Book Review: This is Depression

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 DepressionThis 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

One Month to Launch!

It’s now only one month until the launch of Your Mental Health Repair Manual, which will be available November 25th!

We’re busy working through some of the last details, and cannot wait to finally get this done celebrate its release.

Both the paperback and ebook versions are already starting to percolate out to various bookseller websites for pre-order.

To read more or check out an excerpt, visit https://mhnav.com/book/

Announcing: Your Mental Health Repair Manual!

Mental health awareness week is normally focused on stigma, but we can’t forget that access to quality treatment matters too… and there’s lots more work to be done on that front!

With that in mind, we’re excited to announce the upcoming launch of:

Your Mental Health Repair Manual:

An Empowering, No-Nonsense Guide to Navigating Mental Health Care and Finding Treatments That Work for You.

Pauline Lysak MD and Mark Roseman

This is the answer for all the patients, families, and healthcare providers who’ve been frustrated trying to access mental health services. Finally, the practical, real-world solutions to getting your care on track, in one easy-to-follow guide.

The book will be officially released in late November. To pre-order a copy, or to check out an excerpt, visit https://mhnav.com/book/.

Blog Reboot

As we get ready to launch our new book, it’s time to restart this blog. You’ll see a great deal of new information posted here over the coming weeks and months.

Put another way, note that everything prior to this posting was from 2014-2015, and likely somewhat out of date. We’ll keep them around, and some, like the article on ferritin and B12, are still quite popular. We don’t plan on updating them though.

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.