Mental- health system woes demand new ideas

“There is no health without mental health,” U. S. surgeon general David Satcher famously warned, nearly two decades ago. Determination to address this shortfall is evident in recent commitments, in Ontario and Quebec, to invest millions in publicly funded psychotherapy.

The new approach will topple a barrier to access for many who struggle with depression and anxiety. But it won’t address the most acute needs, according to the lead author of a study published Monday in the Canadian Medical Association Journal.

Many Ontarians still don’t have timely access to a psychiatrist after a suicide attempt or psychiatric hospitalization, the study found. Psychiatrists’ services are funded by OHIP and require a doctor’s referral.

Despite the importance of followup care, two- thirds of patients admitted to hospital were not seen by a psychiatrist within a month of discharge. And only 40 per cent of those treated in an emergency room for attempted suicide got an appointment with a psychiatrist within six months.

As anyone with a loved one facing these wait times can attest, it’s an eternity.

The problem isn’t new. In 2011, the province introduced pay incentives for improved followup, offering psychiatrists a 15 per cent premium for seeing a patient within 30 days of a hospital discharge or six months of a suicide attempt, plus $ 200 a year for each patient who received followup care within a month.

The incentives had no effect, according to a five- year study by the Centre for Addiction and Mental Health ( CAMH) and the Institute for Clinical Evaluative Sciences, which tracked more than 380,000 patients between 2009 and 2014.

“I think it’s great they tried to do something,” says the study’s lead author, Paul Kurdyak. “But there’s not a ton of evidence for these pay forperformance incentives.” The challenge, he says, is much more complicated.

He notes discharged patients do receive followup care from family doctors and other professionals. Yet the lack of specialist consultation following a suicide attempt is concerning. “Say, after developing breast cancer, only 40 per cent of individuals saw an oncologist. I think that would raise some eyebrows.”

Structured psychotherapy can be a component of care after psychiatric hospitalization, he adds, but “we’re talking about a greater complexity of need.”

People often blame long wait times on a shortage of psychiatrists, but that’s only part of the picture, Kurdyak says, citing a 2014 study analyzing supply and practice patterns across Ontario, which he also co- authored. Psychiatrists are highly concentrated in Toronto and Ottawa.

The expectation — more psychiatrists per capita would translate to better access — did not bear out. Instead, the opposite was true: Toronto practices often provided long- term psychotherapy for fewer patients, while psychiatrists in under- serviced areas treated more new patients.

Either way, the people waiting for help came up short.

There are lessons in other publicly funded systems, Kurdyak notes. Access to care has been improved in the U. K. and Australia by integrating psychologists and social workers, while giving psychiatrists a more targeted role as consultants.

He also describes local solutions, such as the crisis clinic at CAMH, where patients can be diverted from hospitalization and into community resources within five business days.

“There’s a real opportunity to be innovative,” he says. “But we need to be doing more scaling and spreading of these kinds of solutions.” write. robin@ baranyai. ca