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Readers respond: The Doctor Won’t See You Now

There are some solutions already in place that could be scaled to provide improved access to mental-health care.

British Columbia has free access to cognitive behavioural therapy for people with mild to moderate depression and anxiety through the Bounceback program, which is provided in collaboration with primary care. An evaluation of the program published in the BC Medical Journal in 2019 showed that 68.5 per cent of the 5,537 patients referred achieved recovery. A similar program is now operating in Ontario. And for more than 30 years, Hamilton has had a shared care program that provides rapid access to psychiatry to primary-care doctors.

For people with complex conditions such as schizophrenia, stepped care gets impressive results. Over three years, multidisciplinary teams which include psychiatrists and other mental health professionals were able to avoid over 32,000 days of hospital admissions.

Better integration of psychiatry with primary care, as proposed by the Canadian College of Family Physicians, would improve access and achieve better outcomes than the status quo.

Steve Lurie Executive director, Canadian Mental Health Association, Toronto Branch

If we want to make a real difference in reducing the need for more psychiatrists, we should do more before someone gets sick in the first place. In the psychiatric facility where I spent my working life as a psychologist, the majority of patients I assessed reported a dysfunctional childhood.

The ingredients for the inoculation of mental illness are now being taught in schools that include psychological wellbeing along with traditional subjects. Social-emotional learning skills are now being advocated by organizations promoting mental health, potentially making up for whatever was happening in a child’s home environment. I believe there is every sign that teaching children more productive ways of handling life’s difficulties can significantly reduce the need for psychiatric care.

Stuart Ross Guelph, Ont.

Non-medical psychotherapists generally provide quality talk therapy that can be as good or even better than medically trained professionals. But since they are not covered by public health care, their private fees deter a large segment of Canadians. How about a universal fee schedule, based on a person’s income, that applies to both medical and non-medical modalities of therapy?

The wealthy could easily afford an hourly fee of $120 or more. Such a model could free up public dollars for those who need it most and allow psychiatrists to concentrate on more severe cases of mental illness. Medical and non-medical professionals should share equally in shouldering the spectrum of suffering – from each according to his means, to each according to his needs.

James FitzGerald Toronto

As a hospital-based psychiatrist, I agree that changes are needed in how we approach mental health care. However, simply having psychiatrists seeing more patients would not address the gaps that impact recovery at all stages: income support and vocational rehabilitation, safe and supportive housing, substance use disorder treatment and access to psychotherapy.

Trying to treat people while these gaps persist feels like a drop in the ocean of human suffering.

Laila Jamal Toronto

As a case manager in mental health and addictions in downtown Toronto, I would be the first one to say we need more psychiatrists. But that isn’t news to me. Doctor shortages in many areas of medicine are well-known, often discussed and never disputed. But I have also seen that all mental health services are dramatically underfunded and overburdened.

Last week, for example, I made an emergency home visit to make sure a client was safe, which kept her out of the hospital, no psychiatrist needed. Community mental health workers are just as important to the system, but as long as doctors remain the focus of policy discussion, funding will likely stay out of communities – and emergency rooms will overflow.

Andrea Jakaitis Toronto

Within medicine, I have found that psychiatry is treated like a poor second cousin. The stigma visited on those with mental illness is displaced onto those, like myself, who treat these complex illnesses.

Treatment is often managing chronic symptoms, always a more expensive endeavour than obtaining a cure. Yet it is the psychiatrist who seems to be blamed for lack of services. My small finger is already stuck in the dam of keeping back some of the mental health need.

I am not sure I can turn myself into a plate-spinning juggler to address the vast gap in services caused by years of underfunding. There is a mountain of statistics, but numbers don’t necessarily measure the humanity of the work. Humanity takes time and patience. Let us not forget this part of the equation.

Heather Weir Toronto

As a psychiatrist and career insight-oriented psychotherapist, I beg readers to consider that there are two aspects to modern psychiatry: medical and psychodynamic; brain and mind. The brain may be the primary cause of a disorder and affect the mind; as well, the mind can be the root cause affecting the brain.

I find that medical psychiatry errs in defining psychiatric problems as brain diseases, and that medication offers, at best, a temporary symptomatic remedy. Psychodynamic psychiatry believes that the mind is most often the cause of human mental suffering. It addresses that cause in a therapeutic healing relationship and I find it has demonstrable lasting results. And it takes time. Things of lasting value do not spring up overnight or from a pill. Ask my patients.

Would that medical and psychodynamic psychiatry work together, rather than in opposition.

Howard Taynen Ancaster, Ont.

We were fortunate to practice family medicine in Goderich, Ont., for 25 years. There were usually only two or three psychiatrists serving all of Huron County’s 60,000 population, and yet the patients usually received timely, accessible, high-quality mental health care, including in-hospital care when needed. How was this possible?

After referral by family physicians or emergency physicians for an initial psychiatric consultation, patients were mainly cared for by an integrated team of social workers and mental health nurses in conjunction with their family doctor. The psychiatrists supervised the team care and were always reachable if problems arose for a helpful call or follow-up consultation. Because of the excellent team members and the well-functioning team-based care model, we felt that our patients had better access to mental health care than did many patients in larger urban centres, where the psychiatrist-to-population ratio was an order of magnitude greater.

While in some more remote areas tele-consultation can help provide access to psychiatrists, the core foundation needs to be a well-supported, strong, integrated, collaborative, shared-care mental health team that includes psychiatrists, psychologists, social workers, mental health nurses, family doctors and other professionals. The time to act is now.

James Rourke Former dean of medicine, Memorial University; co-chair, Rural Road Map Implementation Committee; Ottawa

Leslie Rourke Professor emerita, Memorial University; Ottawa

Roughly seven million Canadians will experience a mental health disorder in any given year, all of whom deserve access to evidence-based treatment. There are less than 5,000 psychiatrists in the country. I don’t believe that changing the practice patterns of a few hundred psychiatrists working in large cities will fix the access problem, nor will training a few hundred more.

Evidence-based treatment should comes in five forms; psychotherapy, medication, neuromodulation, social support (housing or stabilizing income) and lifestyle support (exercise, sleep hygiene, etc.). The public health system should find a way to build capacity to deliver these five forms of intervention in a large-scale way. We should publicly fund psychotherapy from non-MDs. We should have general practitioners who have more comfort with psychiatric medications. We should have psychiatrists who can be high-level managers of big teams, and we should have psychiatrists who can deliver week-to-week care of the most complex and vulnerable patients.

We psychiatrists should stop pretending that we can fix this problem on our own.

Jordan Bawks Toronto

I am a community psychiatrist practicing in London, Ont. I also work at the Centre for Addiction and Mental Health emergency department in Toronto and provide tele-psychiatry consults as a locum psychiatrist. I believe we need to better understand the full range of psychiatrists who provide excellent care to patients with diverse needs.

As with most community psychiatrists, I spend all of my time doing direct clinical work. That’s in comparison to research psychiatrists who split their week doing research, thus taking them away from direct patient care. But research is crucial to patient wellbeing, as well as guiding treatment options for our shared patients. We need all of us: the researchers, the allied health professionals and the community psychiatrists who work hard everyday on patients who may not “look” severe, but are one step away from suicide.

My focus is on PTSD, ADHD, eating disorders and personality disorders, which means that my patients are often very suicidal and require close follow up. My patients are first responders, nurses, teachers and one’s colleagues and family members, people who survived all sorts of personal and work-related trauma. Do we tell them that they do not deserve ongoing psychiatric care for the consequences of horrific events just because they have a job and appear “okay” or not psychotic and are not in the emergency room? Can I fix consequences of years of sexual abuse or exposure as an ER nurse in two to three visits? Our profession is diverse and so are our patients.

And while we argue about who is “complex” or “worried well,” we likely stigmatize the patients who work so hard to “appear normal” and retain function. In my practice, I am the lone care provider to meet my patients’ needs, and it seems grandiose for psychiatrists to think that we alone can cure or treat our patients’ needs. It would be like expecting a surgeon to perform surgery by themselves – impossible and unsafe. We should focus on creating more community teams with allied health professionals to help patients with complex needs.

These patients should also have their needs met on their terms. They face real social barriers, such as poverty, lack of transportation and cognitive difficulties, which can make it difficult to attend office- or hospital-based appointments. But from what I’ve seen, such flexibility and resources for community teams seem like just a dream due to lack of funds and structure.

Maryna Mammoliti London, Ont.

Regarding the shortage of psychiatrists in Canada, long-term psychotherapy can be an important part of life-saving care for those with complex diagnoses, as highlighted by the patient perspectives in the Psychotherapy Saves series on YouTube. In researching my November, 2019, article in the Journal of Psychiatric Practice, I found that such outpatients typically need about one year of therapy to achieve a recovery of 75 per cent, whereas the benefits of short-term therapy are usually brief. Long-term psychotherapy has also been found to be cost-effective by resulting in fewer work absences and hospitalizations.

The root cause of the shortage seems to lie with the stigma against mental illness and its treatment, which makes it harder to recruit and to retain psychiatrists. There should be room for everyone at the table because practice diversity gives patients access to the best possible tools for achieving optimal mental health.

Renata Villela President, Ontario District Branch of the American Psychiatric Association; Thornhill, Ont.

The 3,000-plus members of the Ontario Association of Mental Health Professionals are acutely aware of the gaps in the continuum of mental health care. It is a frequent topic of discussion for medical and allied medical mental health professionals. By “allied medical,” I am referring to the 7,000-plus registered psychotherapists and the thousands of other professionals who, as of Jan. 1, have been regulated to practice the controlled act of psychotherapy in Ontario. Embracing all professionals is crucial.

We should see the mending of the mental health gap as a multidiscipline project where all types of accredited – and, more importantly, available – professionals are called upon to make the system workable. While there is no easy fix, there are some practical remedies available to be found with our current resources.

When MD, PhD and Masters-level regulated professionals are able to combine their time, talents and technology into a true model of collaborative care, I believe we can do better.

Suzanne Dennison President, Ontario Association of Mental Health Professionals; Toronto

As someone who has been struggling with an eating disorder for more than a decade, I have experienced the gap in psychiatric services in this country firsthand.

When I was hospitalized, I would have access to a psychiatrist. However, once I was out of an inpatient setting, my family doctor managed my medication – something she didn’t feel like she had the expertise to do. I live just outside Ottawa, but my doctor still wasn’t able to refer me to a specialist in the city. Luckily, I ended up finding a psychiatrist in Brockville. Even so, I waited about three months for an appointment.

Unfortunately, it is not just outpatient services that seem lacking in Ontario. I discovered that eating disorders treatment centres at The Ottawa Hospital and Toronto General Hospital are currently sharing a psychiatrist who splits her time between the two programs – even the most acute patients have difficulty accessing her.

Psychiatric human-resources planning and care should change with the times. It is important for the future health and well-being of the country.

Hilary Thomson Kemptville, Ont.

While training or recruiting more psychiatrists would be helpful, if we are to come up with sustainable solutions, psychiatrists should also make changes in the way they work. They should serve as consultants to health care teams as well as to patients; discuss or advise about cases they may not need to see themselves; and collaborate with other care providers to enhance their skills and the range of cases they can manage.

Integrating psychiatrists (and other mental health providers) through a shared care approach within primary care settings is one increasingly popular way to enhance mental health care. The provision of excellent mental health care fits easily with the College of Family Physicians of Canada’s Patient’s Medical Home vision, which provides comprehensive, continual and team-based care. And for over 20 years, the CFPC and the Canadian Psychiatric Association have worked together to promote this approach, which has been implemented in many Canadian communities.

In this model, psychiatrists and other mental health specialists visit a family physician’s office to consult together with patients. They also discuss cases with family physicians and provide teaching and transferable skills that may be applied to other patients. Additionally, the psychiatrist is available by phone or e-mail between visits. For more isolated communities, video conferencing helps achieve many of the same goals.

This approach has many benefits. It improves access to psychiatrists in an environment that is comfortable for the patient. There is often a higher degree of cultural safety, especially if the primary care provider is from a patient’s community or speaks their language. The psychiatrist can also practice more efficiently: A program in Hamilton found that a single psychiatrist working full-time in this model can see over 700 new consults a year.

The ability to intervene sooner and prevent lengthy wait times for an outpatient appointment suggests that mental health issues can be identified and treatment initiated earlier. Patients can better maintain their quality of life at home and at work, and prevent avoidable emergency visits or relapses. This model of shared mental health care points to the important roles that family doctors and psychiatrists can play, together, in enhancing care.

Nick Kates and Patricia Mirwaldt Co-chairs, Collaborative Working Group on Shared Mental Health Care (a conjoint committee of the College of Family Physicians of Canada and the Canadian Psychiatric Association); Hamilton and Richmond, B.C.

Victor Ng Associate Director, Department of Programs and Practice Support, College of Family Physicians of Canada; London, Ont.

I believe there is one key element of the continuum of care that warrants further exploration: peer support. Growing in popularity and availability, I have found that peer support services help decrease the need for emergency and crisis service; increase the connection to appropriate supports and services; improve the ability for self-care; enable those in need to gain support earlier, have more confidence to tell other health providers what they need and give a greater sense of hope about their lives.

Rey Carr Peer Resources, Victoria

In order to improve access to mental health services, Canada should consider a federally funded insurance plan that would allow non-physician providers of psychotherapy to bill directly for their services. Australia successfully did this over a decade ago and we could do the same here. The advantages are many.

It would provide access to psychotherapy for the 40 per cent of Canadians who do not have employer-sponsored benefits. It would help relieve the pressure on the limited number of psychiatrists who deliver psychotherapy. It would enable GPs to refer patients knowing that they could afford psychotherapy, and incentivize a better integration of mental and physical health. Finally, it would complement rather than disrupt provincial spending priorities, and enable the provinces to save money by uploading to a federal plan some of the costs for services they already cover.

Why would the federal government even contemplate such an initiative? It seems to me about the only conceivable option for meeting the Minister of Health’s commitment to establish standards for access to mental health services in a way that would be acceptable to the provinces. Despite the many challenges involved in designing a fiscally viable and practical plan, the idea of a new federal insurance fund for psychotherapy should be on the table as a potential option to help address the ongoing crisis in access to mental health care.

Howard Chodos Former director, mental health strategy, Mental Health Commission of Canada; Ottawa

Family members are often the forgotten victims in a mental health crisis.

They are the firsthand witnesses to the effects of severe mental illness and addiction. They have often experienced months and years of attempting to support, advocate for and respond to ongoing crisis with their loved one.

Secondary and vicarious trauma are real. They witness a change in the person they once knew, dealing with verbal and physical abuse when trying to support them.

When they reach out to medical professionals, the health care system can offer little intervention unless the person is willing to accept help. Unfortunately, mental illness and substances can alter a person’s perception of self. So crisis continues to occur.

Hopefully family members are able to set boundaries to protect their own mental health. However, the system often expects families to step in and “pull their weight,” subjecting themselves to more abuse, grief and hopelessness.

When a family is experiencing a mental health crisis, the first question to ask them should be: “How are you doing?” Acknowledge how horrible it must be for them. Let them know you are there to support them and gently remind them that it is okay to set boundaries. Setting boundaries should be seen not as selfish, but essential for survival.

Nicole Lucier Chatham, Ont.

Editor’s note: Jan. 24, 2019: A previous version of this article referred to a Hamilton program which helped avoid over 32,000 days of hospital admissions. In fact, this statistic should have been in reference to a stepped care program.

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