest supply regions saw fewer than 100 patients per year.
It’s difficult to explain why this is happening, but the current provincial fee schedule pays for ongoing psychotherapy with no limits on visit frequency or duration of follow-up, and with no definition of illness severity or complexity – so it certainly plays a role. Such a fee schedule permits psychiatrists to tailor their practices in a way that suits their preferences, but does not necessarily align with greatest public need.
Other countries, such as the United States, Britain, and Australia, have changed the role of the psychiatrist in their mental health systems. In these countries, psychiatrists provide diagnostic assessments and treatment recommendations; other mental health professionals such as psychologists and social workers provide psychotherapy and other front-line treatment. The most extreme – and contentious – example of this role shift is within U.S. Health Maintenance Organizations (HMOs), where psychiatrists are limited to rapid, high-volume psychiatric drug consultations.
The critical question is this: In a publicly funded system, how should psychiatrists’ roles be defined in order to provide as much specialist care to as many high-needs individuals as possible in the most cost-effective way? Because psychiatrists appear to be organized in a far less than systematic fashion within Ontario’s mental health system, there is a fairly steady level of unmet need no matter how many psychiatrists practice in a region.
Instead of calling for more psychiatrists, we need to clarify the role of a psychiatrist in a publicly funded system to ensure that access to specialist care is equitable and based on need. Changing the fee schedule has changed the way psychiatrists practice in other countries, and will likely do the same in Ontario. But, defining the role of the psychiatrist with a view to maximizing equitable access is central to what we have observed, and will require input from psychiatrists, their professional bodies, and the many people who need their services.