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Question: My brother suffers from depression. His doctor says he will have to wait six to nine months to see a psychiatrist. That’s an awfully long wait. He needs help now. But the thing that really bothers me is all the recent media campaigns to raise public awareness about mental illness. What’s the point of drawing attention to this illness if you can’t treat the existing patients within a reasonable time?
Answer: You make a very important point – and your brother is certainly not alone in his plight. Many patients suffering from various forms of mental illness have to wait many months before they can see a health-care professional trained to treat their particular condition. Only one in five Canadians with depression get appropriate treatment, according to some estimates.
Provincial governments have adopted various measures to speed up patient access to mental-health services.
In Ontario, for instance, the number of doctors being trained in psychiatry was boosted by 80 per cent between 2003 and 2013, says David Jensen, a spokesperson for the Ministry of Health and Long-Term Care. The province is also increasingly relying on “tele-psychiatry” – counselling and care through computer-based video conferencing – to reach patients in remote and under-served communities.
However, an intriguing study published last year in the journal Open Medicine, indicates that simply increasing the supply of psychiatrists doesn’t necessarily improve access to treatment.
The major problem appears to be the way psychiatrists choose to run their practices and not a shortage in their numbers.
The researchers used Ontario data to look at the regional distribution of psychiatrists, how many patients they treated, and how often.
The study revealed a very high concentration of psychiatrists in a few urban communities, particularly in parts of Toronto and Ottawa.
In central Toronto, which has the highest supply in the province, there are roughly 63 psychiatrists for every 100,000 residents. In low-supplied regions, there are an average of only seven psychiatrists per 100,000 residents.
That finding was expected. But the researchers were surprised to see that many of the psychiatrists in well-supplied areas chose to see relatively few patients – and don’t take on many new patients.
Indeed, where there are lots of psychiatrists, they tend to treat a small number of patients and see them very frequently, says the study’s lead author, Dr. Paul Kurdyak, an emergency-care psychiatrist at the Centre for Addiction and Mental Health in Toronto.
Psychiatrists practicing in Toronto saw an average of 181 patients (including 105 new patients) over the course of a year. In low-supply regions, the local psychiatrists treated an average of 431 patients (which included 233 new patients) over the same time period.
When you drill further down into the numbers, you discover greater extremes. About 10 per cent of psychiatrists working full-time in Toronto saw only 40 patients a year. And 40 per cent of the Toronto psychiatrists treated fewer than 100.
The study helps to explain why patients in well-supplied areas seem to have just as much difficulty booking a first-time appointment with a psychiatrist as those living in regions with relatively few of these doctors, says Dr. Kurdyak, who is head of mental health and addiction research at the Institute for Clinical Evaluative Sciences.
“If you produce more psychiatrists and most of them end up practicing in Toronto, that is a problem in and of itself,” says Dr. Kurdyak. But it’s made worse when they “tend to see the same patients, one or more times per week, for many years.”
So, you can have full-time psychiatrists treating a fraction of the patient load carried by their peers. Overall, he adds, specialists who see relatively few patients have “an insignificant impact on the broader ocean of need out there.”
Ontario is not the only province struggling with limited patient access to psychiatrists in well-supplied urban areas.
A study published in 2011 in the Canadian Journal of Psychiatry revealed that just a small percentage of Vancouver psychiatrists were willing to accept new patients. For the study, which was led by Dr. Elliot Goldner, the researchers contacted the offices of 230 Vancouver psychiatrists to see how many would take a patient referral from a family physician. Only six psychiatrists immediately agreed to see a new patient and provided a specific date for an appointment.
Dr. Kurdyak says family doctors are going to “give up” on psychiatrists if they have to contact dozens of offices in order to find treatment for a single patient. “This is not a feasible way of working.”
He believes many psychiatrists are not compelled to see more patients, in part, because of the way they are paid under the provincial health-care plans.
Psychiatrists, he explains, provide patients with psychotherapy and they are paid on an hourly rate. There are no limits placed on how many times they see the same individual, nor does the severity of the patient’s condition relate to appointment frequency. “That means a psychiatrist can take on a roster of patients, see them over and over, and be pretty well compensated for it.”
Other medical specialists, in contrast, are usually paid a set fee for an initial visit and significantly less for subsequent appointments. “They are incentivized to constantly see new patients because the payment for a consultation is so much higher than for a follow-up.”
Dr. Kurdyak notes that Ontario’s Ministry of Health has tried to entice psychiatrists into seeing more new patients by ‘sweetening’ some fees. Back in 2011, the Ministry introduced a 15 per cent bonus for appointments with patients who had recently attempted suicide or were just discharged from hospital following a psychiatric illness. “Obviously after a suicide attempt and post [hospital] discharge is a very acute period of time when you need access to specialty care.”
But Dr. Kurdyak doubts that a 15 per cent bonus would be enough to override the attraction for psychiatrists “to see who they like, for how long they like, and to have total control over their patient population.”
So, how do you make sure that patients have timely access to mental-health treatments? And why are some psychiatrists willing to see more patients than others?
Unfortunately, the answers to these two critical questions can’t be gleaned from Dr. Kurdyak’s latest study. His findings are based on an analysis of statistics – not interviews with the doctors involved. What’s needed now is a series of focus groups to determine what motivates them to practice in a certain way.
Dr. Kurdyak would like to do a follow-up study along those lines. He already has some theories about what’s influencing the psychiatrists to either take on more patients or turn them away. In particular, he thinks that psychiatrists who locate in under-served regions may feel the need to affiliate themselves with community mental-health agencies, hospitals or local family-health teams.
“The psychiatrists working in these areas are actually rubbing shoulders with their colleagues who desperately need their services,” speculates Dr. Kurdyak. So, when they get a request to see a new patient, they may feel compelled to adjust their schedules to meet the demand, he adds. That could mean seeing some of their existing patients less frequently in order to squeeze in new patients.
By contrast, a psychiatrist working in a solo practice in downtown Toronto “may not feel the same pressure” to make room for a referral that comes from out of the blue.
If further research shows that Dr. Kurdyak’s hunch is correct, it may point to ways of making sure that patients who are in urgent need of psychiatric care get help sooner rather than later. For instance, he says, all psychiatrists could be required, or mandated, to establish formal links with other health-care providers. In other words, a psychiatrist who once worked alone would become part of a multi-disciplinary team.
“An affiliation [with other health professionals] would create a level of accountability that wouldn’t necessarily exist if you just hung up your shingle and worked in isolation,” Dr. Kurdyak says. He thinks those connections would make it hard to say no to referrals.
It’s also worth mentioning that in other countries, such as the United States, Britain and Australia, psychiatrists perform somewhat different roles than they do in Canada. In those countries, they primarily diagnose the patients and make treatment recommendations. Or, they focus on prescribing psychiatric drugs. Other health-care professionals, such as psychologists and social workers, provide psychotherapy and additional support, says Dr. Kurdyak.
If the Canadian health-care system was organized in a similar fashion, we might not be facing such a bottleneck in the delivery of mental-health services.
Change, of course, tends to come slowly to healthcare. In the meantime, your brother’s options are admittedly limited. But one thing he could do is seek the help of his family physician, until a psychiatrist can see him on a more regular basis.
And hopefully, the point you raised about the long wait-time faced by your brother and other patients like him will help stir the public debate. As Dr. Kurdyak puts it: “People should be really annoyed about the poor access to mental health services. This kind of system performance wouldn’t be tolerated for cancer or cardiovascular care, and is not fair to people who suffer from mental illnesses.”
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Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.
The comments section is closed.
I’ve been waiting 2 years for some help. I’m a single mother with no support to boot. And it’s getting harder and harder to cope. Especially during this pandemic
5 years to see a Psychiatrist oh my God wow
In Regina, where we had a public incident recently. Psychiatrists can easily be seen as emergency room physicians. Even like a priest before the client dies. Don’t worry, it’s that person, and their history with society. Bad or misguided advice is out there already.
i am currently faced with a situation i had a psychiateriest in a hospital and he resigned. now i am left without a psychiaterist and my family doctor can help me from being move out of my existing area where i live in subsidy. what can i do.
my doctor lied to me to keep me with her
I believe only a small percentage of physicians are actually very competent
Most of times that I have seen Drs, they only talk to you for 3 minutes maximum (they don’t even get close to you), I dont believe that 3 minutes is enough time to come out with a proper assessment, so we have to go back to see them several times.
Walk-in clinics are the worse.
Why they can just spend more time on every patient so treatment can be started right the way
imagine all the time and money that will be saved….
How could trust health care system when without any reason for years make you waited and just because can’t diagnose your illness either assume you are lying or it is some type of terminal disease.
Intrupte your life,block your work ,destroy your family and marriage, is it really definition of health and long term care and safety?
It was and is my life ,who can answer my question?
Thanks!
I had excellent psychiatric care while living in Canada. When I moved to the United States the care was practically nonexistent. There was minimal access to an incredibly busy psychiatrist who spent the 10 minute/once every three months visit, writing a prescription for the miracle drug of the day. If you want/need to talk to someone rather than or in addition to downing a bunch of psychotropic drugs, that was pretty easy to find as anyone with a masters degree in the humanities was deemed adequate to help.
While there are some concerns regarding access to care for new or acute psychiatric cases, modeling Canadas care after another nation or culture may not be the best way to meet these needs and may instead wreak havoc with the stellar level of care that Canada is able to provide under many circumstances.
Giving more responsibility to family physicians is ridiculous. Perhaps there are certain cases whom, after working with a psychiatrist, could be handled with a knowledgeable family doctor as long as everything remains stable. However, expecting a physician, who has minimal to zero training in psychiatry, to treat and actually diagnose psychiatric disorders is not fair to the patient or the doctor. The only party to benefit from such a dynamic would be the drug companies who just want to sell drugs.
“Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.”—Allen Frances, MD on DSM 5 goes too far in creating new mental disorders
I so get all these comments, I myself have depression, Mental Health here in B.C. Sure could use a lot of change, yes there are wait list for everything here in other health areas also. I must say when I was in crisis I was admitted to hospital, and they only have a 2 week stay, not long enough to get a person stable for some people, especially if a medication has terrible side effects. And with psychiatrists they don’t keep patients on long term, which is terrible. I’ve seen my doctor longer once or every two weeks, he has tried to be my support and I see a counsellor but they are not trained in psychiatric medications. My doctor put me on a medication that had no tapering down when it was to strong, I suffered for a few years not knowing how to get off this horrible medication and I did go to emerg but the psychiatrists wouldn’t do anything. Finally found a psychiatrist out of town and she switched me to another medication, she said The other one caused mania, my doctor didn’t recognize this. It takes along time to find the right psychiatrist, and she saved me. I see her once a month. See the big problem is family doctors don’t know there psych medications, in my opinion they shouldn’t be giving them to there patients. They need to be adequately trained in psych medications. And the psychiatrists at the hospital don’t know you like your doctor and they don’t communicate if your in hospital. While your in hospital the psychiatrist should be giving updates to the patients doctor. And your family doctor should be making patient visits while your in psychiatric ward, which they don’t here in B.C. They use to years ago, not sure if it’s because in our town we have a new hospital and it’s partly privatized not sure if that has anything to do with it but our health care since the new hospital has gone down the drain.
Making the Drs. take on more patients would likely result in fewer visits per patient (i.e. follow up) Being familiar with the time lag between meds change and response (if any) poses a problem if proper follow ups are not done.
You don’t want to see a psychiatrist. Psychiatry has no scientific basis and no useful treatments. There have been no advances in psychiatry since the 1950’s. All that psychiatry has to offer is uppers and downers (amphetamines or tranquilizers) all with very serious side-effects. The only way forward is through the anti-psychiatry movement, the purpose of which is to expose psychiatry for its fraudulent and immoral practices.
I live in Victoria BC and have been trying for 5 years to get a referral to a psychiatrist with no success. Many doctors have tried on my behalf with no luck. It is a horror story here in Victoria. A basic health service for people who need it essentially does not even exist. I feel like I am living in a third world country and I am outraged!
Very shocking article, which proves all the questions I had about this system.
What is the point of getting care after waiting that long? During relapse, we need help right away instead of ruining months of our lives. I get that Psychiatrists don’t have incentives to new patients but what is their work ethic? The lucky patients who get to see psychiatrists doesn’t even have to do with severity. Also what is the point if you get to see a Psychiatrist but don’t even have chance for follow up? I finally got an appointment with one on Sept, then he prescribed me pills that had extreme side effects. My next follow up was on 2017 Jan. So I just don’t take the additional pills.
What is the point of these treatment if it does not decrease the painful suffering time to majority of patients?
Lastly, does GP’s have knowledge on prescribing special pills for complex symptoms?
It’s horrible all around. We subsidize a healthcare system that some can benefit from while those of us who fall through the cracks are left to fend for ourselves. If We could save an extra few thousand a year from taxes maybe we could get the help we require. I eat healthy, I exercise regularly so I don’t require dr visits or treatment for negligent diseases but mental issues are something I can’t cure on my own. I don’t go to the doctor for common colds and only went when I broke a bone that only required a cast to fix in my 29 years of life.
I feel I’m slowly dying from the anguish I experience and know that one day I’ll end up likely taking my life for it to stop. I’ve lost my job and will lose my home when the money runs out. And I’m just one of thousands in this country in this situation.
Psychologists that I’ve gone to have been mostly duds, they care more about keeping you in treatment and paying their high fees. I had one that bragged about staying out of the cold because he drove from his heated garage to heated garage after I told him how cold it was that day after having to walk to his office in January weather. I know some people have managed to connect with a great psychologist but it seems to take time and money to accomplish as starting over is monetarily and mentally draining.
I never thought I’d be in this position in my life. I worked hard in life, supported myself through school and have been good to my family and others but life doesn’t care if you’re good. I see how people look at me with pity because they know how I once was and it hurts to know that I may never feel ok again.
I just found this article and have experienced ‘selective’ psychiatrists who limit their work load and avoid challenging cases. As a mental health consumer it is demoralizing, frustrating and scary to have diminished capacity and try to advocate for yourself while being shunted around. I truly hope the province takes action to change the way some psychiatrists are running their businesses. This is totally unfair and would never be accepted for any physical illness.
Problem in canada is that as a psychiatrist we try to diagnose and send treatment recommendations but patients don’t want to seek psychotherapy outside of psychiatry as it may require them having to pay. Then they complain and rate us poorly for not seeing them for years. We can’t see people for years and decrease the new patient wait times- pick which you want Canada! The Canadian public needs to be educated on the role of psychiatrists and that when going to a psychiatrist its to get diagnosed and treatment plan recommendations and if there is follow up its short to get them on right path for their family Doctor to follow w therapy from social worker or psychologist.
Maybe people can’t afford to pay for therapy with MSWs and psychologists.
Not all family doctors know psych medications, and not everyone have extended health care to see a psychologist. It’s some psychiatrists that won’t see there patient long term. When a medication isn’t working and the side effects are unbarable and your next appointment isn’t for a few months then what is a person to do, when the psychiatrist prescribed it.
You suffer, not all family phsychians can you get into right away, and sometimes they don’t know what to do either. And then they send you to the emerg at the hospital,you wait hours there, and then you see a psychiatrist they say, who’s your psychiatrist then ask when do you see them next, you tell them, well you will have to see him or her. They don’t know your case or know you, very uncomfortable for the person going through the hoops. It’s a complete cotastraphy, they send you home maybe on a different med now remember they know nothing of your history. Can’t take you off the med your on cause there’s no lower dose for tapering so they give you something on top of the med your already taking that is no good for you. It goes on and on. Then there’s even a bigger problem by the time you see your actual psychiatrist. On top of this you’ve been diagnosed the wrong mental health problem. Mental Health is failing in B.C. It needs to be revamped and major changes the government needs to look into this further. Family doctors are NOT trained in psychiatry quit saying to follow up with your doctor, your just trying to take the load of the psychiatrists, the psychiatrist is a doctor that are suppose to see the more serious patients long term that’s the bottom line, you would send someone to a vet when they are only trained with animals.
I have been falt out denied in tue ayukon for oblver a decade, several suicide attempts, begging and pleading in tears. You call yourself someone who cares and yet that is the professional opinion you wish to present. If that is the case, it is not a professional I a
dress now, just another aforementioned ringer waiting in a hospital lobby for your next payout.
My walk-in does treat my GAD but with the Price Baker report coming and forced rostering, which I will refuse to go to, I need to find a psychiatrist for essentially the same care as the walk-in clinic guy has given me for the last 10 years. I cannot find a family physician who will treat me without cancer screening which I refuse to have as the GAD turns screening into an obsession that dominates your thoughts and gives you zero quality of life. I will just go on the waiting list for a psychiatrist and do the 9 month wait and waste resources that way, luckily I can go to Toronto which has the highest supply. Cancer Care Ontario rules the Ministry of Health and makes no exceptions for people who have GAD and cannot obsess about screening and doctors do not make exceptions either, it’s their way or the highway. There is no informed consent.
I believe that most of patients referred to Psychiatrist could have been seen, diagnosed and treated by their family doctors. To reverse the course, the ministry focus should shift from Psychiatrists to Family doctors who are willing to get extra-training in Psychiatry to look after their own patient OR opening up more community Psychiatry clinic run by family doctor. I am opening the first such clinic in Waterloo, Ontario by the name of Bridgeport Health. I have been part of the Psychiatry on call group since 2007 and have been involved in outpatient and inpatient care as well as consultation liaison. Most of the patients could have been treated by their family doctor or might need one consultation to clarify diagnosis and recommend medications adjustment.
I have been waiting for a counsellor, group therapy, and a psychiatrist since November 2015 and have yet to see any of them and it’s July 22 2016.
I’m registered in Guelph, Ontario.
I would agree as long as the physicians were properly and adequately trained. My GP almost killed me a few years back by prescribing an antidepressant which put me into full blown mania, which I’d never experienced before. Her response to that was to double the dose and I then ended up in hospital. She completely missed on my diagnosis, even the psychologist I saw afterwards was able to see the mistake she made. Scary. So if GP’s are to treat and prescribe mental health issues, they need the same training as Psychiatrists in my view.