From: Submission to the Select Committee on Mental Health and Addictions. Presented by Paul Garfinkel, June 3, 2009.
There is strong evidence that many primary health providers lack the knowledge and tools to adequately assess patients for potential issues related to mental health and addictions. This is a significant barrier to proper diagnosis and treatment of mental health and addiction problems. A key role of the family physician is the identification and early diagnosis of problems; inadequate access to mental health and addiction services often result from the absence of early identification, and lack of support for this function. The four principles developed by the College of Family Physicians of Canada speak to the key role of the family physician and to the high level of skill needed to deliver comprehensive care; however, the current healthcare system does not provide incentives or any support for family physicians to practice according to these principles (Rosser & Kasperski, 1999).
Studies recognize that physicians in the primary healthcare setting lack the tools and other screening instruments required to adequately assess mental health and addiction problems in their patients. The Solberg, Maciosek and Edwards study (2008) found that screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for dependence but do place patients at risk for morbidity and mortality. Furthermore, they found that behavioral counselling interventions with follow-up can produce small-to-moderate reductions in alcohol consumption, sustained over a period of 6 to 12 months.
In terms of follow-up, Simon, VonKorff, Rutter and Wagner (2000) conducted a study using two inexpensive programs to improve the treatment of depression in primary care. The authors believe that despite the high prevalence of depression among patients in primary care, management often falls short of expert recommendations and only a few patients receive the proper levels of pharmacotherapy. Therefore, one inexpensive program was feedback only, wherein the patient would return to the doctor and the pharmacotherapy discussed and the other program was feedback plus care management, which incorporated the first two strategies in addition to follow-up by telephone. The latter program resulted in improved care and the incremental cost was $80.00 per patient.
The general lack of a comprehensive strategy of care contributes to the misdiagnosis and under-treatment of mental health and addiction issues. Improving the access to specialized mental health and addictions care (e.g., psychiatrists) by primary care physicians can address these issues. To further support the need for a comprehensive strategy of care, patients with severe mental health and addiction issues who also have existing co-morbid diseases and physical conditions are not adequately cared for.
For example, individuals with serious mental illnesses living in the community have age-related mortality rates 2.4 times the rate for the general population. Additionally, it is estimated that 35% of individuals with serious mental disorders have at least one undiagnosed medical disorder (Bazelon Centre for Mental Health, 2004). A recent Canadian study found that the cancer death rate is 65% higher among the mentally ill. According to a 2007 study published in the Journal of the American Medical Association, patients with severe mental illness who experience acute MI are significantly less likely than the general population to receive drug therapies of proven benefit, are less likely to undergo cardiac catheterizations and receive emergency angioplasties or coronary artery bypass graft surgery (Newcomer and Hennekens, 2007). As one physician said, stigma often interferes with the doctor-patient relationship because this population doesn’t complain much about their physical ailments (Picard, 2009).
A comprehensive strategy would also contain community resources and other support necessary for those patients who can self-manage. Similar to other chronic conditions, there are opportunities for patients to self-manage mental health and addiction issues; however, systems must be in place to support these patients.
In Submission to the Select Committee on Mental Health and Addictions:
- Executive Summary
- The Centre for Addiction and Mental Health (CAMH)
- Mental Health and Addictions – Out of the Shadows
- Foundations of a Mental Health Strategy
- Key Components of an Integrated System
- Bringing it together