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Rationing Mental Health Care, Part One.

Posted on | by mark

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

Posted on | by mark

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

Posted on | by mark

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

Posted on | by mark | 2 Comments on 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.