There’s a shortage of psychiatrists in Ontario. But do we really need more?
In August, the Coalition of Ontario Psychiatrists, a partnership between the Ontario Psychiatric Association and the Ontario Medical Association, released a report warning Ontarians about an ongoing crisis of access to mental health care due to a shortage of psychiatrists. The report makes three recommendations: 1) to increase exposure to psychiatry in medical school; 2) to increase the number of psychiatrists trained in Ontario; and 3) to increase payment to psychiatrists.
There are a few problems with these recommendations. First and most important, their implementation doesn’t guarantee that access to mental health care in Ontario will improve. There is a shortage of psychiatrists in some areas of Ontario, and an abundance of psychiatrists in cities like Toronto and Ottawa. Many psychiatrists in large urban areas adopt small practices and see patients frequently, often over several years. This means that these psychiatrists are effectively inaccessible. If we train more psychiatrists only to have them practise this way, the access issues in regions with very few psychiatrists will not be addressed.
Second, the time it takes to recruit more people to psychiatry and to train is a lengthy and expensive process—nine years from the start of medical school. People with mental illnesses can’t wait—we need more and better access now. The most urgent issue is not a shortage of psychiatrists, but poor access to mental health services more generally.
Psychiatrists are only a part of a broader mental health system. In my opinion, mental health care should start in primary care. In the same way that family doctors play an important front-line role in the treatment of chronic conditions such as diabetes, they can similarly be a first point of access for patients’ mental health. In fact, this is already happening: Primary care physicians are providing much more mental health care than psychiatrists, just by virtue of their numbers and relative ease of access. And just as happens with diabetes—where specialists such as endocrinologists get involved in more severe or complex cases—mental health care provided by family doctors must be complemented by more specialized services when patients require them.
There are a large number of community mental health and addiction services for individuals with mental illness and addiction issues, and there are psychiatry departments in most hospitals. However, for the most part, these services are not well-integrated into the broader health care system, and people who need them as well as their providers do not know how to access them. Furthermore, there is no guarantee that these services will be well-matched to people’s needs. There are many examples of very high-intensity services being provided over a long period of time to individuals with a low level of need (based on measures such as almost no prior psychiatric hospitalizations), and many more instances of people with very high needs getting no services whatsoever. I led a study by researchers from the Centre for Addicitons and Mental Health and the Institute for Clinical Evaluative Sciences which revealed that 10 percent of full-time psychiatrists in Toronto were seeing fewer than 40 patients total annually. The vast majority of these patients had never had a prior psychiatric hospitalization and mostly resided in the highest income neighbourhoods. In another study, we discovered that only 40 percent of patients who visited an Emergency Department for a suicide attempt saw a psychiatrist within six months of the visit.
Models of care developed in other jurisdictions address the access problems we are dealing with in Ontario. For example, in the U.S., many service provider organizations have adopted a coordinated care approach for the management of common mental illnesses like depression. A team of mental health professionals embedded in primary care clinics systematically screen for mental illness and, when an illness is identified, “treat to target,” systematically measuring patients’ responses to evidence-based treatment. Psychiatrists provide oversight and supervision, their expertise effectively reaching a much larger number of individuals than would occur if they were providing care directly to patients. Moreover, because response to treatment is being monitored, the team knows when things are not going well, prompting the psychiatrist to get directly involved in cases that are more complex. Larger numbers of patients get evidence-based treatment and the specialized care of a psychiatrist goes to those who need it.
Do we need more psychiatrists? Yes, but we also need to redefine their role in the system so that they, as a finite resource, are accessible in a way that brings their expertise to the largest number of people. This requires fundamental shifts in the way mental health care is delivered and a similar shift in the role of a psychiatrist in a publicly funded health care system. We can learn from other jurisdictions that have successfully increased access to quality mental health care without a dramatic increase in the number of psychiatrists. And the models of care that have been successful elsewhere can be implemented today so that people suffering from mental illnesses do not have to wait any longer.
Paul Kurdyak is a psychiatrist and scientist within the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health and Lead of the Mental Health and Addictions Program at the Institute for Clinical Evaluative Sciences.