During a year of unprecedented stress, mental-health care is garnering more than its usual share of the political spotlight in the federal election. The three main national parties are variously promising money, tax credits and policy changes aimed at correcting a chronic inequity in the system: too many Canadians waiting too long for help, unless they can pay out of pocket for the treatment they need.
Still, the issue barely came up in the leadership debates, and how quickly these costly and complicated fixes will happen remains to be seen.
But that timeline matters, now more than ever. This election is unfolding at a moment when how well the country delivers mental-health care will be truly tested. In surveys, Canadians are reporting higher rates of anxiety and depression. Hospitals are seeing more patients with eating disorders. Opioid overdoses have risen. A fourth wave looms over exhausted doctors and burned-out health care workers.
“The pandemic hit, and really exposed the gaps in our system,” says Sarah Kennell, the national director of public policy for the Canadian Mental Health Association. “If we are not going to talk about this now, then when?”
But the system was swamped even before COVID-19. Emergency department visits for mental-health issues, among youth in particular, were already increasing year over year before the first lockdown. A shrinking supply of mental-health clinicians and a shortage of publicly funded talk therapy left vulnerable patients lingering on public waiting lists, while better-off Canadians paid privately for this basic, front-line treatment.
That two-tier system is being addressed on the campaign trail. The Liberals, for instance, have promised funding to hire more university- and college-based counsellors, while also adding psychologists and social workers to the professions eligible for Canada’s student-loan forgiveness program.
The Conservatives have proposed a three-year tax credit for employers who add mental-health coverage to employee-benefit packages. The NDP have committed to expanding free access to mental-health services in the public system, raising the prospect of psychologists and social workers being covered by a fee for service as doctors currently are.
These proposals have the potential to be transformational, says Ms. Kennell, because they move away from the piecemeal, pilot-project funding approach that many non-profit community associations rely upon to deliver talk therapy, a scientifically supported treatment recommended as first-line care for the most common mental illnesses, such as anxiety and depression. While governments have ramped up access to therapy in recent years, the pandemic election will hopefully force a reckoning of “deeper, systemic issues,” Ms. Kennell said. “At a broader level, why is mental-health care being delivered by charities?”
The pandemic has already caused a major shift in mental-health care by moving psychiatric appointments and therapy sessions online – the kind of virtual care that advocates had long argued would provide Canadians in smaller communities with more timely treatment. But that’s also led more psychologists and social workers to leave the public system for private settings, where working conditions are better, the pay is higher and there is no shortage of clients, says Sylvain Roy, a neuropsychologist at Toronto’s Inner City Family Health Team and former president of the Ontario Psychological Association.
“It’s not enough to say, ‘Here is more money,’ and assume the people are there,” he said. Increasing the number of skilled mental-health workers, even if the dollars come and the university space exists, will take time, he pointed out – training a psychologist requires eight years of postsecondary schooling; a social worker requires six years.
The pandemic has set a timeline that requires rapid innovation – not only because early intervention produces better outcomes for patients, but because Canada’s supply of psychiatrists is also shrinking. A Globe and Mail analysis published last year showed that roughly half of all Canadians live in parts of the country where the number of psychiatrists falls below the ratio recommended by a panel of experts with the Canadian Psychiatric Association – 2.3 million Canadians live in areas with no permanent psychiatrists at all.
In recent years – and especially during the pandemic – both Ottawa and the provinces have moved to expand coverage to talk therapy, a treatment that has been largely provided by mental-health professionals in the private system. The federal government launched Wellness Together Canada, an online mental-health site to help people access online or phone therapy. Ontario is moving forward with a structured cognitive behavioural therapy program, started before the pandemic. The newly elected Conservative government in Nova Scotia has boldly promised universal mental-health care, which would include allowing private mental-health care providers to bill the province for services.
The lack of public funding for therapy has long complicated communication between doctors and therapists, even though the co-ordination of treatment, such as therapy and medication, produces the best results for patients. But experts also point to the need to build a true system that gets the right amount of care to the patients who most need it.
Building that kind of system will require co-ordination of government programs, as well as the skilled clinicians delivering services. One example of a grassroots innovation is the Ontario-based program Psychotherapy Matters, which has psychiatrists, patients and psychotherapists attend virtual appointments together. The program is still small-scale – with seven psychiatrists and 215 therapists – and receives no government funding beyond what the psychiatrists bill the province for consultations. It is also complicated because to pay for therapy, clients use workplace plans – which typically have caps on coverage – or have to cover it themselves.
But Victory Nguyen, a psychiatrist with the program, says it allows her to consult with more patients in rural areas knowing a trained therapist is overseeing the treatment plan. It also helps build up therapists’ expertise by enabling them to see more patients with more complex needs.
Holly Mathers, a registered psychotherapist in Kitchener, Ont., who also collaborates on care for her clients through Psychotherapy Matters, says not only does the program enable her clients to see a psychiatrist more quickly – usually within weeks or months – but the care team working together means they can respond faster when treatment needs to be adjusted. “This is what the future should be,” she said.
The pandemic may have applied the pressure, but this election has seen “an explicit recognition of the importance of investing in mental-health care,” said Karen Cohen, chief executive officer of the Canadian Psychological Association.
Ideally, in the near future that would mean building on successful programs, stable funding for community-based services, expanded coverage of therapy and equal access to the best care based on need. As always, Dr. Cohen said, “The devil is in the details.”
Our Morning Update and Evening Update newsletters are written by Globe editors, giving you a concise summary of the day’s most important headlines. Sign up today.