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OPEN MINDS: BETTER MENTAL HEALTH CARE

Psychotherapy: A better funding model must be found Add to ...

This is part of a series on improving mental health research, diagnosis and treatment. Join the conversation on Twitter with the hashtag #OpenMinds

When medicare was cobbled together in the 1950s and 1960s, provinces began to offer publicly funded insurance for hospital care and then physician services. But there was an important exception: “Institutions for the mentally disturbed” were not funded. Asylums (as psychiatric hospitals were called at the time) were not part of the health system because the care they offered was not deemed to be curative. Thus, mental health became the orphan of health care.

Six decades later, the old-style asylums are gone. The long-term patients were “de-institutionalized” and many now live on the streets. The best psychiatric institutions, such as the Centre for Addiction and Mental Health and the Ontario Shores Centre for Mental Health Sciences, and the psychiatrists that came with them, were integrated into the mainstream hospital system.

But the false perception that mental illness is an affliction that can’t really be treated remains.

The combination of stereotype-embracing and structural oddity essentially means that psychologists have been tossed to the curb – or, more precisely, to the private health system.

As a result, most Canadians who need psychological care require private insurance or pay out of pocket, and much mental-health care is left to general practitioners who, because of the fee-for-service payment system, have an incentive to prescribe pills rather than do psychotherapy.

While psychotherapy doesn’t have the greatest public image – many people envisage endless Woody Allenesque sessions on a couch where nothing is ever resolved – it is actually just as effective as medication in most cases, particularly for common conditions such as depression and anxiety. The evidence is strong.

Sadly, the offerings in our health system are driven as much by tradition as they are by evidence.

We needn’t be prisoners of our outmoded structures. In the fifties and sixties, we created a system to provide care in hospitals and in physicians’ offices and it’s almost impossible to break that mould and innovate – for example, by putting psychological care on an even footing with psychiatric/medicinal treatment.

What we really need to do is provide care where people bring their mental-health problems – in primary care. As most provinces try to transition from a solo, fee-for-service model to multidisciplinary teams, it provides a perfect opportunity to bolster mental-health care by integrating psychologists onto teams. Other countries have done so, notably Britain and Australia, and the early evidence is that it’s paying off.

The fear, of course, is that providing public funding of psychological care will cost more. Of course it will. Estimates range from $950-million to $2.8-billion a year.

But the offering of psychological care doesn’t have to be an open buffet like other aspects of health care, and some of the hundreds of millions now paid for (not always trained) doctors to provide psychotherapy can be spent more smartly.

If done right, the investment should pay off down the road, in lower health costs, disability-insurance payouts and absenteeism. Because the greatest costs of mental illness arise when it is left untreated, and festers.

Mental illness is common:

• 10 to 25 per cent of women and 5 to 12 per cent of men experience a major depression;
• 4 to 7 per cent of Canadians suffer from anxiety disorder;
• 7 to 12 per cent experience post-traumatic stress disorder;
• 10 per cent suffer from phobias;
• 5 per cent experience panic disorders;
• 2 to 4 per cent suffer from obsessive compulsive disorder or eating disorders;
• 1 to 2 per cent suffer from bipolar disorder or schizophrenia.

For years, we have been focusing efforts on combatting the stigma, urging Canadians with mental-health disorders to come forward. But the care is not available for those who need it; waits stretch from months to years, and an estimated one in three adults and one in four children don’t get care at all.

Psychotherapy can help fill the gap.

There are 18,000 psychologists in Canada. About three-quarters are in private practice, charging $100 to 200 an hour, and roughly one-third work exclusively in the public system, where there is no charge to patients.

Canadians spend about $950-million on psychological care, most of it covered by private insurance and workers compensation; but a good chunk, about one-third, is paid out of pocket.

We have a mixed health-funding model in this country, but when it comes to mental-health care, we don’t have the mix right. Too many people are being denied care because they can’t afford it, or because their work-based insurance provides paltry benefits for psychological care.

As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care.

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. The organization had no involvement in the creation or production of this, or any other, story in the series.

Editor's note: A previous version of this story incorrectly said there are 8,000 psychologists in Canada. In fact, there are 18,000.

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