For the past decade, Bell Canada has used the month of January to support awareness of mental health issues. Its extensive media campaigns have encouraged Canadians to talk openly about mental health and break the uncomfortable stigma that still tends to hover over such conversations.
There is plenty of data to document the prevalence of Canada’s struggles with mental health. A report by the Canadian Alliance on Mental Illness and Mental Health shows that one in five Canadians suffers from mental illness; it keeps 500,000 Canadians from their work, in any given week; and accounts for 33% of all hospital stays. While the resultant lost productivity is estimated to be $6 billion, it can be presumed that the personal losses are inestimable.
These numbers are grim, but worse still are those that show how badly Canada is failing in its efforts to do anything about it. Sadly, the very best our so-called universal, equal-access medical system can do is put thousands of patients on waitlists that offer treatment … eventually.
Across Canada, the average wait from obtaining a referral by a family doctor to receiving treatment for mental health is 20.8 weeks, and that varies from a best of 12.2 weeks in Saskatchewan to a dismal 47.7 weeks in Newfoundland.
These waits are particularly critical to children and youth, as their brains are still in the formative stages. This understanding should be sufficient to ensure doctors and treatments are available, yet there are currently 28,000 children and youth on waitlists for treatment in Ontario alone. For some, this translates into an unacceptable wait time that extends to more than two years.
Both psychiatrists and advocacy groups have called on the Ontario government to make a substantive investment in mental health. The advocacy group, Children’s Mental Health Ontario, has asked for an extra $150 million per year to reduce wait times.
The Coalition of Ontario Psychiatrists (associated with the Ontario Medical Association) produced a 2018 report on the growing shortfall of psychiatrists and noted two concurrent issues impacting their number and availability: a majority of psychiatrists across Canada are nearing retirement, at the same time as medical students are showing a diminishing interest in the field.
Consequently, this body of professionals has called on the government to hire more psychiatrists and to increase their pay in an effort to “make psychiatry attractive again.” Unfortunately, this is not the kind of solution that will be readily adopted by cash-strapped governments.
It is also rather simplistic, considering other findings that implicate the practice characteristics and demographics of psychiatrists themselves as major factors limiting access to their services.
A series of studies conducted by the Centre for Addiction and Mental Health (CAMH) and the Institute for Clinical Evaluative Sciences (ICES) have provided a quantitative analysis of the practice patterns of psychiatrists.
Their 2014 study showed that one-half of all Toronto psychiatrists have small urban practices where they see a limited number of patients on a frequent basis and over long periods of time. As a result, 50% of that city’s psychiatrists saw fewer than 140 unique patients annually. A further breakdown of the numbers in this group showed that 10% of psychiatrists saw less than 40 patients each year; 40% saw fewer than 100.
Even more frustrating is that most of their patients lived in the highest income neighbourhoods and had never had a prior psychiatric hospitalization. In contrast, it has been reported that only 60% of patients who attended an emergency department for a suicide attempt were able to access psychiatric care within six months after the episode.
It appears that these practice patterns have created a situation where at least one-half of Toronto psychiatrists are overserving people with a “low level of need” (no prior hospitalizations), while people with the highest needs get little or no assistance.
Finally, the research group’s 2019 study examined five years of patient data to determine that one in three Ontario psychiatrists sees fewer than two new outpatients a month.
While the type of psychiatric practice is creating a barrier to patient access, it has also been shown that the demographics of the physician may play a role.
A 2017 study in the Canadian Journal of Psychiatry revealed the impact of physician demographics on their availability to patients. Contrary to the opinions of many, older psychiatrists saw more patients than younger ones, and female psychiatrists saw fewer patients than their male peers. According to the authors, females are occupying an increasingly large proportion of residency training programs and greater numbers of female psychiatrists, with relatively small practices, are entering the workforce. That trend is expected to continue.
The researchers rightly conclude that without “radical changes in the way Ontario psychiatrists’ practice,” access to treatment will not improve.
Although these illuminating studies are focussed on the situation in Ontario, they remain instructive for all of Canada as the issues prohibiting access are not unique to that province.
Based on the above data, the best solutions to enhancing access to mental health care are not likely to be found by paying more money to psychiatrists. There should be a focus on developing innovative ways to encourage psychiatrists to expand the scope of their practices, but providing support and resources for the greater utilization of qualified secondary support services (e.g. family physicians, psychologists, social workers) may be the quickest, and most reasonable, path forward.
Susan Martinuk is a research associate with the Frontier Centre for Public Policy.