In most places, mental health care functions as anything but a unified system. It’s often seen as an unconnected and unevenly distributed collection of independent providers and services. There’s no standard path through the system to follow. Getting lost or stuck is a widespread problem. You need to find the right resources to get the care you need.
To find your way, you need to know what the system looks like. What are the different pieces? Where do you find them? What can they provide? Where are the gaps in the system? Let’s look at these in more detail.
The good news is that if your mental illness is severe enough or you’re actively suicidal, it’s usually possible to access some help, at least in the short term. This is often through emergency rooms or a short-term crisis service.
The bad news is, when it comes to quickly accessing mental health treatment, things usually have to be really bad to be considered bad enough.
You may be crying all the time, unable to get out of bed. You may be so stressed that you’re not able to work. You may be so easily angered and unpredictable that your family is ready to walk out the door.
You may be crying all the time, unable to get out of bed.
You may be so stressed that you’re not able to work.
You may be so easily angered and unpredictable that your family is ready to walk out the door.
These horrible situations can ravage your life. But they may not be bad enough for you to receive urgent mental health care. Unfortunately, while millions of people may be suffering from mental illness impacting their employment, relationships, and personal well-being, most of them cannot promptly access specialized mental health care.
You may think that the mental health system was not built for you, and you’re right. On one extreme, you’ve got motivational books and speakers. They promote self-awareness, personal growth, and development. They’re happy to exchange your money for a promise of an even better you. On the other extreme, you’ve got the hardcore psychiatric services. They deal with the most severe chronic mental illnesses or people who are in an urgent crisis.1
Where do you fit? Probably somewhere in between. You may not be in a life-threatening crisis now, but your illness is having a major impact on your life. You’re not trying to be the absolute best version of yourself but want to get back to where you were before your symptoms started. Increasingly, it seems that if there isn’t a quick and easy fix, you’ve got few places to turn. You’re far less likely to see a psychiatrist or another mental health specialist. If you do, it will probably only be for a short time. Many systems can help if you’re in crisis, but don’t do as well once the immediate crisis passes.
You’ve decided it’s time to get help. Great! Now what? Your first question is likely to be “where do I go?” Table 2 suggests a few common answers.
Treatment takes place in all kinds of settings. It can be at home, by yourself, going through a workbook. It can be at a peer support group held in a community centre basement. Many mental health professionals work in private offices, alone, with a few colleagues, or in a larger organization. You may be treated in a medical clinic or hospital.
So many people, places, and programs. Each plays a role in the overall mental health system. Each offers something different. What do you need? How do you choose?
It’s hard to keep track of all the professionals in mental health. One common confusion is the difference between psychiatrists and psychologists.
A psychiatrist is a medical doctor. After the standard training for any doctor (undergraduate and medical school), they complete a five-year residency across different areas of mental health. Their practice can include a wide range of treatment options, including medications, psychotherapy, laboratory or imaging investigations, etc.
Psychologists typically have a master’s degree or PhD in psychology or a related field. Their practices generally involve psychotherapy of some form.
Many psychiatrists and psychologists have specialized practices, either involving particular illnesses or particular treatments. We’ll have a lot more to say throughout the book about other differences and the importance of seeking care from the full range of mental health professionals.
For many people, the cost of mental health care whittles down their choices very quickly. Cost, access, and restrictions are always complicated. Services vary greatly depending on where you live. Government programs and insurance may have strict limits on what services they cover, how many, and who provides each service. They won’t pay pricey psychiatrists to do psychotherapy if a counsellor can do it for less.
If medications become part of your treatment, you will have to pay for them. If you have private insurance, it may pay for some or all of them. Government plans may help some reduce the cost of medications.
If you’re financially well off or have a job with great benefits, you can access a wide range of treatments, through family doctors, psychiatrists, psychologists, and counsellors. If you’re less well off, you’ll probably see a family doctor who will prescribe a low-cost antidepressant. If you’re lucky, you’ll participate in subsidized group education and therapy programs for a few months.
We won’t say that you should only see a medical doctor for your mental health. But we do think they should be one of the people you see. This is especially true if you’ve been struggling with mental health symptoms for a long time, or if your symptoms came on rapidly with no obvious cause.
Why see a medical doctor? Sure, they’re the only ones who can prescribe medications such as antidepressants that are so much a part of modern-day treatment. But there’s a far more important reason to see a doctor. Many mental health symptoms can be signs of physical illnesses—sometimes serious ones. Finding and treating these illnesses can improve your overall health. Treating the physical illness may also address your mental health concerns, sometimes very quickly.
You may never intend to take a mental health medication. That’s fine, but make sure there’s nothing physical going on. See a doctor.
When most people think about seeing a doctor for their mental health, they picture a psychiatrist. They specialize in feelings, behaviours, and thoughts.
Like other doctors, psychiatrists see people in different settings, such as the emergency room or an inpatient psychiatry ward in a hospital. However, most people are seen as outpatients, having short visits with a psychiatrist in a hospital, clinic, or office. Some psychiatrists care for people with many mental illnesses. Others may treat only some types of illnesses, and a few are very specialized, treating only a single illness.
Most people go for mental health care to the same place they go for their other health needs: their family doctor’s office.
Mental health is a standard part of every family doctor’s training, and something they help with each day. Around 20% of family doctor appointments involve a mental health issue.2 Multiple studies found that most people with a mental health disorder (one suggested as high as 85%) see only their family doctor. Many family doctors manage most cases of common mental illnesses such as depression and anxiety themselves. They’re often more likely to recognize or test for physical problems. Often, family doctors need to assess and refer you before you can see a psychiatrist.
We will have a lot to say about the important role that family doctors play in the mental health system. Learning to work well with your family doctor is one of the best things you can do for your mental health.
Frequently, by the time people ask for help, a lot of time has already passed. You want to get things moving now. You want help, a path forward. You’d like to see a plan and know how long it will take.
If you’ve been at this for a while, you know there is no plan. Instead, there’s waiting. Let’s say you were experiencing depression and saw your family doctor about it. Here are some delays you might face:
You wait days or weeks to see your family doctor. You spend months trying the medication they prescribe. It makes you physically ill from side effects, but your mood remains unchanged.
You spend months with a counsellor or in a community therapy group, but nothing changes.
You feel that your family doctor is sick of listening to you complain and has run out of ideas. You wait months before bringing up that you’re still not coping. They refer you to a psychiatrist.
You wait months or longer for your appointment with the psychiatrist. They see you only once, for a total of 45 minutes. You then wait for your family doctor to receive the psychiatrist’s report.
You spend weeks trying the new medication the psychiatrist recommended, which doesn’t work. You wait even longer to be referred back to that same psychiatrist or a different one for another opinion.
All this and your symptoms are just as bad as when you started. Sadly, this is still better than being stuck, not knowing what to do next, and not having anyone to ask. Is this what mental health care should look like?
We described the mental health system as an uncoordinated patchwork of independent service providers. Each one works in isolation according to its own priorities. This creates several problems for you:
There are multiple entry points to access care. There’s no way to know which is the most appropriate for your needs. Tellingly, most people working in the system are also frequently stumped.
Transitions between care providers can be ad hoc or non-existent. If one can’t help you, they may not send you to someone more appropriate. Some may not understand the value that other providers bring.
You may be treated by people untrained in your actual problem. Patients are routinely misdiagnosed or receive different diagnoses from different providers. Treating the wrong illness will be unhelpful at best and may worsen your condition.
Even with the right diagnosis, all recommended tests and treatments may not be provided. Communication between providers is limited. One provider may assume another has addressed specific issues.
As more providers are added, care becomes more fragmented and poorly integrated. Treatments from different providers seem independent of one another and can even work at cross purposes.
Nobody is tracking where you are on your journey from illness to wellness. Intuitively, you understand that you’re not making progress. But without knowing what the treatment process should look like, you can’t form expectations to measure your progress against.
There are many different kinds of mental health providers to choose from who offer a dizzying array of services. Seeing a provider who is unable to help you is common. Without someone to guide you, it’s too easy to get lost in the system. Your care could stall altogether.
Thankfully, you can do better.
Mental illness is treated by a wide range of professionals in a variety of settings.
Psychiatrists and family doctors play an important role, as many symptoms of mental illness can be symptoms of an underlying physical illness.
Access to mental health care can be difficult, with a limited number of professionals available, and many insurance and other financial barriers. Much of this is related to how mental health is prioritized.
The idea of mental health as a system is misleading. Most providers are independent, there are multiple paths through the system, and people often don’t see providers appropriate for their needs. People often get lost or stuck and don’t receive the treatment they need.
Programs for severe mental illness also have significant problems, and don’t get all the resources they need—far from it.
Arguably, the system wastes a sizeable chunk of mental health funds on people who don’t need help or won’t benefit. These funds could be better spent on those with greater need. This is a large and important topic in its own right but beyond the scope of this book. For some incredible and shocking insights into these issues in the American system, we would recommend the book Insane Consequences by DJ Jaffe.
https://mentalillnesspolicy.org/insane-consequences.html↩
A variety of studies have looked at this question, using surveys of family doctors, as well as by examining administrative (i.e. billing) data, across various geographic areas. The 20% figure +/- 5% comes up frequently. A representative example of this is a paper describing a family doctor survey done in Quebec.
Fleury MJ, Farand L, Aube D, Imboua A. “Management of mental health problems by general practitioners in Quebec.” Canadian Family Physician. 2012;58:e732–8.
http://www.cfp.ca/content/cfp/58/12/e732.full.pdf↩
Now Available! A MSP-supported live course for BC residents based on the book. [Mar/2023]
While you can read it for free online, there are conditions on sharing it with others (see below). You can also still purchase copies in paperback or e-book (PDF, Kindle, Kobo, etc.).
Now Available! A MSP-supported live course for BC residents based on the book.
