Treatment inaccessible to many

What if your treatment for a chronic condition like diabetes or asthma was dependent upon where you worked? If you had benefits, or could afford to pay out of pocket, you could access a variety of treatments. If not, your options would be limited to two. In Canada we don’t accept this situation for physical ailments, but for mental illnesses such as depression or anxiety, we do, says Dr. Patrick Smith, CEO of Canadian Mental Health Association.

“With antidepressants and anti-anxiety medications, a physician has two separate toolboxes to consider for their patients – one if they can pay, and another if they can’t,” says Dr. Smith.

Dr. Patrick Smith CEO of Canadian Mental Health Association

One of these toolboxes contains drugs and other treatments covered by universal health care – all Canadians can access these. The other toolbox is for medications deemed safe and effective in Canada and in other G7 countries, but which are not covered. Medications are sorted into each toolbox by the Canadian Agency for Drugs and Technologies in Health (CADTH). CADTH decides which to approve for provincial basic-coverage lists. Since 2004, 100 per cent of new antidepressants have fallen short of this final approval, according to a 2017 Canadian Health Policy report. (By comparison, about 50 per cent of drugs for physical conditions have been approved.) Other interventions such as psychotherapy and counselling are rarely covered, unless tied to a long waiting list.

“This isn’t an issue where we just don’t have good treatments for mental health conditions,” says Dr. Smith. “The jury is in. Evidence shows that treatments for mental illness are equally effective as treatments for other chronic conditions. All of those treatments should be available and covered just like any other chronic illness.”

Dr. Smith adds that the funded treatments are not inferior to the non-subsidized ones; each medication has its own strengths and weaknesses in terms of side-effects and symptoms targeted. A patient may be successful on one of the approved drugs and never need to try others. Other people may need to try many before finding just the right type and dosage that works for them. The inequality stems from the number of options available. Those without coverage may have only a few, while those with more coverage may have more than 10 to choose from – as well as cognitive behavioural therapy (CBT), psychotherapy and other community- based services and supports.

Other G7 countries offer these treatments as standard. In the UK, for instance, the “Bounce Back” program allows people to access a structured counselling intervention based on CBT in-person, online or over the phone.

“[The program] was found to drastically improve outcomes, improve access for thousands more people, and decrease costs and wait times in physician offices,” says Dr. Smith.

Unfortunately, the public’s perception that antidepressants are overprescribed in North America is true – but not for the reason many people think. Coverage is the reason, not uncaring physicians.

“If you know that your patient cannot pay for CBT, you may prescribe antidepressants because that’s all you have available,” he explains. “You steer toward what is covered.”

In fact, medication is the best option for some people, but the criteria for discovering one’s best option should be personal experience with symptoms and side-effects, argues Dr. Smith, not one’s bank balance or place of employment. As well, making more evidence-based treatments financially accessible to everyone is likely to result in earlier diagnosis and preventive measures as more people report symptoms sooner.

“When it comes to mental health, we have a scarcity mentality because of lack of resources, and it’s like we wait until Stage 4,” says Dr. Smith. “If someone has Stage 1 cancer, you treat, because you have better outcomes. That’s what we want to do with mental health issues, including depression and anxiety. Let’s not wait until it’s so bad that you’re in crisis.”


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