Why is the wait so long to see a psychiatrist?

QUESTION: My brother suffers from depression. His doctor says he will have to wait six to nine months to see a psychiatrist. That’s an awfully long wait. He needs help now. But the thing that really bothers me is all the recent media campaigns to raise public awareness about mental illness. What’s the point of drawing attention to this illness if you can’t treat the existing patients within a reasonable time?

ANSWER: You make a very important point – and your brother is certainly not alone in his plight. Many patients suffering from various forms of mental illness have to wait many months before they can see a health-care professional trained to treat their particular condition. Only one in five Canadians with depression get appropriate treatment, according to some estimates.

Provincial governments have adopted various measures to speed up patient access to mental-health services.

In Ontario, for instance, the number of doctors being trained in psychiatry was boosted by 80 per cent between 2003 and 2013, says David Jensen, a spokesperson for the Ministry of Health and Long-Term Care. The province is also increasingly relying on “tele-psychiatry” –counselling and care through computer-based video conferencing – to reach patients in remote and under-served communities.

However, an intriguing study published last year in the journal Open Medicine, indicates that simply increasing the supply of psychiatrists doesn’t necessarily improve access to treatment.

The major problem appears to be the way psychiatrists choose to run their practices and not a shortage in their numbers.

The researchers used Ontario data to look at the regional distribution of psychiatrists, how many patients they treated, and how often.

The study revealed a very high concentration of psychiatrists in a few urban communities, particularly in parts of Toronto and Ottawa.

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.

Psychiatrists practicing in Toronto saw an average of 181 patients (including 105 new patients) over the course of a year. In low-supply regions, the local psychiatrists treated an average of 431 patients (which included 233 new patients) over the same time period.

When you drill further down into the numbers, you discover greater extremes. About 10 per cent of psychiatrists working full-time in Toronto saw only 40 patients a year. And 40 per cent of the Toronto psychiatrists treated fewer than 100.

The study helps to explain why patients in well-supplied areas seem to have just as much difficulty booking a first-time appointment with a psychiatrist as those living in regions with relatively few of these doctors, says Dr. Kurdyak, who is head of mental health and addiction research at the Institute for Clinical Evaluative Sciences.

“If you produce more psychiatrists and most of them end up practicing in Toronto, that is a problem in and of itself,” says Dr. Kurdyak. But it’s made worse when they “tend to see the same patients, one or more times per week, for many years.”

So, you can have full-time psychiatrists treating a fraction of the patient load carried by their peers. Overall, he adds, specialists who see relatively few patients have “an insignificant impact on the broader ocean of need out there.”

Ontario is not the only province struggling with limited patient access to psychiatrists in well-supplied urban areas.

A study published in 2011 in the Canadian Journal of Psychiatry revealed that just a small percentage of Vancouver psychiatrists were willing to accept new patients.  For the study, which was led by Dr. Elliot Goldner, the researchers contacted the offices of 230 Vancouver psychiatrists to see how many would take a patient referral from a family physician. Only six psychiatrists immediately agreed to see a new patient and provided a specific date for an appointment.

Dr. Kurdyak says family doctors are going to “give up” on psychiatrists if they have to contact dozens of offices in order to find treatment for a single patient. “This is not a feasible way of working.”

He 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.”

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 notes that Ontario’s Ministry of Health has tried to entice psychiatrists into seeing more new patients by ‘sweetening’ some fees. Back in 2011, the Ministry introduced a 15 per cent bonus for appointments with patients who had recently attempted suicide or were just discharged from hospital following a psychiatric illness. “Obviously after a suicide attempt and post [hospital] discharge is a very acute period of time when you need access to specialty care.”

But Dr. Kurdyak doubts that a 15 per cent bonus would be enough to override the attraction for psychiatrists “to see who they like, for how long they like, and to have total control over their patient population.”

So, how do you make sure that patients have timely access to mental-health treatments? And why are some psychiatrists willing to see more patients than others?

Unfortunately, the answers to these two critical questions can’t be gleaned from Dr. Kurdyak’s latest study. His findings are based on an analysis of statistics – not interviews with the doctors involved.  What’s needed now is a series of focus groups to determine what motivates them to practice in a certain way.

Dr. Kurdyak would like to do a follow-up study along those lines. He already has some theories about what’s influencing the psychiatrists to either take on more patients or turn them away.  In particular, he thinks that psychiatrists who locate in under-served regions may feel the need to affiliate themselves with community mental-health agencies, hospitals or local family-health teams.

“The psychiatrists working in these areas are actually rubbing shoulders with their colleagues who desperately need their services,” speculates Dr. Kurdyak.  So, when they get a request to see a new patient, they may feel compelled to adjust their schedules to meet the demand, he adds.  That could mean seeing some of their existing patients less frequently in order to squeeze in new patients.

By contrast, a psychiatrist working in a solo practice in downtown Toronto “may not feel the same pressure” to make room for a referral that comes from out of the blue.

If further research shows that Dr. Kurdyak’s hunch is correct, it may point to ways of making sure that patients who are in urgent need of psychiatric care get help sooner rather than later. For instance, he says, all psychiatrists could be required, or mandated, to establish formal links with other health-care providers. In other words, a psychiatrist who once worked alone would become part of a multi-disciplinary team.

“An affiliation [with other health professionals] would create a level of accountability that wouldn’t necessarily exist if you just hung up your shingle and worked in isolation,” Dr. Kurdyak says. He thinks those connections would make it hard to say no to referrals.

It’s also worth mentioning that in other countries, such as the United States, Britain and Australia, psychiatrists perform somewhat different roles than they do in Canada. In those countries, they primarily diagnose the patients and make treatment recommendations. Or, they focus on prescribing psychiatric drugs. Other health-care professionals, such as psychologists and social workers, provide psychotherapy and additional support, says Dr. Kurdyak.

If the Canadian health-care system was organized in a similar fashion, we might not be facing such a bottleneck in the delivery of mental-health services.

Change, of course, tends to come slowly to healthcare.  In the meantime, your brother’s options are admittedly limited. But one thing he could do is seek the help of his family physician, until a psychiatrist can see him on a more regular basis.

And hopefully, the point you raised about the long wait-time faced by your brother and other patients like him will help stir the public debate. As Dr. Kurdyak puts it: “People should be really annoyed about the poor access to mental health services. This kind of system performance wouldn’t be tolerated for cancer or cardiovascular care, and is not fair to people who suffer from mental illnesses.”