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.
