It’s 4:30 on a Friday afternoon at her Sherbrooke, Que., clinic and Marie Hayes takes a deep breath before opening the door to her final patient of the day, who has arrived without an appointment. The 32-year-old mother immediately lists her complaints: She feels dizzy. She has abdominal pain. “It is always physical and always catastrophic,” Dr. Hayes will later tell me. In the exam room, she runs through the standard checkup, pressing on the patient’s abdomen, recording her symptoms, just as she has done almost every week for months. “There’s something wrong with me,” the patient says, with a look of panic.
Dr. Hayes tries to reassure her, to no avail. In any case, the doctor has already reached her diagnosis: severe anxiety. Dr. Hayes prescribed medication during a previous visit, but the woman stopped taking it after two days because it made her nauseated and dizzy. She needs structured psychotherapy – a licensed therapist trained to bring her anxiety under control. But the wait list for public care is about a year, says Dr. Hayes, and the patient can’t afford the cost of private sessions.
Meanwhile, the woman is paying a steep personal price: At home, she says, she spends most days in bed… Dr. Hayes does her best, spending a full hour trying to calm her down, and the woman is less agitated when she leaves.
But the doctor knows she will be back next week.
So begins an article from The Globe asking a simple question: should we publicly fund psychotherapy? In this week’s Reading, “The case for publicly funded therapy,” Erin Anderssen argues yes.
Anderssen’s piece opened the The Globe and Mail’s excellent new series on mental health, which covers everything from the potential of technology to the search for biological markers.
In “The case,” Anderssen reviews the deep problems with access to mental health services:
In 2012, Canada’s Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse.
But if care is needed, it is often unavailable.
That is particularly true for psychological interventions. The Globe series doesn’t offer comprehensive review, but it does touch on the literature:
In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs – selective serotonin reuptake inhibitors (SSRIs) – and psychotherapy.
The Cuijpers et al. meta-analysis is a good paper to mention. Of course, it would be possible to push further. Take cognitive behavioural therapy, which is supported in the literature; recent papers have shown that CBT helps cancer patients endure chemo, obese patients manage weight loss, and maybe even the unemployed return to work after a depressive episode (over meds). And, for treatment of mood and anxiety issues, CBT is very effective. A review published by the Canadian Psychological Association considered the number needed to treat, or NNT – that is, the number of people who need the intervention to achieve a good outcome – for CBT and several mental disorders. The CPA analysis: depression (NNT 4.4), GAD (2.3), social anxiety (2.2 for youths), PTSD (1.7-1.8), panic (2.6). Let’s put those numbers in some perspective: the NNT for statins is over 90. And remember: one doesn’t exclude the other; in the treatment of depression, for example, there seems to be a synergistic effect between medication and CBT.
But if a body of evidence supports psychological interventions, many Canadians simply don’t have access.
I see that deficiency in the working class neighbourhood where I practice. Most of my patients lack employer-provided health benefits, and private services are financially out of reach. A young man, who battles depression, struggles with the sexual side effects of SSRIs and would prefer some type of therapy but can barely afford rent, never mind a therapist; a pregnant young woman dislikes the idea of medications but can only see a therapist three times with her health plan – and it’s of a supportive type; an older man on a modest pension has read about CBT and hopes to get this therapy for free – by entering into a research study.
A strong analogy? Writer Erin Anderssen offers the following:
Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more.
Anderssen argues that medicare ought to cover such therapy. She looks internationally. Drawing on the British and Australian examples, she suggests it would be possible for publicly-funded therapy but expensive. “Some of the figures being tossed around sound staggering.”
It’s here where I will take some issue with her argument. In fairness, Anderssen does put such spending in the context of total health spending. Still, a fuller context is needed.
Let’s consider the United Kingdom. In 2006, the National Health Service introduced IAPT, or Improving Access to Psychological Therapies, in two demonstration sites. This service is well structured: available on a self-referral basis, stepped care, with an emphasis on resources and basic care for those with milder illness, but also one-on-one therapy for more serious cases of depression and anxiety. (This approach seems more thoughtful than the Australian mass funding of psychologists.) By 2012, after expansion, 700,000 people had completed the program. According to the latest NHS statistics, in February 2015, over 74,000 people were referred or self-referred across England and Wales that month alone.
One of the core justification for IAPT is cost… that is, the cost of not providing such a service. Economist Richard Layard (who, with psychologist David Clark, laid the intellectual framework for IAPT) argues that mental illness is an enormous economic problem. IAPT makes fiscal sense since it moves people off government benefits.
By Lord Layard’s calculation, 4% of service recipients need to move back to the work force to offset program costs; NHS stats peg the number today as being closer to 6.5%.
Anderssen opens her essay by talking about a 32 year old woman who is, literally, bed-bound by her anxiety. A Canadian version of IAPT could get her out of her home – and back to the workforce. That seems like good care for this young woman, and a good deal for taxpayers.
For highlights from The Globe series, as well as links to the articles:
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.