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The Complexity of Closing Gaps in Canada's Mental Health Care System

Earlier this week, Marvin Ross reached out to the Canadian Psychological Association (CPA) for a piece that he was writing for HuffPost about the significant needs and gaps when it comes to "serious mental illness" in Canada. The issues and needs when it comes to Canada's mental health and illness are complex, however, and we wanted to make an opportunity to share our perspective first hand.

Earlier this week, Marvin Ross reached out to the Canadian Psychological Association (CPA) for a piece that he was writing for HuffPost about the significant needs and gaps when it comes to "serious mental illness" in Canada. It was an eight-year-old report written by CPA that provided the impetus for Mr. Ross' post this week and he reached out to us to give us an opportunity to respond to his take on it.

We thank him for this and acknowledge that our response to him was indeed a lengthy five pages and, understandably, not nearly all of its content could be included in his post. The issues and needs when it comes to Canada's mental health and illness are complex, however, and we wanted to make an opportunity to share our perspective first hand.

By way of background, CPA is a professional, not-for-profit association with a mandate to promote the education, research and practice of psychologists and, equally, to contribute to the well-being and welfare of the Canadian public. We do this on behalf of our psychologist members but also with partners and stakeholders in health which include other health professionals, funders and agencies that deliver health service, government, and persons living with illness.

As Mr. Ross mentions, we entirely agree with him that the Mental Health Commission of Canada (MHCC) has had a tall order from its inception. We have long made the point that just as there is a diversity of physical illnesses, there is a diversity of mental illnesses each with varying determinants and each responding to a range of treatments, services and supports. Add to this the fact that the MHCC has no authority to implement the changes to the health systems or workplaces that its strategies recommend and the order gets taller still.

However, CPA also believes that despite the MHCC's ambitious mandate, it has accomplished much. Its many projects, task forces and committees have helped get mental health on many public and private sector agendas, moved public discussion and chipped away at the stigma that has long surrounded anything to do with mental health and mental illness.

The MHCC has not been a quick fix or even a single fix -- and that is the important point. When it comes to mental illness, the same can be said about any other piece of policy, treatment or service, or health profession. The needs and issues when it comes to Canada's mental health and mental illness are complex. Mental illnesses are caused by many factors, are made better or worse by many factors and depend on the collaboration of many people, treatments, services and supports.

The point CPA has been trying to advance in public discussion is that delivering the range of services and supports that combine to work best for particular mental health problems and disorders is challenging indeed for a public health system that is essentially a medical system -- a system that pays designated health care providers (mainly physicians) to deliver designated services (mainly medical ones), in designated venues (mainly hospitals and physicians' offices).

Wait lists for publicly-funded services are long and most often offered in costly tertiary care facilities like hospitals. Because of funding cuts within public facilities, licensed mental health care providers like psychologists are increasingly working in the private sector where their services are not covered by public health insurance plans. For Canadians without financial means or private, extended health insurance, these services are out of reach.

Research shows clearly that when it comes to mental disorders, psychological treatments work. Sometimes they are adjuncts to treatment but sometimes they are the most effective treatment, in and of themselves. Psychological treatments, like cognitive-behavioural therapy, are first line, cost- and clinically- effective interventions, particularly for the most common of mental disorders like anxiety and depression.

Psychological treatments work well for severe and mild cases of depression. They work as well as medication in treating depression and better than medication in preventing relapse. Relapse rates following treatment of depression with CBT are half those when depression is treated with medication alone.

When psychological treatments are used with medication for bipolar disorder, patients tend to better follow through on treatment, feel less burdened by their illness and have lower suicide rates. Psychological treatments work better than medication in treating many kinds of anxiety. In addition, psychological treatments reduce depression and anxiety in people with heart disease which, when combined with medical treatment, leads to lower rates of heart-related deaths. There is also research that points to the effectiveness of psychological therapies, like cognitive therapies, when included in the services and supports for persons living with schizophrenia -- particularly when it comes to preventing relapse.

While psychologists are by no means the only group of licensed, health care providers who specialize in the area of mental health and illness, they are the largest one -- outnumbering psychiatrists almost 4:1. They have training and treatments that work. It is unfortunate for the more than half of people who need but don't receive mental health treatment in Canada that these services are not more accessible.

By calling on private and public health insurance plans to provide better coverage for mental health services, psychologists are not suggesting that medical services or treatments are not also necessary, nor are we saying that psychologists have the single solution to all the mental health problems and disorders that Canadians face. We are saying that we can and do help and we want to see this help better reach people who need it.

Mr. Ross suggests that when psychologists call for better access to their services it is self-serving. It could equally be considered informed when a profession speaks out about the needs and issues it faces. Psychologists are already successfully self-employed -- people want effective mental health help, even if it means paying out of pocket for it. What psychologists don't want is to have to turn people away from treatment because they have no means of paying for it. Many Canadians sit for months and more, waiting for mental health help within our publicly-funded institutions. This is not because publicly-funded institutions are the only place where they can find effective help, but because it is the only place where help is funded.

CPA has long also made the point that we have a responsibility to address the range of mental illnesses that Canadians face, particularly those that are the most common -- depression and anxiety. Psychological factors and psychological health are also important to the development and management of other more commonly understood physical illnesses and chronic conditions, such as recent research on the impact of depression on heart disease.

CPA's concern about these kinds of disorders and factors does not mean that we are not concerned about investing in the needed services and supports for those living with illnesses such as schizophrenia. It means only that we want to be sure that the range of needs when it comes to Canada's mental health and mental illness are acknowledged and addressed.

Schizophrenia is clearly a mental illness that is severe, persistent, typically managed rather than cured, and takes a great toll on individuals and families. The same can be true of many depressions, anxiety disorders, developmental disorders and dementias. People with these kinds of disorders, the people who come to psychologists for help, are not the worried well. They are people with significant problems for which effective treatment exists but which can be out of reach as an insured health service.

Canada does have a two tiered system when it comes to mental health. While we would like to see better publicly-funded coverage of services and supports for mental illness in Canada, the reality is that the services of a great range of licensed health providers working in communities are largely not publicly funded -- psychologists, social workers, and occupational therapists among them.

The services of psychologists are either paid out of pocket by Canadians or reimbursed to some extent by private, extended health insurance plans typically offered through employment. CPA is committed to seeing this coverage enhanced so that a clinically meaningful amount of effective psychological care is covered through extended health insurance plans. We were very glad to learn that the federal government had decided to double the coverage for psychological services available to their employees as of October 2014 Given the need for these services and the cost of untreated disorders on individuals, families, the workplace and the economy, we would like to see other employers and private insurers take similar steps.

There is lots of evidence that when it comes to severe and persistent health conditions, effective services and supports are about management and about the collaboration of a team of health providers and caregivers. Psychologists have a lot to offer health care teams and CPA wants to support their contributions. This is more challenging to do when the work of psychologists often takes place outside of the publicly-funded health care system.

The needs of Canadians when it comes to their mental health are significant. Psychologists help to address these needs through research into the causes of mental health and mental illness as well as into the effectiveness of interventions used to treat mental illness.

They also help through professional practice -- working collaboratively with people who come to them for care and using evidence-based psychological interventions and treatments. When it comes to mental illness, or to many kinds of illness for that matter, effective treatment requires collaboration, as well as a combination of services and supports. Collaboration means different kinds of health providers working together with patients and families to help people recover from or manage illness. CPA is committed to that collaboration and to the innovations in health care delivery that can support people getting care that works.


The Toll Of Mental Illness In Canada
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