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The Seven Deadly Sins of Psychiatrists

What makes a good psychiatrist?

If you ask patients to talk about their bad experiences with psychiatrists (or just ask psychiatrists who have taken over care of a patient from a bad psychiatrist), you’ll certainly get an earful!

Herewith, a highly unscientific list of “sins” that can arise in psychiatric care.

Selective Attention

“You didn’t hear a word I said!!!”

Whether due to unreasonably short appointments, or quickly focusing on only one small aspect of the problem(s), there’s nothing more infuriating than feeling like you haven’t been heard, or your concerns not taken seriously. If the sole response to a half hour of tearfully recounting your struggles in work and relationships is “you should drink less coffee”, you’d have a legitimate right to wonder why you waited six months for this appointment.

Good psychiatrists: Take the time to listen and acknowledge patient concerns. Even if they can only help with a small part of those concerns today, they’ll put small changes into a larger plan or context, and set overall expectations for moving forward.

Dehumanization

Are you a person or just a diagnosis? While a specific diagnosis can be helpful to help narrow down appropriate treatments to consider, ultimately the bigger question is how your symptoms are impacting your overall quality of life. Not everything needs to be treated, and the success or failure of any treatment needs to be measured against that. It’s great if a medication can help with anxiety, but if it causes an athlete to gain 50 pounds or a writer to be unable to concentrate, is that really fixing the problem? This might be the equivalent of a surgeon’s “the operation was a success, but the patient died”.

Good psychiatrists: Look at the whole person. They don’t believe in “one size fits all” treatments, and are cognizant of potential side effects. Their goal is to help improve overall quality of life, as seen by the patient, not themselves.

Polypharmacy

For some psychiatrists, it’s too easy to just add medications to deal with every new problem, or every side effect of the previous medication that was added. It doesn’t take long before someone ends up on four different benzos, a few antidepressants, a couple antipsychotics, a mood stabilizer, and several other drugs to deal with akathisia, insomnia, etc.

Unfortunately, taking people off medications and trying others takes more time and has the potential of destabilizing them for short periods of time. And cleaning up an overly complicated medication regime can be a long-term process. Just adding something else to an existing mix is an easier way out.

Good psychiatrists: Don’t turn patients into walking pharmacies. They realize finding the right combination of medications for a patient, taking into account efficacy and side effects, is worth it in the long term, and will find ways to make sure that happens.

Short Sightedness

If someone has a broken limb it may be well enough to cast them up and send them on their way, but if it happens every few months because they have a habit of jumping off their roof, you might want to look at that. Similarly, prescribing something to control a panic attack may be useful in the short term, but it may be more helpful in the long run to also address the cause of those panic attacks.

Good psychiatrists: Consider root causes and context. They understand that learning better coping strategies or engaging in therapy (even if they aren’t the ones providing it) can help solve many problems in the long term. Medications can be part of the solution, and often are needed to get people to the point they can benefit from other techniques.

Overspecialization

The old chestnut about “if all you have is a hammer, everything looks like a nail” can apply here too. A psychiatrist who specializes in mood may see everything in those terms, and overlook an obvious PTSD. More generally, some psychiatrists may assume every problem they see is as a result of a mental health cause, and try to solve it using psychotropic medications. Psychiatrists who forget they are physicians first may try a patient suffering from poor concentration and energy on five different antidepressants and give up when none of them work, but not bother to find out if their iron levels are in their boots. A psychopharmacology specialist may ignore therapy even when it may be more appropriate to the problem.

Good psychiatrists: Recognize other problems that can present with psychiatric symptoms. They understand that psychiatry makes up only one part in an overall health team, along with a variety of other professionals.

Discontinuity

Some patients who see a psychiatrist regularly can walk out of the office each time with a different diagnosis and a different medication. If their psychiatrist only looks at the symptom of the day, and ignores the patient’s overall history, patterns and changing circumstances, they’ll end up on a never-ending medication roller-coaster.

Good psychiatrists: Take a thorough history and work in the context of an overall treatment plan. They often have frighteningly good memories of seemingly trivial statements or incidents from previous sessions. They differentiate between regular behaviour patterns for each individual, normal human reactions to external circumstances, and unexplained mental status changes requiring further investigation.

Narcissism

Beware the psychiatrist who knows everything, has no need of opinions or help from others, and prides themselves on knowing exactly how to solve a patient’s every problem within two minutes of meeting them. They see themselves on high, separate and better than their patients, dispensing wisdom to those patients who should feel fortunate enough to be seen. They are quick to dismiss advice or treatments you may have received from others in the past, as those people don’t know what they’re talking about.

Good psychiatrists: Become partners with their patients and other caregivers. They demonstrate empathy, not hubris. They recognize the limitations of their own knowledge and skills, and how much time it takes to really understand another human being. They value rather than shun other opinions and perspectives.

 

Consequences

In the health care system, many people fall through the cracks. A lot of people shrug and say “that’s just the way it is”. Sometimes the consequences aren’t too severe. Sometimes though, they are.

Mental health writer Natasha Tracy vividly shared the story of her own suicide attempt (trigger warning). If you’re able to, read it.

If you’re one of the people working in mental health who goes out of their way to help people in need, know that it can make a difference.

If you’re one of the people in mental health who sometimes lets people slip through the cracks because “it’s not my problem” this should hit you like a punch in the gut.

If you’re a politician, health ministry worker, etc. in any position to influence how the system functions, understand that this one incident encapsulates what it means to have a mental health system in crisis.

Now multiply that by the hundreds and thousands in comparably dire circumstances.

Now multiply that by the hundreds of thousands who are suffering because they can’t get mental health help.

Okay, intellectually that may be useful to think about the scope of the problem, but it makes it too abstract. It takes the feeling out of it. Focus back on that one person, that one story.

Now focus on you.

One person can’t fix the system, and nobody should get trapped into thinking that they need to personally make up for all the flaws in the system.

But one person can make a difference.

And a lot of people pushing in the same direction can change a system.

Alberta Mental Health Review

First off, my apologies for the lengthy delay since my last posting. We relocated from Alberta to Victoria, BC at the start of May, and the period before and after that has been chaotic to say the least.

As it happens, I’d like to talk about Alberta today. It’s certainly been politically interesting there the last few months, to say the least. If you didn’t see it, I want to draw your attention to a recently announced review of the province’s mental health system, which the premier accurately acknowledges “has failed too many Albertans.” (Kudos also for getting Dr. Swann, a Liberal, involved).

I’d like to chime in on exactly how Alberta’s mental health system has failed Alberta. I’ll focus mostly on the outpatient side, but first…

Too Few (Treatment) Beds

I’m sure this will be the item that gets the most coverage. There aren’t enough mental health beds, and too many are for crisis patients only. If people need acute inpatient treatment, but are passed the point where they are certifiable, there are not enough resources around. Which of course leads to the revolving door of crisis admission, streeted, relapse.

Too Few (Unlocked) Entrances

It’s hard to access the mental health system if you’re not in crisis. There are a number of entry points (help lines, community clinics, family doctors, etc.), and efforts at stigma reduction are helping. Yet, too often these entrances are “locked”.

What I mean by that is people get turned away, either because they don’t meet criteria for whatever program they’ve approached, or they’re told by someone, often their family doctor, that they’re fine and don’t need any help. As I’ve said before, too often after working up the nerve to talk to someone in the first place, they get shut down when they first try. Particularly when its a medical professional telling you you’re fine, what are you supposed to think? How often do you try again?

Too Many Exits

Even if you are getting help from someone, if you reach the limit (for whatever reason) of what they can provide, too often you’ll get a “sorry that’s all I can do for you” and not get directed towards further help. There’s not someone following behind to make sure you get the care you need. It’s very easy to end up in what I like to call mental health limbo.

Poorly Coordinated Programming

There are lots of different providers, ranging from individual psychiatrists, counsellors, community mental health clinics, crisis teams, mental health workers associated with Primary Care Networks, etc. Again, beyond crisis work, there isn’t a lot of coordination even when it comes to the mandate of each group. Local decision making can be good, but if a PCN is deciding what services it offers, it doesn’t mean there still aren’t a lot of important services that aren’t being provided anywhere in the community. Most often actual evidence-based, effective treatment.

Wrong People, Wrong Treatments

There are lots of different mental health providers, in many professions. They all can do different things. Many of them are excellent at what they do. Many others are not.

Sending someone with an illness that responds best to treatment A (whether meds, a certain type of therapy, etc.) to a provider who only offers treatment B is not helpful. And rarely is there oversight from anyone to intercept or abort a poor match, leaving the responsibility up to the patient and/or provider.

And poor providers (or charitably, poor fit between patient and provider) are legendary.  We had one group of completely unrelated providers that offered such a horrible experience to so many patients (a psychiatrist, a community clinic, and a therapy program) that we referred to the patients who had unluckily found their way to see all three in the past as “winning the trifecta”.

(To say nothing of being sent to what you think is a psychiatrist, and finding out that they aren’t actually qualified in Alberta as a psychiatrist!)

This is all made worse because people generally have a poor understanding of mental health treatment and providers, and so will have a difficult time identifying a poor treatment or treatment provider. They’re counting on the system to ensure they’re getting the right care.

Their trust is misplaced.

No Results Accountability

What measurement occurs in the system usually revolves around capacity in one form or another. Number of beds, number of therapists, number of patients seen, number of contact hours, etc.

If someone gets seen ten times, that’s what the system tracks. Nobody is tracking whether that person is better afterwards.

We may feel good saying we’ve added X number of beds or therapists or whatever, but if they’re not actually helping people get better, are we any further ahead?

No Escalation

People get stuck going around in circles in the system for years on end. Every few years they might get sent to another psychiatrist for a consultation and another set of recommendations. But even if they’re not getting better, the cycle continues. It’s rare that someone stands up and says:

Wait a minute. Why do we keep doing the same thing again and again and expect different results?

Nobody is keeping track of how many years of someone’s life is wasted in mental health limbo. As long as they’re still seeing a treatment provider, the system is happy. Shouldn’t there be a mechanism that catches people in these situations and escalates them to a higher level of care, e.g. a psychiatrist who will spend more than half an hour with them? Or any kind of mechanism to look at what care this person should be receiving?

Not a System

The root cause of all of this is that there really isn’t a coherent system underlying mental health, just a disparate network of providers.

And navigating that network of providers is not easy, particularly when very few people have the necessary knowledge to understand both their individual needs and the providers. Often there is nobody, not even their family doctor, who can effectively help them.

The concept of patient navigation comes up a lot in other areas of medicine, e.g. cancer care. It’s not perfect, but it helps people find their way through a system, and know where to turn when they get lost.

When it comes to mental health, we could use a little less thinking in terms of episodic care, and a little more thinking in terms of patient’s long term navigation within a coordinated system.

I wish for the best out of this review, and I hope it can escape the well-meaning platitudes and vague yearning to provide more resources. I don’t think fixing the system is easy. I do think identifying what is not working should be expressed in a way that is simple, straightforward and bluntly to the point.

I Talked. Now What?

Let’s talk about mental illness.

Good advice, and if you’re ready to take this step (or have already), congratulations! That in itself is a very big and scary accomplishment.

But sometimes you don’t know what to say, or how to say it. Or are too scared and overwhelmed to get it out clearly.

Or maybe you’ve tried to talk with your doctor or another care provider, but it didn’t go as well as you wanted. Maybe you didn’t feel you were heard, or your cares were dismissed. Or you weren’t talking to the right person.

Download, print and fill out this free worksheet. It will help you collect your thoughts and the information you need to have a useful and productive conversation with your care provider.

Download: Your Mental Health Worksheet (PDF)

(If you find this helpful, please sign up for my newsletter via the form at the bottom right of this page. You’ll be informed of more helpful resources like this worksheet in the future).

You’ve come this far. Don’t stop now.

Keep talking, until you get the answers (and help!) you need.

Let’s Talk, Don’t Stop!

January 28th is Bell Let’s Talk Day. Kudos to Bell and all the people who participate in this event for the work they’re doing to help reduce the stigma of mental illness.

Working up the courage to step forward and admit to someone else that you’re worried you may have a mental health problem is one of the toughest things to do for many people. With continued efforts to reduce stigma, hopefully asking for help will be easier.

But what if you work up the nerve and ask for help, and get completely shut down?

Too often, that is exactly what happens. And if your concerns get dismissed out of hand, what then? It’s likely going to be a long time before you try to ask for help anywhere again. And that is a tragedy.

Things you Don’t Want to Hear

Below are some of the many things that have been said to people worried about their mental health, looking for help for the first time. And these are all coming from health providers, mostly physicians or in some cases mental health professionals.

“Don’t be silly, you’re fine”

This is likely to come from friends and family members, often parents, worried about the stigma of mental health and how being labelled might affect you (and them). But it can come from health providers too, whether they’re too busy, think you just worry about everything (helloooo…), or are themselves stigmatized or biased against dealing with mental health issues.

Of course, some times it is true that you’re fine. Most people aren’t experts at differentiating between emotions that are a normal part of human experience and those suggestive of mental illness. You’re asking for their expertise, and at the very least a conversation about whether or not your feelings are causing you problems is warranted. In fact, using that opening to probe deeper is prudent, as many people have a hard time talking about these things, and will downplay or minimize their symptoms.

If you’re approaching someone for the first time about mental health concerns, they should at the very least take you seriously. Most people don’t do this as a joke.

(Ok, some people may do it in a humorous manner, but that’s usually nervousness. And people who have been receiving mental health treatment for some time often develop a very biting sense of humour. But it’s certainly not there at first.)

“Psychiatrists are only for people with schizophrenia”

Yes, a family doctor actually said that to someone asking if it would make sense to speak with someone about a problem they were having.

Yes, many family doctors treat mental health issues, as do many other professionals. And yes, some psychiatrists are very specialized, and may see only people with certain types of disorders. But to suggest that psychiatrists in general don’t see people with more common mood and anxiety disorders is ludicrous.

“Here’s a prescription”

You unburden yourself after feeling for months that your life is falling apart, and that’s your doctor’s answer? Take a pill?

This is worth exploring in more detail another time, but that’s no way to respond to someone. Medications may well be the right answer, but they definitely need to be placed in a larger context. If that’s all you heard, you’re certainly not going to feel like you were taken seriously or listened to. And most people, rightly so, are probably hesitant to jump into mind-altering drugs without some education.

Yes, family doctors are busy. But really? You deserve better than that kind of response.

“Go see a counsellor”

Again, this needs to be put in context. As I’ve talked about before, there are lots of different types of mental health professionals, but knowing which one is right for you, and being able to financially or otherwise access them is often difficult or impossible.

Without any context, and some pointers in a particular direction, you’re probably going to get stuck, and feel about as good as you did if a prescription was shoved in your face.

“Well at least you don’t have cancer”

Possibly one of the most ignorant and dismissive things you could say to someone struggling with mental health issues.

“Get some more exercise and you’ll feel better”

This may well be true for some people, but certainly not for most. If that (or any other “quick fix”) is the answer given when you first approach someone, they haven’t been listening to you.

It’s true that exercise can be helpful for many people with mild-moderate depression. I know personally it delayed me needing to start antidepressants for a year or two, and keeps the dose I need lower than I would need without exercise.  But that’s several steps down the road, after some basic things like investigating the exact nature of your problems, and perhaps trying to find out what may be causing them.

“You should go to church”

Yes, some people take comfort in religion (for the record, I’m not one of them). And while I won’t downplay that, it has its limitations. Mental illness is a health issue. And to turn a previous question around, “would you go pray as the only thing you do if you have cancer?” And yet, some people still do.

Speaking to a religious or spiritual leader may be helpful, but like any other type of counsellor, you have to understand their background and training. While many clergy are getting better at recognizing legitimate mental health concerns and redirecting people appropriately, many have absolutely no knowledge or training in this area whatsoever. I’d rather not take my health on faith. And if the words “sometimes exorcisms are appropriate…” cross their lips, run.

“You must have done something wrong”

Otherwise known as “it’s all your fault.”

It’s truly amazing how often people get confronted with this, again often from family and friends, but there are even some health providers who will respond to certain types of mental health issues (e.g. some personality disorders) in this way.

Blaming people is not the answer, and shows just how far we still need to go in terms of education. Or how many people make themselves feel good by putting other people down. Mental health blogger Natasha Tracy describes this far better than I could.

“It’s all just in your head”

Technically, this may be mostly true (though you’d be amazed how much serotonin you can find in the intestines). But what people are really saying is that you’re imagining things, and that you don’t have a real health issue.

This is an obstacle for a lot of people, in the sense that there’s no blood test or diagnostic imaging investigation that will provide a mental health diagnosis. Without such “objective” evidence, it can’t be real, can it?

Yes it can. Very, very real.

“Just suck it up, you’re not even trying”

This often comes from people (including some doctors) who think that you’re consciously choosing to feel the way you’re feeling, and that if you just decided to, you could “snap out of it.” Again, this is one of the things that separates normal fluctuations in mood from mental illness.

In lieu of rebutting this, I’ll share one of my favourite cartoons on the matter (see original source):

2013-11-21-Helpful Advice

Don’t Stop Talking

Talking about your mental health concerns is the first step.

But sadly, you’re not always going to get a respectful and helpful response.

If that is the case, remember that you’re not alone. There are still too many barriers to accessing good mental health advice and care, and it’s too easy to get discouraged. It may not be easy, but try again. Keep asking for help.

You may or may not have a diagnosable mental illness. But there are trained professionals out there that can help you determine that, and what to do next.

Remember, whatever your mental health symptoms get labelled, if they are affecting your quality of life, it’s a problem.

Keep talking.

Don’t stop.

Rationing Mental Health Care, Part Two: Doctor Fees

In the previous post, I talked about how healthcare administration, by controlling the training opportunities, facilities, hiring and activities of physicians, psychologists and other mental health practitioners can restrict the amount and type of access to mental health care.

In this post, I want to take a closer look at another mechanism that is used, the physician fee schedule. Most physicians, in part or in whole, generate income by billing governments for specific services they provide. Exactly what services they can bill for, and how much they can bill, are determined by agreements negotiated between payers (i.e. provincial governments) and doctors (via provincial medical associations). This is known as “fee for service”.

So important to note, fee for service physicians aren’t paid for their time, and everything they do isn’t billable, which is why so many will charge you for things like letters, doctors notes, missed appointments, etc. (Try finding a lawyer who will do work for free). Also important to note, not all billable services pay the same or take the same amount of time. Other things being equal, most doctors will probably try to maximize the amount of their billings. This makes the structure, regulations and restrictions of the fee schedule extremely important, not only for provincial government health budgets, but also for the type of care that will be delivered.

A Study in Contrasts: Alberta and British Columbia

While you’d think that there wouldn’t be much more to say about different fee schedules than one province overall paying more or less than another (depending on the bargaining strength of the respective doctor’s association), surprisingly there are some big differences that significantly impact care.

I’ll illustrate this by comparing geographical, if not always ideological, neighbours, Alberta and British Columbia.

Yes, in general Alberta pays a fair bit more (25%, give or take) for many equivalent psychiatric services, which perhaps makes it easier to attract and retain more psychiatrists to Alberta, but there’s a lot more to it than that.

One interesting thing that BC’s psychiatry fee schedule does is make explicit that the schedule explicitly recognizes the shortage of psychiatrists as compared with the need for care, and is designed to influence the amount of care offered and how it is distributed:

Due to the unmet demand for psychiatric services, prolonged time-intensive psychiatric treatment must be provided only to the extent that it is justified and cost-effective in the context of limited psychiatric treatment resources and waiting lists.

Where Care is Delivered

In Alberta, psychiatrists who provide 15 minutes of patient care in a hospital would get reimbursed the same amount if they provided the same care in an outpatient clinic or a private office.

In BC, services provided in hospital get reimbursed at approximately a 15% higher rate.

Other things being equal, this would push more psychiatrists in BC towards practices where they can do inpatient work. Which, in an age where you’re pushing care away from hospitals and into the community, is a bit puzzling.

But, the BC healthcare bureaucracy can control how many inpatient psychiatrists they hire, as well as the number of inpatient psychiatric beds. When it comes to outpatient care, there’s nothing to stop any number of psychiatrists from opening up their own private practice. That’s an amount of care (and a cost) that can’t be as easily controlled. Better to encourage psychiatrists to take inpatient jobs.

But is 15% really that big a deal? Enough to have an impact, but here’s also where the much lower fees in BC compared with Alberta can make a difference. If you’re running your own private practice, you’ve got a lot of overhead to pay for (office rent, administrative support, supplies, etc.). That comes straight out of your pocket.

Another option is for psychiatrists to find a job working in a government run outpatient mental health clinic. You still bill the same as if you were in private practice, but usually most of your overhead is covered by the clinic, rather than it coming out of your pocket. Plus there are certain mysterious yet scarce extra incentive payments called “sessionals” to help cover non-billable work, not available if you’re in private practice. All of a sudden you’re back to clearing a pretty reasonable amount of money.

Did I mention the number of psychiatrists, their scope of practice, and the type of work they do in government run outpatient mental health clinics is controlled by the healthcare bureaucracy?

In contrast, Alberta psychiatrists bill the same whether they’re doing outpatient or inpatient care. Those running private practice still have overhead, but with the higher amount of billings (and as it turns out, more things that are billable) you can still make a pretty respectable amount of money.

This is purely an approximation (though based on a real scenario), but an outpatient psychiatrist in private practice in Alberta might bill $300,000 per year, pay overhead of $75,000, and so bring home $225,000 before taxes.

In BC, the same private practice outpatient psychiatrist would likely bill only about $225,000, yet have the same $75,000 overhead, yielding $150,000. That’s 1/3 less than in Alberta, which is quite a bit. The same BC psychiatrist working inpatients or in a government outpatient clinic would bring home pretty close to $225,000.

Needless to say, there are a pretty reasonable number of psychiatrists in private practice in Alberta. But in BC, the vast majority work in government-run clinics or hospitals, where the amount and type of care provided can be controlled.

Consultations

That was a lot of detail, but it illustrates how the fee schedule can drastically impact the type of practices that psychiatrists will work in.

Here’s something a bit simpler, that illustrates how the type of care provided can vary.

Consultations are when typically a family physician refers a patient to see a psychiatrist. The psychiatrist sees the patient once, and usually comes up with a diagnosis and some recommendations. They then write a report which is sent back to the family physician, who (hopefully) implements the recommendations.

In BC, a psychiatrist will bill a flat fee for a consultation, currently about $215, regardless of how long the consultation may take.

In Alberta, the psychiatrist is paid a flat fee for the first half hour (currently $179), and then $50 for each additional 15 minutes spent on the consultation.

One hour is probably the minimum time you’d need to do a good consultation on a fairly straightforward patient, so again factoring in that BC generally pays lower than Alberta, the fees sort of match up.

But what if you’ve got a complex patient? In Alberta, the psychiatrist can choose to spend the time they need to do a good job. In BC, there is no way to bill for a longer consultation. So the psychiatrist can spend the extra time, but they’re not getting paid for it.

My psychiatrist wife’s private practice (in Alberta) specializes in complex patients, often those with multiple diagnoses, who have been sick for a long time, and who generally have multiple other medical problems to boot. It’s not unusual for her to spend two hours or longer to get a good handle on these patients. As a result, she’s often able to identify and solve longstanding patient problems that may have been going on for years, and missed by several other psychiatrists who never spent the time.

In BC, where longer consultations aren’t compensated, what happens to the complex patients?

Appointment Length

Another area of difference influences the length of followup appointments for those seeing a psychiatrist on an ongoing basis.

Both BC and Alberta bill followup care in 15 minute blocks called “units”. One unit of care in Alberta is $54, in BC it’s $46. Two units are double that, so $118 or $92.

Three or four units? In Alberta, it’s triple or quadruple the one unit rate. But not in BC, where it’s about 10% less. And even longer than four units (one hour)? In Alberta, you keep going up at the same rate, but in BC you can’t bill more than four units. Talk about an incentive to keep appointments short, regardless of the circumstances or need.

Interestingly, for those who really want to maximize their income at the expense of good care, Alberta wins. In Alberta you can bill one unit as long as you spend “the majority” of the time (i.e. at least 7.5 minutes). In BC, you need to spend a lot more (12.5 minutes) to bill. So the psychiatrist in Alberta who runs 8 minute appointments can see seven people per hour and bill each one for a full unit, making nearly twice as much as someone who sees them for a reasonable amount of time.

Care for the Many or the Few?

On top of that, BC places more restrictions on following patients. If you need to see a patient for more than two hours a week, you need to justify it and get it approved before you’ll be paid. If you see a patient for longer than six months, you need to have their family doctor essentially “okay” that they still need to be seen by a specialist. Again, no such restrictions in Alberta.

The rationale here is to avoid valuable psychiatric care being used on people who really don’t need it, the so-called “whiny well”. A controversially titled article in the October 21, 2014 issue of The Medical Post (a physician trade rag) called “Psychiatry: A Profession in Decline?” talked about the phenomenon of some psychiatrists seeing a small number of wealthy clients for years on end, who neither really needed the care of a psychiatrist, and could certainly afford a psychologist.

Summary

As this deep dive into fee schedules shows, these dry and bureaucratic documents can have a massive impact on the type of mental health care delivered in a province. From the number of psychiatrist, where they practice, what services they offer, and how many patients can receive care, they are an important tool in rationing mental health care in Canada.

Aside from the overall higher fees in Alberta, this discussion illustrates how that province’s fee schedule imposes fewer actual restrictions on psychiatrists and less incentives to adopt a particular practice model. It encourages more flexibility by individual practitioners by its effective absence of policy, and so reduces certain opportunities to tailor the mental health system towards a particular structure.

I actually applaud BC for being explicit that the fee schedule helps implement a policy, in particular that given there are so few psychiatrists, it’s better to have more people receive perhaps lesser care, than some people perhaps receive very good care, but others receive nothing. I’m less sure about the policy itself, but at least it puts it out in the open (to a small audience) for discussion.

I’m less excited that so many policy decisions in BC are embedded in an opaque and largely unaccountable health bureaucracy, which at best centralizes opportunities for responsiveness, excellence and innovation, and at worse stifles them.

Further Reading

You can find Alberta’s fee schedule online (both the description of services and fees for those services). It contains services for all physicians; you can search for psychiatry codes, which start with “08.”).

BC’s fee schedule for psychiatrists, including both service descriptions and fees is also available online.

A 2012 position paper by the BC Psychiatric Association had a very good discussion about BC’s fee schedule, and the impact it had on care and psychiatrist recruitment and retention. This appears to have been prepared as a planning document leading up to the recently concluded MSP negotiations, and has since been removed from the web.

 

 

Rationing Mental Health Care, Part One.

Anyone who has tried getting mental health help knows that it can be very difficult to find. Clearly, there isn’t enough care available to satisfy the need that’s out there. One look at the recent shameful stories about Canadian Forces Veterans who are unable to access adequate mental health resources for widespread problems like PTSD, provides a glimpse into the problem.

There are significant practical, philosophical and economic issues at play in terms of how much care should be provided, particularly within our publicly funded healthcare system. This is not a simple problem with a simple answer, and I’m not offering one.

I will say this: serious, widespread, public, adult conversations on these issues need to be happening, and they are not. Our public discourse resembles cheerleading squads chirping at each other with ideological, “gotcha” sound bites. Real decisions are being made by a small minority, with little input, that do have significant impacts on all of us.

I want to demonstrate though, how these decisions, made by politicians and an expansive healthcare bureaucracy, worlds away from those on the front lines, affect the care that is available. Make no mistake, health care is rationed, including mental health care. And if you want to talk about changing how we ration it, we need a better understanding of how it works now.

We Have Two-Tier Healthcare

Let’s get this out of the way right now. We do not have “free” healthcare, and we do not come close to providing for all the healthcare needs of the population. Dental, prescription drugs, ambulance services… there’s a long list. Some things (doctors visits, many expenses associated with hospital stays, etc.) are paid for by governments from tax revenues, and many other things are not covered. Including, most notably for our discussion, psychotherapy delivered by anyone other than a physician.

For many, psychotherapy may be the most effective treatment for their mental illness, or at least part of that treatment. Those with means to pay for it privately, or who have insurance whether from work or elsewhere, can access it with relative ease (though locating the right therapist for your needs may be difficult). If you don’t have the means, your chance of accessing psychotherapy is much lower.

In the remainder of this post, we’ll look at a few ways that access to care is rationed.

Rationing Psychiatrists

In our system, psychotherapy provided by physicians is normally covered by provincial health insurance. We all know that family physicians are far too busy with far too many patients to be able to regularly provide any kind of psychotherapy. That leaves psychiatrists.

The first way we ration psychiatrists is by limiting the number we produce. If you’re not familiar, after they’ve completed medical school, psychiatrists need to complete a typically five year residency training program to become psychiatrists. There are only a certain number of residency spots available across the country, which means only a certain number of new Canadian-trained psychiatrists each year. The number of those positions are determined based on government funding.

Whereas in the past, many psychiatrists may have simply opened up a private practice, it’s more common now for them to take a position in a hospital or some type of outpatient clinic. There are advantages to doing so, not the least of which is financial. Such positions often pay overhead costs that would otherwise be the responsibility of the psychiatrist (office rent, supplies, admin staff, etc.). Using very round numbers, a psychiatrist who might generate $300k/yr in fee-for-service billings can avoid up to $100k in expenses this way.

The downside is the position will require the psychiatrist giving up some autonomy. For example, the types of patients they see, how many they see, how long they can book appointments for, and to some degree even the types of care they provide may be dictated by the organization.

And there aren’t a lot of clinics that will hire psychiatrists to spend most of their time doing psychotherapy.

Rationing Psychologists and Other Therapists

While psychologists, social workers and other counsellors who provide psychotherapy are not covered by provincial health insurance plans, there are usually some places where you can receive some psychotherapy without needing to pay out of pocket.

Generally these are government funded mental health or other clinics, who hire a number of staff to run programs that provide a variety of services to their designated clientele.

Again, the clinic management and its associated budget will dictate the number of allied health workers who are hired, the structure of the programs (what type and how many sessions are provided).

It goes without saying there are not nearly enough of these no-charge services to meet the demands of everyone looking for (or who would benefit from) psychotherapy.

Bottom Line

If you want access to psychotherapy, unless you luck out and find a psychiatrist who does a lot of therapy as part of their practice, or your work has a very generous Employee Assistance Program (which tends to recognize the value of psychotherapy in getting people back to work sooner), you’re going to have to pay.

(Again, I’m not saying that rationing care in some way is a bad thing. What I think is a bad thing is when we refuse to honestly talk about how our health system actually works, and how we may want it to change.)

But have you ever wondered why so few psychiatrists, even those in private practice, actually do much psychotherapy? In the USA it’s largely that most HMO’s won’t pay for it, or at least pay much for it. But that wouldn’t happen here in Canada, would it?

The followup to this post takes a bit of a deep dive into how provincial fee schedules for physicians influence care.

Five Ways Your Psych Consult was Doomed Before it Started

Have you had this conversation with your family doctor yet?

“You sent me to see that psychiatrist and I’m no better than before!”

“Look, I’ve already sent you to the specialist, what more do you want me to do?”

There’s a lot of possible things that could have gone wrong to get you to that point. The simplest is that your family doctor mistook a midpoint of an inherently uncertain treatment process with the end of that process.

But I bet you’d be surprised to find out how much could have gone wrong before you even set foot in that psychiatrist’s office.

 1. Your Family Doctor Isn’t Fully Aware of Your Problem

Some people are under the impression that when your family doctor says they’ll “send you to a psychiatrist” that their secretary just sends over your name and contact information. Nothing could be further from the truth.

Your family physician will put together a letter to the psychiatrist, detailing the problems you’re having and how they’d like the psychiatrist to help. Yes, doctors have to do a lot of paperwork. Your family doctor needs to decide who to send you to, what kind of help to ask for, how to concisely describe your relevant history and symptoms, and what background information should be sent along.

This can be a difficult task, particularly if they’re not fully aware of all your problems. That’s why it’s important for you to not withhold information from your family doctor, and do your best to communicate it clearly. The presence or absence of certain symptoms may make a difference in preparing the referral, and your doctor may not have time (or remember) to ask about them during your appointment. Consider bringing some notes to your appointment, or someone to help.

Make sure you have enough time to fully describe your concerns. When you call to book the appointment, don’t say it’s for a med refill if it’s really to describe how your life is falling apart, or you’ll be booked too short an appointment. Similarly, don’t leave it as a “oh just one more thing” at the end of your appointment.

Communication being a two-way street, your family doctor may not be doing a good job of listening to everything you’re saying, or not asking clarifying questions. They may jump to conclusions early and cut you off. Or they may have their head buried in their laptop fighting with their Electronic Medical Record software to the point you may need to scream to get their attention.

Not having all the information about a problem can certainly make it harder to ask someone else for a solution. But even if they have all the relevant information, they may not use it.

2. Your Family Doctor Didn’t Send a Useful Referral Letter

The best referral letters contain a concise summary of the symptoms you’re experiencing, confirmed and/or suspect diagnoses, a summary of past and current mental health treatment, a summary of other health issues, current medications, and recent lab results. They also explain why the referral is being made, e.g. clarify diagnosis, medication recommendations, provide ongoing management and therapy, etc.

A referral just saying “please see for depression” or “medication recommendation for anxiety” is less helpful.

Why does this matter? If your real issue is that you’ve got a form of Bipolar Affective Disorder or Post-Traumatic Stress Disorder, and your family doctor has—with great certainty—diagnosed you with simple depression or anxiety, the psychiatrist isn’t necessarily going to ask you the questions needed to clarify your diagnosis. Alternatively, if a thorough medical, psychiatric or medication history isn’t provided, they may well recommend treatments that are entirely inappropriate for your situation.

Generally, the more information that can be sent to the psychiatrist, the better. Doctors are skilled at quickly absorbing large amounts of material, and it’s certainly faster for them to extract what they need from a detailed referral letter than to spend time asking about it all in your appointment. Which brings me to…

 3. Your Appointment was Booked for the Wrong Amount of Time

You’ll be booked for an appointment with the psychiatrist for a certain length of time. While every psychiatrist’s office works differently, it’s quite likely that someone sent for a simple medication consultation on a confirmed diagnosis will be booked for a shorter appointment than someone with all kinds of symptoms, on multiple medications and tried many others, where the family doctor is looking for more general guidance.

If it turns out at the appointment that things are a lot more complex than what they appeared from the referral letter, one of two things is likely to happen. First, they may try to rush through and cram everything in, and things will get missed or misinterpreted. Or second, things that really needed to be covered won’t be covered, and the recommendations sent back to your family doctor will be far less useful or reliable. There is a third possibility, that the psychiatrist may realize they don’t have enough time for what you need, and book you an appointment of the appropriate length, within a relatively short period of time, to properly complete the consult. Hey, it happens.

Not every psychiatrist’s office works the same way, and some may just book everyone for e.g. one hour, regardless of what they were referred for, and what gets done in that time is what gets done.

4. The Psychiatrist Didn’t Read the Referral

It’s also possible that the first time the psychiatrist sees your referral letter is when their hand is on the door to the interviewing room. If they’re running behind, if the appointment time is tight, or if there’s a lot of information to go through, that could be a problem. It also does not exactly inspire your confidence, either in them or your family doctor, if they start asking questions showing they don’t have the slightest clue why you were sent to them in the first place!

Not only is this a waste of everyone’s time, but most people are not quick on their feet when thrust into a totally new, unfamiliar environment. This makes giving good answers to the psychiatrist’s questions more difficult. That’s not to say that they won’t deliberately go over some of the things your family doctor provided, to confirm or clarify them.

But while they’ve got dozens or hundreds of patients to see, this is your one chance to get in with this specialist, which you’ve probably been waiting a very long time for. Not having at least a basic familiarity with your situation before they walk in the door shows disrespect.

5. You were Referred to the Wrong Psychiatrist

What else could have gone wrong, even before your appointment? Your family doctor could have sent you to the wrong psychiatrist altogether.

Not to put too delicate a spin on it, like with every profession, there are good psychiatrists and bad psychiatrists. Ones who are more adept at being able to help you with your problem, and others less so. They may have gaps in their knowledge, have difficulty applying it, be poor listeners, poor time managers (see above), and have prejudices or biases against certain groups or problems. They may be highly specialized in the narrow area of psychiatry you need help with, be all-around excellent generalists, or interested in something other than your problem.

And then of course, they may be excellent psychiatrists, but there’s just some weird personality mismatch between them and you, that makes it difficult to really divulge all the highly personal information that may be needed.

Ideally, you’d be referred to the most appropriate psychiatrist for you and the type of mental health challenges you’re facing. But that choice often comes down to other factors: geographical, waiting lists, and your family doctor’s familiarity (or lack thereof) with the various psychiatrists in the area.

Probably more than in any other area of medicine, there isn’t a standard psychiatric consultation, or a standard psychiatrist. With such variation in their approaches, skills and proficiencies, your experience with one may be entirely different than if you were sent to someone else.

Bottom Line

If you weren’t satisfied with the visit to the psychiatrist that you had, take heart. You’re far from alone. This post has only scratched the surface of things that could have gone wrong, even before you walked through their door.

In future, we’ll talk about many other things that could go wrong, in your consult appointment, or after your family doctor gets their report.

Take Action!

Get a copy of your family doctor’s referral letter and the psychiatrist’s report. Do they seem completely off the mark? Ask for help interpreting anything that is unclear.

Push for another referral, to the same psychiatrist (if they seem helpful) or another, and get a copy of the referral letter ahead of time.

If you think your family doctor has underplayed what you’re experiencing, ask them why. Alternatively, write up a short narrative describing your symptoms and their effect yourself, and either ask your family doctor to send it along with the referral, or send it directly to the psychiatrist’s office (more on this another time). At the very worst, it will be ignored.

Don’t be swayed by a simple “you’ve already seen a psychiatrist” again. Get them to explain why they think a referral to someone else really wouldn’t be useful.

On Antidepressants, Still Anxious

Antidepressants, despite the name, are first-line treatments for anxiety as well as depression.

Choosing the right antidepressant is hard, a topic we’ll come back to frequently. It involves a lot of trial and error, but there is both some science to it and some knowledge to be drawn from practical experiences.

Here are two pieces of practical experience that don’t seem to be as well known as they should be:

  1. Wellbutrin tends to increase anxiety in a lot of people.
  2. Higher doses of SNRI’s (e.g. Effexor, Pristiq, and Cymbalta) tend to increase anxiety in a lot of people.

Usage of Wellbutrin

Wellbutrin, generic name bupropion, can be used by itself to treat depression. It’s also used as a smoking cessation aid, marketed under the name Zyban. But more often, it’s added to another antidepressant to either complement it, or reduce the impact of the first antidepressant’s side effects.

For people who get “slowed down” a bit when taking an antidepressant, sometimes Wellbutrin can help give them a little bit more pep. It’s also very commonly used to combat the dreaded sexual side effects brought on by many antidepressants.

Using Higher Doses of SNRI’s

SNRI’s like Effexor (venlafaxine), Pristiq (desvenlafaxine), and Cymbalta (duloxetine) are commonly prescribed antidepressants that can help with a wide range of anxiety and depressive symptoms.

Everyone is different, but most people start at a low dose of each and may gradually increase. Most people top out around 225mg of Effexor, 100mg of Pristiq, or 60mg of Cymbalta. But you can certainly go quite a bit higher on all of them. After all, if you’ve gotten a good response at a particular dose, maybe you’ll get a better response at an even higher dose?

Taking a Step Back

Before going any further, let’s take a step back and get a refresher on what antidepressants actually do. Your brain has a set of chemicals called neurotransmitters which help control your mood. There are several different neurotransmitters, most notably serotonin, norepinephrine and dopamine, which all affect slightly different aspects of your mood.

Different antidepressants target different neurotransmitters. They don’t actually create more of them, but they make sure that they’re all available right where they are needed. Selective Serotonin Reuptake Inhibitors (SSRI’s) work to maximize the availability of serotonin. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s) work to maximize both serotonin and norepinephrine availability. And so on.

Neurotransmitters and Anxiety

For most people, increasing the amount of serotonin available will help improve anxiety symptoms. That is why SSRI’s and SNRI’s tend to be the first meds prescribed for anxiety.

What isn’t most recommended to try first for people with anxiety? Antidepressants that increase the amount of dopamine that is available, which makes many people more anxious, not less.

Guess what neurotransmitter Wellbutrin tends to target? Dopamine.

So what about SNRI’s? The current generation do, as the name suggests, primarily target serotonin and norepinephrine. But they also weakly target dopamine as well. However the larger increase in serotonin tends to more than offset the small increase in dopamine availability for most people.

As you move to higher and higher doses, the amount of extra serotonin made available gets smaller and smaller. That is why increasing the dose of some drugs past a certain point doesn’t greatly improve symptoms. In contrast, at the higher doses of current SNRI’s, the amount of extra dopamine made available does actually get larger.

As an example, somebody taking Cymbalta 60mg will have only a very small amount more dopamine available. That same person taking 90mg or 120mg may have quite a bit more extra dopamine, which can cause nervousness or anxiety.

Every drug has a different behaviour at different doses, which is known as the dose-response curve.

Take Action!

Are you on Wellbutrin and experiencing anxiety? Ask your doctor about reducing or removing the Wellbutrin, and see if it helps your anxiety. If so, will you still need to find something else to replace it?

Are you on an SNRI and experiencing anxiety? Particularly if it’s a higher dose, talk to your doctor about the possibility of going down to a lower dose and seeing it it makes a difference. If it does reduce your anxiety, and the lower dose isn’t enough to help with your other symptoms, you may end up discussing a switch to another antidepressant, or something else to augment the lower dose of your current SNRI.

There are lots of other reasons you may be anxious, which I’ll have more to say about in a future post, but these two kinds of medication-induced anxiety seem to very commonly get missed.

Get your Ferritin and B12 Levels

If I could only give out one piece of advice when it comes to people suffering from depression or anxiety, it’s this: find out your ferritin (stored iron) and Vitamin B12 levels.

If every family doctor checked just these two things before putting someone on an antidepressant, it would save an incredible amount of grief. Such a simple thing, but not having recent ferritin or B12 levels, or them being too low, is one of the most commonly-missed and easily treated causes of depression and anxiety.

Why Ferritin and B12 are Important

Iron and B12 are used for a variety of things in the body, including assisting in the process of creating neurotransmitters like serotonin which help regulate your mood. If you don’t have enough iron and B12 available, you don’t produce enough neurotransmitters. You can end up severely fatigued, with low energy, poor concentration, bad memory, more anxious, etc.  In other words, low iron or B12 mimic many of the usual symptoms of anxiety and depression.

Antidepressants are designed to keep the number of neurotransmitters available in your brain at a high enough level. But no antidepressant is going to help you if you don’t have enough neurotransmitters to begin with. Experimenting with antidepressants under these circumstances is an incredible waste of your time and money.

What Causes Low Ferritin and B12?

There are lots of causes. For example, excessive bleeding can reduce iron. Inadequate dietary intake can be an issue, as can inadequate absorption of what you eat. Many medications can decrease absorption, as can some foods. Many people gradually lose the ability to absorb B12 as they get older, and develop all kinds of cognitive problems as a result. Too many, whose B12 isn’t checked, may be mistakenly assumed to have some kind of dementia. If the low B12 is corrected (e.g. via injections), the cognitive problems often quickly go away.

What you Need to Check

There are multiple different blood tests to check for iron levels, but for this purpose you need to make sure your serum ferritin is checked. This is a measure of the amount of iron stored in your blood that’s not already part of other things like blood cells, and so is available to help create neurotransmitters. Vitamin B12 levels are more straightforward. So ask your doctor if you’ve recently had a ferritin and a B12 level done, and if not, get them to order it. Then ask for the actual result of each.

Within Normal Range Isn’t Good Enough

You probably know that different blood tests have a range that’s considered normal, and anything above or below that range gets flagged in the lab reports that go back to your doctor.

Here’s the problem: for people with mental health symptoms, the normal ranges are too low.

The normal range for ferritin is 12–300 ug/L. That’s good enough to make sure there’s enough iron for building blood cells, but not enough for neurotransmitters. To avoid problems with fatigue, memory, concentration, etc. your ferritin level must be at least 50.

Similarly, the recommended level of Vitamin B12 is a minimum of 150 pmol/L, but for optimal mental health your B12 level should be at least 240.

Consequences in Practice

Many doctors, if they’ve ordered these tests at all, see them come back normal, and that’s the end of it. This is not good enough. The clinical difference between the official normal range and the optimal range for people with mental health symptoms can be substantial. I’ve seen many people have their symptoms improve, in some cases dramatically, simply by correcting these deficiencies.

Becoming deficient can happen anytime too. Some people are on antidepressants for years, with good effect, when they gradually start developing symptoms again, which worsen over time. Too many doctors are quick to assume that their antidepressant has “pooped out” and try to switch them to something else, instead of first checking if there is a new or worsening ferritin or B12 deficiency.

There is so much research and evidence behind this, that it is one of the few things that I would recommend truly pushing with your doctor if they are hesitant. Too many doctors (and pharmacists) are reluctant to treat low ferritin or B12, as long as the numbers are close to the normal range. Unless they can offer a good reason that supplementation to these higher minimum levels would be harmful, this is one worth fighting for.

Take Action!

Go to your doctor, check if you’ve had recent ferritin and B12 levels measured. If not, get them to order it. Ensure your ferritin is at least 50, and your B12 at least 240. If not, ask them how best to correct it. Make sure it gets checked again several months later.

Further Reading

Effect of iron supplementation on fatigue…  Canadian Medical Association Journal, August 7 2012.

It Could Be Old Age, or It Could Be Low B12. New York Times, November 28 2011.