The majority of people treated in an Ontario emergency room after a suicide attempt are not seen by a psychiatrist within six months, according to a new study.
Even patients who are admitted to hospital for a serious mental-health issue – a high bar given bed shortages – rarely receive timely follow-up care. Two-thirds don't see a psychiatrist within the first month after being discharged, even when the government offers the specialists extra cash.
That's like showing up in emergency with a heart attack and not seeing a cardiologist after you leave.
The large-scale study, published Monday in the CMAJ, highlights a chronic problem in the country's mental-health care system: The people most in need don't get access to the specialists best trained to heal them – even in times of crisis.
And without a fix to the way psychiatrists are paid, how they work within the health-care system, or the kind of patients they treat, that's not going to change. In fact, the shortage will only get worse, as psychiatrists, particularly those in smaller communities, close in on retirement.
The new study tracked what happened after the Ontario government introduced a pay incentive in 2011 to encourage psychiatrists to treat patients after they left hospital or after a suicide attempt. Over five years, researchers from the Institute for Clinical Evaluative Sciences and the Centre for Addiction and Mental Health followed more than 380,000 patients, including roughly 78,000 who had attempted suicide. Only 40 per cent of the latter group of patients, for instance, saw a psychiatrist within six months after their visit to emergency, and this was consistent over time. The researchers found that the bonus – about $30 an appointment and an annual $200 a case – made no difference.
Maybe the bonus wasn't enough, the authors theorized, or psychiatrists didn't know about it.
Here's another possible reason: Too many psychiatrists are busy elsewhere, where there is easier money to be made. They are currently the only mental-health professionals who can bill the public system on a fee-for-service basis for talk therapy. Among those who practise privately, there are few limits on the therapy they provide, or the patients they choose to treat. In Toronto, for example, many can – and do – see the same small group of patients for years on end. (Notably, as research has found, these patients also tend to come from wealthier neighbourhoods, and are significantly less likely to have been admitted to hospital for a mental illness.)
Meanwhile, family doctors describe psychiatrists as the most difficult specialists to access. In a Vancouver experiment a few years ago, researchers tried to book a real patient from a GP's office: Out of 230 psychiatrists in private practice, only six could see the patient on short notice.
The way the system works now, "we have people getting a ton of services who appear not to need it. And people who have a ton of need, dropping off the cliff," says Paul Kurdyak, the medical director for performance improvement at the Centre for Addiction and Mental Health, one of the co-authors of the new paper, who has been studying how psychiatrists practise for years.
Basically, the system allows for the most expensive and highly trained experts in the field to provide long-term, psychological treatment to people who may not need it – while the most severely ill wait in line for even an initial consultation.
John Haggarty, a psychiatrist and senior medical director at the St. Joseph's Health Centre in Thunder Bay, puts it this way: "If I wanted to quit my job, and go into long-term psychotherapy, I would have a full practice in a few months."
Seeing the same patients over and over again would be easier, he says, than being "constantly bombarded with complex cases."
But the complex patients are the ones who most need his skills, Dr. Haggarty says, especially in smaller cities such as Thunder Bay, where psychiatrists are typically in shorter supply, and already overworked.
Although specialists are only one part of an overwhelmed mental-health system, Dr. Kurdyak's work points to the need for steps already taken in countries such as Britain and Australia, where psychiatrists serve almost exclusively as consultants, provide continuing care for the most severe mental illnesses, and are paid significantly less to provide talk therapy.
In the United States, Dr. Kurdyak says, some private health insurers withhold payments to hospitals for treating mental-health patients until they have been seen by a psychiatrist after their discharge – a recognition, he points out, that follow-up care improves recovery rates and saves the system money, particularly in cases of relapse. (Some of the patients in the study may be seen by their family physicians, says Dr. Kurdyak, but the severity and complexity of their cases merit more expert care.)
Time won't fix the issue either. In a follow-up study published last year, Dr. Kurdyak's team found roughly the same proportion of new psychiatrists are choosing to start smaller, urban practices as their older peers.
So what are the solutions? Tweaking the fee scale for psychiatrists – paying more for consultations and less for continuing therapy – is one option. Another, Dr. Kurdyak says, is to have hospitals or clinics handle patient lists for psychiatrists so that those most in need get priority – as is standard practice for other specialists.
Some locations work better than others. At the crisis clinic at CAMH for instance, he says, high-need patients typically see a psychiatrist within five days and are followed for six weeks. But there's no consistent standard of care across the province.
In countries such as Britain, changing the way psychiatrists practise has also meant expanding public access to less expensive professionals, such as social workers and psychologists. (Last week, Quebec announced plans to build a provincewide system of public therapy; Ontario is piloting a similar model on a smaller scale.)
Adrian Lawson, a psychiatrist who practises out of a family health team that serves Dufferin County, a rural area northwest of Toronto, mostly consults on cases. But he sees some patients over and over again because they can't get access to talk therapy otherwise.
"If we could just give them what they need," he says, "that would open up a lot of capacity for me."