Integrating psychologists into the Canadian health care system: the example of Australia.
Mental illnesses such as depression and anxiety disorders make up a substantial component of the disease burden of Canada and Australia, (1,2) with over 10% of the population having a disorder in any one year. If left untreated, such disorders lead to substantial personal misery, disability, functional impairment, disruption to family, increased health care costs, and increased rates of suicide. However, research shows that these disorders are responsive to certain well-defined psychological treatments, (3,4) suggesting that the use of such evidence-based therapies is one avenue whereby a large proportion of the disease burden could be averted. (5) For example, the evidence-based guidelines of the National Instititute for Health and Clinical Excellence in the UK recommend depression-focused psychological treatment (problem-solving therapy, brief cognitive-behavioral therapy [CBT] and counseling) or serotonergic medication for mild-to-moderate depression; and combined serotonergic medication and CBT for severe or treatment-resistant depression. (6) Such evidence and recommendations leave policy-makers in both countries with the question of how best to provide broad community access to evidence-based psychological treatments. In this paper, we compare the Canadian and Australian approaches to improving access to psychological treatments in primary care. We believe that such a comparison is timely, given that Canada has launched a national mental health commission to inform the development of sound public policies and to improve service delivery. (7)
Comparability of Canadian and Australian systems
Canada and Australia share many similarities in terms of their demographics, mental health needs, and models for providing health care. Both countries have a large landmass with an increasingly aged and highly urbanized population that is mainly of Caucasian descent, with a proportion of immigrants and Indigenous peoples. Both have relatively strong primary health care systems, (8) with provincial/state level governments being responsible for the provision of a substantial proportion of health care. (9) Both have a universal, publicly-financed health insurance, termed Medicare, which covers the majority of medical costs, although in Australia this is controlled federally rather than at province/state level. In both countries, family physicians/general practitioners operate at the centre of the health care system, performing a gate-keeping role, and operating predominantly on a fee-for-service basis. (9,10) In Canada, following the Romanow Report, different models of delivery and remuneration are being developed to increase access to family physicians and to encourage team or interdisciplinary approaches in primary care. (9-11)
Psychological care in Canada
Canadian family physicians have practices that are burdened by the most prevalent mental disorders (depression, anxiety) and welcome collaboration with psychologists. (12) However, such services remain generally inaccessible. (12-14) Below, we describe the typical Canadian experience of primary mental health care.
Within the Canadian publicly-funded primary care system, a range of mental health interventions is offered, with the family physician at the core. Low-prevalence mental disorders such as schizophrenia are generally referred to psychiatrists for pharmacological treatment. High-prevalence/common mental illnesses such as depression are treated either within the public or private system. In the public system, usual care involves drug therapy and/or generic counseling delivered by the family physician. Such psychological interventions primarily entail emotional support and counseling (listening/giving advice) rather than formal psychological treatments. (15)
Alternatively, the family physician can refer a consumer to see a professional such as a psychologist. In 2001, approximately 80% of consultations with psychologists were within the private system, with a proportion covered by private insurance and the remainder funded predominantly by consumers' out-of-pocket expenses. (13,16) In a recent survey, Ontario family physicians reported such costs to be the greatest barrier to referring consumers to psychologists. (12)
Recent primary care reform has facilitated the development of alternative service delivery models involving interdisciplinary care teams. Examples include "Shared Mental Healthcare" initiatives, (17) which most frequently involve collaboration between family physicians, psychiatrists and mental health workers or social workers. (15,18) Consumers with severe and/or persistent mental illnesses or those requiring a psychiatric consultation along with emotional support are served well with this model, but the most prevalent psychological problems do not necessarily require psychiatric interventions. Family Health Teams (FHT) in Ontario and Family Medicine Groups (FMG) in Quebec aim to promote interdisciplinary care. (19) Again though, while FHTs increase access to mental health services, they are generally rendered by counselors/social workers, with psychologists incorporated into only a few FHTs and none of the FMG teams. (20)
We believe that the move towards multidisciplinary teams is to be applauded. However, there are approximately 15,000 psychologists working in Canada; (21) a workforce that has undergraduate and graduate-level education and training (e.g., in Ontario it takes approximately 10 years to achieve autonomous practice) and who are licensed with authority to exercise controlled acts. We find it of concern that, despite their range of expertise as diagnosticians, consultants and providers of evidence-based psychological treatments as opposed to generic/supportive counseling for a range of mental disorders, this workforce is mostly excluded from the primary care component of mental health treatment.
Psychological care in Australia
Australian psychologists traditionally operated in similar settings to Canada, including hospitals, community health centres and private practice. In the former two settings, access has been free at the point-of-service for some time, but until recently, consumers incurred significant out-of-pocket costs if they visited a private psychologist.
In 2000-01, the Australian Government provided funding for the Better Outcomes in Mental Health Care program (BOiMHC). The BOiMHC involves a number of components, one of which explicitly aims to improve access to psychologists. Divisions of General Practice (locally-defined networks of GPs) are provided with capped funds to manage Access to Allied Psychological Services (ATAPS) projects. These projects enable GPs to refer consumers to psychologists (and other selected allied health professionals) for up to 12 sessions of free or low-cost evidence-based mental health care. Like the Canadian FHTs, the ATAPS projects are tailored to meet local needs. For example, some Divisions directly employ their psychologists while others contract them on a sessional basis, and some co-locate their psychologists with GPs whereas others encourage them to operate from their own rooms. Ongoing evaluation suggests the projects are achieving positive outcomes for consumers. (22)
In 2006, the Federal Government instituted the Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule (Better Access) program, which now sits alongside the BOiMHC program. This program increases access to private psychologists via a different means, namely by making services eligible for a rebate through the Medicare Benefits Schedule. The program enables a consumer to receive up to 12 sessions of evidence-based mental health care from registered providers, when their GP, in consultation with the consumer, judges such services to be of benefit. The GP retains his role as the provider of continuing care, with psychologist feedback to the GP, and a progress review by the GP after six sessions.
Several factors seem to have been important in these Australian reforms, and these may be worth fostering in the Canadian context. First, consumer advocacy was a strong driver. In particular, reports by the Mental Health Council of Australia were widely distributed and had a major impact. (23,24) These reports highlighted unmet needs for basic mental health services, with many individuals relying on increasingly overworked GPs for such services. Second, there was an increasing appreciation of the cost of mental illness. The Australian Burden of Disease Study, for example, found that mental illness had the greatest burden through Years Lost due to Disability (YLD) of any illness. (25) Third, a series of Australian cost-effectiveness studies provided compelling evidence that psychological services represented value-for-money from a public health perspective. (26) Fourth, there was an increased policy recognition of the role of primary care providers in the delivery of mental health care. (27,28) The National Mental Health Strategy emphasized the need for partnerships between primary and secondary care; and the General Practice Strategy emphasized that mental disorders could be more effectively treated with improved primary care services. (27) A major theme of an Australian Senate report on mental health, (29) which immediately preceded the Better Access program, was the heavy load on primary mental health care workers such as GPs. As a solution, they report psychiatrist Professor Ian Hickie's submission: "If the Commonwealth were to immediately recognise the number of psychologists who would automatically meet that [standard of training]... we would immediately double the mental health specialist work force, and it would not kill the Treasury" (ref. 29, p.146). Fifth, and related to these policy drivers, there was strong interprofessional advocacy, with various multidisciplinary groups promoting developments in primary mental health care, including the incorporation of psychologists into the primary care workforce. (28,30)
The multidisciplinary primary care teams in some parts of Canada share similarities with Australia's mental health programs, with their emphasis on management of mental illness in primary care and their flexibility to suit local needs. However, in the Canadian programs, underutilization of the psychologist workforce is an issue, given their specialist training in providing diagnostic/treatment/ consultative services and the evidence for the efficacy of psychological treatments in treating high-prevalence mental disorders in primary care. (4) We hope that reflecting on the conditions leading to Australian reforms will provide some principles-of-value in increasing access to psychologist-provided diagnosis, consultation, and treatment within the Canadian context, providing a cost-effective and immediately available solution to an overworked primary mental health care workforce, and improving outcomes for consumers experiencing mental illness.
Received: April 21, 2008
Accepted: November 11, 2008
(1.) Stephens T, Joubert N. The economic burden of mental health problems in Canada. Chron Dis Can 2001;22(1):18-23.
(2.) Begg SJ, Vos T, Barker B, Stevenson CE, Stanley L, Lopez AD. The burden of disease and injury in Australia 2003. PHE 82. Canberra: Australian Institute of Health and Welfare, 2007.
(3.) Roth A, Fonagy P. What Works for Whom? A Critical Review of Psychotherapy Research. New York, NY: Guildford, 2005.
(4.) Schulberg HC, Raue PJ, Rollman BL. The effectiveness of psychotherapy in treating depressive disorders in primary care practice: Clinical and cost perspectives. Gen Hosp Psychiat 2002;24(4):203-12.
(5.) Arnett JL, Nicholson IR, Breault L. Psychology's role in health in Canada: Reaction to Romanow and Marchildon. Can Psychol 2004;45:228-32.
(6.) National Institute for Health and Clinical Excellence (NICE). Published clinical guidelines. Updated 2007. Available online at http://www.nice.org.uk/ guidance/index.jsp?action= ByType&type=2&status=3&p=off (Accessed August 22, 2008).
(7.) Mental Health Commission of Canada. Key Initiatives. Available online at: http://www.mentalhealthcommission.ca/keyinitiatives.html (Accessed May 11, 2007).
(8.) Starfield B, Shi L. Policy relevant determinants of health: An international perspective. Health Policy 2002;60:201-18.
(9.) Hutchison B, Abelson J, Lavis J. Primary care in Canada: So much innovation, so little change. Health Affair 2001;20:116-31.
(10.) Deber RB. Health care reform: Lessons from Canada. Am J Public Health 2003;93:20-24.
(11.) Marchildon GP. Health Systems in Transition: Canada. Toronto, ON: University of Toronto Press, 2006.
(12.) Grenier J, Chomienne MH, Gaboury I, Ritchie P, Hogg W. Collaboration between family physicians and psychologists: What do family physicians know about psychologists' work? Can Fam Phys 2008;54:232-33.
(13.) Romanow RJ, Marchildon GP. Psychological services and the future of health care in Canada. Can Psychol 2003;44:283-95.
(14.) Dobson KS. A national imperative: Public funding of psychological services. Can Psychol 2002;43:65-75.
(15.) Craven M, Cohen M, Campbell D, Williams J, Kates N. Mental health practices of Ontario family physicians: A study using qualitative methodology. Can J Psychiat 1997;42:943-49.
(16.) Canadian Psychological Association. Putting human behaviour at the heart of health care in Canada. Written submission to the Commission on the Future of Health Care in Canada. November 1, 2001.
(17.) Hamilton Family Health Team. Shared mental health care in Canada. Available online at: http://www.shared-care.ca/index.shtml (Accessed November 26, 2007).
(18.) Nickels MW, McIntyre JS. A model for psychiatric services in primary care settings. Psychiatr Serv 1996;47:522-26.
(19.) Ontario Ministry of Health and Long-Term Care. Family Health Teams: Advancing primary care. Bulletin No 1. December 2004. Available online at: http://www.health.gov.on.ca/transformation/fht/fht_bul/fht_bul_1_ 120604.pdf (Accessed September 21, 2007).
(20.) Turcotte V. L'integration de psychologues dans les equipes multidisciplinaires de premiere ligne; facteurs facilitants et obstacles. Memoire presente a la Faculte des etudes superieures de l'Universite Laval dans le cadre du programme de maitrise en sante communautaire pour l'obtention du grade de maitre es sciences (M.Sc.). Quebec, QC: Universite Laval, 2005.
(21.) Canadian Institute for Health Information. Health and Personnel Trends in Canada (1995 to 2004). Updated 2006. Available online at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page= PG_399_E&cw_topic= 399&cw_rel=AR_21_E. Accessed 11/4/2008 (Accessed July 2006).
(22.) Morley B, Pirkis J, Sanderson K, Burgess P, Kohn F, Nacarella L, Blashki G. Evaluating the Access to Allied Psychological Services Component of the Better Outcomes in Mental Health Care Program (Eighth Interim Evaluation Report): Consumer outcomes: The impact of different models of psychological service provision. Melbourne: Program Evaluation Unit, University of Melbourne, 2006.
(23.) Mental Health Council of Australia. 'Out of Hospital, Out of Mind!' A Report Detailing Mental Health Services in Australia in 2002 and Community Priorities for National Mental Health Policy for 2003-2008. Canberra, Australia: Mental Health Council of Australia, 2003.
(24.) Mental Health Council of Australia. Not for Service: Experiences of injustice and despair in mental health care in Australia. Canberra: Author, 2005.
(25.) Mathers CD, Vos ET, Stevenson CE, Begg SJ. The Australian Burden of Disease Study: Measuring the loss of health from diseases, injuries and risk factors. Med J Australia 2000;172:592-96.
(26.) Vos T, Corry J, Haby MM, Carter R, Andrews G. Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression. Aust N Z J Psychiat 2005;39(8):683-92.
(27.) Hickie I, Groom GL. Primary care-led mental health service reform: An outline of the Better Outcomes in Mental Health Care initiative. Australas Psychiat 2002;10:376-82.
(28.) Pirkis J, Blashki G, Murphy AW, Hickie I, Ciechomski L. The contribution of general practice based research to the development of national policy: Case studies from Ireland and Australia. Aust NZ Health Policy 2006;3(4):doi:10.1186/1743-8462-3-4.
(29.) The Senate Select Committee on Mental Health. A national approach to mental health from crisis to community: First report. Canberra: Commonwealth of Australia, 2006.
(30.) van Gool K. National Mental Health Action Plan: One year on. Health Policy Monitor 2007; April 2007. Available online at: http://www.hpm.org/survey/ au/a9/2 (Accessed September 20, 2007).
Richard Moulding, PhD, [1,2] Jean Grenier, PhD, [3-5] Grant Blashki, MD,  Pierre Ritchie, PhD,  Jane Pirkis, PhD,  Marie-Helene Chomienne, MD [4,5]
[1.] Primary Care Research Unit, Department of General Practice, University of Melbourne, Australia
[2.] Swin-PsyCHE Research Unit, Swinburne University of Technology, Melbourne, Australia
[3.] School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, ON
[4.] Montfort Hospital, Ottawa, ON
[5.] Department of Family Medicine, University of Ottawa, Ottawa, ON
[6.] Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
[7.] Centre for Health Policy, Programs and Economics, School of Population Health, University of Melbourne, Australia
Acknowledgements: This work was partially supported by a PHCRED Research Fellowship for author Grant Blashki.
Correspondence and reprint requests: Dr. Grant Blashki, Nossal Institute for Global Health, University of Melbourne, Level 5, Alan Gilbert Building, 161 Barry St., Carlton Victoria 3010 Australia, Tel: +61 8344 2623, Fax: +613 9347 6872; E-mail: email@example.com