This is the second instalment in a three-part series examining the state of mental-health care in Ontario. You can read Part 1 here. Watch for Part 3 on Thursday.
All Canadians are used to waiting for health care. But parts of our system work great, and fast, if you can afford to access them.
I have young children. My son, five, though thriving now, struggled at times in his earliest years. He needed a series of assessments to rule out alarming possibilities and to work on strategies for his advancement. As a rule, when dealing with parts of the system that were fully publicly funded, the wait was weeks (in one case, two months). But, when my wife and I were asked to have him seen by a mental-health specialist for an assessment, the wait was — well, there wasn’t one.
We called a nearby clinic and explained that we had a child who’d been recommended for an assessment to check a variety of possible mental-health or emotional challenges. The receptionist said, sure, no problem, when would you like to come in? I asked her for some dates and already had the calendar on my phone zoomed out to show the entire month. She laughed and said, no, I mean what time today?
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I was floored. But it was true. My son had his initial assessment that very week, and that delay was only because I wasn’t able to take him that very evening. A few follow-ups for specific tests were arranged as easily. The entire process took just weeks, start to finish. The cost of the sessions and assessments was just under $500, which was 100 per cent covered by my workplace insurance plan. It was a remarkably pleasant experience, and it had a happy ending, as my son was given a clean bill of (mental) health.
But none of this was a given when seeking mental-health care in Ontario. My wife and I went into that appointment with a lot in our favour. We had private insurance. We had the financial means to proceed even if we didn’t have the insurance or if we exhausted it. We live in an area with good overall access to mental-health-care specialists. And our son, once assessed, did not require any ongoing care or treatment by a specialist. This was almost the optimal experience of mental-health care in Ontario.
It wouldn’t take much to radically alter this happy outcome. Change any of those variables, and you’d have a very different scenario. We had the best possible experience, but imagine the exact opposite: imagine an Ontarian with no insurance, living in poverty in a remote rural area, with no local care options and a need for long-term — perhaps permanent — care by a specialist, potentially including medication, which must also be paid for out of pocket.
This is the reality for thousands of Ontarians.
Taking on a topic as big and complicated as mental-health care is unusually challenging because there’s almost no natural limit to the scope of what can be discussed. The limits, imposed only by this writer’s time (and the readers’ patience) are admittedly arbitrary. In order to break down the topic into manageable bites, my editor and I agreed to draw a line between mental-health care that requires in-patient treatment and everything else. But it’s important for the reader to understand that this isn’t precisely the same thing as dividing the need into “major” and “minor” categories. Some Ontarians who’ll require in-patient care will have relatively straightforward diagnoses and treatment plans, and will thrive once discharged. Other Ontarians will never require in-patient care but will struggle with their mental health or addictions, in life-altering ways, for all their time on this Earth.
Roughly 2 million Ontarians seek mental-health care each year. Although there is no typical case, consider, as a hypothetical example, an adult who experiences periodic bouts of depression or anxiety but remains high-functioning, does not consider self-harm, and does not require medication. That person may have all their needs met through periodic visits with a therapist. On the other end of the intensity spectrum, consider an Ontarian with crippling depression or anxiety, or a history of paranoia or delusions, or a severe enduring addiction, all of which are managed in part through medication that requires professional supervision and monitoring. Even if they’re treated outside a facility, on an out-patient basis, the need for service is going to be orders of magnitude greater.
Patients who absolutely need ongoing therapy will be handled by OHIP, which will fund it. In an ideal scenario, this works via a referral to a psychiatrist by a family physician — both are funded by OHIP. As far as it goes, this is an effective arrangement, but there are two major problems that should be apparent to anyone with any experience of health care in Ontario. First, in order for this to work, you must have access to a family physician, and the physician must be sufficiently trained in and aware of mental-health issues to draw the correct conclusion and make the referral. That’s not a guarantee. Next, and here’s the part all Ontarians are familiar with, a referral isn’t care. It’s a health-care IOU — you’ll get the care, but only when the system gets back to you.
There are approximately 1,900 psychiatrists in Ontario. The CBC reported last year that the average patient load has been increasing, and many are nearing retirement age. (In Part 1, I mentioned a friend of mine, whose psychiatrist recently retired — she faces a wait of perhaps 12 months until another can take her on as a patient.) These delays are annoying when you’re waiting to see a dermatologist because of a mole that’s doing something strange. Imagine how devastating they can be when you need care immediately, when there is a very real impact on your life and the lives of others, and when delays will only worsen the condition. That’s the reality for psychiatry in Ontario. You’ll get the care when the system can take you.
And the system is massively skewed by geographical constraints. A study in 2009, for example, found that, while there were 63 psychiatrists per 100,000 residents in the Toronto region, some remote parts of the province had barely four per 100,000 — a whopping fifteenfold difference.
Again, there’s nothing unique to mental-health care about this. This mirrors the health-care system broadly. Access to care, and specialists in particular, is greatest in the largest population centres. But with many physical ailments, there it at least a hope of managing a medical crisis and restoring a patient to something close to their normal health. With mental-health care, there is a much higher chance of a need for ongoing, perhaps lifelong, treatment. If your only access to care is hours away, and you’ll need that care for life, the disruption to your life and finances can obviously be considerable.
There’s a related problem. The 2009 study found that, in areas with a relatively greater number of available psychiatrists, each psychiatrist saw, on average, fewer patients but saw them more. There was an opportunity to develop a deeper relationship between the doctor and the patient. In contrast, in areas with relatively fewer available psychiatrists, each was responsible for a larger number of patients and so had correspondingly less time available for each of them. This, of course, makes intuitive sense — in areas that are relatively starved for psychiatrists, the provision of care must be more of an assembly line: in, treated, out, repeat. In some cases, this will be sufficient. In others, needless to say, it won’t be.
Not all mental-health care provided on an outpatient basis is handled by a psychiatrist. Psychologists are also trained therapists who can work with patients; they cannot prescribe medication but can still be enormously helpful. Social workers can also provide therapy (though, again, they cannot prescribe medication). Thousands of Ontarians receive good results from working with these professionals, and they can be approached directly and paid for through private insurance or directly out of pocket. (The clinic where my son was assessed was staffed by such professionals — psychologists and social workers who, though not funded directly by the health-care system, had relationships with local schools and community doctors.)
Psychiatrists, psychologists, and social workers can specialize in certain forms of therapy or develop expertise handling patients with specific issues — a psychologist may specialize in treating patients with post-traumatic stress disorder, for instance, while a social worker in the same clinic may work mostly with children suffering from anxiety or depression. In a sense, the private system can offer more flexible options for a patient with the means to pay: they can seek out the professional best able to deal with their specific needs. Psychiatrists, of course, can also specialize, and prescribe medications that suit a patient’s specific needs, but the patient may not have the luck of the draw, which would mean being assigned the best option in a timely manner.
And timeliness matters. Mental-health outcomes are best when a patient is seen rapidly, and then consistently, as needed. Again, this isn’t any different from any other form of treatment — mental-health care is health care, and, in Ontario, it involves the same pros and cons as any other part of the system.
But there are those who simply can’t be treated in the community and must go, at least for a time, to a facility. And we’ll talk about that in Part 3.