Let’s Talk about a comprehensive mental health system
Psychiatric medications are valuable tools for treating many mental illnesses. Some psychiatric conditions, such as schizophrenia, can only be effectively treated with medication. However, pharmaceuticals have become the default treatment for all mental illnesses in Canada, even when the evidence suggests that medications are not effective for all of the conditions for which they are prescribed. For example, despite good evidence that anti-depressants have limited efficacy for mild to moderate depression, in practice they are still widely used as first-line treatment for these conditions. This is troubling, because for many of the most common mental illnesses – mild/moderate depression, anxiety and ADHD – the evidence for psychotherapy is as good or better than for medication. It’s cost-effective, too.
This isn’t to say patients shouldn’t be offered medications. The evidence tells us many of the most common illnesses may be best treated through a combination of medication and psychotherapy. However, too often it appears patients are only getting the pills, when guidelines are clear that psychotherapy (either alone or in combination with medication) should be first-line treatment.
So why exactly are psychiatric medications over-prescribed, while psychotherapy is under-utilized?
There are, of course, many reasons. One driver has been pharmaceutical manufacturers, who have promoted their products aggressively to both consumers and prescribers, with the goal of maximizing the return on investment for their shareholders. Without the same multi-billion dollar marketing budget, it’s not surprising that psychotherapy has a hard time competing with pharmaceuticals for attention.
But there are other drivers. The Canadian health care system itself reinforces the over-prescribing of medication and the under-utilization of psychotherapy.
Medical education is part of the problem. Graduating medical students are expected to be competent to prescribe an SSRI for depression, but they are not expected to be competent in administering cognitive behavioral therapy for the same condition. Family doctors, most of whom provide an enormous amount of mental health care as part of their practices, receive no routine training in psychotherapy as part of their residencies. Some individual doctors seek it out, but such training is not a matter of course.
But even if doctors get trained in psychotherapy, the system is designed to turn them into prescribing machines. Psychotherapy takes time; a lot more time than simply writing a prescription for medication. It is well documented that many regions of the country do not have enough family doctors; so in many regions, doctors must carry very heavy patient loads. Faced with the choice between twelve one hour sessions of CBT for a single patient or one fifteen minute appointment to write a prescription for an SSRI, most doctors feel forced to prescribe the pills so that they can see the rest of their patients. Psychiatrists are in the same boat. They must choose between providing a more effective treatment to a small number of patients, or providing a less effective treatment to a large number.
Ontario’s move to capitation for family doctors (paying doctors per patient instead of per service) has only made this problem worse, because if family docs wish to provide evidence-based but time-consuming psychotherapy, they will likely end up rostering fewer patients, which hurts them financially. We have essentially created a health care system that punishes doctors financially for providing evidence-based care.
But recognizing the pressure on doctors just highlights an even older problem: Canada does not have a comprehensive mental health care system. When Medicare was established, first in Saskatchewan and then nationally, it covered only physician services delivered in hospitals. While public health care has expanded since that time to include physician services delivered outside of hospitals, 30% of all health care spending in Canada is still financed privately. One of the areas still left out of Medicare is mental health services delivered by non-physicians.
Psychotherapy can be effectively delivered by appropriately trained clinical counsellors, clinical psychologists and social workers, yet none of these professions are covered by our “universal” health care system. As a result, patients with mental illness who cannot afford the services of these professionals must turn to a doctor (possibly at a walk-in clinic), who likely lacks either the time or the training to do anything but prescribe a medication. That the medication is covered by most provinces’ public drug plans for low-income earners and seniors just feeds the problem, since doctors know that if they write a poor or elderly patient a referral to a psychologist the patient probably won’t be able to afford it, but if the doc writes a prescription for a drug it will probably be covered.
If we are serious about getting over-prescribing under control and providing patients with evidence-based treatment for the most common mental illnesses, we must recognize that there are deep structural problems in our health care system that create barriers to providing the best care for patients. Evidence-based psychotherapy needs to become first-line treatment for mild to moderate depression, anxiety and ADHD (where appropriate for age, etc). To make this happen it must be covered under the public health care system regardless of what type of practitioner is providing this care. This is already happening on a small scale in Ontario’s Community Health Centres and Family Health Teams, and last October’s announcement of expanded community psychotherapy programs is a step in the right direction. But as good as these initiatives are, they currently serve less than a quarter of the province’s population.
Could we afford such an expansion of Medicare? Yes, absolutely. International experience suggests that making psychotherapy first-line treatment could actually be cost saving, because we’re already spending the money on expensive prescription drugs that the evidence tells us don’t work as well.
We know over-prescribing is a problem. Let’s talk about how to solve it. Let’s talk about universal comprehensive evidence-based mental health care.