Mental health: moving beyond just medication
Recently, we’ve seen two major announcements around funding for mental health care. Against the backdrop of a worsening opioid addiction crisis, the federal government negotiated deals with the provinces to provide billions in additional funds targeted to mental health. And Ontario has promised a $140 million mental-health investment over the next three years.
As part of that, the provincial government is focusing specifically on expanding access to psychotherapy provided in person and by phone, as well as online. “The goal of this program is to make evidence-based psychotherapy accessible across the province,” says Ministry of Health and Long-Term Care spokesman David Jensen.
It’s still in the process of developing the plan, but it’s focused on time-limited, solution-focused therapies. Those include cognitive behavioural therapy (CBT), which works on identifying and changing negative thoughts and behaviours, and interpersonal psychotherapy, which focuses on maintaining fulfilling relationships. These often take less than 20 sessions and focus on specific, present problems.
Increasing access to those and all forms of psychotherapy would address a problem with our current system, where medications for mental illness are much easier to get than psychotherapy — at least for those without means. Publicly funded psychiatrists often have long wait times, and psychologists can cost upwards of $200 an hour. Employer health-care plans only cover an average of $300 to $1,000 of psychotherapy a year.
Low-income Canadians, who are much more likely to have mental health needs, are also less likely to have private insurance. They might turn to clinics, schools or other groups that offer provincially covered services, through psychiatrists, psychologists, counsellors and social workers. But they also tend to face long wait lists. According to a recent report from Children’s Mental Health Ontario, for example, children in some parts of the province who are in need of urgent mental health care wait up to 1.5 years to receive it.
The evidence behind psychotherapy
This limited access exists despite the fact that psychotherapy is just as effective as pharmaceuticals at treating many common mental health conditions, that it’s preferred by many patients, and that it’s often cost effective. Often, the best treatment is both medication and psychotherapy. “Rather than seeing it as one versus the other, often times we should see it as being synergistic,” says Jeff Daskalakis, chief of the mood and anxiety division at the Centre for Addiction and Mental Health.
Psychotherapy is about as good as medication at treating moderate depression, and the preferred treatment is both medication and psychotherapy together. (For severe depression, it’s not recommended that psychotherapy is used alone, but a combination of psychotherapy and medication is also the preferred treatment.) Psychotherapy is also equal to medication at controlling anxiety disorders; it’s significantly better than drugs at treating obsessive compulsive disorder, and it’s an effective way to treat attention deficit disorder.
Psychotherapy also has the advantage that its benefits persist for a while after treatment ends, reducing the risk of relapse. And patients seem to prefer psychotherapy, with a meta analysis of studies finding patients are three times more likely to prefer psychotherapy over pharmaceuticals.
How other countries cover psychotherapy
Several other countries have focused on improving access to psychotherapy. The U.K. is a prominent success story, thanks to its improving access to psychological therapies (IAPT) program. It followed a series of systematic reviews from the National Institute of Health and Care Excellence (NICE) that emphasized the effectiveness of specific types of CBT on depression and anxiety.
To achieve this, the IAPT used technology: IAPT starts most patients off on guided self-help programs, moving them up to face-to-face psychotherapy only if that fails. “According to the NICE guidelines, online CBT is one of the first lines of treatment, before you get into more intensive costly types of activities,” says Cindy-Lee Dennis, Women’s Health Research Chair at the University of Toronto and St. Michael’s Hospital. It also added psychological therapists, many of whom were trained specifically for this initiative, to existing primary care teams. And it seems to be effective: A study that looked at the effects of the IAPT initiative on nearly 20,000 patients found that 40 percent showed reliable recovery and 64 percent showed reliable improvement, while seven percent deteriorated.
Meanwhile, Australia also introduced a new system, the Better Access to Mental Health Care Initiative, where the government paid private psychologists on a fee-per-service basis. Patients still need to be referred by a GP, but any registered psychologist is acceptable. By 2009, this program had provided subsidized access to 1 in 11 Australians.
How Canada could cover psychotherapy
Canada’s potential approaches to making more psychotherapy available mirror these two examples, says Francine Knoops, senior policy advisor at the Mental Health Commission of Canada. The first way to expand services is the insurance-funding model. “One would have to create a public insurance plan or expand the current insurance plan to allow privately employed providers to bill government directly,” she says – along the lines of what happened in Australia.
The second is the grant-funding model: “We could use public money to hire additional providers, within the purview of agencies and service vehicles that already exist,” she says, noting that many of the groups that currently provide services, like hospital and community-based clinics, have long wait lists, so increasing their capacity might be a logical way to serve more people. That might also include integrating more psychologists, social workers and counsellors into family health teams and family practice, since primary care currently treats a lot of mental health issues.
Many of the sources we spoke to preferred the second model. One was Karen Cohen, CEO of the Canadian Psychological Association. “We’re recommending that governments consider integrating psychologists into primary care,” she says. “That’s the publicly funded door” – and where people bring their mental health issues.
About half of mental health services in Ontario are provided by family doctors, says Rachel Forman, of the Ontario Medical Association. Yet there are a number of barriers to providing it, she adds, including “diagnostic complexities and managing challenging medication regimens. In addition, it is difficult to devote the time necessary to meet patients’ needs in the context of a busy family practice environment.”
This is also a moment to think about shaping the services provided so that they better suit the needs of the population. “Simply expanding access isn’t going to solve our inequity problems,” Knoops points out. Those include having limited access in rural and remote areas, and a need for more culturally appropriate programs that serve indigenous communities, refugees, immigrants and others.
That could involve integrating social workers, especially for programs like CBT for moderate anxiety or depression. Currently, “people are coming forward and being able to find the space to say I have an issue, I’m experiencing an issue, but [then they] really run into the wall,” says Fred Phelps, executive director of the Canadian Association of Social Workers. Social workers often fill the gap, staffing many employee assistance programs and offering crucial support in rural and northern communities.
While some have expressed concern that there aren’t regulations around how much training social workers need to provide services, that’s less of an issue in community-based clinics, where social workers are under the supervision of a psychologist – a relationship that could be replicated by bringing them both into primary care.
Using social workers and nurses to offer services can also help lower the costs of providing them. Another way is to offer services by phone or, as the U.K. did, through online-based therapy programs.
In fact, mental health is already the biggest use of the Ontario Telemedicine Network, says CEO Ed Brown, primarily connecting patients with psychiatrists. “Telemedicine is perfect for mental health,” he says, adding that users include people in jail, people with addictions, and women experiencing postpartum depression who might have trouble leaving the house.
They’re also looking at adding e-CBT programs and self-guided addictions programs. And an online treatment for depression and anxiety, Big White Wall, is currently being tested in some places in Ontario. It was brought over from the U.K., where is it endorsed by the National Health Service. “It’s an online environment that’s curated by mental health workers where people can share their feelings, track their mood, and take online courses [in things like CBT],” explains Brown.
The pilot is available by prescription, though the idea of self-referral has been considered. It’s too early to know its results in Canada, but “the anecdotal evidence is fabulous,” says Brown. “People say things like, ‘This is the first time I’ve actually shared my feelings with anybody.’”