Enough to Drive You Crazy

IStock_000007658798SmallToday is Bell Let's Talk day, an annual mental health awareness fundraiser.

We've got lots of people speaking out about mental illness, and preaching the message that it's okay to talk about, to get over the stigma surrounding it. It's a real problem that causes too many people to suffer needlessly. Luckily, attitudes seem to be changing, at least among younger people.

The Governor General and his wife gave an interview yesterday encouraging people to talk about it and ask for help. But what happens then?

The string of military suicides and the issues they have exposed has brought questions about the mental health system back into the public awareness, exposing many of the shortcomings. Let's talk about that.

In fact, let's talk about what many peoples' experience is dealing with the mental health system.

For some people, things work out okay. I've long dealt with dysthymia and the occasional bout of MDD. Given awareness of symptoms, family history, etc. it was something that has been on my radar screen for a long time. Exercise helped keep things in check for a long time. When an hour a day, seven days a week wasn't enough to keep things in check, my family doctor (who had been in on the loop) and I agreed it was time to add an antidepressant. That was over ten years ago, and to this day an exercise routine and a combination of antidepressants is still more-or-less good enough to keep me functional.

Of course, this scenario presupposes people are aware of their symptoms, willing to talk about them, have a family doctor (hardly a sure thing), have a good family doctor (also not a sure thing), and have one that is both knowledgeable and comfortable dealing with mental health issues.

Frighteningly, there are many doctors who don't want to deal with mental health in their practice, and it's far from unusual for them to further stigmatize their patients. You really don't want to hear "just snap out of it" or "go to church more" from a physician when coming in with serious mental health issues, but that's the reality many people face. Not exactly the gateway to the system you want to see, especially if you don't have the knowledge to understand how full of crap that is.

But, for most people if they can get in and talk to their family doctor, and their family doctor is receptive, they'll get put on an antidepressant. Usually without enough counselling about how it works, side effects, what to watch for, etc. And sure, there may be lots of other things going on, but in your average hurried medical appointment these days, what else are they going to have time to do? With the patient load they have to carry, there just isn't enough time for most family doctors to do much more.

If you get referred to a psychiatrist, good luck on that front. Waiting lists are very long, because there aren't nearly enough psychiatrists available either. When you do get in, you have no idea how long they'll spend with you, if they'll actually listen, or if they'll just adjust your psychotropics and send you on your way.

Why is that? Because every psychiatric practice is different, every psychiatrist has different areas of interest, and different treatments they offer. Most people don't know that. You're counting on your family doctor referring you to an appropriate psychiatrist for your problem, which isn't always the case. How long you wait, how long you're seen, if you're seen only once or for ongoing treatment, and what the psychiatrist looks at also depends heavily on how the family doctor writes up the referral. Good luck if you have a family doctor who just doesn't want to deal with any mental health issue. Most people don't know that either.

If you've dealing with mental health issues with your underage children, all the above applies, except it's ten times worse, because there's an even greater shortage of child psychiatrists, and most of them are even more sub-specialized.

Think psychotherapy might be the answer? Not an insurmountable problem if you have money or private insurance that will cover it. While in Canada psychotherapy provided by physicians is fully covered under provincial health plans, far fewer physicians (both family docs and psychiatrists) offer it than is required, again because of large patient loads, and the fact that it takes a lot more time than sending someone on their way with an antidepressant. There are lots of psychologists (many of them very qualified, but then again, not always), but that takes money.

Need more intensive treatment? Most inpatient beds are for acute care (i.e. actively suicidal) and patients are discharged long before they are fully well. Yes, there are specialized inpatient and outpatient programs available for less acute, more chronic psychiatric care, but like with the rest of the medical system in Canada, they are harder to access than emergency care.

For "serious" mental illnesses (e.g. schizophrenia), there are a good number of community-based programs around to help keep people out of hospital, but again, the amount of resources dedicated to them pales in comparison with the demand.

People like to talk about the mental health "system", but it should be pretty obvious that there isn't actually a system. Instead, we have a disjointed set of independent care providers who have different competencies, attitudes and capacities, each connected to some effectively random set of other care providers.

Falling through the cracks isn't a possibility, it's almost inevitable. And it's left up to the patient or their supports to both recognize it and navigate through.

Is it really this bad?

Pauline's private psychiatric practice is a bit of a "boutique" practice, in that she tends to see patients more often and for longer than many other psychiatrists would. She offers a wide range of treatments including psychotherapy. She'll see most patients for a two hour initial consultation, and it's not uncommon for even one-time consultations to come back to finish things up if that wasn't enough time or if more investigations are needed.

After years of what sometimes feels like "assembly line" psychiatry, she enjoys being able to treat and care for people the way she wants to. But because that takes more time, she can only manage a relatively small number of patients. They don't have to pay or anything to get access, but it does mean she has an extremely long waiting list.

I help her out in her front office a lot, and so get to know a lot of her patients too. So many times I've heard things like "finally I feel listened to" or "I'm so lucky to have found her" or "at last I feel like I'm being treated like a person who matters". And these are comments from people who have seen many care providers in the past.

While I could just say "wow, she's good" (which I think she is), I think it's more striking how hard it has been for so many of her patients, many of whom have out of necessity become extremely knowledgeable about the mental health system, and who have seen a lot of care providers, to find the right care for them.

For way too many people, the right care just isn't available due to availability (no provider or providers at capacity), affordability, access (unable to get referral), or the systemic or knowledge roadblocks that can be set up at every step in the process.

In some places, she couldn't even offer that kind of care... well, she could, but she'd be losing a fortune. In BC for example, psychiatrists are paid a fixed rate for a consultation (no matter how long it takes, which means if you spend the extra time to do a thorough job, the bulk of it is unpaid work). They also have to justify seeing patients more frequently (even if they're doing unwell for a period of time), and need them to basically be re-referred to care for them longer than six months. There are lots of other things she does now that would also be uncompensated there.

That's effectively a policy decision in BC due to the extreme shortage of psychiatrists vs. the demand. They've tried to put rules into the system to ensure as many people get access as possible, at the possible expense of the best care for each and every one who does get seen. It's an arguable, but entirely reasonable choice. Here in Alberta, it's far more laissez faire as far as policy goes.

At her office, I field a lot of calls from people looking to get help. I do my best to point them in the right direction and help them understand and navigate the system, and often they're grateful someone is willing to help even that much. But I know the odds are against them, and even the little bit of advice I can offer is only because with her seeing relatively few patients, the front office side is far less busy than in a typical overworked doctor's office.

We've been talking for a long time about getting past the stigma, and that's a talk that still needs to continue happening.

But we also need to do a lot more talking about what happens when people do try to seek help, about the kind of mental health care we provide, about the quality of care, the type of investments we're willing to make in the system, and ultimately about the kind of society we want to have.

We've barely scratched the surface of that conversation.

Yeah, let's talk.