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Out of Pocket

By Elizabeth Lines
Network, Fall 2007

Mental illness comes with many costs attached. Beyond the personal toll the illness can take, there are hard financial costs as well. Against a backdrop of publicly funded medicare and social safety nets, consumers can face significant expenses in their efforts to get well and stay that way.

According to Dr. Annette Dufresne, a psychologist with a part-time private practice who also works with CMHA, Windsor-Essex County Branch, there is no doubt that cost is a barrier to treatment. One of the most pressing needs she sees is for affordable access to psychotherapy.

For 16 months the doctor had to give me samples because I had no insurance coverage and couldn’t afford the prescribed medication.”
— Bruce

“While in the past psychotherapy wasn’t seen as necessary in the treatment of serious mental illness, there’s a growing body of evidence in support of some talk therapies, such as cognitive behavioural therapy (CBT), as an efficacious adjunct in the treatment of serious mental illnesses including chronic depression, bipolar disorder, and schizophrenia. And for the treatment of mild or moderate mental illness, there is solid research evidence that, either in conjunction with medication or on its own, it can be effective.”

But resources are scarce. Dufresne continues, “Our services here at CMHA, Windsor-Essex County Branch consist largely of case management done by community support workers, and they provide supportive counselling, but not more in-depth psychotherapy. Rather, as case managers they help with problem solving, working on goals and accessing services. But I know there are a number of clients who could benefit from psychotherapy.”

“And,” she explains, “not only are the agency’s resources for psychotherapy limited but the community resources for such services in the Windsor area are also very limited. While we know that some general practitioners [or family physicians] in some parts of the province are providing psychotherapy, there are very few in this vicinity. It’s just not a common thing.”

I was hospitalized in another city and it was difficult and costly for my family to come and visit me. When I was able to come home for visits, there were travel costs too.”
— Nancy

Karen Liberman, executive director of the Mood Disorders Association of Ontario (MDAO) and a vocal advocate for increased access to evidence-based psychotherapies, notes that “while theoretically, consumers have access to psychotherapy through either a general practice psychotherapist (GPP) or a psychiatrist, the reality is that the number of family doctors and psychiatrists who actually do CBT or interpersonal therapy (IPT) is so small that waiting lists can run two to three years in some locations.”

Dr. Victoria Winterton, a practicing GP psychotherapist and President of Ontario’s General Practice Psychotherapy Association (GPPA), knows the story only too well. “I have a waiting list of close to a year,” she says. “I know most GPPs have waiting lists or aren’t taking on new patients. It’s difficult to assess overall but I believe the wait times are a real problem. We ourselves have a long wait even to see a psychiatrist for a consult.”

Fast Facts

10,641
Number of family physicians in Ontario as of 2005

436 
Number of GP psychotherapists in Ontario (GP psychotherapists are family doctors who bill more than 50 percent of their caseload as psychotherapy)

(Source: Ontario Medical Association)

A large part of the issue is that, with some exceptions, Ontario’s public health insurance only covers services rendered by medical doctors, whether family physicians or psychiatrists. Some private coverage through extended health plans, often available through the workplace, will cover some costs of psychotherapy services provided by other health professionals such as psychologists. But Dufresne notes that, while most clients in her private practice have some private coverage, it is very inadequate.

Winterton continues, “The need for greater access to psychotherapy in this province is enormous and acute. I practice in a rural area and we are particularly short on publicly funded providers of psychotherapy. We have few psychiatrists and those in the area cannot offer psychotherapy because they are so busy that they cannot afford the time. Even those who used to do some psychotherapy had to stop.”

“So, at least in rural areas like this, we seem to have created a two-tier system where those who can afford it can access private therapists. People with good jobs who have employee assistance programs and private health insurance through their employers can get some coverage.”

“And most importantly,” adds Winterton, “the fact is there’s a huge volume of people who have neither of those resources. So their only options are mental health clinics, where there are very well-qualified practitioners but there just aren’t enough of them.”

I knew I needed more than medication. I knew I would need some kind of talk therapy. Ironically I had to wait until I was recovered enough to work in order to be able to afford the therapy. Even then, I couldn’t afford the full price.”
— Tony

Outside Ontario, there are jurisdictions where services such as CBT are being publicly funded. For example, Medicare in Australia will cover up to 12 psychological therapy sessions per year with qualified psychologists, social workers and occupational therapists. Dufresne says that in the UK there’s a push for the government to start funding more psychotherapy. “And it makes economic sense,” she adds. “In fact, it was the economic argument in the UK that seems to have caught government’s attention. But unfortunately, Ontario seems to be moving in the opposite direction, looking to family physicians to be the primary line of service for mental health services. It’s a big expectation that may not be realistic.”

The fact that there is strong evidence in support of the efficacy of therapies like CBT is the impetus behind the position of MDAO. “Our stance is this,” explains Liberman. “If something is a recommended treatment and we operate under the Canada Health Act, and people are denied a recommended treatment by virtue of their inability to pay, this is contrary at least to the spirit if not the word of the Act. It is certainly contrary to what we pride ourselves on in this country in terms of providing recommended treatments to those who need them. Access should not be limited because they cannot pay.”

If something is a recommended treatment and we operate under theCanada Health Act, and people are denied a recommended treatment by virtue of their inability to pay, this is contrary at least to the spirit if not the word of the Act. Access should not be limited because they cannot pay.”
— Karen Liberman, Mood Disorders Association of Ontario

“We’re about to launch a major advocacy initiative around the issue of access to psychotherapy. In the treatment of mood disorders, the generally accepted treatment guidelines are antidepressants or mood stabilizers and certain forms of psychotherapy — specifically CBT or IPT. That is what the Canadian psychiatric treatment guidelines recommend.”

And that is definitely what people expect, Dufresne says. “When people first enter the mental health system I think they are very surprised to find they don’t have more ‘talk therapy.’ I think people expect that they’re going to have that opportunity but for the most part that’s not what they get.”

Tony recalls that when he was first diagnosed with schizophrenia back in 1991, talk therapy was not presented as an option. “I was told at the time that it wasn’t necessary and I couldn’t even get a referral. I didn’t really know what to do or what my options even were at the time — where to go or who to see. And when you’re ill it’s overwhelming to have to look for help.”

Now, certain psychotherapies such as CBT are accepted as integral to treatment for a growing list of mental disorders. But finding access to treatment is still an issue. “It’s so difficult to deal with day-to-day tasks when you’re trying to recover that I didn’t even pursue psychotherapy for many more years,” continues Tony. “Eventually, I did manage to get a referral. Payment was on a sliding scale but the cost was still substantial given my disability income. At times I went into arrears. It was very tight. But once I got therapy I thought, ‘Wow, I wish I’d had access to this years ago!’ I found it very helpful. The insights I arrived at through therapy remain helpful to this day.”

CBT and IPT

Cognitive-behavioural therapy (CBT) is considered by many experts to be the number one way to treat depression and anxiety. It focuses on helping clients become aware of how certain negative automatic thoughts, attitudes, expectations and beliefs contribute to feelings of sadness and anxiety. Clients learn how these thinking patterns, which may have been developed in the past to deal with difficult or painful experiences, can be identified and changed in their day-to-day lives to reduce unhappiness. They learn to have more control over their moods by having more control over the way they think.

Interpersonal therapy (IPT) focuses on identifying and resolving problems in establishing and maintaining satisfying relationships. These problems may include dealing with loss, life changes, couple difficulties or conflicts, and increasing the client’s ease in social situations.

(Source: “Challenges & Choices,” Centre for Addiction and Mental Health, 2003,www.camh.net.)

Nancy too, recovering from a major depressive episode, faced similar financial challenges. “Many thought I’d never be well again. But I’d been reading that the best treatment for my illness was a combination of medication and psychotherapy. So when I was discharged from hospital I found a psychologist who helped me immensely, but I had to pay for that out of pocket. I saw him once every week or two over several years and had to pay $160 each time. It was only because my husband was able to help with payment. Now that we’re divorced I can’t afford ongoing support like that.”

But like Tony, Nancy can’t imagine where she’d be now if she hadn’t found this help. “At my lowest, my psychologist combined with the medical help provided by my psychiatrist kept me alive,” she says. “For a long time, during the darkest times, he walked with me through the depression and was always able to remind me of how important life is. He was an integral part of my recovery even though it was very expensive. I just really had no choice. At least for my medications, I still have insurance from my old workplace that covers the cost, or that would be a problem too.”

While the barriers to accessing appropriate talk therapies loom large, they are not the only financial costs faced in recovery. Some find that complementary medicine can provide a further boost to being well. “I found that along with psychotherapy, vitamins and other nutritional supplements have helped too,” says Tony. “These too are a big expense that aren’t covered by any kind of income or insurance program. Yet I notice a big difference when I take them. And at times I’ve had back problems that are helped by chiropractic, but I usually can’t afford the visits.”

[Our clients are] trying to build a life for themselves, yet even accessing proper nutrition or being able to have a little bit of money for recreation — both of which should be a part of their recovery — remain out of reach.”
— Dr. Annette Dufresne, CMHA, Windsor-Essex County Branch

This situation is not uncommon. Dufresne sees the difficulties that people have in accessing health-related services beyond psychotherapy. “A lot of our clients at CMHA have a number of health problems, such as chronic pain, and they could really benefit from services like physiotherapy and chiropractic — but it’s difficult to get funding for these types of health services.”

“And in fact, access to health services isn’t the only problem. Many of our clients are not able to work and are living either on disability or on social service payments waiting to hear if their disability application has been approved. Either way it’s a huge challenge for them to live on the small amount of money that they get. They’re trying to build a life for themselves, yet even accessing proper nutrition or being able to have a little bit of money for recreation — both of which should be a part of their recovery — remain out of reach. And then there’s something as basic as transportation and the cost of getting to treatment. That too can be a challenge.”

In Nancy’s case, the need for hospitalized care on occasion took her out of Windsor to London and Toronto. The travel costs incurred in order to visit with her family during these periods were a burden. “Then, later on in my recovery, I had a period of relative health and was living at home but unable to work. I was still in need of support, but there was little available here so again I went back to London by train once a week for two years to attend a support group for discharged patients.”

“So the financial piece is very challenging for them,” adds Dufresne. “Many have seen a real decline in their standard of living since becoming ill. Before that, many were well and were working and had intact families and adequate housing-and now they’re not working, they’ve lost financial stability and they’ve lost their social identity.”

“I see this problem every day. I don’t think others realize the enormous impact a mental illness can have on an individual and how difficult it can be for an individual to try to work on their own recovery. If people could only see the effects this has on a person and on their life. I think we should do whatever we can to help them to succeed.”

Elizabeth Lines is a researcher/writer in the areas of health and social issues.


Resources

Centre for Addiction and Mental Health, “Challenges & Choices: Finding Mental Health Services in Ontario,” 2003
www.camh.net

Centre for Applied Research in Mental Health and Addictions (CARMHA), “Cognitive Behavioural Therapy: Core Information Document,” BC Ministry of Health, March 2007
www.carmha.ca

General Practice Psychotherapy Association (GPPA)
www.gppaonline.ca

Mood Disorders Association of Ontario (MDAO)
www.mooddisorders.on.ca

Check Up from the Neck Up
www.checkupfromtheneckup.ca


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