Mental health leaders have the opportunity for courageous change as they assemble in Toronto this week. Psychiatrists from around the world will be attending the American Psychiatric Association’s Annual Meeting, and I hope that there will be serious and thought provoking conversation on the future of the specialty. As a neurologist, new to the mental health sector, I have developed some strong opinions on the topic, and I see an opportunity for psychiatrists to transform their specialty towards better patient care, a more robust mental healthcare system and a more equitable society.
Here’s how it would look. Psychiatrists would be galvanized by the opportunity to care for the most acutely ill and complex patients – because it’s intellectually engaging and gratifying work and because the compensation is fair – a pattern that is common in other medical specialties. Psychiatrists would do less consultant care, where the implementation is left to others, and deliver more principal care. Psychiatrists would maintain the skill and confidence necessary to monitor the impact of their treatments and ensure that their patients receive good primary care. Psychiatrists would get political and become powerful advocates for people they serve.
The need to think of and respond to mental illness more expansively is necessary if we are to address the toll that it takes on individuals, families, communities and societies. The time is right. People are more willing to seek help. Over the past decade, the Centre for Addiction and Mental Health (CAMH) has documented a 53 per cent increase in the number of individuals seeking care and supports. Our emergency visits have doubled, our patients have increasingly complex needs and many are gravely ill.
The bar has been set too low when it comes to our expectations for resourcing mental health care. There is still significant marginalization of mental health within healthcare, where the resources allocated by society continue to lag behind the desire we publicly express for justice and equity. It’s difficult to recruit psychiatrists to hospital positions where they care for severely ill patients. They are poorly reimbursed, the settings are often substandard and in some cases they face risks to their personal safety. Private practice in a comfortable office is much more attractive to newly minted psychiatrists and our education and training constructs are weighted towards readiness for this type of practice.
This phenomenon was reported in a 2014 study of access to psychiatrists in Ontario conducted by CAMH and the Institute for Clinical Evaluative Sciences (ICES). The study found that in Toronto, which has the highest number of psychiatrists per capita, 10 per cent of full-time psychiatrists see fewer than 40 patients a year. In low-supply, non-urban areas, psychiatrists see more patients and more new patients. These are practice and lifestyle choices that are enabled by reimbursement structures, our medical education patterns, slow uptake of evidence based therapeutic practices and the fact that despite public discourse to the contrary, mental health care is still not central in healthcare discussions.
The opportunity of psychiatry to lead and to do good is enormous. The long view requires an education plan that creates psychiatrists who are comfortable with and enthusiastic about caring for people who are critically ill or in crisis, and a system that incentivizes this practice.
The psychiatrist of tomorrow understands the social context of the illnesses and injuries she treats. She understands that people with mental illness have human, civil and healthcare rights and is prepared to help these people get the supports they need and to actively protect those rights. Tomorrow’s psychiatrist is confident in directing and coordinating care for people with the common combination of psychiatric and non-psychiatric illnesses.
I have encountered many psychiatrists who are committed to this vision of their field. They are tomorrow’s leaders. In my own practice, I’ve seen and heard first-hand the wants and needs, hopes and dreams of patients, their families, their friends. They need and deserve excellent care from great doctors with specialty expertise and a deep commitment to the wellbeing of their patients.
I look forward to welcoming our international colleagues to Toronto during this week’s APA conference.
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I disagree with Judy on two points. In Toronto, psychologists and social workers most often bill patients at higher rates than OHIP pays psychiatrists. Further, of all the mental health professionals, psychiatrists have the most comprehensive training. Residency training allows graduate psychiatrists to do a thorough biopsychosocial formulation and engage with patients in a number of treatment modalities- eg DBT and CBT and IPT and psychodynamic therapy, as well as pharmacotherapy. Social workers have more limited training and psychologists generally specialize in one modality, hardly “holistic”.
I am concerned that misdiagnosed persons in the ER are being put in psych hospitals under the false pretense of mental illness.
Kept in psych ward and treated medically. Easy to pull off if a brain disease is misdiagnosed.
ECT done without consent from patient and no consent form signed. ECT is being used to disable memory of ER harm or misdiagnosis. Instill fear in victim from speaking out.
@ Judy:
So you believe that Nurse Practicitioners and Physician Assistants can perform many duties a GP can perform? Well, guess what, a plumber can perform many duties that a physician can perform too. Such as checking temperature on patient or pressure in blocked sink hole.
I agree with Judy – too subtle. We are in a crisis in terms of mental health care and all of the professions – psychiatry, social work, psychology, nursing and child and youth work to name a few – need to apply their skills and wares to the areas they are trained in and can contribute the most. And frankly – and this may not be popular – our children and families need psychiatrists to treat the most ill, be available for consultation, and most of all manage the complex pharmacotherapy issues – cause they are the only ones who can do this!!
With that said – let us not forget – if mental health care is marginalized – then children’s mental health care is more so and those of us who live in the North … well we cannot even see the margins……
As for doing therapy in the office … a bygone luxury for all of us is my take …
Diane Walker,
CEO Children’s Centre Thunder Bay
‘This phenomenon was reported in a 2014 study of access to psychiatrists in Ontario conducted by CAMH and the Institute for Clinical Evaluative Sciences (ICES). The study found that in Toronto, which has the highest number of psychiatrists per capita, 10 per cent of full-time psychiatrists see fewer than 40 patients a year. In low-supply, non-urban areas, psychiatrists see more patients and more new patients. These are practice and lifestyle choices that are enabled by reimbursement structures, our medical education patterns, slow uptake of evidence based therapeutic practices and the fact that despite public discourse to the contrary, mental health care is still not central in healthcare discussions.’
Catherine, Interested in reading the full report of the above study. Would you put the link to the full study for the viewers to read. Thank You
Catherine, Your comments are diplomatic but mask a real crisis in care.The ROI for psychiatrists doesn’t work. The healthcare system should hire more psychologists and social workers, who do a better job of holistic, ongoing care, at lower cost. They engage in broader solutions, including self-management therapies, nutrition, housing, exercise, career, family, and finances. Psychiatrists are most valuable for an initial assessment, drug management, or a care plan. As an analogy, nurse practitioners can perform many of a GP’s duties. Furthermore, since 50% of mental illness has a concurrent addiction, more professionals should have addiction training.
Here is a 12 point plan for treatment, devised from self-education and experience:
Security:
1. Safety: no abuse, no danger, no legal threats
2. Housing: secure, safe, clean, sober, sustainable
3. Health Care: a care co-ordinator, a care plan, correct diagnosis, therapy, GP for primary care
4. Financial: secure income, no debt, affordable meds if needed
Structure
5. Productivity: manageable paid work, volunteering, home maintenance
6. Meaning & Purpose: reason to live, values/principles, spirituality, future goals
7. Leisure: passions and hobbies, alone and with others
8. Physical care: healthy food, sleep, fitness, meds that work with few side effects
Relationships
9. Healthy, honest, loving, low stress, for isolation avoidance
10. Supports: Peer groups, informed family, a sponsor 24/7, informed work peers
Attitudes and Behaviours
11. Self-awareness: strengths, weaknesses, emotional intelligence, resilience
12. Mindful self-management & coping skills: gratitude, compassion, forgiveness,
humor, flexibility, patience, persistence, accepts imperfection, checks impulsivity, a problem solver-not just a finder.
Thank you for your splendid advocacy
Judy Tyson
Partners for Mental Health, FWLE Volunteer
So very true!