We've all heard stories of people who have mental health issues but who can't find a psychiatrist. In fact, in one Canadian survey 35 per cent of family doctors actually rated access to psychiatrists as poor, compared to access to other specialists. Dr. Paul Kurdyak, himself a psychiatrist, has not only heard those stories; he and his colleagues have lived them, having often treated people who turn up in hospital ER departments desperately needing help but not able to access it in the community.
Given the widespread difficulties with access, we assume the problem to be due to a shortage of psychiatrists. But is it?
That assumption and the pressing issue of poor access motivated Dr. Kurdyak, director, Health Systems Research at Toronto's Centre for Addiction and Mental Health (CAMH) and lead of the Mental Health and Addictions Research Program at ICES (the Institute for Clinical Evaluative Sciences) and a research team to look at the supply and practice patterns of psychiatrists across Ontario.
What they found was surprising.
In terms of availability, psychiatrist supply varied from a low 7.2 per 100,000 people outside of Toronto to 62.7 per 100,000 people in Toronto. They then hypothesized that patients in regions with higher psychiatrist supply would have better and more timely access to care, but the opposite was actually true.
"We wanted to understand how, with so many psychiatrists in places like Toronto, could there still be an access issue," Dr. Kurdyak explained. But what they found was that in regions like Toronto where psychiatrists were many, a substantial number of those psychiatrists saw fewer outpatients while their colleagues in low-supply non-urban areas had more patients and more new patients.
Furthermore, in Toronto, which has the highest number of psychiatrists per capita, 10 percent of those practicing full-time saw fewer than 40 patients per year. These patients were seen more frequently and for longer visits, suggesting these were patients who might be undergoing psychoanalysis or long-term psychotherapy. Thus, having more psychiatrists does not seem to equal more access to psychiatric services.
The study, Universal Coverage Without Universal Access, is published Tuesday in the journal Open Medicine. In addition to finding that the per capital psychiatrist supply throughout the province was extremely variable, the researchers also found that patients who were seen more frequently were wealthier and less likely to have had a prior psychiatric hospitalization. In Toronto, 44 percent of patients seen more than 16 times per year were from the highest income level by neighborhood.
So how to fix what appears to be broken?
Dr. Benoit Mulsant, co-author of the study and Physician-in-Chief at CAMH notes that the research "raises questions about psychiatrists' scope of practice, their practice patterns, and the reimbursement system." Addressing these issues may improve the mental health care system for all, he adds.
Dr. Kurdyak says that psychiatrists might look at various factors such as putting in accountability mechanisms in their practice to make sure that new patients can be seen in time. Results of their study also may re-open the debate about fee schedule. In Ontario, for example, the fee schedule does not have limits on duration or frequency of visits. Changing that may be one way of opening up room for psychiatrists to see more patients. Dr. Kurdyak suggests that modifying the fee schedule to "incentivize" psychiatrists could ensure that those patients who have an acute need may be seen more quickly. Simpler solutions include making better use of tele-psychiatry and making it easier for patients to travel distances for access of care.
Another idea, adopted in Australia, the U.K and the U.S. includes shifting the psychiatrist's role to that of a consultant on a multidisciplinary team. In such a model, psychiatrists provide the initial diagnosis, oversee any pharmaceutical treatment, and work with a team of social workers and psychologists to provide psychotherapy, support and to monitor progress.
With results of the study indicating a mismatch between supply and population need, the time seems ripe for addressing the issue of universal access, says Dr. Kurdyak. "We are talking about mental illness more than ever before. But we talk less about how the mental health system is structured in terms of access. We have a very well organized system for access when it comes to cancer or cardiovascular care. But there's no such capacity in the area of mental health."
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