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There needs to be more access to counsellors, psychologists, and other therapists, particularly for patients who do not have the financial means. They provide essential services that the medical system (i.e., family doctors and psychiatrists) cannot offer. Full coverage is a bigger issue, but there are areas we can target now.

Expanding DBT

In particular, focused investment to improve access to dialectical behaviour therapy (DBT) groups would be invaluable. In DBT groups, patients typically attend weekly two-hour sessions for around 26 weeks and learn a wide variety of distress tolerance skills.

These skills help prevent stressors from escalating to the point they result in a crisis presentation to PES. DBT is the most effective treatment for many personality disorders (unfortunately named and oft-stigmatized). The ER or PES may defuse an acute crisis but is the wrong place to treat the underlying problem.

In Victoria, affordable DBT is scarce, usually only available through a group at USTAT. However, with limited capacity and wait times that have escalated from weeks to many months, that’s no longer a viable option for the majority of people who would benefit.

Making it Happen

Expanding DBT groups would require funding for several therapists. Each full-time therapist hired could handle several DBT groups in parallel. While this would divert resources from individual private-pay therapy available in the community, it would provide a much-needed treatment option and keep many people out of PES. Much more could be offered, but it’s a start.

Ideally, access to DBT groups would be similar to BCalm or CBT Skills groups (both run primarily by family doctors, not mental health), needing only a doctor’s referral. Both of these provide a great service accessible to many. Neither require dedicated funding, but are facilitated by doctors who bill group medical visits through MSP. However, that wouldn’t work for DBT, which would require hiring specifically-trained therapists; very few doctors have that training and are in very short supply as it is.

As with the above groups, expanded access to DBT groups doesn’t have to happen through VIHA. Issue an RFP and let private counsellors or counselling groups provide this service.

Related: see all Victoria posts here

Access to outpatient treatment is one of several intertwined mental health crises in Victoria. We can fix it if we make it a priority. Ownership must be assigned. Gaps between silos called out and eliminated. It demands public metrics and accountability. Better access to therapists and psychiatrists won’t happen otherwise.

I’ve previously described the impact that woeful access to mental health care in Victoria is having. Patients can’t access essential care, and family doctors on the front lines are stuck. The impact is spilling over to the emergency room.

There are concrete, incremental, and realistic steps we can take to improve access. We can make progress without relying only on pie-in-the-sky “let’s remake the system in one fell swoop” or “cover all therapy through MSP” long shots. But these cannot succeed without clear ownership and accountability.

Access is Nobody’s Problem

Access to essential mental health treatment in Victoria is a problem. And nobody owns that problem. We can’t fix it until that changes.

To the best of my knowledge, nobody has clear responsibility for ensuring an adequate number of psychiatrists and other mental health resources are available in Victoria. Or at least, that’s not an essential component of anyone’s job performance. I don’t mean just in VIHA or a particular service like USTAT or mood disorders, but overall. I hope I’m wrong; please correct me if so!

I don’t mean accountability or responsibility in a punitive or backward-looking sense. Criticism and identifying flaws have their place. And witch hunts may be cathartic, but they can’t be the entire answer. Assigning ownership should be a positive step towards solving problems.

As a specific example, nobody is responsible for ensuring we have enough psychiatrists in community practices, which generally fall outside health authority concerns. It becomes a system-wide issue when health authorities choose to exclude large classes of patients and expect “the community” (i.e., maybe a dozen psychiatrists) to pick up the slack, as happened at VMHC a few years ago.

Such decisions aren’t malicious. Someone decides “we’ll prioritize X.” Implicitly, that means “we won’t prioritize Y,” or less charitably, “Y is not our problem.” The latter statement is often unsaid (at least in public) or not kicked back up the ladder to properly review. We celebrate “X.” We don’t ask: “What are the consequences of not doing Y? Should Y be prioritized higher? If you’re not doing Y, who is?” It’s not visible, so it slips through the cracks. (In this case, “Y” has become “patients who need psychiatric care but haven’t required extended inpatient hospitalization.”)

Expectations and Disclosure

Expecting a 100% solution any time soon is not realistic. Just pinning failure on someone or creating a scapegoat isn’t helpful.

Real ownership requires responsibility and resources. Accountability means reporting on efforts and progress. Equally, it requires reporting on why things have fallen short. What stands in the way of solutions? Are there alternatives? What needed resources aren’t available? Where could we find them?

Honesty and a solution-focused orientation must take priority over providing political cover for those higher up the food chain.

Measure and Report

Let’s start by recognizing the management truism that you can’t improve what you don’t measure. Metrics need to be frequently updated, reviewed, and public. Think report cards.

Some possible metrics to start with:

• number of psychiatrists (or FTE’s) and where they work
• psychiatry referral statistics (e.g., how many received, accepted/rejected, wait times for each service)
• level of care provided (e.g., single consult vs. ongoing care, frequency seen)
• affordable counselling and therapy groups (e.g., number of referrals, number served, wait times)
• outcomes (e.g., re-referrals, crisis line usage, PES presentations, hospital admissions, other service utilization)

Some of these may need substantial effort and new resources to collect. They need to encompass all services, not just within VIHA.

We generally do a poor job of measuring and reporting on health care performance in Canada. Wait times are a good example; ridiculously few are published. The overall culture leans towards not wanting to highlight news that might reflect poorly. For change to happen, that’s not good enough.

A Starting Point

In future posts, I’ll be suggesting several concrete steps we can take to improve access. Ownership, accountability, and good metrics are necessary for any such efforts to succeed.

I also believe that ownership, accountability, and metrics for both access and quality are necessary to address PES concerns. Without baking these into the system, the temptation is to treat the current situation as a short-term PR crisis. Without structural improvements, any fixes will be temporary. While it’s beyond the scope of what I can usefully comment on, I hope others will take up this call.

Related: see all Victoria posts here

A survey of family doctors in Victoria highlights the challenges they face in providing mental health care to their patients. Hampered by poor access to treatment from psychiatrists or therapists, they’re overrun by the ever-increasing demand for essential care.

Background

Victoria, like many other places in Canada, faces several intertwined mental health crises. The pandemic is exacerbating them all. We’re acutely aware of the opioid crisis and the homelessness crisis (often driven by severe mental illness and substance abuse). Recently, two young women spearheaded a Facebook Group to draw attention to concerns with Victoria’s Psychiatric Emergency Services (PES).

Access to mental health treatment is a fourth crisis. As I’ve said elsewhere, access issues compound the problems at PES. Too few people can access treatment earlier and in more appropriate settings. Far too many people end up in PES that never should have. But there are no options.

Family doctors are at the front lines of mental health care in the medical system. They’re frequently the first and often only care provider patients see. But they need the support of a robust mental health system behind them. How do they think that system is functioning?

What do family doctors think of the mental health system?

This week, Pauline and I put out an informal survey of family docs in Victoria. Most of them are referral sources for her private psychiatric practice. We feel their voice is crucial to hear.

We’re still collecting answers. But of the first ~30 responses we’ve received so far, some themes are emerging. Keep in mind, this is not a rigorous or quantitative analysis, and respondents are self-selecting.

Here’s a snapshot showing the percentage of respondents who chose each answer:

Bottom line: we’re not doing great

We first asked if the overall healthcare system meets their patients’ mental health care needs. So far, the vast majority strongly disagreed that it does. The remaining handful only disagreed. Some specific comments:

There is a crisis in mental health access in Victoria that has been worsening over the past 10 years.

Main issue is lack of resources for mental health and substance use.

Access to psychiatry is severely constrained

All respondents reported difficulty getting their patients seen by psychiatrists at all. Referrals were often rejected outright, or waiting lists were too long.

This was true both for psychiatrists through Island Health and elsewhere. Most outpatient psychiatrists in Victoria work through a handful of clinics run by Island Health. There are about a dozen in private practice.

No psychiatrists accepting referrals.

No psychiatry outpatient options.

I have essentially stopped trying to refer to community psychiatrists due to the extremely low number of available physicians. I see this, and lack of coverage for counselling, as the two largest barriers.

Even access to treatment for urgent situations (but not an emergency or crisis) has stretched to unacceptable levels. In the past, this was a matter of weeks. Family doctors noted:

Getting psychiatry consults in a timely manner when people are in crisis is very difficult (rarely happens). This places a huge burden on family doctors.

It is up to 18 months wait to see a psychiatrist (USTAT)!

Psychiatric treatment is virtually nonexistent

One particular trouble spot was that when psychiatry sees patients, it is nearly always for a one-off consultation. Actual treatment through psychiatry is frequently not available except for the very sickest patients.

It has been extremely difficult to arrange psychiatric referrals, and if accepted for assessment it is often only a one-time consultation.

Often complex patients – bipolar etc. – seen once for a consult and sent back to GP to start meds/manage. This is too complex for us.

When psychiatry is able to see a patient, it is usually just a one-time consult… followup would be very helpful as multiple medication trials or adjunct treatment are often needed to treat significant anxiety/depression.

Biggest issue is wait times and lack of followup for people with chronic mental health issues. Every time they get worse, they start over with a new care provider. Unless acutely ill, will only get one-time consult and no followup. Many people would benefit from ability to go back to same psychiatrist when ill.

In one-off consultations, psychiatrists see patients for a single visit (typically 45-60min). They then send treatment recommendations to the family doctor. Given the broad scope of topics that need to be covered, it’s tough to get through everything in that time. Interviews are tightly circumscribed. Patients must give brief, specific, and rapid answers to often profoundly personal questions in front of someone they’ve just met, with few opportunities to elaborate.

It’s hard to get an accurate picture of anyone in that single visit. Most psychiatrists who continue working with patients find their understanding improves over future sessions after gathering more information and as patient trust and rapport deepens.

Access to therapy is not much better

Nearly all survey respondents noted that a lack of accessible and affordable counsellors, psychologists, and other therapists was a major issue. Unlike doctors, fees for therapists are mostly not covered by public health insurance (MSP).

Victoria is blessed with many talented therapists. No doubt, our generally well-off populace and abundance of government jobs with excellent extended health benefits helps. Even still, increased demand from the pandemic is testing that capacity.

That still leaves many, many people without the financial resources to access this essential form of mental health treatment. There are very few no-fee or low-fee options available, and wait times can stretch several months or longer.

Lack of available counselling is the worst.

One bright spot mentioned by several family doctors was group therapy available via BCalm and the CBT Skills Group. These groups are organized and facilitated primarily by family doctors. Because they are treated as group medical visits (paid by MSP, not special funding), they require minimal or no fees from participants.

CBT skills group is a god-send!

Too Acute Patients, Too Little Time

For family doctors providing mental health care to patients themselves, two mutually reinforcing problems recur. The first is that they have to manage increasingly complex and acute problems in the primary care setting (because psychiatrists aren’t providing treatment). But that runs up against the nature of family practice – too many problems to squeeze into too short appointments.

Often takes so much time just to calm people down initially, it’s difficult to come up with a treatment course.

I spend way too long (regularly > 30min) to try to help… if a cardiac patient was as sick as my psychiatry patients they would be followed by cardiology!!

Other factors

Doctors raised a smattering of other factors. Many noted that demand for mental health care (especially anxiety) has increased due to COVID-19. Financial disincentives for GP’s providing mental health care were frequently mentioned. Certain other areas, e.g., treatment for adult ADHD, also came up. Patients having poor experiences in PES was also mentioned. This list will be expanded as we collect additional survey responses.

Family doctors are stuck

All this leaves family doctors in an untenable position:

• they have an ever-increasing number of people seeking mental health care
• they are unable to access psychiatrists or therapists to assess and treat their patients
• that leaves them stuck managing patients who are too acute or complex to treat in a primary care setting
• people are coming to appointments with too many problems, all of which are time-consuming
• family doctors are unable to provide longer appointments which would be needed to make headway

Family physicians can often manage patients who respond adequately. It is the complex patients or severe patients who need treatment urgently who cannot be seen.

Fallout

The family doctors who responded to our survey are clearly frustrated. They can’t provide the mental health care they’d like to without better support. Unfortunately, access to needed psychiatrists and therapists is at crisis levels in Victoria.

Patients are suffering as a result. They’re not getting the help they need. Illnesses that could be treated early instead worsen over time until emergency services are required. But that’s just the tip of the iceberg.

This survey isn’t telling us anything we haven’t all known for a long time. But at least on the ground, the problem feels to me like it’s accelerating. If we continue on this course, I’m worried about how the future will look.

Related: see all Victoria posts here

Context: There’s been some public awareness recently of criticisms of care received at Victoria’s Psychiatric Emergency Services (PES) at the Royal Jubilee Hospital (RJH), run by the local health authority, Island Health (VIHA). All thanks to a Facebook Group spearheaded by two brave and strong young women.

As far as my involvement: my wife is a psychiatrist in Victoria, not at VIHA (she did work at other VIHA sites for a year when we first moved here six years ago and did call at PES). I help run the front office of her private practice. We know many psychiatrists and other staff at PES/RJH and work with them whenever our patients need care in the hospital. And we hear from lots of patients. And incidentally, no, my wife’s been too busy taking care of patients and didn’t help write this post.

Without commenting on the horrific stories that have been exposed, they’re indicative of a bigger problem: not a few bad apples, depraved indifference, specific policy decisions, or underfunding.

And not to minimize former patients’ experiences, but few PES staff are having an easy time of it either (predating the recent attention). It’s not a clear good-guy, bad-guy situation.

PES should be like the proverbial canary in the coal mine. It’s an early indication of breakage in the overall system, a warning to act before things get worse. But dead canaries don’t help if nobody is paying attention. And these birds have been piling up for years.

What’s the root of the problem?

PES is being pushed well beyond its mandate of providing emergency psychiatric services.

In a functioning system, people could access high-quality care early on. In many cases, early treatment would prevent most problems from spiraling into emergencies. When it’s not an emergency, people should be referred to places to access more appropriate treatment.

In Victoria, those places for non-emergency treatment are scarce and wholly inadequate. There’s nowhere to direct people for early care. So far too many people end up in PES because there’s nowhere else to go. And once they’re there, if it’s not an emergency, there’s nowhere they can be referred to get the care they need. There’s nothing right “underneath” PES that people can access quickly for urgent but not emergency care.

This isn’t unique to psychiatry. People with no access to family docs, who are turned away from walk-in clinics or urgent care clinics for physical health problems, end up at the regular ER. They’re sent home with instructions to access follow-up that often isn’t there.

Getting help before it’s an emergency

We’ve published tips for finding a psychiatrist in Victoria, but the story is pretty grim. Waits at the VIHA urgent short-term clinic (USTAT) are long. The largest VIHA outpatient clinic, VMHC, has effectively stopped taking almost all new referrals (over capacity). There are only about a dozen or so non-VIHA psychiatrists in the community. Waits are insane if you can get accepted onto a waiting list at all.

We get multiple cold calls a day from people desperate to access a psychiatrist. Many people don’t have family docs or don’t have family docs that are willing/able to address most mental health issues. Those family docs have nowhere to refer their patients. If a psychologist or counsellor won’t suffice or isn’t accessible, most people are out of luck. With nowhere to turn early on, people get worse and end up at PES… because there’s nowhere else to go.

PES has become a “choke point” for the whole system. What should be a place for emergencies gets overloaded because the entire infrastructure that should exist right below it to provide support isn’t there.

Should we be surprised when things turn out the way they have been?

Related: see all Victoria posts here

Antipsychiatry is hard to avoid when seeking mental health help, online and elsewhere. Several years ago, I’d written a detailed critique of Dr. Bonnie Burstow’s Psychiatry and the Business of Madness. This popular tome was intended to provide a rigorous underpinning and academic gravitas to boost antipsychiatry’s credibility. Spoiler alert: I was far from convinced, and found it seriously flawed.

I’ve migrated my review/critique to this site; it can now be found as a series of posts titled Deconstructing Antipsychiatry.

Here in Canada, as elsewhere, there’s suddenly a lot of new programs for “mental health” being announced. Typically, these are online mindfulness or CBT courses, lists of ways to relax, calming mantras, or something similar.

These programs are helpful to some, particularly those experiencing a normal, human level of anxiety in these unusual circumstances. They’re not helpful for everyone. As we’ve said numerous times, mental health (and mental illness) is not a one-size-fits-all problem, and no one solution will solve it.

It’s not surprising that those with existing mental illness who are finding things more difficult now (which is to be expected) are often having more difficulty accessing care they need. Many clinics and mental health offices are closed, or running more focused and stripped-down care. That’s a problem, but not what I want to talk about.

How do you find the right help?

What’s missing, now more than ever, is a way for people to find the specific care they need. You’re told that if you need mental health help, check out this online (mindfulness, CBT, etc.) program. As Henry Ford would have said, “you can choose any color you’d like, as long as it’s black.”

What do you do if that program isn’t right for you? Or you try it and it doesn’t work?

There aren’t many answers in all the funding and announcements.

In fact, given the insidious nature of mental illness, your brain is more likely to turn to thoughts like:

I failed the program that was supposed to fix my mental health. I must be stupid. I’m doomed.

We can do better

We need to acknowledge that one size does not fit everyone. We still need to help people find the care they need. Now we’re relying on them to do that on their own. Those most capable of doing that are those most likely to fit those simple programs anyway. Those who need the help are on their own.

Now more than ever, people need help with navigating their mental health care.

As resources aren’t likely forthcoming, people are left on their own. That’s one of the big reasons we wrote Your Mental Health Repair Manual. It guides you through the process of navigating your mental health care, on their own, or with the support of friends and family.

It’s no substitute for professionals who can help direct you to the help you need, and make sure it works. But it will help you keep moving forward in the right direction.

People need this sort of guidance now more than ever.

We’re thrilled to announce the official release of Your Mental Health Repair Manual!

Check out the release announcement. (PDF)

The book is set to launch on Monday, and still way behind on things we wanted to get done ahead of time!

As the previous tongue-in-cheek Christmas ‘ad’ went over well, here’s another… share and enjoy.

Only one week to go until Your Mental Health Repair Manual is officially released!

We’ve finalized the text, uploaded it to our various distributors (Amazon, Draft2Digital, and Ingram), and have a bulk order in with a local printer. Working now on website updates, as well as various launch-date announcements.

Exciting (and very busy) times!

Incidentally, the ‘ad’ above is very tongue-in-cheek, initially inspired by the always-too-early Christmas marketing blitz you see everywhere before or at Hallowe’en and Remembrance Day. Several people got a kick out of it, so sharing it here. Please feel free to pass along or post on social media!

What do we do when we’re not working on finishing up our book? Yes of course, check out other books! Both of us had an opportunity to examine this new book from Dr. Diane McIntosh. Our review(s) follow.

This Is Depression: A Comprehensive, Compassionate Guide for Anyone Who Wants to Understand Depression by Diane McIntosh
My rating: 5 of 5 stars

Mark’s thoughts…

An empathetic and optimistic hands-on tour through the world of depression.

Book titles can be obscure and misleading… not this one! Dr. McIntosh’s book fully delivers on its promise, giving patients and others most everything they need to know about depression. Definitely comprehensive, she covers a wide range of subjects: what depression is, what it looks like in all its diversity, how it’s diagnosed, what causes it, how to talk to people about it, where to find help, myths, and information on a broad range of treatments. The book covers talk therapy, supplements, electroconvulsive therapy, exercise and many others (kale enemas, incidentally, are not recommended). She extensively covers the confusing and misunderstood universe of medications. She tackles the real questions people have about how they work, what to expect, how to deal with side effects, and more.

The other keyword in the subtitle is “compassionate,” and this is the real strength of the book. It’s refreshingly positive, hopeful, and, most of all, human. Her explanations, intermixed with patient vignettes, treat the reader with respect and serve to empower. They normalize what can be a frightening and lonely illness for many people. Readers will also find actionable advice throughout the book. This includes specific recommendations and suggestions around where to go to find help, how to approach appointments, and talk to others, whether caregivers, family and friends, or someone that you’re concerned about. It’s clear that nurturing informed and fully engaged patients is her mission, unlike some doctors who are threatened or intolerant when patients step up.

While well-referenced, this is far from a dry and monolithic academic text. The writing is very accessible. It’s broken up into small sections and chapters, which makes it very easy to follow. Readers can skim through topics of less interest and take a deeper dive into others (budding genetics and neuroscience geeks will rejoice!). I especially like the extensive glossary. It helps not only when encountering an unfamiliar term in the text, but also helps when deciphering jargon from doctors or others. Items in the glossary are bold-faced throughout the book, which again makes it easier to skim through.

This is a very practical book, delving into medical evidence and standards when they’re useful, but not being constrained by their limits. She’s not shy about offering real-world advice based on her experiences with patients, which mostly works. At times though, it’s a challenge. There are great benefits in sharing what too rarely ends up written down, but some risks of over-generalizing with such diversity in patients and illnesses. For example, when briefly describing specific medications, she suggests “other SSRI options are better.” This may be a bit heavyweight and could shut down rather than open up a conversation with a prescriber. Limited space makes this difficult to pull off perfectly, though appropriate caveats are usually close by.

‘This is Depression’ covers a lot of ground in an approachable and relevant way. Anyone hoping to gain a better understanding of this illness and how to recover from it will benefit. Dr. McIntosh has done a superb job bundling everything together in one comprehensive, compassionate package.

Pauline’s thoughts…

A great resource for patients and families

So far, I’ve only had a chance to briefly flip through it, but I’m excited to have a book like this to recommend to my patients and their families. Like Diane, patients in my own psychiatry practice are always looking for more information about their illness. Too often, they end up finding a few things here, a few things there, not all of it reliable or easy to digest. She’s put together a great collection of solid and easy to read information on a very diverse range of topics. Most importantly, patients will be able to find answers to nearly all their questions in one place. I like that she doesn’t shy away from specific biological details for the many patients who are eager to learn more. I’m looking forward to going through this in more detail, and I’m sure will learn a few new things myself.

View all my reviews