‘Paradigm shift’ needed to deal with mental-health catastrophe

While there is no health without mental health, provincial governments in Canada still cover only half of treatments for mental-health conditions – paying for doctors and hospitalizations but rarely for psychotherapists and psychological services.

It’s not that the public system can’t afford to cover such services, it’s that we can’t afford not to, according to Canadian researchers who have calculated that each $1 invested in psychological services yields a net benefit of $2 savings to society.

The United Kingdom and Australia are among the countries that cover psychological services in their public systems, with well-documented effectiveness.

Even before the pandemic, 20 per cent of Canadians experienced a mental-health issue each year and 85 per cent of Canadians agreed that mental health was among the most underfunded services in health care. Now, COVID-19 has turned that crisis into a catastrophe, with 50 per cent of Canadians reporting worsening mental health during the pandemic.

The causes and treatments for mental-health conditions are complex. The biological components are typically funded in the health-care system – doctors, hospital stays and medications (covered for those with low-household income) – but the equally important psychological and social components are frequently left to individuals to attain privately or for society to fight for politically.

The current system also weighs heavily on acute crisis intervention and away from prevention and health promotion.

“Having worked as a nurse in acute psychiatry settings for several years, I know that our response is to have people at the point of suicidality or an acute psychosis in order to receive care,” says Emily Jenkins, assistant professor of nursing at the University of British Columbia, who recently collaborated with the Canadian Mental Health Association (CMHA) to study the mental-health impacts of COVID-19 in Canada.

“People come in and out of the system because they’re not being served by that singular approach,” she says. “And then all of the people who aren’t able to access that kind of care – which is probably most people – are not getting what they need.”

Jenkins calls for “a paradigm shift … where we work along the full spectrum from mental-health promotion through prevention to treatment and recovery, and (do) not rely on having to get to the point of crisis before people can try to access the care that they need.”

Psychological services are predominantly in the private system, which has a large workforce of trained psychologists, social workers and counselors readily available, either through employment plans or paid out of pocket (up to $200 a session) – a barrier that makes treatment inaccessible for many and is particularly worrisome as people living with mental-health conditions have lower earning potential and socio-economic status (both as risk factors and as consequences of their illnesses).

Jenkins’s yet-to-be-published data collected during the second and third waves last September and January show that 45 per cent of Ontarians (and slightly fewer in other provinces) said their mental health was worse or much worse during the pandemic. Ten per cent of Canadians reported being suicidal in a two-week period during the second wave compared with 2.5 per cent in the year before the pandemic, she says, a trend that has persisted in the third wave.

Jenkins says the inequities are widening. The most heavily impacted are those who had already been living with a mental-health disorder or disability. Others disproportionately affected are youth aged 18 to 24, parents, women, LGBTQ+ and Indigenous peoples and people with low household incomes.

Margaret Eaton, the CEO of the CMHA, says “what we saw during COVID-19 was (that) it was the most vulnerable who had the most severe challenges for their mental health and oftentimes those are the people who cannot afford to get help. So, it’s a really unfortunate system that in effect favours the privileged.”

We are not only failing to offer treatment to many of the people who need mental-health services the most, but we are also paralyzing a medical system already plagued by shortages of family doctors and psychiatrists. Up to 80 per cent of mental health is managed in primary care, with publicly funded physicians often the only affordable option for patients.

“Mental health is overwhelming the primary-care system more than ever,” says family doctor Jennifer Ross, who works in Victoria, a community with long-standing family doctor shortages. Since the pandemic began, she has spent about 90 per cent of her time seeing patients on mental health, she says, up from around 50 per cent before the pandemic.

While Ross is doing her best trying to help her patients with the tools she has, most could be better served by mental-health professionals, she says.

David Goldbloom, a front-line psychiatrist and former chair of the Mental Health Commission of Canada, says there will never be enough doctors to provide mental-health services to everyone who needs them. But doctors are only one of many armies of helpers offering mental-health treatment.

“We have to think differently about how we organize and provide services,” says Goldbloom, who is releasing a new book, We Can Do Better: Urgent Innovations to Improve Mental Health Access and Care, on May 4. “We are understandably proud of the universal health-care culture in Canada, the values it reflects. However, its realities currently exclude expert allied professionals from its basket of publicly funded outpatient services…. The solution isn’t more and bigger emergency rooms but rather more accessible and effective alternatives.”

A clear solution is to publicly fund psychological services by non-physicians, as is done in Australia, the U.K. and many other European countries, he says. That may sound expensive, but the total economic burden created by mental-health problems is more than $50 billion annually in Canada.

The U.K.’s National Health Services (NHS) introduced the Improving Access to Psychological Therapies (IAPT) program in 2008 after its co-founders argued that the program’s cost would be offset by the savings to the economy, says Goldman.

“It involves creating a whole new cadre of providers of structured psychotherapy,” says Goldbloom. The program has provided a variety of interventions – serving one million people last year alone – that match people’s needs to the level of services offered, from self-help and groups to individual and couples’ therapy services, both online and in person, he says. The program doesn’t require a doctor’s referral, which helps with accessibility.

This approach differs significantly from Canada, where “there is little logic in who gets what kind of help; it can be more a reflection of where you live, how much money you have, or who you know,” says Goldbloom. “Some people end up getting no help at all, while others use highly specialized resources when a simpler intervention could work.”

The lower intensity IAPT interventions are offered by “psychological well-being practitioners,” mental-health workers with less training than traditional clinicians such as psychiatrists, psychologists, clinical counsellors or social workers, who are saved for higher-intensity interventions, says Goldbloom.

And because it’s publicly funded, the program has accumulated data and outcomes on 98.5 per cent of all of its encounters, available transparently on its website, Goldbloom says. For example, in February, 93 per cent of people started treatment within six weeks, with 50.4 per cent recovered after completing a course of treatment (with an average of eight sessions per person). “This is unprecedented public accountability,” he says.

Ontario and Quebec have recently begun trialing publicly funded psychological services on a smaller-scale. “It isn’t as sweeping as the initiative in the U.K. but it’s definitely a start,” he says.

Goldbloom supports a “stepped care” approach – like that of the IAPT – based on the principle of matching the level of intensity of services to the complexity of the needs for each person.

One successful lower-intensity intervention, offered by the CMHA, is Bounce Back, a program that offers free self-guided Cognitive Behavioural Therapy (CBT) with online or phone coaching, already offered in B.C., Ontario and parts of Manitoba, and soon to be expanded across Canada.

CBT, which focuses on teaching skills to manage the difficult thoughts, emotions and behavioural patterns that affect our mental health, is a treatment for depression and anxiety disorders. Therapist-guided, internet-based CBT has been shown to be effective in many research studies, Goldbloom says. Six years of data show that Bounce Back significantly reduces depression and anxiety symptoms, with a recovery rate of 69 per cent.

Since the pandemic began, Ontario has begun covering Mind Beacon, an online platform that offers online assessment, customized therapist-guided CBT programs and live therapy sessions. Two-thirds of Beacon users report a clinically significant improvement with treatment, he says. However, a major obstacle is that six per cent of Canadians can’t access the service because they don’t have access to the internet.

Also as a response to the pandemic, the federal government last May began funding a similar mental-health tool, Wellness Together Canada, a national online portal that provides free wellness self-assessments, resources and apps, group coaching and counselling by text or phone, says Goldbloom.

“It represents a coming together of government, community agencies and the private sector in common cause to respond to an unprecedented national emergency. Change can happen quickly – within a couple of months of the pandemic disrupting the lives of all Canadians,” Goldbloom says. “But what happens when the heat of the crisis inevitably subsides?”

While Eaton commends the government for funding Wellness Together, she argues that urgent action is needed: “We already know that won’t be enough … We need a long-term mental health pandemic recovery plan that is well-coordinated, well-funded and monitored to address persistent and systemic gaps in the system.”

In particular, the CMHA highlights the need to fund more intensive psychological services, such as psychotherapy, especially for those with pre-existing mental-health conditions.

The CMHA is also calling on the federal government to amend the Canada Health Act to include a mental-health parity provision that would include providing universal coverage for mental-health care.

“By changing the way we think about mental-health care and investing in community-level interventions and supports, we can get people the help they need sooner and alleviate pressure on an acute-care system already hit hard by COVID-19,” Eaton says.

Adds Jenkins: “I hope we can start to understand that everybody has mental health. Mental health is a resource that we need to build and support for everyone.”