Canada's provinces are without a publicly funded psychotherapy program for common mental disorders despite evidence that psychological services help reduce the length and number of depressive episodes, symptoms of post-traumatic stress and associated negative outcomes (hospitalizations and suicide attempts). Studies also show that including psychological services as part of the service package offered under the public health plan for those without access pays for itself. We posit that a publicly funded psychotherapy program in Canada, including digitized self-guided psychotherapy platforms for common mental disorders, will lead to improved population health useful in the COVID-19 context and beyond.

Background

In a recent Commonwealth Fund study, Canada ranked second with 26% of adults "experiencing stress, anxiety, or great sadness that is difficult to cope with alone since the COVID-19 outbreak started" (Williams II et al. 2020). Among Canadians needing and wanting care, only 47% received help (Williams II et al. 2020). This has left close to 5.2 million Canadians in need of mental healthcare. Pandemic-related effects include significant increases in symptoms of post-traumatic stress, insomnia, depression and anxiety (Brooks et al. 2020; Ettman et al. 2020; Rossi et al. 2020). This can have devastating consequences on suffering, disability and suicide behaviours, leading to considerable health system and societal costs. Before the pandemic, up to 20% of Canadians lived with a mental or substance use disorder (MHCC 2017) and 17% reported a need for mental health care, of which one in four reported an unmet need for psychotherapy/counselling (Sunderland and Findlay 2013).

On May 6, 2020, the Québec government announced an investment of $31.1 million for the implementation of a mental health action plan designed to address the rising psychological distress due to the COVID-19 pandemic (Gouvernement du Québec 2020a, 2020b). This plan aimed to improve access to timely mental healthcare by hiring 300 psychologists from the private sector into the public sector, improve the 811 mental health lines and provide grief services (Gouvernement du Québec 2020a). On November 2, 2020, the Ministry of Health and Social Services announced $25 million to buy mental health services from the private sector to improve waiting lists for psychological therapies for college and university students, and $10 million for those waiting for mental health services in the public sector (MSSS 2020a). These follow an announcement made by the government in December 2017 of a $35-million investment to launch the first public psychotherapy program in Québec (Association des psychothérapeutes du Québec 2017). Québec's Institut national d'excellence en santé et en services sociaux had published three reports on the effectiveness and costs of equitable access to psychotherapy services (Fansi and Jehanno 2015a; Fansi and Jehanno 2015b; Lapalme et al. 2017; Lapalme et al. 2018). In May 2018, a pilot phase of the new "Quebec Program for Mental Disorders: From Self-Care to Psychotherapy" got underway to test the guidelines for depression in children and adolescents, and generalized anxiety and panic disorder in adults. The program's launch was scheduled for the fall of 2019 (MSSS 2020b). In November 2017, the Ontario Health Technology Advisory Committee recommended in their economic evaluation (Health Quality Ontario 2017) that structured psychotherapy offered by nonphysicians be publicly funded for common mental disorders. The Ontario government had announced $72.6 million in funding over three years to support psychotherapy programs. In March 2020, the Ontario government announced an additional $20 million to increase access to mental health services (Anderssen 2020), one such being the Ontario Structured Psychotherapy program, providing short-term, face-to-face cognitive behavioural therapy (CBT) for adults (Health Quality Ontario 2017; Ontario 2020a). During the COVID-19 pandemic, Ontario and Manitoba also expanded access to virtual mental health therapies for their residents, such as the internet-based CBT programs MindBeacon and AbilitiCBT (Manitoba 2020; Ontario 2020b). In October 2020, Manitoba increased access to cover two virtual counselling sessions for their residents until the end of 2021 (Manitoba 2020).

Key Messages

Findings from the literature can be summarized into the following:

1. Studies show that for every dollar invested in covering psychological services in Canada, two dollars in savings for society over the longer term can be generated. Yet, Canada, unlike many other nations, does not have a publicly financed evidence-based psychotherapy program for common mental disorders in primary care.
2. In the context of the COVID-19 pandemic, one may argue that the return on investment of publicly funded psychological services for the healthcare system and the society would be greater than the amount invested by governments.
3. Digitized self-guided psychotherapy platforms for common mental disorders are effective treatment options and require less personnel time and public spending.
4. Population coverage of both medications and psychotherapy for the treatment of mental disorders under a public or private insurance plan will lead toward equitable access to mental health services for all Canadians.

Publicly Funded Psychotherapy Is Cost-Effective

Increased access to mental health treatment and psychological services is associated with reduced disability and negative outcomes due to mental illness and suicide behaviours, and improved health-related quality of life (Mavranezouli et al. 2020; Vasiliadis et al. 2015; Vasiliadis et al. 2017). This can translate to lower health system costs associated with reduced outpatient and in-patient visits, reduced loss of productivity due to absenteeism and presenteeism and short- and long-term disability. Funding psychological services in Canada can lead to societal savings over the long term (Vasiliadis et al. 2017). In other words, including psychological services, such as psychotherapy, as part of the treatment package offered under a province's public health plan for those without access pays for itself (Vasiliadis et al. 2017).

In the backdrop of the potential economic and social benefits, why is the increase in public financing of psychotherapy for common mental disorders a one-time response to COVID-19? Calculations show that the $35-million investment by the Québec government would cover 48,077 individuals – representing only 0.6% of the population – to receive, from psychologists and psychotherapists, an eight-session treatment plan of consultations at an average of $91 per session (CNESST 2021; SAAQ 2020).

Compared with Australia and the UK – countries with similar general practitioner (GP) gatekeeper systems – Canada has failed to implement policy responses to improve public access to psychotherapy for common mental disorders in primary care (Vasiliadis and Dezetter 2015). As of 2019, the Better Access program in Australia, whereby GPs are able to prescribe psychotherapy to patients, had registered 22,577 psychologists and allied health professionals (e.g., social workers, occupation therapists and nurses) to offer psychological services under the Medicare benefits schedule. The latest Australian annual report shows that 1.4 million individuals received close to 5.9 million mental health services under this program (AIHW 2020). At an average fee of $127 per consultation (Medicare Benefits Schedule: items 80010 – psychological therapy services and 80110 – focussed psychological strategies), this translates into an annual expenditure of $749 million in covering up to 5.5% of the Australian population. The cost-effectiveness and significant health improvements in the severity of psychological distress, depression and anxiety associated with Better Access have been previously reported (Pirkis et al. 2011). In the context of the ongoing COVID-19 pandemic, where many experience distress (Brooks et al. 2020; United Nations 2020; Williams II et al. 2020), one may argue the avoided healthcare costs and related disability to be greater than the amount invested by provincial governments (Dezetter et al. 2013; Vasiliadis et al. 2017).

The UK's Improving Access to Psychological Therapies (IAPT) has thus far trained close to 10,500 therapists to offer psychological treatments (Clark 2018; Community and Mental Health Team, HSCIC 2014). Recent reports from the National Health Services (NHS) in the UK show 57,814 referrals to IAPT in April 2020, with 86% of individuals starting treatment within six weeks (NHS Digital 2020d). The average number of sessions was 6.7, which is similar to previous NHS reports. Among individuals who completed treatment in April 2020, 47% had recovered (NHS Digital 2020d) as compared to 51% (NHS Digital 2020b) and 48% (NHS Digital 2020c) in February and March 2020, respectively. Investments in IAPT aim to expand access by 25%, representing close to 1.5 million individuals each year by 2021 (Mental Health Taskforce 2016). To ensure access to and continuity of services during the imposed COVID-19 physical distancing measures, the NHS also published a guide for the offering of IAPT services remotely by telephone, video-conferencing, written support, digitally enabled programs, etc (NHS 2020a).

Internet-delivered psychotherapy for common mental disorders has been shown to produce similar effects as face-to-face therapy (Carlbring et al. 2018); yet, they require much less of the therapist's time (Andrews et al. 2018). Two online platforms providing digitized psychotherapy include BounceBack and This Way Up. BounceBack, a low-intensity intervention, is freely available for residents in British Columbia and Ontario and helps youth and adults manage moderate depression, anxiety, stress and worry (https://bouncebackbc.ca; https://bouncebackontario.ca/). Primary care staff including GPs can refer patients to BounceBack. The program includes videos and workbooks to encourage change in thinking patterns and coaching by trained psychologists (Lau and Davis 2019). Data collected over six years (2008–2014) show significant reductions in symptoms of depression and anxiety, with 3,794 program participants reporting no clinical symptoms post-treatment with a recovery rate of 69% (Lau and Davis 2019). This Way Up was created by Australian clinicians and funded by the Australian Government's Department of Health and Ageing to provide online learning programs and education on anxiety, depressive disorders and physical health (https://thiswayup.org.au/). As of 2015, over 9,700 patients participated in This Way Up courses, with a cost averaging $59 for six lessons. Clinicians can refer patients to This Way Up, and once signed up, patients have access to the courses, exercises and support of healthcare professionals. Through this program, healthcare professionals can monitor patients' symptoms and intervene, should it be necessary, based on pre-established clinical criteria via validated mental health scales. This Way Up reduced symptoms in patients compared to those on waiting lists, and results are comparable to those from psychological treatment offered in person (Ashford et al. 2016). These digitized programs may lead to timely access to evidence-based psychotherapy for people with common mental disorders by better matching service need with service intensity, leading to improved efficiency (Lau and Davis 2019).

Ensuring Equitable and Timely Access to Effective Publicly Funded Psychotherapy in Canada

This unprecedented crisis is forcing us all to better understand not only the importance of mental health in overcoming the devastating effects of the pandemic but also the flaws in our delivery of mental health services. In the backdrop of a system already bottlenecked, how will we ensure timely access and who will be given priority? The following question remains: Why is there skepticism around publicly financing evidence-based psychotherapy for common mental disorders in primary care?

With Australia and the UK as examples, each Canadian province should publicly finance the currently unmet mental health service needs for psychotherapy/counselling of their residents annually, which on average is estimated to reach 4.3% of their total population. The workforce across provinces for the adequate provision of mental health services within primary care from GPs, psychologists and allied mental health professionals is reported in the Mental Health In Your Pocket 2019 report (IHE 2019). The psychologist workforce in Canada is 49 per 100,000 population, ranging between 16 and 95 per 100,000 population in Manitoba and Québec. Latest available data show that for registered nurses working directly in mental healthcare, the average in Canada is 40 per 100,000 population, with a range between 20 and 70 per 100,000 population in Saskatchewan and Newfoundland and Labrador. The estimated workforce of social workers in Canada is 146 per 100,000 population, with the lowest in British Columbia and the highest in Newfoundland and Labrador at 87 and 286 per 100,000 population, respectively. Finally, a Canadian Institute for Health Information (2021) report shows that the lowest and highest rate of the GP workforce in provinces ranges between 110 and 137 per 100,000 population in Manitoba and New Brunswick. When comparing our GP workforce to other countries, the rates are 160 and 80 per 100,000 population in Australia and the UK, respectively (Papanicolas et al. 2019). Despite the presence of some differences between these countries, the latest figures show that each province has the overall trained workforce necessary to start planning for some initial coverage of publicly funded psychotherapy.

Conclusion and Recommendations

To ensure patient-centred care and the efficiency of the health system, psychotherapy should be offered as a mixture of face-to-face and virtual therapies that include self-guided treatments and those guided by health professionals online. In the COVID-19 context, we are given a unique opportunity to rethink and contribute to the ongoing discussion surrounding the Canada Health Act for the provision of mental health treatments, such as structured psychotherapy provided by nonphysicians, for example, psychologists and allied mental health professionals (Government of Canada n.d.).

Québec's universal drug insurance plan implemented in 1997 should be used as an example, where, by law, each resident is covered under either a private employer or insurer, or the public drug insurance plan (Régie de l'assurance maladie du Québec). In Québec, as in other Western countries, medications are the most economically viable treatment option for most, thereby ignoring patient treatment preferences (Clark 2018; Marcus and Olfson 2010; McManus et al. 2016). For example, close to 67% of Canadians hold private insurance allowing for additional drug and health service coverage (Papanicolas et al. 2019). This leaves 12.4 million Canadians without private or employer insurance giving access to psychological services, such as psychotherapy, suggesting significant limitations in equitable access to quality mental health services that can efficiently meet the health needs of Canadians while providing safe, effective and person-centred healthcare. A well-performing health system can only be achieved when every Canadian is covered for not only medical services but also mental health services, and this, within a responsive health system that ensures continuity and fluidity from primary to specialized care and back to primary care. Insuring Canadians for both medications and psychological services under a public or private insurance plan would help move provincial health systems forward in providing equitable access to mental health services.

Financement public de la psychothérapie fondée sur les données probantes pour les troubles mentaux courants : appels à l'action croissants dans les provinces canadiennes

Résumé

Les provinces canadiennes n'ont pas de programme de psychothérapie financé par l'État pour les troubles mentaux courants, et ce, malgré les données indiquant que les services psychologiques permettent de réduire la durée et le nombre d'épisodes dépressifs, les symptômes de stress post-traumatique ainsi que les résultats négatifs qui y sont associés (hospitalisations et tentatives de suicide). Des études montrent qu'il est rentable d'inclure les services psychologiques dans le régime public d'assurance maladie pour les personnes qui y ont un accès restreint. Nous argumentons qu'un programme de psychothérapie canadien financé par l'État, y compris des plateformes numériques de psychothérapie autogérée pour les troubles mentaux courants, entraînerait une amélioration de la santé de la population utile dans le présent contexte de la COVID-19 et au-delà.

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