Valuable New Insights into Access to Mental Health Care Services

The 4 papers in this month’s issue of The Canadian Journal of Psychiatry offer significant commentary on access to and availability of mental health care.1–4 The first paper, an Original Research paper by Daniel Poremski and coauthors,1 uses data from the homeless population with mental illness in the At-Home/Chez Soi study, from 5 Canadian centres, and includes a representative sample of over 2000 participants. Unemployment at all sites was over 90%, but the proportion that wanted to work was between 61% and 83%. Just over one-quarter of the sample relied exclusively on welfare for income, and slightly less than one-half received disability benefits—28% received neither. At all sites, most participants had an income between $200 and $1000 below the low-income threshold. Many of these homeless people with mental illness were not—for various reasons—accessing disability benefits for which they might have been eligible or able to receive much assistance in finding employment where they desired it. As such a high proportion are living on extremely low incomes, anything approaching a healthy lifestyle and diet is probably not possible. It is not surprising that many of the studies of people with psychoses show significantly increased mortality and reduced life expectancy, and that this population does not receive adequate general medical care. How much of these problems are related to deinstitutionalization is speculative, but surely we can improve the clinical and social services for this group. The second Original Research paper, by Sara Ling and coauthors,2 uses patient self-reports of their experience of restraint use while in hospital. This is a qualitative study of a limited number of patients in a single institution. It is not accompanied by any reports from staff about the problems that led to the use of restraint (chemical, physical, or seclusion). Patients frequently reported that they did not like the loss of autonomy, they did not feel that staff heard them or that their problems were addressed in a timely fashion, and that they lost trust in staff and in the treatment program. The study has many gaps in trying to overview the use of restraint in psychiatric settings. The type of restraint used in each case, who can order restraint, which type and for how long, and how frequent the review must be were not specified. The use of restraints has been a topic in psychiatry since before the reformers, such as Pinel in France, the Tukes in England, and Rush in the United States, cast off the chains. Mental hospitals used to pride themselves on being able to drastically reduce or even eliminate the use of physical restraints. Frequent review of any patient in restraint (with documentation) tends to reduce its use, as does having to get only a senior staff member to order it. In many cases, it seems that a more comprehensive conversation with the patient and understanding of their difficulties could preclude the use of restraints. A comment is made in the report2 that suggests that the acuity on the unit may be related to the use of restraints and also to the crowding, which may limit the possibility of a patient being able to seek privacy and quiet time on their own. Some of these comments2 seem to harken back to those made by the reformers of 200 years ago. The report does not contain any information about the level of observation on patients who are under some form of restraint, yet this can be important for safety, as several coroners’ reports have investigated deaths of patients while physically or chemically restrained and have been critical of the procedures. There are many reports about increasing acuity on general hospital psychiatric units, as the availability of beds has decreased, leading to only the most severely ill patients being admitted. If this is associated with low or reduced staffing, particularly when those staff are relatively inexperienced or unskilled, then there is likely to be a concomitant increase in the use of restraint of various kinds. The third paper, a Systematic Review by Nadiya Sunderji and coauthors,3 offers what the authors call a scoping review of urgent psychiatric services. I understand a scoping review to be a rapid gathering of the evidence to map the current state in a given field. This the authors do admirably. The problem is the paucity of the evidence to support the adoption of the widespread practice of providing urgent care services. Nevertheless, it is clear that urgent services are developed because the usual services fail to meet a need for urgent access. It is also clear that this is a widespread problem. The limited studies that do exist, despite methodological issues, generally support the urgent service being described. There are several studies from Britain on crisis services, which reach generally similar conclusions. Sunderji et al3 and the authors of these British studies clearly recommend that the gap in research and evaluation for urgent crisis services should receive attention. Sunderji et al3 reference the Canadian Psychiatric Association’s 2006 policy paper entitled “Wait Time Benchmarks for Patients With Serious Psychiatric Illnesses.”5 This policy paper states that patients referred with urgent psychiatric conditions should be seen by a psychiatrist within 1 or 2 weeks, depending on the condition. The same guidelines also recommended that a psychiatrist should see emergent cases within 24 hours. The last paper, a Perspective by Joel Paris and coauthors,4 reviews some of the aspects of psychiatric practice in Canada’s largest cities, pointing out that an unspecified proportion of the psychiatric resources are devoted to providing long-term psychotherapy, a treatment modality unsupported by evidence. 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 al4 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. Paris et al do not mention the need for long-term, often close, multidisciplinary follow-up of patients with chronic psychoses for which there is ample evidence. These 4 papers1–4 provide useful and needed insight into different aspects of the delivery of mental health care in Canada and some of the problems in ensuring that adequate, timely services are available to the people who need them the most. It should also be clear that the services needed are not only clinical psychiatry services but also that they encompass a much broader spectrum, including housing, income support, employment, and timely access to urgent services, and, moreover, that they include aspects of how patients are managed within a hospital. None of the items that the authors1–4 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 papers1–4 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.

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