From the Editor

As we start 2018, additional funding for mental health care is widely discussed.

But what are current funding levels? How have they changed over the past decade? Which provinces are funding more and which are funding less? A new paper just published by The Canadian Journal of Psychiatry attempts to answer these questions. While the paper looks at different aspects of funding, it reaches a surprising conclusion: between 2003 and 2013, “the percentage of mental health costs with respect to total provincial public health care expenditures decreased overall…”

In this Reading, we review that paper and consider the broader implications.

In the second selection, we consider the life and contributions of Dr. Jimmie Holland, who recently passed. Dr. Holland has been called the “mother” of psycho-oncology.



Provincial Spending and Mental Health

Public Expenditures for Mental Health Services in Canadian Provinces”

Jian Wang, Philip Jacobs, Arto Ohinmaa, Anne Dezetter, and Alain Lesage

The Canadian Journal of Psychiatry, 11 December 2017  (Online First)

According to the Canadian Community Health Survey–Mental Health component, conducted by Statistics Canada in 2012, 10.1% or approximately 2.8 million Canadians aged 15 and older experienced at least 1 mental or substance use disorder, including depression, bipolar disorder, generalized anxiety disorder, or alcohol, cannabis, or substance abuse or dependence, in the 12 months prior to the survey. Statistics from the Mental Health Commission of Canada (MHCC) revealed that more than 6.7 million people in Canada are currently living with a mental disorder or illness. Even though a number of public services and programs that target this group are provided with funding from a range of health and nonhealth ministries, the magnitude of the expenditures is seldom estimated.

In an article in the Canadian Journal of Psychiatry in 2008, a wide variety of mental health costs per person and mental health expenditures as a percentage of total health expenditures were reported for the provinces. Jacobs et al. reported that total public and private mental health expenditures in Canada in 2003-2004 amounted to $6.6 billion, of which $5.5 billion was from public sources. Furthermore, public mental health expenditures, a widely used indicator of mental health service availability, was about 6% of the total public health expenditures, with wide variations occurring between the provinces. In the interceding years, a great deal of attention was paid to this issue in reports by the Senate of Canada, the Parliament, and the MHCC. Nevertheless, any policies or programs to promote mental health were left to be implemented by each province. In this article, we consider the publicly funded health care costs associated with mental illness a decade after Jacobs et al. (fiscal year [FY] 2003) estimated expenditures for publicly funded mental health services. We consider data for FY 2013, the most recent year for which data are available, and compare the estimates to those of FY 2003.

Jian Wang

So begins a paper by Wang et al.

Here’s what they did:

  • Drawing on national databases (largely through CIHI), they collected data for several types of expenditures: general hospital, psychiatric hospital, total clinical payments to physicians, community mental health centers, and pharmaceutical services. (Drug spending data was from IMS Health Canada.)
  • Because of uneven provincial reporting, “expenditures for community mental health are missing from our analysis.”
  • Expenditure data was adjusted for inflation using the provincial Consumer Price Index.
  • Statistical analyses were done, with expenditures for mental health services expressed per capita and as percentages of total provincial health spending.

Here’s what they found:

  • “Total public spending for the included mental health and addiction programs/services was estimated to be $6.75 billion.”
  • “Of the estimated spending on mental health services, the largest costs were in hospitalization ($4.02 billion, 59.6%), clinical payments ($1.69 billion, 25%), and then prescribed psychotherapeutic medications ($1.04 billion, 15.4%).”
  • “Overall, inflation-adjusted mental health service costs per capita increased from $135.2 to $192.7 over the 10-year period. The increase varied across provinces, with New Brunswick having the largest, due to increases in hospitalization costs.”
  • “From 2003 to 2013, mental health–related hospital inpatient costs in Canada substantially increased from $70.4 to $104.2 per capita… moreover, the proportion of inpatient costs to total public mental health costs increased by $1.335 billion to 58.1% in 2013.”
  • “[M]ental health services amounted to 4.9% of provincial government health expenditures in FY 2013, compared to 5.4% in FY 2003. Only New Brunswick had an increase, owing to its large increase in mental health hospitalizations.” See figure below.


They go on to note:

We measured provincial publicly funded mental health care services for FY 2013, including inpatient services provided by general and psychiatric hospitals, costs of consultations provided by psychiatrists under fee-for-service or alternative payment plans, and prescribed psychotherapeutic medications. Our results during FY 2003 and FY 2013 show that the inflation-adjusted dollar value of public mental health services increased from $135.1 to $192.7 per person. Nevertheless, the percentage of mental health costs with respect to total provincial public health care expenditures decreased overall for the same period, as a national average, from 5.4% to 4.9%.

A few thoughts:

  1. This is a good paper.
  1. The numbers add nicely to our understanding of national health spending.
  1. Of course, there are limitations to the work. First and foremost: the lack of inclusion of community mental health programs.
  1. We also need to consider the broader context. Here are national health expenditures over that period (source: CIHI).

(Note that total health expenditure includes private spending.) Still, the pattern is clear: while all spending is up, public mental health spending is (relatively speaking) down slightly.

  1. There are many unanswered questions. This paper looked at funding – but what about outcomes? Do people in New Brunswick get significantly better care than those in neighbouring Nova Scotia? How does care (in terms of outcomes) compare in Saskatchewan and Manitoba – two prairie provinces with very different funding stories.


The Life and Career of Jimmie Holland

“Founder, ‘Mother’ of Psycho-Oncology, Jimmie Holland Dies”

Megan Brooks

Medscape, 28 December 2017

Jimmie C. Holland, MD, known internationally as the founder of the subspecialty field of psycho-oncology, died suddenly on December 24 at age 89.

Dr Holland was an attending psychiatrist and Wayne E Chapman Chair in Psychiatric Oncology at Memorial Sloan Kettering Cancer Center (MSK) in New York City. She was the first chair of MSK’s Department of Psychiatry & Behavioral Sciences. She was also professor of psychiatry at Weill Medical College of Cornell University in New York City.

“Jimmie was a pioneer in the truest sense,” William Breitbart, MD, chairman, Department of Psychiatry & Behavioral Sciences at MSK, told Medscape Medical News.

“With colleagues, she established a full-time psychiatry service at Memorial Sloan Kettering in 1977 — one of the first of its kind in the field of oncology — and served as its chief from then until 1996. She then became chair of the newly formed Department of Psychiatry and served in that role until 2003. In the interim she founded the American Psychosocial Oncology Society, the International Psycho-Oncology Society, and the international journal Psycho-Oncology,” noted Dr Breitbart.

“We’ve lost a remarkable woman; a once-in-a-generation influencer,” he added.

Jimmie Holland

So begins a short article by Megan Brooks describing* the life of Dr. Jimmie Holland.

Dr. Holland was born in Nevada, Texas, in 1928. She received her medical degree from Baylor College of Medicine. She served on many national committees for the American Cancer Society and the National Cancer Institute.

The article notes her many contributions:

  • “She conducted some of the first studies on the psychological impact of cancer on patients and showed that interventions to address cancer-related anxiety and depression are helpful.”
  • “In 2000, she published a book for patients titled The Human Side of Cancer.”
  • “[She] played a key role in development of the NCCN Distress Thermometer and Problem List for Patients, a psychosocial distress-screening tool that measures a patient’s distress level and helps identify those who would benefit from referral to a mental healthcare specialist and closer monitoring.”

UHN’s Dr. Gary Rodin is quoted: “Jimmie was a role model and a hero to generations of women and men in supportive care  — and her legacy of compassion, humanity, and evidence-based psychosocial care have forever transformed what is now considered standard in cancer care. I will miss the twinkle in her eye but I will always be guided by her spirit.”

A couple of thoughts:

  1. The New York Times ran a nice obituary. You can find it here:
  1. Dr. Holland is featured on the website Changing the Face of Medicine. Asked her biggest obstacle, she responds: In the small community in rural Texas [where I grew up], I knew of no women who had become doctors.” You can find her profile here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.