Canadian Psychiatric Association
Association des psychiatres du Canada
Editorial
New Government, New Opportunity, and an Old Problem with Access to Mental Health Care
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2017, Vol. 62(1) 8-10 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716669084 TheCJP.ca | LaRCP.ca
David Gratzer, MD1,2 and David Goldbloom, MD2,3
For those concerned about access to mental health services, the present moment in politics holds promise. A federal Liberal government has been elected promising to address mental health access issues, a commitment recently reaffirmed by the Minister of Health.1 In Ottawa, bettering mental health care is nonpartisan: in the last election, every major political party promised action on improving services (unprecedented in federal campaigns); in the last Parliament, all parties supported a national suicide strategy. Good news is frankly welcome news. The interest is there and the need is great: 1 in 5 Canadians experiences a mental health problem in any given year,2 and they face a patchwork of care; many Ontarians have their first contact with the mental health system through the emergency room (roughly 1 in 3 with an anxiety disorder), according to a newly released Health Quality Ontario–Institute for Clinical Evaluative Sciences (HQO-ICES) report.3 Access is problematic—especially if the bar is raised to the standard of access to evidence-based care. Consider recent articles published in this journal: In a study by Dezetter et al.4 involving 1300 people treated at a Quebec primary-care clinic, 40% had unmet psychological needs. In a study by Goldner5 that surveyed Vancouver psychiatrists, of 230 psychiatrists, only 6 were available to provide a consultation in a timely manner. In an article by Patten et al.,6 drawing on census data, only about half of Canadians with depression received ‘‘potentially adequate care’’; in a study by Puyat et al.,7 drawing on British Columbia data, 13% of people with depression received ‘‘minimally adequate counseling/psychotherapy.’’
spent on mental health (in the United Kingdom and Australia, spending is closer to 12 cents).2 What could the federal government do to address access issues? More spending would be welcome, bringing Canada in line with other countries; the Mental Health Commission of Canada suggests 9 cents on every health dollar by 2020.2 But if there is any lesson of the Martin-Harper years of increased health transfers, more money alone does not necessarily result in better care. For the federal government, we offer 3 recommendations with a focus on improving access: A.
B.
1 2 3
And, despite the impact of mental health need on our society—the HQO-ICES report found that 1 in 10 family physician visits is for a mental health problem—historically, spending is limited. Just 7 cents of every health dollar is
Ottawa should look to scale up successful existing mental health programs. Access to mental health services is problematic, but creative programs already exist in this country. Strongest Families Institute, for example, helps families of youth with anxiety and attention issues by educating them, with DVDs and workbooks, and weekly follow-ups with e-therapists. Here’s the irony: this evidence-based program is not available in several Canadian provinces, but it is used in Vietnam and Finland (P. Lingley-Pottie, Strongest Families Institute, personal communication, 2016). The Advisory Panel on Healthcare Innovation (chaired by Dr. David Naylor) recommended that Ottawa establish an innovation fund8; in mental health, there is plenty of innovation, and that type of targeted funding would be important. Ottawa should better develop technology to deliver emental health services. Across the country, people
The Scarborough Hospital, Toronto, Ontario Department of Psychiatry, University of Toronto, Toronto, Ontario Centre for Addiction and Mental Health, Toronto, Ontario
Corresponding Author: David Gratzer, MD, The Scarborough Hospital, 3030 Birchmount Rd, Toronto, ON M1W 3W3, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 62(1)
C.
struggle with access to mental health services, but those in rural areas find access to care to be particularly problematic. Consider the gap between cities and noncities in Canada’s largest province: psychiatrist supply is 62.7 per 100,000 population in Toronto but just 8.3 in northeastern Ontario.9 Technology could help: Internetdelivered cognitive behavioural therapy (CBT) programs that are well designed have been shown to rival traditional, in-person CBT.10 Future work could be modeled after Australia’s e-therapy programs that offer CBT and other psychotherapies to people with Internet access.11 And televideo psychiatric consultation also overcomes geographic barriers. Furthermore, Internetdelivered therapies could be used to bridge cultural and language barriers, not just geographic ones—relevant both in Toronto and northeastern Ontario. Modeled after the United Kingdom’s National Institute for Health and Care Excellence (or NICE; www.ni ce.org.uk), Ottawa could create a national clearinghouse for treatment recommendations. With most of psychiatric care provided by family physicians, rather than psychiatrists, access is not just about getting better specialty care but about accessing informed primary care. But if primary care doctors need timely and relevant information on psychiatric conditions, this information is currently provided by different professional bodies, using different formats and standards. The federal government has a role here and should work to make it easier for primary care providers to get unbiased information on evidence-based care. Indeed, the creation of a knowledge exchange centre was part of the original mandate of the Mental Health Commission of Canada, which has not been fully realized. A Canadian version of NICE would be nice— and given its impact in the United Kingdom, it would be important.12
But we would also emphasize that not all problems can be solved by the federal government. Let’s look again at the Ontario data that show a nearly 8-fold difference in the supply per capita of psychiatrists between the province’s largest city and the rural Northeast. Yet their waiting lists are comparable.9 With access, we suggest that physicians—and particular psychiatrists—need to modernize their work to better address the poor access to care. For physicians, we forward 3 recommendations with a focus on improving access: 1.
Psychiatrists should incorporate more scales and objective measures into their work. With long waiting lists for care, psychiatrists should seek ways to make their patient encounters more clinically effective. A recent major study found that a measurement-based approach to depression management (using a simple treatment algorithm) produced a remission rate that was 2.6 times better than that of standard treatment.13
9
2.
3.
Psychiatrists should work more closely with family doctors, seeing their role not simply as consultants but also as educators and partners. With the majority of care provided by family doctors, psychiatrists need to work more closely and collaboratively with primary care. Collaborative care models are being tried across the country and are increasingly incorporated into resident teaching programs. Still, many psychiatrists and family doctors will not work in this formal structure, and stronger ties are needed. Evidence-based interventions that are effective and efficient should be given priority over other care. Psychiatrists offer a wide variety of services, from psychopharmacology to psychoanalysis. With people struggling to gain access to care, is all care of equal value? In other countries, payment systems have pushed physicians to practice in a certain way.9 A voluntary effort would be preferable.
Of course, there is much more work to be done: from reducing prison recidivism by improving mental health services for the incarcerated to addressing the special needs of Aboriginals seeking mental health care. That said, the above recommendations would significantly help improve access to mental health services for Canadians. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Collier R. Profile: Dr. Jane Philpott. CMAJ. 2016;188(2): 100-102. 2. Mental Health Commission of Canada. Changing directions, changing lives: the mental health strategy for Canada. Calgary (AB): Mental Health Commission of Canada; 2012. 3. Brien S, Grenier L, Kapral ME, Kurdyak P, Vigod S. Taking stock: a report on the quality of mental health and addictions services in Ontario. An HQO/ICES Report. Toronto (ON): Health Quality Ontario and Institute for Clinical Evaluative Sciences; 2015. 4. Dezetter A, Duhoux A, Menear M, Roberge P, Chartrand E, Fournier L. Reasons and determinants for perceiving unmet needs for mental health in primary care in Quebec. Can J Psychiatry. 2015;60(6):284-293. 5. Goldner E. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Can J Psychiatry. 2011;56(8):474-480. 6. Patten SB, Williams JV, Lavorato DH, Wang JL, McDonald K, Bulloch AG. Major depression in Canada: what has
10
changed over the past 10 years? Can J Psychiatry. 2016; 61(2):80-85. 7. Puyat JH, Kazanjian A, Goldner AM, Wong H. How often do individuals with major depression receive minimally adequate treatment? A population-based, data linkage study. Can J Psychiatry. 2016;61:394-404. 8. Health Canada. Unleashing innovation: excellent healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. Ottawa (ON): Health Canada; 2015. 9. Kurdyak P, Stukel TA, Goldbloom D, Kopp A, Zagorski BM, Mulsant BH. Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario. Open Med. 2014;8(3):e87-e99.
The Canadian Journal of Psychiatry 62(1)
10. Gratzer D, Khalid-Khan F. Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness. CMAJ. 2016;188(4):263-272. 11. Gratzer D, Goldbloom D. Making evidence-based psychotherapy more accessible in Canada. Can J Psychiatry. 2016 Apr 5. [Epub ahead of print] 12. Cromwell D. Impact of NICE guidance on rates of haemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit. Qual Saf Health Care. 2008;17:264-268. 13. Guo T, Xiang YT, Xiao L, et al. Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. Am J Psychiatry. 2015;172(10):1004-1013.
Association des psychiatres du Canada
Editorial
New Government, New Opportunity, and an Old Problem with Access to Mental Health Care
The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie 2017, Vol. 62(1) 8-10 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0706743716669084 TheCJP.ca | LaRCP.ca
David Gratzer, MD1,2 and David Goldbloom, MD2,3
For those concerned about access to mental health services, the present moment in politics holds promise. A federal Liberal government has been elected promising to address mental health access issues, a commitment recently reaffirmed by the Minister of Health.1 In Ottawa, bettering mental health care is nonpartisan: in the last election, every major political party promised action on improving services (unprecedented in federal campaigns); in the last Parliament, all parties supported a national suicide strategy. Good news is frankly welcome news. The interest is there and the need is great: 1 in 5 Canadians experiences a mental health problem in any given year,2 and they face a patchwork of care; many Ontarians have their first contact with the mental health system through the emergency room (roughly 1 in 3 with an anxiety disorder), according to a newly released Health Quality Ontario–Institute for Clinical Evaluative Sciences (HQO-ICES) report.3 Access is problematic—especially if the bar is raised to the standard of access to evidence-based care. Consider recent articles published in this journal: In a study by Dezetter et al.4 involving 1300 people treated at a Quebec primary-care clinic, 40% had unmet psychological needs. In a study by Goldner5 that surveyed Vancouver psychiatrists, of 230 psychiatrists, only 6 were available to provide a consultation in a timely manner. In an article by Patten et al.,6 drawing on census data, only about half of Canadians with depression received ‘‘potentially adequate care’’; in a study by Puyat et al.,7 drawing on British Columbia data, 13% of people with depression received ‘‘minimally adequate counseling/psychotherapy.’’
spent on mental health (in the United Kingdom and Australia, spending is closer to 12 cents).2 What could the federal government do to address access issues? More spending would be welcome, bringing Canada in line with other countries; the Mental Health Commission of Canada suggests 9 cents on every health dollar by 2020.2 But if there is any lesson of the Martin-Harper years of increased health transfers, more money alone does not necessarily result in better care. For the federal government, we offer 3 recommendations with a focus on improving access: A.
B.
1 2 3
And, despite the impact of mental health need on our society—the HQO-ICES report found that 1 in 10 family physician visits is for a mental health problem—historically, spending is limited. Just 7 cents of every health dollar is
Ottawa should look to scale up successful existing mental health programs. Access to mental health services is problematic, but creative programs already exist in this country. Strongest Families Institute, for example, helps families of youth with anxiety and attention issues by educating them, with DVDs and workbooks, and weekly follow-ups with e-therapists. Here’s the irony: this evidence-based program is not available in several Canadian provinces, but it is used in Vietnam and Finland (P. Lingley-Pottie, Strongest Families Institute, personal communication, 2016). The Advisory Panel on Healthcare Innovation (chaired by Dr. David Naylor) recommended that Ottawa establish an innovation fund8; in mental health, there is plenty of innovation, and that type of targeted funding would be important. Ottawa should better develop technology to deliver emental health services. Across the country, people
The Scarborough Hospital, Toronto, Ontario Department of Psychiatry, University of Toronto, Toronto, Ontario Centre for Addiction and Mental Health, Toronto, Ontario
Corresponding Author: David Gratzer, MD, The Scarborough Hospital, 3030 Birchmount Rd, Toronto, ON M1W 3W3, Canada. Email: [email protected]
La Revue Canadienne de Psychiatrie 62(1)
C.
struggle with access to mental health services, but those in rural areas find access to care to be particularly problematic. Consider the gap between cities and noncities in Canada’s largest province: psychiatrist supply is 62.7 per 100,000 population in Toronto but just 8.3 in northeastern Ontario.9 Technology could help: Internetdelivered cognitive behavioural therapy (CBT) programs that are well designed have been shown to rival traditional, in-person CBT.10 Future work could be modeled after Australia’s e-therapy programs that offer CBT and other psychotherapies to people with Internet access.11 And televideo psychiatric consultation also overcomes geographic barriers. Furthermore, Internetdelivered therapies could be used to bridge cultural and language barriers, not just geographic ones—relevant both in Toronto and northeastern Ontario. Modeled after the United Kingdom’s National Institute for Health and Care Excellence (or NICE; www.ni ce.org.uk), Ottawa could create a national clearinghouse for treatment recommendations. With most of psychiatric care provided by family physicians, rather than psychiatrists, access is not just about getting better specialty care but about accessing informed primary care. But if primary care doctors need timely and relevant information on psychiatric conditions, this information is currently provided by different professional bodies, using different formats and standards. The federal government has a role here and should work to make it easier for primary care providers to get unbiased information on evidence-based care. Indeed, the creation of a knowledge exchange centre was part of the original mandate of the Mental Health Commission of Canada, which has not been fully realized. A Canadian version of NICE would be nice— and given its impact in the United Kingdom, it would be important.12
But we would also emphasize that not all problems can be solved by the federal government. Let’s look again at the Ontario data that show a nearly 8-fold difference in the supply per capita of psychiatrists between the province’s largest city and the rural Northeast. Yet their waiting lists are comparable.9 With access, we suggest that physicians—and particular psychiatrists—need to modernize their work to better address the poor access to care. For physicians, we forward 3 recommendations with a focus on improving access: 1.
Psychiatrists should incorporate more scales and objective measures into their work. With long waiting lists for care, psychiatrists should seek ways to make their patient encounters more clinically effective. A recent major study found that a measurement-based approach to depression management (using a simple treatment algorithm) produced a remission rate that was 2.6 times better than that of standard treatment.13
9
2.
3.
Psychiatrists should work more closely with family doctors, seeing their role not simply as consultants but also as educators and partners. With the majority of care provided by family doctors, psychiatrists need to work more closely and collaboratively with primary care. Collaborative care models are being tried across the country and are increasingly incorporated into resident teaching programs. Still, many psychiatrists and family doctors will not work in this formal structure, and stronger ties are needed. Evidence-based interventions that are effective and efficient should be given priority over other care. Psychiatrists offer a wide variety of services, from psychopharmacology to psychoanalysis. With people struggling to gain access to care, is all care of equal value? In other countries, payment systems have pushed physicians to practice in a certain way.9 A voluntary effort would be preferable.
Of course, there is much more work to be done: from reducing prison recidivism by improving mental health services for the incarcerated to addressing the special needs of Aboriginals seeking mental health care. That said, the above recommendations would significantly help improve access to mental health services for Canadians. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Collier R. Profile: Dr. Jane Philpott. CMAJ. 2016;188(2): 100-102. 2. Mental Health Commission of Canada. Changing directions, changing lives: the mental health strategy for Canada. Calgary (AB): Mental Health Commission of Canada; 2012. 3. Brien S, Grenier L, Kapral ME, Kurdyak P, Vigod S. Taking stock: a report on the quality of mental health and addictions services in Ontario. An HQO/ICES Report. Toronto (ON): Health Quality Ontario and Institute for Clinical Evaluative Sciences; 2015. 4. Dezetter A, Duhoux A, Menear M, Roberge P, Chartrand E, Fournier L. Reasons and determinants for perceiving unmet needs for mental health in primary care in Quebec. Can J Psychiatry. 2015;60(6):284-293. 5. Goldner E. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Can J Psychiatry. 2011;56(8):474-480. 6. Patten SB, Williams JV, Lavorato DH, Wang JL, McDonald K, Bulloch AG. Major depression in Canada: what has
10
changed over the past 10 years? Can J Psychiatry. 2016; 61(2):80-85. 7. Puyat JH, Kazanjian A, Goldner AM, Wong H. How often do individuals with major depression receive minimally adequate treatment? A population-based, data linkage study. Can J Psychiatry. 2016;61:394-404. 8. Health Canada. Unleashing innovation: excellent healthcare for Canada. Report of the Advisory Panel on Healthcare Innovation. Ottawa (ON): Health Canada; 2015. 9. Kurdyak P, Stukel TA, Goldbloom D, Kopp A, Zagorski BM, Mulsant BH. Universal coverage without universal access: a study of psychiatrist supply and practice patterns in Ontario. Open Med. 2014;8(3):e87-e99.
The Canadian Journal of Psychiatry 62(1)
10. Gratzer D, Khalid-Khan F. Internet-delivered cognitive behavioural therapy in the treatment of psychiatric illness. CMAJ. 2016;188(4):263-272. 11. Gratzer D, Goldbloom D. Making evidence-based psychotherapy more accessible in Canada. Can J Psychiatry. 2016 Apr 5. [Epub ahead of print] 12. Cromwell D. Impact of NICE guidance on rates of haemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit. Qual Saf Health Care. 2008;17:264-268. 13. Guo T, Xiang YT, Xiao L, et al. Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. Am J Psychiatry. 2015;172(10):1004-1013.
