Chris is a family doctor at a Family Health Team in a Southern Ontario farming community (some details including his name have been changed to protect his and his patients’ identities). He sees many children and youth who have mental illnesses such as depression, anxiety and severe ADHD. While he can care for some of these patients himself, others need a level of care he cannot provide despite being in a well supported group practice. When he tries to get these children help, however, he is confronted with what he feels is “a broken system.”
Many of his patients face at least 12 month wait times to see a child psychiatrist, and if they are admitted to hospital because their illness reaches a crisis point, they are simply put back on the wait list once they are discharged. “There’s no continuity for these kids,” he says.
While they wait for specialized care, Chris does his best to manage their conditions himself, but he wishes he could get more training in child mental health, and that he could call a child psychiatrist to get their input about treatment options for his patients with complex needs.
Most frustrating for Chris is that many of his patients cannot afford to send their children to see counselors or psychologists who could help treat their conditions, because the Ontario Health Insurance Plan and their personal insurance do not cover these services. While the schools and community agencies in Chris’ area do provide some of these services, he believes they are “overwhelmed,” and that his patients are falling through the cracks. “They’re not getting the care they need” he says.
A broken system
Reports released over the last decade paint a bleak picture of child and youth mental health services at both the national and the provincial level.
In 2006, the senate released its report Out of the Shadows at Last, which identified numerous problems with child and youth mental health services across the country. It found major gaps in early intervention, turf wars between service providers and a system based on arbitrary age categories, leading to disruptions in care.
It also found severe shortages of mental health professionals, including psychiatrists, psychologists, nurses and social workers.
In 2008, Ontario’s Auditor General reviewed the province’s child and youth mental health agencies, and found that they had been suffering from 10 years of eroding funding. The Auditor reported that this erosion created strain on these agencies’ core services and resulted in a reduction of preventative and early intervention programs.
The report also found that there was insufficient wait time monitoring, little in the way of case management standards across organizations, and a lack of evidence-based programming.
“Surge” in demand
Adding to the strain on Ontario’s system, experts believe mental health services are experiencing a “surge” in demand.
While data on prevalence of mental illness in Canada is limited, the Senate report on mental health found that epidemiological studies indicate that “the overall prevalence of mental illness in Canadian children and adolescents, at any given point in time, is about 15%. This translates into approximately 1.2 million of children and adolescents who experience mental illness and/or addiction of sufficient severity to cause significant distress and impaired functioning.”
Ian Manion, executive director for the Ontario Centre of Excellence for Child and Youth Mental Health, which develops evidence-based training and tools for mental health providers, says there are several hypotheses about what may be behind the increase of demand. He suspects it is related to success in reducing stigma around mental illness. “Right now only about one in six children who have a mental illness actually receive treatment; so if we succeed in decreasing stigma there is going to be enormous demand. I think we’re seeing that now,” he says, “and we’re not ready to meet the demand now that more people feel safe to come forward for help.”
Simon Davidson, medical director of the Mental Health Patient Services Unit at the Children’s Hospital of Eastern Ontario, agrees that demand on specialized psychiatric services has increased. “We are absolutely overwhelmed with demand,” he says. “Many more families are now coming forward – often the first time parents become aware of mental illness in their children is when their child has suicidal thoughts. When that happens they bypass the school system, guidance counselors or community mental health services – they come straight to hospital to see a psychiatrist.”
A chronic shortage of mental health professionals, coupled with this increase in demand, means that a progressively larger share of the medical management of mental illness among children and youth is falling to primary care providers in the community.
Ontario’s Open Minds, Healthy Minds strategy
In 2011, Ontario unveiled a new long-term strategy for mental health and addictions, with children and youth as the focus for the first three years. Manion describes the strategy as “ambitious,” and believes that it has put Ontario’s child and youth mental health system on the “cusp of transformation.”
This “whole of government” strategy was intended to develop an overarching vision, mission and goals to bring together the Ministry of Education, Ministry of Children and Youth Services and the Ministry of Health and Long Term Care, who all share responsibility for child and youth mental health.
At the core of this strategy was a funding commitment of $257 million over three years, targeted for child and youth mental health.
While the strategy is vague on details, it emphasizes improving timely access to mental health services, early intervention, and closing service gaps for vulnerable children and youth.
Importantly, the strategy recognizes that primary care physicians and nurse practitioners, despite providing mental health care to many children, are not currently well integrated with the rest of the child and youth system. It also acknowledges that primary care providers need additional training, tools and support to be able to provide effective mental health care in the community.
To date, the Ministry of Health and Long Term Care has designated $11million to hire Registered Nurses and/or Registered Practical Nurses with mental health and addictions expertise to assist school boards in recognizing and responding to student mental health and addictions issues. Another $6 million has been designated for service collaboratives to improve transitions and support collaboration and coordination of services for children, youth and adults. $9 million has been earmarked for expansion of eating disorders treatment programs. $2 million has been designated to develop an evaluation program, including development of outcomes and indicators, which is intended to be adapted to encompass adult mental health and addictions.
The mantra of integration
For patients, Ontario’s mental health system is badly fragmented and many find its complexity daunting. “Right now you need a graduate degree just to figure out the maze of services,” says Davidson.
Mental health services in Ontario are overseen by the three Ministries mentioned above. Services are delivered by 440 child and youth agencies, 330 community agencies, 150 substance abuse agencies, 50 problem gambling centres, 68 school boards, 36 public health units, and more than 10,000 doctors.
Administrators and providers work in silos, at both the ministry and the agency level. Despite working in the same communities, primary care providers often have limited interaction with schools or child and youth agencies.
As a result, “integration” has become a mantra among Ontario mental health experts. “What is needed is a shared vision” says Michael Boyle, who holds a Canada Research Chair in the Social Determinants of Child Health, “something to bring these very different groups together and help them get over their differences.”
“The good news,” says Davidson “is that these Ministries are finally talking. I honestly wasn’t sure if it would ever happen, but it is.”
Integrating primary care
While conversations at the highest levels have begun, on the front lines there has been limited progress on integrating primary care providers into the wider system.
Davidson believes that right now primary care providers are largely on their own. “They’re isolated not only from community mental health services, but also from hospital services,” he says.
He believes that “if hospital services connected better to family doctors, so that more family doctors could just pick up the phone and get a quick consultation with a child psychiatrist over the phone, family doctors would feel a whole lot better supported.” He thinks that more access to this kind of telephone consultation could also be used to help primary care practitioners find additional services in their communities.
Some progress has already been made on this front. Under the OHIP fee schedule, family doctors and psychiatrists can arrange telephone consultations. In addition, the Ontario College of Family Physicians has launched a Collaborative Mental Health Care Network, which brings together family doctors with psychiatrist mentors. Ontario also has a telepsychiatry program, operated out of Sick Kids, which connects children and family doctors in remote areas with specialists in Toronto. However, so far participation in these programs is relatively low (for example, only about 4% of Ontario’s family doctors are enrolled in the collaborative program), due to a mix of lack of awareness, tight budgets and limited availability of psychiatrists.
Likewise, some organizations have made real progress in bringing primary care together with community mental health services, and their experiences may be instructive for others. One example is found in the Owen Sound region, where the Owen Sound Family Health Team has joined with Keystone Child, Youth and Family Services to provide publicly funded, multidisciplinary mental health care in their region. Patients at the family health team have access to all of Keystone’s services, including respite care, recreational sessions and support groups. Shared electronic health records allow the patients to transfer seamlessly between practitioners and programs.
Supporting primary care: tools and training
While greater integration will be of help to primary care providers, family doctors and nurse practitioners also need tools and training to be able to effectively screen and manage childhood mental illness.
Here Ontario may be able to benefit from innovative work in British Columbia, which has developed a child and youth mental health training program and tool-kit specially tailored for primary care. Liza Kallstrom, the lead for Change Management and Practice Support at the British Columbia Medical Association, explains “the program is based on a burning platform of early identification – we know that most adult mental illness starts in childhood, and that it can be much less severe if it is identified and treated at an early age.”
The program was developed in collaboration with Dalhousie University’s Stan Kutcher, an internationally recognized expert in child psychiatry.
This program includes a set of screening and treatment tools to support family doctors in making early and accurate diagnosis of the three most common mental illnesses that can be treated effectively in the primary care setting: depression, anxiety and ADHD. Many of these tools can be directly incorporated in to the most common electronic health record systems.
“The treatment tools emphasize non-pharmacological treatments first, such as cognitive behavioral therapy and group therapy” says Kallstrom, “medications may be necessary, but we recommend non-drug therapy first.” (With the exception of ADHD, where medication is first line treatment.)
The program also familiarizes and connects family doctors with other mental health services in their area, including psychiatrists. In addition, upon completing the training, family doctors may access special billing codes, which allow them to book longer appointments with children and youth for screening and treatment.
By equipping primary care practitioners with the tools they need to effectively treat depression, anxiety and ADHD in the community, it is hoped that care gaps will begin to close and psychiatric specialists will be able to focus more of their time on treating more severe conditions that cannot be managed in the community.
So far over 100 family doctors in British Columbia have been trained by the program since it launched last year, and it has secured funding to train 400 more. The first phase of program’s evaluation has been completed, and results to date are very promising. Further, the adult version of the program, which has been in operation longer, also appears to perform well.
The program was designed with national scalability in mind. “It can easily be adapted for Ontario and for the rest of Canada as well,” writes Kutcher in an email. “It is an outstanding program with great promise and has the potential to transform how mental health care can be delivered for young people across our nation.”
A number of other countries have expressed interest in adapting BC’s mental health training programs to their own jurisdictions, says Garey Mazowita, the program’s executive director.
While there is often temptation in Canada’s largest province to re-invent the wheel with “made in Ontario” solutions, if the three Ministries who share responsibility for child and youth mental health are eager to make more rapid progress in building capacity in primary care, they may wish to look west for a possible ready-made solution.
The beginning of meaningful cooperation between Ministries in Ontario is a positive development. However, many primary care practitioners like Chris have yet to notice much change on the front lines. With the strategy nearly halfway through its three year term, it will be essential to turn strategy into the kind of action that improves mental health care for Ontario’s children and youth.