Mental health services in Canada: Barriers and cost-effective solutions to increase access

Abstract

In this article, an overview of the barriers to accessing mental health services in Canada is provided and the recent federal funding commitments toward increasing the availability of evidence-based and cost-effective solutions to improve access to mental health services are highlighted. Barriers pertain mainly to costs, not knowing where to get help, excessive wait times, and insufficient funding. Through the Common Statement of Principles on Shared Health Priorities agreement, action is being taken by all jurisdictions in Canada to increase community-based mental health promotion programs and early interventions, especially those targeting children and youth. A growing body of evidence is demonstrating how specific community and primary care-based interventions are both effective and cost-effective. These integrated community solutions, shown to be effective for increasing access to appropriate services for patients while saving costs to the healthcare system, would benefit from the recent funding investments put in place by the federal government.

Introduction

The Government of Canada’s 2017 $5 billion investment to support increased access to mental health services¹ underlines the importance being placed on the implementation of evidence-based, cost-effective solutions. Federal funding commitments and published governmental priorities for Mental Health and Addiction (MHA) services offer opportunities for healthcare leaders to invest in promising programs and interventions shown to be effective in increasing access to services for patient populations within the community and virtually.

Barriers to accessing mental health services

Mental illness refers to a wide range of mental health conditions characterized by alterations in thinking and/or mood or behaviour associated with distress and impaired functioning.² Examples of mental illness include mood disorders, anxiety disorders, schizophrenia, eating disorders, and substance use disorders.³ While many people have mental health concerns periodically, a mental health problem becomes an illness when ongoing symptoms affect the ability to function.³ Mental health and addiction services are provided by professionals and include care through pharmacotherapy and psychotherapy.^4,5 Care can be delivered by family physicians, psychiatrists, psychologists, nurses, and other mental health providers in hospitals or in the community.⁴ The focus of this review is not on the population use of pharmacotherapy but rather on preventive and risk-mitigating interventions that can increase access to services. The disorders that can be addressed through MHA services range from mild and moderate conditions, including depression, anxiety, and substance abuse disorders, to severe conditions such as psychoses.⁶

There exists a well-documented need for MHA services in Canada. In 2018, an estimated 5.3 million Canadians reported they needed help for their mental health in the previous year.⁷ Of these 5.3 million people, 1.2 million reported that their needs were only partially met (22%) and 1.1 million (21%) reported that their needs were fully unmet.⁷ The need for medication was most likely to be met (85%), while the need for counselling was the most likely to be unmet (34% reported counselling need was unmet).⁷ Furthermore, access to services is limited by long wait times for primary and/or psychiatric care, as well as community care that is often not integrated with healthcare services.^8
–10

Documented barriers to accessing MHA services across Canada include not knowing where to go for help,^7,11 long wait times,^9,10 shortage of accessible mental health professionals,⁹ lack of mental health service integration and government oversight,¹¹ culture and language barriers,⁹ concerns about stigma,¹² inequities due to geography or demographics (eg, youth, rural communities, and Indigenous populations),^4,9 and cost of services not covered by private insurance plans (eg, coverage typically ranges from only $400 to $1,500 annually, covering only 2-8 therapy sessions).^9,13 Of the 2.3 million Canadians who reported unmet or partially met mental healthcare needs, the most frequently reported barriers were related to personal circumstances (78.2%), such as not knowing where to get help, being too busy, or not being able to pay for services.⁷ Canadians collectively spend $950 million annually on private practice psychotherapists for mental illness, and 30% of Canadians pay out of pocket for these services.⁹ Stigma continues to be a barrier as Canadians with mental health needs report being uncomfortable talking about their problems in general or feel devalued by health professionals.^7,12 Finally, Canadians living in rural areas have a severe lack of access to mental health services.⁴

High demands for care and barriers to accessing services within the community are contributing to Emergency Department (ED) overcrowding across the country. A 75% increase in the number of mental health-related ED visits by children and youth aged 5-24 years has been reported since 2006/2007.⁴ Additionally, in 2013/2014, 39% of children and youth who visited the ED for a mental disorder had 3 or more ED visits.⁴ These repeated ED visits point to the access challenges and gaps in community care.⁴ It is also noteworthy that in the ED, young adults between the ages of 20 and 29 years use the most resources, as measured by total length of stay (hours).⁴ Better access to mental health services outside the ED would not only benefit people with mental health conditions but the healthcare system at large.

Nevertheless, in an outpatient setting, wait times for counselling and therapy are generally too long for effective care when it is needed most, especially for children and youth. In Ontario, wait times of 6 months to 1 year are common.¹⁴ In 2017, in Ontario alone, 12,000 children and youth were reported to be waiting up to 2.5 years for services, with an average wait time for intensive treatment of 92 days.¹⁰ An underfunding of community-based mental health services and a reliance on high-cost services like the ED or hard-to-access psychiatrists are part of the causes of these long wait times.^8,15 Indeed, accessing mental health services in the community could be much more effective than accessing them in the ED. Up to 80% of Canadians already rely on their family physician to meet their mental health needs,⁹ but only 23% of family doctors report feeling well prepared for severe mental health problems.⁴ Evidence-based mental healthcare, such as psychotherapy, provided by allied health professionals is the foundation of the mental health response in Organisation for Economic Co-operation and Development (OECD) countries other than Canada.^15,16 However, as allied health professionals in Canada cannot typically bill for psychotherapy under Medicare,^9,16 access to mental healthcare may be limited by wait times for psychiatrists.

These barriers contribute to the already high healthcare costs. Indeed, mental illness and mental health problems cost the Canadian economy $51 billion annually in healthcare costs, lost productivity, and reduced quality of life.^6,14 As such, barriers to accessing appropriate care should receive proportionate attention. Lack of sufficient funding has been highlighted as a key barrier to mental health service delivery.^9,14 In 2015, Canada spent $15.8 billion on mental health (public and private sector), and this was just 7% of Canada’s total health spending.⁶ In comparison, in England, mental health constituted 13% of total healthcare expenditure in 2014, and in France constituted 15% in 2017.⁴ The Mental Health Commission of Canada recommends raising health spending for mental health to 9% by 2022.⁴ This is desperately needed, as relative to the 13% burden of disease imposed by mental and behavioural disorders in Canada, care for these conditions is underfunded by an estimated $3.1 billion.^17,18

Governmental commitments to addressing barriers to accessing mental health services

Federal priorities and commitments to increase access

Federal governments have made clear efforts to increase access to mental health services. In 2007, the Mental Health Commission of Canada was created to help to identify areas of need. Recently, in 2017, the Federal Government committed $5 billion over 10 years to support mental health services.¹ Subsequently, Budget 2019 articulated a commitment of $25 million to support the development and implementation of a phone/technology-based Pan-Canadian Suicide Prevention Service.¹⁹

The need to address the increased demands for mental health services were captured in 2017 by the Common Statement of Principle on Shared Health Priorities, an agreement made between the provinces and territories and the federal government to respond to the pressing health needs of Canadians.^20,21 Bilateral funding agreements set out how each jurisdiction uses the federal funding earmarked for mental health services in Budget 2017.²⁰ The Common Statement of Principle affirms that health ministers will work together to improve access to evidence-based MHA services, mainly through expansion and integration of community-based services for children and youth (ages 10-25 years).²¹

To track progress, the health ministers have agreed to work with the Canadian Institute for Health Information (CIHI) to develop a set of 6 common indicators, which would be reported on annually, for assessing pan-Canadian progress on agreed priorities for MHAs specifically.²² Standardized indicators will enable consistent tracking of progress across different regions in key interest areas, such as early interventions for youth.²² In May 2019, CIHI released 3 new indicators based on the Shared Health Priorities agreement.²² Two of these indicators were chosen specifically to measure access to MHA services: (1) tracking ED use for help with mental health and/or addictions and (2) tracking hospital stays for harm caused by substance use.²²

Provincial/territorial priorities and commitments to increased access

Likewise, the provinces and territories are implementing strategic plans to improve access to mental health professionals by increasing the supply of mental health workers, including providers for specialized needs, and using virtual technologies to overcome geographic barriers.⁴ New funding commitments supplementing federal investments have also been made by provinces, including British Columbia (BC), Ontario, and Quebec, to increase access to mental health services. Ontario’s Budget 2019 announced an investment of $3.8 billion for mental health, addictions, and housing supports over 10 years, focused on creating an integrated MHAs system.²³ The government of Quebec committed $261.4 million in its 2020/2021 Budget to expand mental health services by 2024-2025.²⁴ In its 2019 Budget, BC committed $74 million over 3 years to enhance access to MHA services with a focus on early interventions for children and young adults.²⁵ These financial investments demonstrate explicit recognition, on the part of federal, provincial, and territorial governments, of the need to expand access to community-based MHA services and to promote early interventions.²¹

System restructuring: Solutions and interventions to increase access

With the growing demand for mental health services and associated high costs to Canada’s healthcare system, there is an urgent need for cost-efficient delivery approaches, particularly for youth and remote populations.^4,6,13 There exist evidence-based programs designed to improve outcomes through increased access to MHA services, while providing a return on government investment by reducing health system costs associated with related health complications and less efficient service delivery options.⁶ Examples include community-based service delivery, expanding access to psychotherapy, and e-mental health interventions that have been shown to effectively improve access and system efficiency.

Solutions to increase access to services

Programs that offer services at the primary and community care levels have been shown to be effective in improving access and delivering early interventions while also yielding returns on investment; importantly, they show promise for improving delivery of mental healthcare to priority populations (ie, children and youth) through stepped care models.^6,11,26 Community-based mental health delivery and stepped care models can reduce wait times and increase access to mental health services by coordinating care.^6,27 Up to 80% of Canadians already rely on their family doctor for mental health needs,⁹ and primary care can provide quality assessments and treatments to most people with mental health needs.⁶ Only 1.5% of the population with a mental health disorder requires access to specialty care.⁶ Furthermore, integration of psychotherapy into primary care could result in a 20% to 30% decrease in medical costs.²⁸ Appropriate training for primary care practitioners and including allied health professional services in health insurance plans would allow primary, allied health, and community care providers to deliver early interventions, thereby accelerating access to care for the majority of people with mild-to-moderate mental illnesses while reducing system costs.^6,16,28

About 38% of Canadians with a mental health concern or substance use disorder reported that their symptoms started before the age of 15.⁴ As most mental health problems and illnesses begin in childhood or adolescence, early interventions delivered through primary prevention and primary care can prevent delays in receiving care and thereby also yield significant returns on investment.^6,29 Indeed, scaling up early interventions and mental health promotion has been identified as key to reducing the burden of disease and containing public costs.^6,14 For example, Ontario has created a Centre of Excellence for Child and Youth Mental Health³⁰ focused on continuously improving primary care pathways (ie, creating a better connection and continuum of care between primary care and community-based mental health supports) for children and youth, ensuring earlier intervention and a system that is easy to navigate.³¹

Expanding access to psychotherapy is another evidence-based solution to overcoming the barriers to mental health services. Psychotherapy can improve quality of life, and evidence shows that, in Canada, every dollar invested in psychotherapy would save two dollars to society.³² Models implemented in England and Australia have already demonstrated the cost-effectiveness of expanding access to psychotherapy services.³³ England, for example, implemented a grant-based program for funding the expansion of psychotherapy to its population,^17,33 while an insurance-based expansion model tested in Australia³³ has been shown to increase access to psychotherapy while reducing wait times.

The grant-based Improving Access to Psychological Therapies (IAPT) program piloted in the England has seen success, and similar programs are now being implemented in Ontario, Quebec, and BC. Through the IAPT’s stepped care pathway,¹⁶ clients participating in the program experienced a significant improvement in their mental health, for both common and severe illness, with 52% of clinical cases meeting the target for clinical recovery in 2018/2019.^17,34 In March 2020, Ontario released its “Roadmap to Wellness,” outlining plans to use the 2017 federal funding to implement its new program, “Mindability,” an in-person/virtually accessible stepped care model, based on the UK program.¹¹ Quebec is also implementing a new psychotherapy access program based on IAPT principles and clinical benchmarks.³⁵ Similarly, BC is building an integrated care network with a “tiered clinical framework” to increase primary care’s ability to respond early to prevalent mental disorders through interventions such as psychotherapy and Internet-based Cognitive Behavioural Therapy (iCBT).^9,26,36 British Columbia is evaluating the feasibility of increased publicly funded psychotherapy, while “Mindability” will be offered free to those who need it under the Ontario Health Insurance Program.^11,26 Expected outcomes include increased access to mental health services and a lower number of ED admissions.¹¹

E-mental health initiatives are expanding across Canada and show promising results in terms of increasing access to mental health services. Newfoundland’s piloted Stepped Care 2.0 program has been shown to be effective in combining in-person counselling with distance technologies to deliver mental health services with an extended geographic reach.^27,36 The program integrates a stepped-care model with e-mental health modules.^27,36 New virtual care solutions to response to the mental health implications of the COVID-19 pandemic have also appeared; in addition to provinces providing billing codes for virtual care, the Vancouver-based company Starling Minds is providing free access to its iCBT platform.³⁷ As Canada’s demand for mental health services increases, e-mental health solutions extend access points for those seeking care, particularly for those living in rural and remote communities.³⁸

Responding to unexpected challenges and increased demands for mental health services

Unexpected challenges, such as the emergence of a novel coronavirus (COVID-19) and its rapid global spread, have placed an overwhelming demand on health services, including mental health services, in 2020. The result of school closures and reduced access to community resources, in addition to social isolation, greatly increased the demand for on-line counselling services and virtual care.³⁹ In response, the federal government quickly committed $7.5 million to Kids Help Phone.³⁹ Provincial governments across Canada also introduced temporary billing codes for virtual visits.^40
-42 These rapid reactions were facilitated by the relatively recent commitments and investments in mental health services, although it remains to be seen whether these efforts will be enough to meet the increased demands. We may be able to learn more from China, one of the hardest hit countries by the outbreak, which implemented emergency psychological crisis interventions to reduce the negative psychosocial impacts on public mental health.⁴³ The COVID-19 pandemic, among its many lessons, taught us about the need for better integration of the Mental Health System into public health preparedness and emergency response plans.

Conclusion

The international and Canadian evidence base reviewed here demonstrates that community and primary care-based mental health promotion programs and interventions improve access to care and thus produce greater value to patients and save costs to the healthcare system.⁶ The importance of virtual care has been further emphasized in the face of the COVID-19 pandemic. As the level of reported mental health problems and illness continues to rise, it is imperative for health leaders to be aware of the changes that are necessary to modernize the mental health system to improve mental health outcomes through efficient, value-based solutions, as well as to advocate for financial investments and sharing of best practices. Additionally, mental health response protocols should be formally integrated into public health preparedness and emergency response plans.

With clear strategic plans for all jurisdictions, the development of community-based and e-mental health solutions is underway across Canada. To support these developments, detailed program evaluation across Canada and inter-jurisdictional benchmarking and comparisons of mental health service delivery programs will be of vital importance moving forwards. Based on mental health system action plans and recommendations outlined in Canadian MHA strategies^11,26 and in policy documents,^9,16 this last section proposes how health leaders should consider using the current federal funding to support a mental health system change:

Allocate funding to support the scaling-up of cost-effective service delivery interventions, including increasing access to psychotherapy and e-mental health solutions such as Stepped Care 2.0 and iCBT. Additionally, improve access and mental health service delivery by including psychotherapy delivered by allied health professionals in public insurance plans to enable them to bill under Medicare in Canada.

Allocate funding to strengthen management and evaluation of the new programs and strategies that are being implemented across Canada. As new MHA plans and systems develop and expand across Canada, close coordination of these services to improve access to care must be ensured. Ontario, for example, is creating a “Mental Health and Addictions Centre of Excellence,” an institution that will specifically provide system management, service coordination, and continuous quality improvement for Ontario’s new MHAs system, enabling a more consistent patient experience.¹¹ On a national level, while the pan-Canadian mental health indicator development led by CIHI is promising, the 6 outlined indicators may not be enough to track in-depth provincial details regarding system management and service delivery. Comprehensive and well-funded program evaluation, such as that seen with England’s IAPT program, is needed to track the number of people who successfully reach clinical benchmarks and to clearly outline success in terms of cost-effectiveness and benefits to public health. Investment in program evaluation is needed to identify successful program components in Canada as well as areas in need of further investment, including opportunities to scale up activities/programs that show promise of positive impact across Canada’s diverse populations.

In line with the previous point, as similar mental health system updates and plans are being implemented across multiple jurisdictions, there is a need to consider and allocate funding towards establishing a centralized national body to evaluate the mental health programs being implemented across Canada, similar to IAPT in England.

A growing interest in and use of telehealth during the COVID-19 global pandemic necessitates increased investments in digital health and digital tools like smartphone applications to enable access to high-quality mental healthcare. The success of telehealth in the management of the present crisis and the mental health spike expected to follow require allocation of funding into workforce training, generating high-quality evidence of effectiveness of these technologies, and ensuring digital equity, among other factors. Harnessing the current surge in interest, enthusiasm, and acceptance of digital mental health services provides a unique opportunity to advance the field rapidly.

Footnotes

Authors’ note

Research ethics board approval was not needed as no human/animal subjects participated in this study.

Acknowledgments

The authors would like to acknowledge Isabelle Gagnon-Arpin, Charles Boyer, and Dr. Bill Howatt for their reviews of earlier drafts of this article as well as Value-Based Healthcare (VBHC) Canada for supporting the Conference Board of Canada’s health policy research agenda.

ORCID iD

Nicholas Moroz

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