How Canada Fails People with Mental Illnesses
Canada Needs Improved Access to Mental Healthcare Services
In any developed country, politicians and clinicians are struggling to improve quality of care while reducing costs of healthcare systems. To remedy this, groups of doctors across North America–including here in Canada–have banded together to create lists of medical procedures or tests that are likely to be of no benefit (at best) or can possibly do harm while adding unnecessary costs. The goal of this initiative, called Choosing Wisely, is to improve quality of care and to address rising healthcare costs. This campaign hopes to inspire a dialogue between clinicians and patients about making good, evidence-based, cost-effective choices about their health and healthcare.
But the big dilemma for those working in the field of mental health is not about overuse or misuse, but how difficult it is to get any treatment at all. You can’t choose wisely if you can’t access care.
There is overwhelming evidence that access to mental healthcare across Canada is poor. Only one in five people with depression get appropriate treatment. And shockingly, only one in three patients discharged from a psychiatric hospitalization sees a primary care physician or psychiatrist within a month in Ontario as reported by Health Quality Ontario. This poor post-discharge follow-up rate is far worse than the nearly 100% of patients who see a physician following a hospitalization for heart failure.
So why do we do so poorly for people with mental illnesses?
The answer to that question is complicated, but mental illness is one of the biggest predictors of inequitable access to care in this country. We know that having a mental illness means that you are far less likely to get the healthcare you need than someone without a mental illness and that mental illness is a bigger predictor of poor access to care than low income.
This is truly bad for patients with psychiatric illnesses, but it’s also bad business and costly to taxpayers – the price of a physician visit following hospitalization is far less than the cost of ending up back in the hospital because you had no hope of continuing the treatment that helped you get better.
The good news is that we often know what works for people with mental illnesses. There are many types of treatment, both drugs and psychological (talk) therapies, that are well-tested and effective. But in the mental health realm we need to start ‘Working Wisely’ before we can ‘Choose Wisely.’
What would ‘Working Wisely’ look like?
Cancer care is an example of a system of care that is largely efficient across Canada. It works because most people with cancer get a good diagnostic work-up to measure the cancer severity, and based on those tests, get the cancer treatment they need. In most provinces, we know what the population burden of cancer is and can create systems of care accordingly. Outcomes are also constantly measured and processes of care are modified based on continuous quality feedback.
We have nothing close to this in mental health across the country, which means we don’t have a good sense of population-based need. And if we don’t have a clear sense of need, we won’t be able to align existing resources with present demand.
‘Working Wisely’ for mental healthcare in Canada would mean investing in the capacity to screen and triage for mental illnesses, to create care pathways based on the burden of illness highlighted by the screen and triage process, and to measure meaningful patient outcomes to constantly improve the way care is delivered. The Mental Health Commission of Canada’s National Strategic Framework, and virtually every province with a mental health strategy, has called for better performance measurement in the past five years. This is a daunting task – nothing less than the creation of a system of care where none currently exists.
One of the reasons we are hearing more about mental illness in the media these days is because there is less stigma thanks to courageous individuals who are willing to share their stories. People are no longer willing to suffer in silence and we literally can’t afford to ignore the burden of mental illness.
But as people come forward seeking help for the first time, they need a system that is ready, responsive and able to meet their needs. Without that, we will simply continue to read the depressing headlines on a weekly basis.
Sanjeev Sockalingam is a psychiatrist and Deputy Psychiatrist-in-Chief at the University Health Network and Associate Professor at the University of Toronto.