Improving access to evidence-based mental health care
=====================================================

* David Gratzer

[See related articles at www.cmaj.ca/lookup/doi/10.1503/cmaj.190603](http://www.cmaj.ca/lookup/volpage/192/E329) and [www.cmajopen.ca/lookup/doi/10.9778/cmajo.20190094](http://www.cmajopen.ca/lookup/doi/10.9778/cmajo.20190094)

KEY POINTS
*   Although psychotherapy has been shown to be as effective as pharmacological therapy for people with mood and anxiety disorders, a minority of Canadians with such conditions have access to it, and new evidence shows that increasing the number of physician psychotherapists is unlikely to fill the gap.

*   Canadian policy-makers could consider looking at successful models used internationally for the scale-up of evidence-based psychotherapies.

*   Internet-delivered cognitive behavioural therapy and artificial intelligence approaches may be useful in closing the care gap for certain populations (e.g., people in geographically remote locations and those with social anxiety) or in developing a stepped-care strategy for people with less severe illness.

*   Policy-makers could also make better use of existing resources by aligning population needs, evidence of effectiveness and provider compensation.

More need, more care needed. Chiu and colleagues, in a related population-based study published in *CMAJ*, found that self-rated fair or poor mental health status increased among adults in Ontario from 4.9% in 2003–2005 to 6.5% in 2011–2014 alongside an increase in individuals’ use of mental health services (7.2% to 12.8%).1 The findings provide a Canadian perspective on a global pattern in mental health care. Mood and anxiety problems are common and rank among the most disabling disorders in our society.2 Unfortunately, many people with common mental health conditions do not receive the care that they need. For example, a recent study drawing on data from British Columbia found that just 13% of people with depression had access to any psychotherapy or counselling in the public system.3 Recent research by Kurdyak and colleagues, published in *CMAJ Open*, examined whether the current or even an enhanced complement of physicians could meet the need for publicly funded psychotherapy in Ontario; they found that less than 20% of the need was met by the province’s psychotherapist physicians (family doctors or psychiatrists who offer psychotherapy) in 2015/16.4

Cognitive behavioural therapy (CBT) is particularly effective for the treatment of mood and anxiety disorders, matching medications in efficacy and possibly having a synergistic effect with antidepressants,5 yet psychotherapy not delivered by physicians is largely not funded in Canada. In Kurdyak and colleagues’ estimation, about 900 000 Ontarians could have benefited from psychotherapy in 2015/16, but psychotherapist physicians saw just 176 000, which means that even if Ontario were to quadruple capacity tomorrow (an impossible task for obvious reasons), this would not be sufficient to meet today’s demand. In fact, Kurdyak and colleagues’ findings show how we must move the access debate past simplistic solutions like calls to train more psychiatrists and compensate them better.

Patients with mental health concerns across the country know all too well that it is challenging to receive needed care, and they desire better access to care. What can be done to improve access to evidence-based mental health care in Canada? First, we need to learn from successful mental health policies internationally. Since 2008, the National Health Service in England has experimented with publicly funded psychological interventions through the Improving Access to Psychological Therapies (IAPT) initiative; currently, more than 500 000 individuals receive treatment each year.6 The initiative focuses on a handful of psychotherapies, including CBT, and clients may self-refer. The program emphasizes measurement-based care (an outcome-monitoring system ensures the collection of symptom scores before and after treatment for 98% of patients) and public accountability (data on outcomes are released on a monthly basis). A recent analysis of data found that 44.44% of patients showed reliable recovery and 64.47% showed reliable improvement.6

Other jurisdictions have experimented with the concept, including Sweden, Norway and Australia. Kurdyak and colleagues mention Ontario’s growing IAPT-inspired CBT program, which has shown promising early data.4 These experiments vary in their implementation but have a common theme: psychotherapy does not need to be delivered by physicians, or even psychologists. This is evident in the literature: a 2014 randomized trial showed that psychotherapy provided by trained lay counsellors could be effective.7 Those implementing IAPT initiatives have faced challenges, including in the delivery of care to rural areas, but the approach provides a useful model for the scale-up of delivery of effective psychotherapy delivered by nonphysicians.

Second, Canadian jurisdictions could make better use of innovative approaches. Internet-delivered CBT (iCBT), which is psychotherapy based on CBT principles delivered via the Internet, overcomes geographical barriers to access and can be made available to patients on their time and schedule.8 The authors of a recent review of randomized trials found “moderate to large effects [of iCBT] reported for panic disorder, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder, and major depression.”9 Although iCBT appears to be both effective and cost effective, it is not a panacea; it needs to be offered as one part of a well-conceived suite of psychotherapy options, as it is not for everyone, and drop-out rates can be high.8

In the future, artificial intelligence (AI) may also be part of mainstream access solutions. Chatbots are programs “that use machine learning and artificial intelligence methods to mimic humanlike behaviours and provide a task-oriented framework with evolving dialogue able to participate in conversation,” according to the authors of a recent scoping review of AI approaches in mental health care.10 Some chatbots provide psychotherapeutic interventions (e.g., CBT); an advantage is that they can offer people a route to evidence-based care in real time. Another advantage of chatbots over human therapists is that chatbots are always available and never distracted. Although evidence is currently sparse, the recent review found that studies report high satisfaction rates among users and little risk of harm.10 Although chatbots are unlikely to be appropriate for every patient in every circumstance, AI approaches could be helpful for certain subpopulations, such as patients with social phobia and other specific anxieties. A stepped-care approach might be considered to broaden and speed up access; less severe need could be matched quickly with less resource-intensive approaches to care — such as Internet- and AI-delivered CBT — to allow for people with more severe conditions to access inperson psychotherapy more promptly.

Third, there is scope to make better use of existing resources. Kurdyak and colleagues note that although there is a shortage of psychiatrists and psychotherapist physicians in certain regions of Ontario, others, such as the cities of Toronto and Ottawa, enjoy a surplus.4 And the problem of unequal provision extends beyond urban concentration. People with urgent needs (including those recently discharged from hospital for a mental health condition) are particularly poorly served by the current system: between 1% and 3% are seen by physician psychotherapists.4 Furthermore, all psychotherapy is not equally effective — some psychotherapy currently offered is of poor quality and unstructured, and may not be evidence based — yet different psychotherapies may be compensated equally in many Canadian jurisdictions. Policymakers need to carefully consider the opportunity costs of paying for poor-quality care and develop funding strategies that better align population needs, evidence of effectiveness and compensation. This realignment would include physician compensation, but it would also need to consider how psychotherapy provision is paid for, ideally moving past the physician-dominated model of today, to a multidisciplinary model, such as the model used in IAPT.

There is no single solution to address the care gap that people with mental distress face in Canada. But by looking to international examples, exploring innovative approaches and making better use of existing resources, barriers to access are more likely to be successfully overcome.

## Footnotes

*   **Competing interests:** None declared.

*   This article was solicited and has not been peer reviewed.

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