This is part of a series on improving mental health research, diagnosis and treatment. Join the conversation on Twitter with the hashtag #OpenMinds
‘We have the evidence…
Why aren’t we providing evidence-based care?’
Mental illness affects one in five Canadians and costs us nearly $50-billion a year. So why aren’t we treating it like any other health-care crisis?
Erin Anderssen explores the case for publicly funded psychotherapy
It’s 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. “It is always physical and always catastrophic,” Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient’s abdomen, recording her symptoms, just as she has done almost every week for months. “There’s something wrong with me,” the patient says, with a look of panic.
Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy – a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can’t afford the cost of private sessions.
Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed. She is managing to care for her two young children – for now – but her husband also suffers from anxiety, and the situation is far from ideal. Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves.
But the doctor knows she will be back next week. And that their meeting will go much the same as it did today.
- Only one in five young people get the help they need. There is a better way
- Why medicating our kids isn’t the only, or best, answer
- Is childhood self-harm contagious?
- Can kids refuse treatment? All you need to know about consent
- We can’t afford not to increase access to publicly insured psychotherapy
- The power of technology to deliver psychotherapy
- Picard: Psychotherapy: A better funding model must be found
- How bias in mental health care hurts women, from the lab to the medicine cabinet
- Inside the world's best mental-health program to keep homeless people off the street
- Can your diet shape your mental health?
- Workplaces have responsibility to promote mental well-being of employees
In its broad strokes, this is a scene that repeats itself in thousands of doctors’ offices every day, right across the country. It is part and parcel of a system that denies patients the best scientific-based care, and comes with a massive price tag, to the economy, families and the health care system. Canadian physicians bill provincial governments $1-billion a year for “counselling and psychotherapy” – one third of which goes to family doctors – a service many of them acknowledge they are not best suited to provide, and that doesn’t come close to covering patient need. Meanwhile, psychologists and social workers are largely left out of the publicly funded health-care system, their expertise available only to Canadians with the resources to pay for them.
Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient’s colon, the government kicks in and offers the mainstream treatment that is most effective.
But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all.
But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression – which also constitute more than 80 per cent of all psychiatric diagnoses.
Mental illness affects one in five Canadians. It is a factor in 90 per cent of suicides. And its cost to the economy in health-care dollars spent, and in lost productivity, amounts to nearly $50-billion a year. Yet, no province currently pays for therapy provided by a private psychologist or social worker.
According to a 2012 Conference Board of Canada report, $20.7-billion in productivity is lost from the Canadian economy annually due to mental illness. This is measured as “indirect costs” of mental illness.
What else does roughly
Canadian spending on national defence, 2012-13
- Approx. $20B
Market valuation of Airbnb, 2015
- Approx. $21B
GDP of Kitchener-Cambridge-Waterloo region, 2009
- Approx. $21B
Amount food manufacturing contributed to the economy, 2012
- Approx. $22B
Amount quarrying and mining contributed to the economy, 2012
Low-income Canadians – who are three times more likely to report poor to fair mental health, and yet are the least likely to be able to afford private psychotherapy – are suffering disproportionately. At the same time, an inaccurate and damaging message is being broadcast to all Canadians: that therapy isn’t a valid treatment; that it’s more Woody-Allen ruminating than science-based solution.
Another major side effect: Canada is becoming one of the most pill-popping nations in the world. A 2012 survey by Statistics Canada found that, while only 65 per cent of patients reported getting the therapy they sought, 91 per cent received the drugs they wanted. Family doctors, meanwhile, faced with managing the bulk of Canada’s mental-health burden, are often going it alone, and working on the fly.
“We have the evidence,” says Paul Kurdyak, the director of health-systems research at Toronto’s Centre for Addiction and Mental Health (CAMH). “Why aren’t we providing evidence-based care?”
The case for psychotherapy
Research has found that psychotherapy is as effective as medication – and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor’s appointments and emergency-room visits, and making it more cost-effective in the long run.
Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health.
There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy – an approach that focuses on changing negative thinking – in large part because CBT, which is time-limited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs – as therapy doesn’t have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs – selective serotonin reuptake inhibitors (SSRIs) – and psychotherapy.
“The issue is not one against the other,” says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. “I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice.”
Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months.
A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.
But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse – an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.
According to treatment guidelines by leading international professional and scientific organizations – including Canada’s own expert panel, the Canadian Network for Mood and Anxiety Treatments – psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is “highly recommended” in maintaining recovery in the long term. Britain’s independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety – a finding that led to the creation of a $760-million public system, which now handles therapy referrals for nearly one million people a year.
Treatment for all: How it could be done
In Europe, public coverage for psychotherapy varies widely. Long-term private therapy is covered by a public system in Germany, while in Sweden, psychologists work in primary-care teams and online therapy is widespread. In Switzerland, therapy is covered only when it’s provided in a family doctor’s office. Here is a breakdown of how different countries have approached the issue.
The Netherlands: Primary-care psychologists provide up to eight sessions of publicly funded therapy a year. Most patients are referred through their family doctor, who collaborates with the psychologist and often shares office space, but more than one-third are self-referrals. Severe cases are referred to specialists or in-patient care.
Norway: Private-practice psychologists are contracted with the state to provide publicly funded care as part of their caseload, either full- or part-time. In recent years, the focus has been to move psychologists into doctor’s offices. Psychiatric outreach teams often treat patients in their homes, if possible. Norwegians make a small co-payment, with income-based exceptions.
Denmark: A portion of the cost of private psychologists is covered by the state. In September, Denmark will introduce a right to psychiatric consultation within one month of referral, along with a right to treatment for serious conditions one month later, and for less serious conditions within the following two months.
Germany: Publicly funded therapy has been the standard for decades. Germans who are not covered through a private employee plan must pay into the public plan, with a sliding scale based on income. Patients are referred by doctors and, after five initial diagnostic sessions, therapists submit a treatment plan to the public-insurance agency for approval. Many more sessions are covered if the need is deemed to exist – cognitive behavioural therapy can start with 25 sessions, and go up to 120; psychoanalysis can run up to 300 sessions. Waiting lists can be months long. There is currently debate among researchers and policymakers about covering additional types of therapy.
Sources: The Canadian Psychological Association, the Commonwealth Fund 2014 International Profile of Health Care Systems, Thrive: The Power of Evidence-Based Psychological Therapies by David Clark and Richard Layard, Globe and Mail interviewsErin Anderssen
In 2012, Canada’s Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, “has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won’t get help.” What would happen if the health-care system outright “ignored” two-third of tumour diagnoses?
Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. “Think about it,” he says. “We have a new antidepressant. It works as well as many others, and it may even have some advantages – it works better for remission – with fewer side effects. The patients may prefer it. And [in the long run] it doesn’t cost more than what we have. How can it not be covered?”
A heavy price
This isn’t just a medical issue; it’s an economic one. Mental illness accounts for roughly 50 per cent of family doctors’ time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined. Mental illness – and depression, in particular – is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases.
Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.
Yet, when family doctors were asked why they didn’t refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres.
And it’s not just the uninsured who are affected. Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higher-income workers with stable employment. Federal public servants, notably, have one of the best plans in the country – their benefits were doubled in 2014 to $2,000 annually for psychotherapy.
Many of those who can pay for therapy are doing so: A 2013 consultant’s study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates that 30 per cent of private patients pay out-of-pocket themselves.
When the afflicted don’t seek help, the cost isn’t restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors’ offices, ERs, and operating rooms. And an inexorable burden for the patients’ families forced to fill the gaps in caregiving – or carry on when they lose a loved one.
Canada’s investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did.
Falling off a cliff, again and again
In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn’t sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy.
“You do what you can,” says Dr. Szajkowksi. “You provide some support and encouragement.” He did his best, but he always had other patients waiting.
These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn’t been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eating-disorder program because she couldn’t follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don’t have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.
Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times.
Family doctors interviewed for this story admitted that they are often “handholding” patients with nowhere else to go. “I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else,” says Dr. Batya Grundland, a physician who has been in family practice at Toronto’s Women’s College Hospital for almost a decade. “But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely.” More senior doctors have told her that once in a while “a light bulb goes off” for the patients, but often only after many years. That’s not an efficient use of health dollars, she points out – not when there are trained therapists who could do the job better. However, she says, “in some cases, I may be the only person they have.”
Family doctors aren’t the only ones struggling to find therapy for their patients. “I do a hundred consultations a year,” says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, “and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy.”
A fractured, inefficient system
“You fall into the role that is handed to you,” says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide “active listening” to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy.
“Five of those minutes are spent talking about the weather,” he says, “and then maybe you get into the meat of the problem, but the reality is we don’t have the appropriate amount of time to give to therapy, even to listen, really.” Often, he watches his patients’ symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. “The whole system could save on productivity and money if people were actually able to get the treatment they needed.”
One result can be overloaded family doctors minimizing mental-health problems. “If you have nothing to offer someone,” asks Dr. Anderson, “how much are you going to dig around to find out what is going on?” Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don’t have mental illness.
And yet family physicians alone bill about $361-million a year for counselling or psychotherapy in Canada – 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it’s often more supportive listening than actual therapy.
Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training – or the time – to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, “If a patient cries, then it’s psychotherapy.” Another described it as “listening to their woes.”
A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. “Do family doctors really need to do that much psychotherapy,” Dr. Hameed asks, “when there are other people trained – and better trained – to do it?”
What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient “immediately,” but even then, their wait times ranged from four to 55 days.
Psychiatrists are in increasingly short supply in Canada, and there’s strong evidence that we’re not making the best use of these highly trained specialists. They can – and often do – provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.
A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 – on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.
And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.
As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty “can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. … By treating the rich and famous, there is zero risk of being punched in the face by a patient.”
Left out in all this, by and large, are other professionals who can provide therapy. It doesn’t help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed by their professional colleges, in some provinces a person can call himself a marriage counsellor or music therapist without any oversight. As of this April, for instance, Ontario finally brought into effect a 2007 psychotherapy act that requires anyone calling themselves a “psychotherapist” to be registered with a new provincial college, that will set standards and handle complaints. But a part of the act preventing unregulated practitioners from treating people with serious mental health disorders is still not in force.
The brain keeps many secrets
Psychotherapy was already getting a bad rap – Freud’s fixation with penis envy didn’t help – even before the 1980s, when today’s go-to medications for depression and anxiety first hit the market. If the alternative was a psych ward run by Nurse Ratched, a quick fix taken in the privacy of one’s bathroom was understandably compelling. The new drugs, Prozac among them, quickly became the most lucrative prescriptions to pass across the pharmacist’s counter. They worked for many people, especially those with severe mental illness, and were better tolerated than their predecessors, most famously Valium, although patients complained of weight gain, drowsiness and lower libido. And they are considered less than ideal for teenagers and pregnant women.
Still, Canadians lined up for such drugs. In a 2013 OECD study, Canada ranked third among 23 countries in the use of anti-depressant prescriptions. Here, anti-depressants are a $1.4-billion market, with doctors handing out 40 million prescriptions a year. Almost one in 10 Canadians are on antidepressants; two-thirds of them are women.
Given the billions spent to sell pills, the pharmaceutical industry has been heavily invested in advancing the notion of depression as a chemical imbalance – and thus, a problem to be solved by chemicals. Tinker under the hood, and off you go, good as new. Well-meaning anti-stigma campaigns have also latched onto the biological theory; if depression is like diabetes, it can’t be a shameful weakness of character.
Science, however, has yet to find depression’s equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The “chemical imbalance” theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control.
SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren’t sure why the drugs help some patients and fail with others. “Basically, it’s like we have a bucket of water and we pour it over the patient’s head,” says Dr. Georg Northoff, the University of Ottawa’s Michael Smith chair of Neurosciences and Mental Health. “But you want a drug that injects the water in a very specific brain regions or brain system, which we don’t have.”
Critics of therapy have argued that it’s basically “good listening” – comparable to having a sympathetic friend across the kitchen table – and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That’s true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania – although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.)
But drugs also don’t work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.
Yet it’s talk therapy that the public often views most skeptically. “Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy],” says Dr. Paris, the Montreal psychiatrist. “They are very skeptical, and they don’t believe the research. It’s amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us.”
Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University’s medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. “It was transformative,” she says. “We looked after everything in-house.”
Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. “I just made it my business to teach myself what to do.”
Today, her Halifax practice is the kind of workaround that GPs are increasingly forced to experiment with, waiting for the system to catch up. At her clinic, patients have access – either on-site or through specific referrals - to many different kinds of therapies, including mindfulness, interpersonal therapy and family and couples counselling. She calls it treating “the spirit, mind and body” - a phrase, she says, that still gets “eyes rolling” at medical meetings.
After reducing her overhead with a paperless, electronic system, Dr. Jayabarathan doesn’t charge therapists for office space on the condition they adjust their fees to treat patients who don’t have insurance on a sliding scale. The maximum for a one-hour appointment is $100; as many as one-third pay half that much. (She works with social workers and psychotherapists, she says, because psychologists are too expensive.) Dr. Jayabarathan acts as the case manager, overseeing how well the treatment is working, getting her patients support when warning signs first appear.
“Family doctors work in the real world,” she says, where people are more complicated than a randomized-controlled trial. Even when a doctor can treat the symptoms of depression and anxiety, she says, it’s managing the fallout of those illnesses - the loss of work, the strained ties with family, the link to chronic health problems, including substance abuse - that requires complex care the system doesn’t cover. For those problems, she argues, neither a drug prescription, nor 15 minutes with a doctor go very far. “It’s time spend with someone that is a determinant of health.”
Who would pay – and how?
The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec’s science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.
In Manitoba, the Liberal Party – albeit well behind in the polls – has made the public funding of psychologists one of its campaign platforms for the province’s spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy – though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.
There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mental-health change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not “preclude provinces and territories from extending public coverage to other services or providers such as psychologists.”
But these issues aren’t insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don’t need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.
So how would Canada pay for access to such therapy? It wouldn’t be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier.
Some of the figures being tossed around sound staggering. Rolling out a version of Britain’s centre-based program across Canada would cost $950-million. Michael Kirby’s plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.
But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care.
Figuring out how to make the system most cost-effective is, according to sources, currently delaying the INESSS report to the Quebec government. “You need to facilitate the government,” says Helen-Maria Vasiliadis, a professor of community health at the University of Sherbrooke. “You can’t be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions.”
An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec’s health minister last month. In its design, the system would work much like Quebec’s public drug plan – Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades.
One step forward, one step back
Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. “We wanted to be careful she didn’t become a waiting list – like everything in the system,” says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic.
As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32-year-old mother with anxiety attended sessions with the psychologist. “She is making progress,” says Dr. Hayes, “slowly.”
In Toronto, meanwhile, Batya Grundland juggles her most complicated patients as best she can. As in Sherbrooke, the clinic has a small team of mental health professionals in the collaborative family practice who offer different kinds of therapy. Given the needs of the clinic’s 20,000 patients, providing long-term support for complex patients with multiple problems is a challenge. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a life-changing accident. Every month, doctor and patient would repeat the same conversation they’d already had more than a dozen times – and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist who she can see regularly over a longer time frame, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.
But there’s no extra money in the patient’s budget for a psychologist. “I do my best,” Dr. Grundland says, “but it’s not my area of expertise.”
Meanwhile, the patient isn’t getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. “But,” says Dr. Grundland, “she has nowhere else to go.”
Erin Anderssen is a feature writer at The Globe and Mail.
TWO COUNTRIES, TWO GAME PLANS
In the past decade, Britain and Australia have made huge investments in publicly funded therapy. Their approaches, however, set them apart.
In the U.K., the PHQ-9 form helps doctors screen patients and refer them to the best care.
What they did
Since 2008, 211 centres have opened across the country to provide assessment and therapy to adults specifically suffering from mild to moderate depression. The goal was to provide access to 15 per cent of the adult population needing therapy, with recovery rates of at least 50 per cent. In 2013, roughly 900,000 adults were referred to the program; 364,000 completed at least two sessions of therapy.
How it works
The program follows treatment guidelines laid out by the National Institute for Health and Care Excellence, an independent scientific body that makes evidence-based recommendations. Patients, either self-referred or sent by their doctor, are screened to determine the appropriate level of treatment. Based on their symptoms, they are slotted into levels of care of various intensity, from self-directed counselling (or housing or employment support), to individual therapy, to referrals to psychiatrists.
The government has invested over $760-million cdn to date. Politicians were persuaded by an analysis conducted by Oxford University psychologist David Clark, and Richard Layard, a renowned “happiness” expert at the London School of Economics. “It was very important to bring the clinical researcher together with the economist to advance the argument,” says Dr. Clark.
Lord Layard spearheaded several reports highlighting the massive cost of mental illness to the economy, government entitlements and the health-care system, which was deemed “scandalously” unfit to deal with the problem. Studies proposed that providing psychotherapy would pay for itself by reducing disability benefits and getting people back to work.
Who provides the therapy
The program has trained 5,000 new therapists, with a special focus on cognitive behavioural therapy. The goal is to increase that number to 8,000 by this year. They are supervised by psychologists.
A key component of the program, called Improving Access to Psychological Therapies (IAPT), is data collection (to improve quality of service) and public disclosure of success rates. The overall recovery rate has been reported at around 45 per cent (with 60 per cent of all patients found to make a significant improvement in symptoms). These statistics, however, are based on the roughly 60 per cent of referrals who complete one or two sessions. (IAPT was designed to “assess” patients, as well as provide therapy, so the portion who don’t receive therapy, says Dr. Clark, includes people sent to other services, given take-home information, or referred to more serious interventions.) Overall, patients attend an average of six sessions, even though more are available – the reason for this isn’t entirely clear. About 13 per cent of those taking medication at the start of treatment stopped doing so at the end. Those who self-refer tend to come from more marginalized populations, and have often been ill for longer than those referred by doctors, but recover at similar rates, and often with fewer sessions. (Researchers attribute this to a high motivation to get better.)
What needs fixing
Recovery rates vary widely between centres. The program has been criticized for focusing too heavily on cognitive behavioural therapy, as recommended by the National Institute for Health and Care Excellence, rather than a wider variety of approaches. Waiting lists have grown and dropout rates between referral and treatment remain high. Still, the data being collected, argues Dr. Clark, makes it possible to identify issues relatively quickly. The program is being slowly rolled out to expand to youth services.
What they did
In 2006, the government decided to fund private psychotherapy through its public health system.
How it works
Australians referred by their doctors are provided with up to 10 sessions with a qualified therapist. Patients may also access 10 publicly funded group sessions. The fees covered under the health-care system are roughly half those set by the professional psychological association, which means many patients still pay a portion out-of-pocket – on average, about $35 a session. The co-pay is based, to some extent, on income. Australians can also use employment plans, but can’t combine them with government coverage. Therapists must report back to family doctors after six sessions.
The program proved more popular than expected, and, in 2013-14, 1.7 million Australians received mental-health services under the new benefits. The cost of the program has turned out to be two- and-a-half times what was originally anticipated; medicare payments for mental-health services totalled $682-million in 2013, accounting for about one-third of the government’s total mental-health spending. (Of that amount, about 40 per cent was claimed by psychologists and other mental-health professionals, the remainder by doctors and psychiatrists.) Demand for the program now appears to be levelling out.
Rather than treating the “worried well,” research has found that over 90 per cent of patients were found to have a clinical diagnosis of anxiety or depression, and 80 per cent were scored, in assessments, as being in high or very high distress. “It is clear that the ‘worried well’ comprise only a very small minority,” observed Anthony Jorm, a mental-health researcher at the University of Melbourne, and early skeptic of the program, in a paper in the Australian and New Zealand Journal of Psychiatry. The majority of patients were getting help for the first time. Most patients who received therapy saw their symptoms improve, according to early findings, and on average, five sessions of therapy were used.
What needs fixing
A recent report found that, as with private services, therapy covered by medicare was less likely to be accessed in poor or more remote communities. Cost has also been an issue, leading the government to reduce the number of sessions covered. But there have been “enormous demands and support from the Australian public,” says Prof. Jorm. “It would be difficult for the government to undo [it] at this point.”
The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other, story in the series.
Editor's note: The original version of this article implied that the family practice clinic at Women’s College Hospital in Toronto doesn’t include mental health care professionals; in fact it does, but there are not enough staff to provide the level of mental health care needed for all the clinic’s patients. Also in the original version, an Ontario law to create a regulatory college for psychotherapists was described as being in limbo; it was brought into effect in April. Additional details on Dr. Jayabarathan’s practice have been added to this version.