The COVID pandemic – despite the dire economic and personal toll on all Canadians – is helping us move forward. It bears light on the most vulnerable. Indeed, it has aggravated the mental health of those with such disorders as anxiety or depression and revealed the precarity of our mental well-being. The health system, and most particularly our primary care system, is overwhelmed and its capacity to answer to the mental healthcare of Canadians is put to the test. It is, therefore, time for family physicians to be able to find support in various ways and means to answer the needs of their patients. This support may be through public coverage to psychotherapies, which has been proven effective in Australia and the UK since the last decade, or open access to various validated web-based tools offering cognitive behavioural therapies for the most common mental health disorders in both official languages.

Introduction

The evidence submitted to inform this article (Vasiliadis et al. 2021) reminds us that the time has come to support public coverage of psychological therapies by qualified professionals, with appropriate parameters to frame such coverage. The COVID-19 pandemic has exacerbated gaps in mental healthcare for several populations, including additional needs for mental health support for healthcare providers and front-line workers.

Discussion

The burden of mental illness on all sectors of society has been very significant: (1) One in five Canadians will experience a mental illness in their lifetime (WHO 2019). (2) Five of the 10 leading causes of disability worldwide are mental disorders (Douglas Foundation 2021; Vigo et al. 2016). (3) Twenty-four percent of all deaths among those 15 to 24 years old are from suicide, which claims 4,000 lives in Canada every year. The World Health Organization estimated that depressive illnesses would become the second leading cause of disease burden worldwide and the leading cause in developed countries such as Canada (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators 2018; WHO 2001). We also need to consider the impact of mental illness in one person on family members, friends and colleagues.

There is often a tendency to view mental health issues as a silo in our healthcare system. Although mental illness may arise as an isolated issue, the reality is that it may be associated with, and influenced by, other medical problems (e.g., chronic illnesses, such as diabetes, ischemic heart disease), as well as social determinants of health (e.g., poverty, homelessness) and of oppression (e.g., being an Indigenous person, an immigrant or a refugee). Consideration of the inclusion of public coverage of psychological therapies offers an opportunity to build the capacity of such care and better integrate it as part of community-based care (primary care/family practice). Recent evidence from innovative practices where such integration was facilitated demonstrated better access, more seamless communication among providers and a high level of satisfaction from patients and providers (Chomienne et al. 2011; College of Family Physicians of Canada, Canadian Psychiatric Association, and Canadian Psychological Association 2020; Grenier et al. 2008).

As per guidelines from various organizations (Canadian Network for Mood and Anxiety Treatments 2016; NICE 2009, 2019), recommended options for the treatment of common mental disorders include medication and psychological therapies, most commonly cognitive-behavioural therapy (CBT). As described by Vasiliadis et al. (2021), psychological therapies can be web based through self-treatment or provided with a qualified professional, either face to face or virtually. A hybrid model offering the above modalities, along with appropriate communication with the provider most responsible for ongoing care – either a family physician or a nurse practitioner – and one that respects a patient's preferences makes sense.

The authors suggest that the Quebec funding model for drug coverage introduced in 1997 should be considered for psychological therapies. Under such a model, each citizen who is currently unable to access such treatments through their employer could do so through public insurance. Various options are under consideration for a national pharmacare program, each with its advantages and disadvantages (Dinh et al. 2018). Similar options need to be considered for psychological therapies and weighted with the need for public coverage in other areas, such as pharmacare, dental care and eye care.

Conclusion

Notwithstanding the fiscal realities facing us as we emerge from the pandemic, we can do better regarding public coverage of psychological therapies. Facilitation of a collaborative approach between family physicians/nurse practitioners and other qualified professionals (psychologists, social workers, other family doctors who incorporate such care), as part of robust community-based care, is consistent with the objectives of the Quadruple Aim (Ontario 2019): better care, better patient experience, lower overall costs following initial investments and satisfied providers.

Commentaire : Le temps est venu d'améliorer l'accès aux psychothérapies – point de vue de la médecine familiale

Résumé

Malgré des conséquences économiques et personnelles désastreuses pour tous les Canadiens, la pandémie de COVID présente l'occasion d'aller de l'avant. Elle met au jour les plus vulnérables. En effet, la pandémie a aggravé la santé mentale de ceux qui souffrent de troubles tels que l'anxiété ou la dépression et a révélé la précarité de notre bien-être mental. Le système de santé, et plus particulièrement le système de soins primaires, est débordé et sa capacité à répondre aux besoins en santé mentale des Canadiens est mise à rude épreuve. Il est temps que les médecins de famille soient en mesure de trouver du soutien sous divers formes et moyens afin de répondre aux besoins de leurs patients. Ce soutien peut prendre la forme d'une couverture publique des psychothérapies – laquelle s'est avérée efficace en Australie et au Royaume-Uni depuis une dizaine d'années – ou d'un accès libre à divers outils Web validés qui proposent des thérapies cognitivo-comportementales pour les troubles de santé mentale les plus courants, dans les deux langues officielles.

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