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.
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Here in Ontario, Canada If the working psychiatrist did their job in a diligent way it would help at this moment. Psychiatrist who watch the stock market on one monitor while seeing clients is not doing their job! Psychiatrist bitch and complain about coming to emerg when on call. When you are booked for duty you don’t take it out on the patient and staff.
Their was an in home acute care program which ran about 10 years in Kitchener when their mandate changed. Seems the head of in patients was angry that the nurses were having too many difficult patients since the in home crisis program started. I thought only the sickest are meant for hospital?
That program had an 80% approval rating and saved the government over 10 MILLION per year in diverting care from in patient care. In the end the psychiatrist got together and changed the program back to the same old!
Seems a SHAME!
If the working psychiatrist did their job in a diligent way it would help at this moment. Psychiatrist who watch the stock market on one monitor while seeing clients is not doing their job! Psychiatrist bitch and complain about coming to emerg when on call. When you are booked for duty you don’t take it out on the patient and staff.
Their was an in home acute care program which ran about 10 years in Kitchener when their mandate changed. Seems the head of in patients was angry that the nurses were having too many difficult patients since the in home crisis program started. I thought only the sickest are meant for hospital?
That program had an 80% approval rating and saved the government over 10 MILLION per year in diverting care from in patient care. In the end the psychiatrist got together and changed the program back to the same old!
Seems a SHAME!
For the past year, I have been a psychiatrist in-bedded in a community family practice group of 10 family doctors. The deal is that I see their patients in consultation and for one or two follow-up appointments only right in their offices. The family doctors are expected to write the prescriptions, to do the routine follow-up and renew the prescriptions. I am act as back up if things go wrong, share in their EMR and messaging system and I am available to discuss their cases directly. Such close collaboration is the best way to deliver treatment.
Unfortunately there is a disincentive to do what I am doing as it pays too poorly to do mostly consults ($30 more than a routine 46 min visit) and is twice the work, if you don’t have hospital staff to help with intakes. You and the policy makers belong to academic centres and regardless of your statistics, are out of touch with the needs out here in the community, even within the GTA. Until you consult with psychiatrists who work in the suburbs and communities and arrange to reward psychiatrist better, there will be a continuing “shortage” and I fear nothing will change.
They are glorified pharmacists. They are able to duck any real responsibility by just dishing out drugs and in many cases offering ZERO therapy. I am waiting for the results of my complaint to the Ontario College of Physicians and Surgeons at this very moment. They need to have more governance. This profession, the way it srands, is damaging.
Wonderful insights, psychiatry needs to redefine its role in the bigger mental health system world. I’m not sure if seeing a few select people for psychotherapy would pay back the system especially that physicians get funded for providing psychotherapy while other as capable colleagues don’t!
have OHIP cover no shows and charge patients a nominal fee for skipping their appointments and access will change remarkably.
I concur with your assessment and the need for collaborative and innovative approaches towards improving access to mental health care.
I’m surprised that no one has commented about the work in Australia and the potential of eMental health resources as an augment to existing face-to-face therapy. For instance, enabling e-consultation among psychiatrists and primary care physicians. I see a tiered, integrated and centralized model with linkages among primary and tertiary care. At the primary care level, better utilization of the skills and capacity of multiple disciplines, beyond a physician-centric model.
I’m glad that you are raising awareness of the need for system change.
You offer the concept that no prior psychiatric hospitalizations is equivalent to a low level of need in a patient. I’m confident that has merit. However, I wonder if the lack of prior hospitalizations amongst many patients might also be explained as a sign of the efficacy of treatment they receive from their psychiatrists on an ongoing basis. I don’t know that all patients with a high level of need have been hospitalized.
I do agree, however, that simply adding more psychiatrists is unlikely to solve the problem of limited access. Thank you for a thought provoking piece.
After 35 years as a clinical social worker and manager I concur with this debate, more access is needed but equal is the need for interprofessional models of care that would improve access to many who are waiting. Triage models would allow for those who are most in need of psychopharmacology being seen sooner for acute and high risk presentations and separating out those needs and maximizing identification of larger numbers of people that can benefit from counselling. Many psychiatrists never receive therapy training or counselling training. Other professionals who can provide this can do this with great skill, less cost and greater efficiencies. Still in some rural areas there can be anywhere from 0 to 5 psychiatrists per 300,000 population which is highly inadequate. Need a stronger focus using population health approaches.
all psychiatrists receive psychotherapy training now. but the demand is too high for the other services they can uniquely offer that most forego it altruistically. if a psychiatrist sees one patient for 16 hours, there’s 5 patients that didn’t get an assessment.
What other services? They push pills.
What exactly do you mean by pushing pills? Psychiatrists are trained to diagnose and treat psychiatric illness. Treatment often consists of medications AND/OR psychotherapy. Have you ever tried to treat psychosis or acute mania without pills? Psychiatrists are quite often trying to convince people that they do NOT require pills. Some people get upset and storm off, saying that the psychiatrist refused to treat them.
A great piece from Dr. Kurdyak. And yes the recommendations of the Coalition of Ontario Psychiatrists are sadly and predictably ill-founded. The problem Dr. Kurdyak points to is long-standing and has been addressed in successive reviews and reports in Ontario, going back to the 1988 Graham Report and before. Kurdyak describes a central challenge of getting our psychiatrists to serve those most in need, to be more responsive to those in crisis and to have them provide needed specialist support to primary care providers on the front line of mental health care. If this is the challenge, should we not be systematically moving psychiatrists off a fee-for-service reimbursement model that allows them to continue practicing where they wish, how they wish and providing them with little incentive to be part of a boarder health care team?
Totally agree.. We urgently need a better and easier access to mental health services.
Thanks
I am a pharmacist in a team that provides wraparound support for patients with mild to moderate mental
illness, and we consult with a psychiatrist when needed. I appreciate your piece very much as it gives weight to he valuemof our model. We have had great success with patients yet are having a tough time getting referrals for the team approach. (Most are referred to social work, yet need medication management as well. We are able to provide both as well as have our Nurse Practitioner write the prescription and we can do the monitoring.) Yet, physicians are reluctant to grant the whole patient over to us, even though they remain on their roster and we are basically a support to primary care. I am hopeful and confident that eventually, your opinion will be the norm, as the team approach is far more successful and economically sound than more direct access to psychiatry. Thank you for writing this.
As a US-trained psychiatric mental health nurse practitioner who has worked in both inpatient and ambulatory settings in Ontario, Canada – with interprofessional teams including psychiatrists, social workers, psychologists, occupational therapists, nurse practitioners, clinical nurse specialists, registered nurses, registered practical nurses and unregulated mental health providers, we need to adopt innovative approaches to workforce planning that starts with population health needs and models of care that optimize all members of the interprofessional team. There has been an active lobby for decades to limit nurse practitioners across Canada as evidenced by the fact that Canada has 1% of the number of advanced practice nurses that the US has – yes 1%!
There are 5000 nurse practitioners (NP) and clinical nurse specialists in Canada and there are 500,000 NPs, clinical nurse specialists, nurse anethetists and nurse midwives in the USA – this means that the US has 1 Family NP for every 1 Family Physician. As recent reports highlight, we are slow to implement innovative models of care or optimize our ENTIRE workforce to meet population health needs – likely the innovations required will not occur in my lifetime as I entered my NP training in 1998 and enjoyed amazing collaborative relationships with many psychiatrists and other interprofessional colleagues – but profession-specific interests are getting in the way of meeting the mental health and addictions service delivery needs of Canadians (and other populations). We need true leadership and bold political action that focuses on integrated workforce planning – likely I will be writing this again in a decade like I did in 1998, 2008 and now 2018… there is too big a price to be a status quo mediocre performer – the price being limited to no access for 1000s of Canadians.
I think we should also look at covering counsellors and social workers by OHIP. Wondering if any other province does. Where we live in Kitchener, I believe Psychiatrists only do medication treatment. I am lucky enough to have some coverage for counselling in our benefits plans, but many are not.
better to cover psychology. “counselling” has little evidence. plus, there is some access to it. time limited structured and semi structured modalities such as a course of CBT or IPT treatment is a better idea. one of the biggest problems with OHIP covered mental health services are no show rates and that’s often not discussed. there’s a lot of wasted resources because people decide to not go to their appointments and there are no consequences for them financially. that’s also why most private practice psychiatrists will stick with a small population of patients they know will show up. because OHIP pays them zero dollars if the patient fails to show and that no show rate is remarkably high.
Absolutely. For a more detailed practical analysis of how the system needs to be transformed to achieve this, please see the book I wrote called It’s Not About Us; The Secret to Transforming the Mental Health and Addiction System in Canada. https://www.amazon.ca/Its-Not-about-Transforming-Addiction/dp/0993817335