A survey of family doctors in Victoria highlights the challenges they face in providing mental health care to their patients. Hampered by poor access to treatment from psychiatrists or therapists, they’re overrun by the ever-increasing demand for essential care.
Victoria, like many other places in Canada, faces several intertwined mental health crises. The pandemic is exacerbating them all. We’re acutely aware of the opioid crisis and the homelessness crisis (often driven by severe mental illness and substance abuse). Recently, two young women spearheaded a Facebook Group to draw attention to concerns with Victoria’s Psychiatric Emergency Services (PES).
Access to mental health treatment is a fourth crisis. As I’ve said elsewhere, access issues compound the problems at PES. Too few people can access treatment earlier and in more appropriate settings. Far too many people end up in PES that never should have. But there are no options.
Family doctors are at the front lines of mental health care in the medical system. They’re frequently the first and often only care provider patients see. But they need the support of a robust mental health system behind them. How do they think that system is functioning?
What do family doctors think of the mental health system?
This week, Pauline and I put out an informal survey of family docs in Victoria. Most of them are referral sources for her private psychiatric practice. We feel their voice is crucial to hear.
We’re still collecting answers. But of the first ~30 responses we’ve received so far, some themes are emerging. Keep in mind, this is not a rigorous or quantitative analysis, and respondents are self-selecting.
Here’s a snapshot showing the percentage of respondents who chose each answer:
Bottom line: we’re not doing great
We first asked if the overall healthcare system meets their patients’ mental health care needs. So far, the vast majority strongly disagreed that it does. The remaining handful only disagreed. Some specific comments:
There is a crisis in mental health access in Victoria that has been worsening over the past 10 years.
Main issue is lack of resources for mental health and substance use.
Access to psychiatry is severely constrained
All respondents reported difficulty getting their patients seen by psychiatrists at all. Referrals were often rejected outright, or waiting lists were too long.
This was true both for psychiatrists through Island Health and elsewhere. Most outpatient psychiatrists in Victoria work through a handful of clinics run by Island Health. There are about a dozen in private practice.
No psychiatrists accepting referrals.
No psychiatry outpatient options.
I have essentially stopped trying to refer to community psychiatrists due to the extremely low number of available physicians. I see this, and lack of coverage for counselling, as the two largest barriers.
Even access to treatment for urgent situations (but not an emergency or crisis) has stretched to unacceptable levels. In the past, this was a matter of weeks. Family doctors noted:
Getting psychiatry consults in a timely manner when people are in crisis is very difficult (rarely happens). This places a huge burden on family doctors.
It is up to 18 months wait to see a psychiatrist (USTAT)!
Psychiatric treatment is virtually nonexistent
One particular trouble spot was that when psychiatry sees patients, it is nearly always for a one-off consultation. Actual treatment through psychiatry is frequently not available except for the very sickest patients.
It has been extremely difficult to arrange psychiatric referrals, and if accepted for assessment it is often only a one-time consultation.
Often complex patients – bipolar etc. – seen once for a consult and sent back to GP to start meds/manage. This is too complex for us.
When psychiatry is able to see a patient, it is usually just a one-time consult… followup would be very helpful as multiple medication trials or adjunct treatment are often needed to treat significant anxiety/depression.
Biggest issue is wait times and lack of followup for people with chronic mental health issues. Every time they get worse, they start over with a new care provider. Unless acutely ill, will only get one-time consult and no followup. Many people would benefit from ability to go back to same psychiatrist when ill.
In one-off consultations, psychiatrists see patients for a single visit (typically 45-60min). They then send treatment recommendations to the family doctor. Given the broad scope of topics that need to be covered, it’s tough to get through everything in that time. Interviews are tightly circumscribed. Patients must give brief, specific, and rapid answers to often profoundly personal questions in front of someone they’ve just met, with few opportunities to elaborate.
It’s hard to get an accurate picture of anyone in that single visit. Most psychiatrists who continue working with patients find their understanding improves over future sessions after gathering more information and as patient trust and rapport deepens.
Access to therapy is not much better
Nearly all survey respondents noted that a lack of accessible and affordable counsellors, psychologists, and other therapists was a major issue. Unlike doctors, fees for therapists are mostly not covered by public health insurance (MSP).
Victoria is blessed with many talented therapists. No doubt, our generally well-off populace and abundance of government jobs with excellent extended health benefits helps. Even still, increased demand from the pandemic is testing that capacity.
That still leaves many, many people without the financial resources to access this essential form of mental health treatment. There are very few no-fee or low-fee options available, and wait times can stretch several months or longer.
Lack of available counselling is the worst.
One bright spot mentioned by several family doctors was group therapy available via BCalm and the CBT Skills Group. These groups are organized and facilitated primarily by family doctors. Because they are treated as group medical visits (paid by MSP, not special funding), they require minimal or no fees from participants.
CBT skills group is a god-send!
Too Acute Patients, Too Little Time
For family doctors providing mental health care to patients themselves, two mutually reinforcing problems recur. The first is that they have to manage increasingly complex and acute problems in the primary care setting (because psychiatrists aren’t providing treatment). But that runs up against the nature of family practice – too many problems to squeeze into too short appointments.
Often takes so much time just to calm people down initially, it’s difficult to come up with a treatment course.
I spend way too long (regularly > 30min) to try to help… if a cardiac patient was as sick as my psychiatry patients they would be followed by cardiology!!
Doctors raised a smattering of other factors. Many noted that demand for mental health care (especially anxiety) has increased due to COVID-19. Financial disincentives for GP’s providing mental health care were frequently mentioned. Certain other areas, e.g., treatment for adult ADHD, also came up. Patients having poor experiences in PES was also mentioned. This list will be expanded as we collect additional survey responses.
Family doctors are stuck
All this leaves family doctors in an untenable position:
- they have an ever-increasing number of people seeking mental health care
- they are unable to access psychiatrists or therapists to assess and treat their patients
- that leaves them stuck managing patients who are too acute or complex to treat in a primary care setting
- people are coming to appointments with too many problems, all of which are time-consuming
- family doctors are unable to provide longer appointments which would be needed to make headway
Family physicians can often manage patients who respond adequately. It is the complex patients or severe patients who need treatment urgently who cannot be seen.
The family doctors who responded to our survey are clearly frustrated. They can’t provide the mental health care they’d like to without better support. Unfortunately, access to needed psychiatrists and therapists is at crisis levels in Victoria.
Patients are suffering as a result. They’re not getting the help they need. Illnesses that could be treated early instead worsen over time until emergency services are required. But that’s just the tip of the iceberg.
This survey isn’t telling us anything we haven’t all known for a long time. But at least on the ground, the problem feels to me like it’s accelerating. If we continue on this course, I’m worried about how the future will look.
Related: see all Victoria posts here