From the Editor
“Mental health is out of the closet. Now that we’ve opened the door, time for a closer look at what’s been out of sight for so long.”
This week, we consider three selections. They appeared in newspapers in recent days, and discuss mental health topics. The opening quotation – which is from the first essay – applies to all of them; a closer look: calls for more debate about how mental health services are organized, the care that patients are offered, and the way mental illness is portrayed in our culture.
In our first selection, we consider an op ed from Toronto Star columnist Martin Regg Cohn. He wonders about improving access to mental health care. In a provocative essay, he mulls the mismatch between the supply and demand of services (particularly psychiatric services). He argues: “We might as well accept that our mental health spending will increase significantly over the years. All the more reason to start reallocating funds wisely now.”
In the second selection, we look at an essay by Dr. Mariam Alexander, an NHS psychiatrist, who discusses ECT. She opens simply: “It might come as quite a surprise to learn that, as a psychiatrist, if I ever had the misfortune to develop severe depression, my treatment of choice would be electroconvulsive therapy (ECT).”
And in our third selection, the University of Toronto’s Dr. Mark Sinyor considers the popular show “13 Reasons Why” and offers a cautionary note about the portrayal of suicide. The LA Times op ed notes that Netflix and others have “the potential to do good in the world when handling sensitive mental health issues.”
Selection 1: “Mental health reform in Ontario is no easy matter”
Martin Regg Cohn
Toronto Star, 24 July 2019
Mental health is out of the closet.
Now that we’ve opened the door, time for a closer look at what’s been out of sight for so long.
Yes, the stigma has faded, but traditional barriers to treatment are only getting worse.
To understand the gap, consider how efficient our public health care system has become at treating physical versus psychological conditions.
Thanks to medicare, no one with a physical ailment goes untreated (and almost no one gets special treatment). If waiting lists grow too long, the public complains, the press clamours for action, physicians cry foul and politicians swing into action.
Mental health, however, is still a different story.
So begins an essay by Toronto Star columnist Martin Regg Cohn. He talks about problems with access and mulls their root causes:
First, the availability of psychiatrists is skewed by both geography and demography. Many of these specialists are concentrated in the big cities, and are closer to retirement age than other physicians, suggesting the current shortage will become even more acute in outlying areas.
Second, we will witness an explosion in demand as people who once suffered in silence find their voices, seeking the treatment they need and deserve. One in five Canadians suffers from mental illness, but barely one in three of them currently seek help — a proportion that is bound to change as attitudes shift.
Third, mental distress typically takes longer to treat than physical trauma. Medicare is magnificent at fixing a broken leg as a one-off, at a fixed cost; our public health system isn’t quite so proficient at treating a mood disorder that can be a lifetime challenge, requiring continued followup.
While the head of the Ontario Psychiatric Association “insists that time spent with a patient should be left entirely to a doctor’s discretion,” Cohn cautions against that approach: “[I]n a publicly funded health care system, where the most effective treatments must be scaled up to deal with rising demand based on empirically proven metrics, how much time is too much time – and money?”
He goes on to conclude:
Part of the solution is leveraging our limited number of psychiatrists in the most medically effective (and cost-effective) manner. One way is to encourage them to offer consultations, overseeing and conferring with teams of other practitioners – such as psychologists, social workers, nurses and addiction counsellors – trained in life-saving and life-changing therapy. In the same way that OHIP now pays nurse-practitioners and pharmacists to deliver services once reserved for physicians, it should extend the fee schedule to other providers.
Cohn’s argument is coherent, but it is controversial, touching on the way we compensate and organize (or don’t organize) psychiatric services.
For those looking for further thoughts on compensation and psychiatric services, see these two op eds:
And Dr. Doidge’s essay, the first published on the topic, was considered in a past Reading, as was response to his argument.
Selection 2: “As a psychiatrist, if I had severe depression I’d choose ECT”
The Guardian, 22 July 2019
It might come as quite a surprise to learn that, as a psychiatrist, if I ever had the misfortune to develop severe depression, my treatment of choice would be electroconvulsive therapy (ECT). Why? Well, to put it simply, ECT is the most rapid treatment for severe depression that we currently have to offer – with a recent study in the BMJ highlighting its effectiveness.
So begins an essay by Dr. Alexander, who practices in the UK’s NHS.
She comments about the stigma around ECT:
It’s almost impossible to discuss ECT without the word ‘barbaric’ being used. For anyone who is familiar with the psychiatric era of One Flew Over the Cuckoo’s Nest, this is understandable. But things have moved on a great deal since then. Indeed, if you’re looking for a ‘b’ word to describe the process of contemporary ECT, top of my list would be ‘boring’ – the use of a general anaesthetic and muscle relaxant means there’s probably more drama involved in having a filling than ECT.
But she advocates for the procedure strongly:
Most people would be totally opposed to the idea of a surgeon amputating their leg. However, if there was an infection rapidly rising from their foot and an amputation was the best option to save their life, I suspect most people would then see it as a necessity. Context is key.
In liaison psychiatry, we see individuals so severely depressed that they have become catatonic – a state that means they may be unable to move, speak or eat. Admission to a medical ward is required in order to give nutrition via a nasogastric tube and medication to reduce the risk of dangerous blood clots forming due to immobility – seeing one of these patients, you’d be forgiven for thinking that the reason for admission was stroke rather than depression… I have seen many people in a catatonic state respond really well to ECT. Sometimes, in just a couple of treatments, they go from being speechless and immobile to talking and walking – it’s amazing to witness.
To a psychiatrist, Dr. Alexander’s arguments aren’t particularly surprising. But interest in ECT wanes. A Canadian Journal of Psychiatry paper that found that ECT volume was down by a third over 15 years in Quebec. With that in mind, this Guardian essay may be important to share with patients and their families.
For more on ECT, see these past Readings; the second considers the CJP paper mentioned above:
Selection 3: “Deleting the graphic suicide scene won’t fix what’s wrong with ‘13 Reasons Why’”
Los Angeles Times, 25 July 2019
Two years after the series ‘13 Reasons Why’ debuted, Netflix has finally edited out a graphic and highly controversial suicide scene. The network deserves some credit for deleting the on-camera suicide of a teenage girl, Hannah Baker, who remains a central character of the show even in death. But her suicide never should have been shown in the first place.
So begins a new essay by Dr. Mark Sinyor of the University of Toronto.
Dr. Sinyor draws from the literature in criticizing the popular Netflix show.
- “A study my colleagues and I recently publish in the journal JAMA Psychiatry showed that suicides increased in the U.S. among those from age 10 to 19 in the three months following the show’s release, when interest in ‘13 Reasons’ was at its highest. The sudden increase occurred only among youths, and it was particularly pronounced among young women.”
- “Another study, published in April in an adolescent psychiatry journal, found that suicide rates spiked among boys between ages 10 and 17 in the month after the show was first released.”
He goes on to conclude:
Netflix and other content providers have the potential to do good in the world when handling sensitive mental health issues – if they adhere to safe and responsible practices. That means they must avoid showing suicide as inevitable or in a positive light and instead present the reality: Treatment saves lives and people who contemplate suicide almost always find other ways of coping.
It’s exciting to see mental health topics discussed more openly – including in our shows and movies. Dr. Sinyor, though, raises important points about the right way to discuss suicide.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.