Moving Out of the Office: Removing Barriers to Access to Psychiatrists

Abstract

Our paper offers a perspective on barriers to access to psychiatric care. Research shows that access depends not simply on the total number of trained specialists but also on their kind of practice. In some large cities, some practitioners follow a small number of patients in long-term psychotherapy, a practice supported by government insurance, which places no limits on the number of sessions or treatment duration. The problem is that long-term psychotherapy, despite a rich tradition in psychiatry, is not an evidence-based treatment. This review recommends a model in which psychiatrists spend more time in consultation with primary care professionals, in acute care for patients with severe mental illness, and in briefer, more cost-effective forms of psychotherapy.

Valuable New Insights into Access to Mental Health Care Services

“…None of the items that the authors [1][2][3][4] identify as needing improvement are beyond the realm of possibility for the professions or our governments, nor are they necessarily more costly than the present services. All of the papers [1][2][3][4] highlighted the need for better information and (or) research to clarify the best practices. Again this should be seen as an essential component in improving services to get the best value.…”

“…Meanwhile, in the same larger cities that are comparatively well resourced, compared with most parts of the country, wait times for a psychiatric consultation, or an urgent consultation, are excessive, leading to overuse of emergency departments and the need for the urgent psychiatric services mentioned above. Paris et al 4 correctly point out that Canada's health care system, which provides medically necessary services, is prepared to fund these therapies provided by psychiatrists, even if there is no evidence base, but does not fund the provision of evidence-based, short-term psychotherapies often provided by psychologists, social workers, or other qualified health care providers. It is noted that Australia and the United Kingdom have made provision for the evidence-based, short-term psychotherapies.…”

The Psychiatrist as Clinical Behavioural Scientist

“…To make more effective use of their expertise, psychiatrists in the publicly funded system need to stop operating on a private practice model that provides long-term individual follow-up for a panel of patients so large that these practitioners are unable to see new patients. 4 Medication followup can be done by family doctors in consultation with psychiatrists 4 or through group medication follow-up. 23 The publicly funded mental health care system cannot afford to continue to support psychiatrists doing long-term individual therapy, particularly psychoanalytic or psychodynamic therapy.…”

“…23 The publicly funded mental health care system cannot afford to continue to support psychiatrists doing long-term individual therapy, particularly psychoanalytic or psychodynamic therapy. 4,11 Whether long-term individual psychotherapy should be an uninsured service like cosmetic surgery is open to question. 4 Preferential reimbursement through changes to fee schedules for psychiatrists with proven competence in CBT or IPT is an option, along with limiting the number of individual sessions that are reimbursed.…”

“…Poor public access to evidence-based care is the biggest current challenge for psychiatrists in Canada. [1][2][3][4] Despite a huge increase in prescriptions for antidepressants, there is no evidence that the impact of depression is decreasing, 5 suggesting an urgent need for better access to psychological treatments. 2 Psychiatrists tend to practice in ways that limit access and create a misalignment so that many people who need services do not receive them and some people who do not require specialty services have access.…”