David Zitner is a family doctor, past director of Medical Informatics at Dalhousie Medical School and the senior fellow in health-care policy for the Atlantic Institute for Market Studies (aims.ca).
Poor access to high quality mental health services, and high cost is a serious problem for many Canadians. Provincial policies exacerbate these problems by encouraging Canadians to get answers to mental health problems from psychiatrists, even when other mental health workers offer better and less expensive choices.
Psychiatrist services appear to be free to consumers because Medicare pays for them. Consequently, demand for psychiatrists is inflated leading to lengthy wait times and an apparent shortage. Other non-medical mental health workers must charge for the same services. People have little difficulty making timely appointments with psychologists, social workers, or personal trainers.
Physicians are the only mental health professionals who can legally prescribe medication. However, apart from medication, all mental health professionals use similar techniques to help change the way people think, what people feel, and how they behave.
The good news is that most mental health problems do not require medicines or psychiatric solutions. The overuse of physicians inflates costs, reduces access, leads to unnecessary use of drugs, and an increase in unnecessary adverse drug reactions.
Psychotherapists and psychologists use conversation as a tool to solve mental health problems. Some conversations focus on past events and early relationships, others focus on the current context, while other therapeutic conversations focus on the future, helping people define and meet specific goals. Some psychologists use rewards and punishments as incentives to influence behavior. Personal trainers recommend and supervise exercise programs to help people feel more energetic and reduce feelings of depression.
General practitioners and psychiatrists often treat depressed feelings by prescribing anti-depressants even though most people who feel depressed do not require medication and their laboratory tests do not show any biochemical abnormality or imbalance. People who lack energy because of a proven biochemical abnormality such as low thyroid hormone need to see a doctor and are always told exactly which hormone is out of balance and by how much.
A recent article in the prestigious Journal of the American Medical Association suggested that antidepressants are only effective for the small proportion of people who feel severely depressed. The National Institute for Mental Health reports that 2 per cent of the U.S. population is severely depressed. Yet the Centers for Disease Control and Prevention report that 10 per cent of the population is taking these potentially harmful drugs. For most depressed people, therefore, harmless placebos are as effective as potentially harmful antidepressant drugs. These statistics suggest that only one person in five who is prescribed an antidepressant is likely to benefit. Yet all who take these powerful drugs are at risk of serious complications, including gastrointestinal bleeding, and increased suicide risk. Antidepressants are now the third most commonly used category of drug in Canada. Better methods are needed to ensure that potentially harmful drugs are prescribed only to those who are likely to benefit.
Drugs influence our mood and behavior regardless of how healthy or sick we are. Street vendors know that previously healthy people will buy drugs to help them relax (e.g. Valium), to have more energy (amphetamines) or to change how they think (marijuana, LSD). Drugs prescribed by a doctor, or purchased illegally from a street vendor, may cause unpleasant and sometimes harmful adverse reactions.
One solution to the cost, quality, and access crisis in Canadian mental health is to enable nonmedical professionals to provide the talking and behavior therapies that help most people. Health departments should reserve scarce psychiatric consultations for those unfortunate people who have exhausted non-medical solutions and might require a professional with the power, for benefit or harm, of the prescription pad.