Why Mental Health Care Is More than Numbers

A while ago, I was informed that I lived in the mecca of mental health services: Toronto. There are a plethora of private-pay therapists including registered psychologists and registered psychotherapists here, but most with complex needs can't afford them and must turn to medicare-covered psychiatrists. The University of Toronto, which has over 900 psychiatrists on faculty, trains one-quarter of Canada’s psychiatrists. Although forty-two percent of the faculty are full-time academics, that still leaves hundreds in clinical practice, in addition to community psychiatrists and a few medicare-covered psychologists and social workers.

But the "roughly 63 psychiatrists for every 100,000 residents" are not enough to meet the need since the adequacy of mental health care isn’t solely about how many psychiatrists or therapists there are per 100,000 population, it’s also about the quality and effectiveness of care provided, especially for those of us with brain injury and/or PTSD since we require long-term specialized care.

Recently, Mary Fernando, a Canadian physician, revealed on Twitter that the Ontario government intends to change this situation by telling physicians to practice psychiatry as a short-term method, not by extending medicare to cover non-MD mental health professionals who can share the load of treating long-term chronic-care patients. This will change the numbers but continue the dismal situation of providing inadequate mental health care. So if Toronto is Mecca, then Canada and her provinces are absolutely failing its citizenry.

The report “The efficacy and effectiveness of psychological treatments” published by the University of Ottawa on September 10, 2013 said:

“In the treatment of anxiety and related disorders, there is strong evidence to support the use of psychotherapy as a first line treatment. This holds across the lifespan for generalized anxiety disorder, social anxiety disorder, specific phobia, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder [PTSD].

Although the strength of evidence varies considerably across the treatment of anxiety and related disorders, in general, psychotherapy and medication appear to be equally effective. For many of these disorders the rates of premature termination of treatment are lower for psychotherapy than for pharmacotherapy.” (Bolding mine.)

In other words, medications alone don’t cut it for complex issues like PTSD since premature termination makes treatment essentially ineffective. Complex issues require labour-intensive care. That makes sense because we humans are social animals. Every aspect of our health from hearts to brains work better when we are connected to other human beings. And in our judgemental world, having a connection to a professional who treats you as a normal human being while recognizing the true severity of your issue, makes an enormous difference.

Those of us with brain injury and PTSD have as much right to treatment as people with cancer do.

We should not have to defend ourselves against the idea that a little bit of treatment is better than no treatment. No one in their right mind would say cap the funding by giving every cancer patient the same amount of chemo; yet that's the answer the current Ontario government is offering people who need mental health care.

For years and years I did not have competent mental health help, competent for my complex case, that is, because I couldn't find it. A therapist who doesn’t understand brain injury and won’t educate themself is not competent enough to treat me though they may be competent for a person with anxiety or depression. I thought I could get by without. I was wrong. After my insurance lawsuits were settled, I began deteriorating. I think when a fight is over, that’s when you feel its emotional and psychological effects. And so I began round two of seeking a mental health professional.

I asked and asked and asked. I asked doctors, people I knew, CCAC (Community Care Access Centre) professionals. I got handed a couple of names on Post-Its. No new patients, was the reply when I called. I kept begging and searching. No one knew any health care professional who understood brain injury; no one knew neuropsychiatrists who had less than a two-year wait. Except for one person, no one treated my search as a critical care one where they needed to actively participate like they would if they had a patient or client with cancer. They pretty much left it up to me to seek and call names. I finally gave up from the utter exhaustion of looking.

Then my skin began to shred. I was sent to a dermatologist, who noticed I was not all right. I’d seen all kinds of medical professionals before I saw him; he was the first to look into my eyes and ask me how I was doing.

He said he could refer me to a neuropsychiatrist. You’d think the fight was over.

Uh, no.

I was referred to a community psychiatric clinic, which called me and said my case was too complex for them. This affirms my first point, that access to mental health isn’t just about the numbers, but more critically about the abilities of the health care professional to treat complex problems like brain injury and PTSD. It’s also about having stamina and persistence to find one or one that doesn’t have a years-long waiting list. I returned to bugging the dermatologist to call a specialized clinic and then to wait in dermatology until the referral was written and faxed.

The referral didn’t end the wait. I continued to wait.

And wait.

And wait.

At last, I had an appointment! But that didn’t mean I was in, for the appointment was to assess the severity of my case and to see if I met the criteria to be treated. I did. Yet I wasn’t able to start treatment. First, I needed to meet with my new neuropsychiatrist three times to give a detailed history, and I had to wait for those appointments, too.

I waited.

And waited.

Finally, I saw him for those appointments. Three forty-five-minute appointments were insufficient for my history, but that was standard protocol. I think that affected my treatment down the line, and I was too trapped in my brain at the time to advocate for more history taking to ensure he had as complete a picture as possible. I was just relieved I was in, and no one else would or could advocate for me. Once I had completed the history-taking sessions, the clinic allowed me to book appointments for actual treatment every other week, its standard protocol. In contrast, a person with cancer would have the standard protocol individualized to maximize the effectiveness of treatment.

I had to wait two months for treatment to start.

Back then, I was still “recovering” from having years of several-times-per-week medical appointments, and so I was fine with every two weeks. Monthly would have suited me. You see, I knew I needed the help, but brain work is tiring and hard. I dreaded the exhaustion to come. But if Medicare funded care appropriate to the need, the neuropsychiatrist could have held longer history-taking sessions and had an honest discussion with me about what frequency my needs demanded instead of simply following dollar-saving protocol.

However, after watching me deteriorate over the months, he assessed I needed more frequent appointments. He didn’t change the schedule though — the demand for his kind of specialized services is too high for the piddling funding provided, and seeing me more would mean adding more hours to his workload. It was me who instigated it. I became more cognizant of how much work was required, how my slow processing of the session worsened my functionality two days after an appointment, and how much trauma therapy paralyzes in the beginning, especially in the context of little social support. I began to nag and beg for a change in frequency to at least be able to see him at the time my processing speed had caught up to and was responding to what he'd said or done in session. But he didn't move from protocol until my deterioration made it obvious he had to meet my individual need. These issues of needed frequency, individual variability, effect of therapy, effect of little social support, etc. are not revealed in mere numbers. Numbers don't tell you the why behind them.

For example, the author of a study on the supply of psychiatrists made a disrespectful assumption toward his fellow psychiatrists based on his analysis of numbers alone:

“In central Toronto, which has the highest supply in the province, there are roughly 63 psychiatrists for every 100,000 residents. In low-supplied regions, there are an average of only seven psychiatrists per 100,000 residents.

That finding was expected. But the researchers were surprised to see that many of the psychiatrists in well-supplied areas chose to see relatively few patients – and don’t take on many new patients.

Indeed, where there are lots of psychiatrists, they tend to treat a small number of patients and see them very frequently, says the study’s lead author, Dr. Paul Kurdyak, an emergency-care psychiatrist at the Centre for Addiction and Mental Health in Toronto.” (Your Health Matters, March 16, 2015)

Central Toronto has a high concentration of people with severe mental illnesses and who are homeless. They come from all over Canada. Downtown contains more subsidized housing than elsewhere, and people on Ontario Disability Support Program tend to live in subsidized housing. It doesn’t take much thinking to recognize that people with disabilities and severe mental illnesses will require more mental health care than someone adjusting to divorce, for example, that they can’t travel far, and that therefore downtown psychiatrists won’t be able to have many patients on their roster if they are to provide good health care to the most vulnerable with the most complex needs in society. Good care is more than medication and infrequent medication checks. If medication was the panacea many make it out to be, there wouldn’t be so many living lives of quiet desperation.

“[Dr. Kurdyak] believes many psychiatrists are not compelled to see more patients, in part, because of the way they are paid under the provincial health-care plans.

Psychiatrists, he explains, provide patients with psychotherapy and they are paid on an hourly rate. There are no limits placed on how many times they see the same individual, nor does the severity of the patient’s condition relate to appointment frequency. “That means a psychiatrist can take on a roster of patients, see them over and over, and be pretty well compensated for it.””

I’m really not sure where the disdain for psychiatrists using psychotherapy comes from. After all, wasn’t it originally the domain of psychiatrists as well as psychologists? People with brain injury and PTSD have a need for health care professionals who understand neurophysiology, the intersection of medications, surgeries, and neuroplasticity on their injuries, physical sequelae and their effect on the brain, and the effect of social isolation and know how to use psychotherapy to change the brain in a positive way. Not many have the kind of neuro- and electrophysiology, anatomy, medication, psychological, and social systems background to do that. When community psychiatrists and counselling family physicians feel inadequate to the task of treating people with brain injury and PTSD, why do Dr. Kurdyak and others in the Ontario government begrudge us receiving the kind of care we need from the very, very few qualified and willing to treat us? As the University of Ottawa paper showed, psychotherapy is effective and people are more likely to stick to it until they’re well. Premature termination of medications inherently makes medication less effective than psychotherapy.

Also, I note Dr. Kurdyak's bias against frequent appointments and his ascribing careless misuse of scarce resources as the motivation to seeing patients "very frequently" instead of professional judgment. His bias throws into question his conclusions. He also seems oblivious to the difficulties other medical specialists have when trying to treat their chronic care patients.

“Other medical specialists, in contrast, are usually paid a set fee for an initial visit and significantly less for subsequent appointments. “They are incentivized to constantly see new patients because the payment for a consultation is so much higher than for a follow-up.””

Dr. Kurdyak holds up for praise this method of payment that is designed for acute care only. This method ensures either specialists have to see their chronic care patients for virtually no money, making it difficult to pay staff and maintain equipment, or wait until their patients inevitably become so sick they land in the ER and then are referred back, costing the health care system much more than if medicare had simply paid for regular appointments. Both options greatly stress the specialists who'd prefer to keep their patients as healthy as can be. Chronic conditions are never static and require a stable relationship with the treating physician to be best managed. People with brain injury and PTSD are chronic care patients.

“The Ministry of Health and Long-Term Care is offering to pay physicians in full for the first 24 hours of psychotherapy a patient receives per year, but wants to claw back fees by 50 per cent for any care provided after that.

The ministry says the clawback will save $13.2 million and boost access to mental health services.

“Claims utilization data also suggests that there are some physicians in Ontario who are providing a high volume of psychotherapy to a small number of patients for an extended period of time, with uncertain clinical benefit, while also limiting access for new patients,” the ministry’s 230-page submission to government-appointed arbitrators William Kaplan, Ron Pink and Kevin Smith reads.

The OMA section’s response says that is baseless. Of particular concern is patients with higher needs, such as those who are suicidal or experiencing post-traumatic stress disorder, who may not have received all the care they need after 24 hours of therapy.

. . . “The reason we object is because this puts patients’ health at risk. Restricting much needed medical services on the basis of incomplete or biased evidence for political convenience is absolutely unacceptable,” the doctors say.”” (Queen’s Park Today, February 8, 2019)

Society needs to come to grips with the fact that effective mental health care for brain injury and PTSD, as well as other brain-related issues, is labour intensive. Medicare must thus fund not only psychiatrists, but also registered psychologists, registered psychotherapists, social workers, occupational therapists, behavioural therapists, in order to serve the need and to allow people to return to work instead of languishing for years or, worse, dying. We have as much right to receive care from a (neuro)psychiatrist as we should have by a registered psychologist or social worker or registered psychotherapist, as the need dictates, as a person with cancer does from an oncologist.

Two years after I began searching for a qualified psychiatrist funded by Medicare, I found one through a strange set of circumstances.

So if this is Mecca where you have to fight every step of the way from finding names to getting in for an assessment to being booked for treatments to being booked in for the frequency you need — and where when we have it, we now face deterioration from the government moving to actively prevent us from receiving critically needed and effective care — then God help Canadians outside of Toronto in severe mental and emotional distress, especially those who cannot ask for help and particularly those of us in the brain injury community who require highly specialized labour-intensive neuropsychiatric care. The push to change neuropsychiatrists to acute-care consultants only will fail us all even more.

Copyright ©2019 Shireen Anne Jeejeebhoy. May not be reprinted or reposted without permission.