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Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand Mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of Mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a Mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to Mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

And one to which many family doctors, struggling to help mentally ill patients, can attest. After months of research, and as detailed in our Open Minds series, The Globe and Mail identified some of the top evidence-based approaches to building a mental health system that will work for Canadians. These are changes that would move the country beyond its patchwork, fragmented mental health system in which the care patients receive is too often determined by what they can afford, or where they live or what they are savvy enough to cobble together on their own. These initiatives abide by the principals of Medicare and good science, and treat the disorders of the mind as diligently as the diseases of the body.

Expanding access to publicly funded therapy One in five Canadians will be affected by mental illness in their lifetimes. The cost to the country's economy is staggering: $50billion a year in health care and social services, lost productivity and decreased quality of life, estimates the mental Health Commission of Canada. The personal costs are more devastating - unemployment, family breakup, suicide. Canadians who seek help for a mental illness will most often be prescribed medication, even though research shows that psychotherapy works just as well, if not better, for the most common illnesses (depression and anxiety) and does a better job at preventing relapse. According to a 2012 Statistics Canada study, while 91 per cent of Canadians were prescribed the medication they sought, only 65 per cent received the therapy they felt they needed. Access to evidencebased psychotherapy, which experts say should be the front-line medical treatment, is limited and wait-lists are long.

No provinces cover therapy delivered in private practice by a psychologist, social worker or psychotherapist, creating a twotier system, which means families without coverage through work - those more likely to be low-income - often either pay out of pocket or go without or, if they are lucky, rely on a non-profit group working to fill a gaping hole in a flawed health-care system. Even Canadians with coverage rarely have enough for a proper dose that meets treatment guidelines. This kind of inconsistent, unequal and scientifically flawed approach to care would be untenable for diabetes, cancer or heart disease. Yet it persists for some of the most debilitating illnesses suffered by Canadians. "Clearly this is the biggest gap we have, and the one that most needs to be fixed," says psychiatrist Elliot Goldner, director of the Centre for Applied Research in Mental Health and Addiction. Psychotherapy is a medically necessary treatment, he argues, that should be publicly funded. The question is not whether Canadians need it, but how to deliver it.

With no history of care, Dr. Cookson had no way to know for sure. She advised him to make sure he told his mom if he had suicidal thoughts again and wrote a referral to see a psychiatrist, though even an urgent request would take weeks. Other than that, she had little to offer. They had no coverage for psychotherapy, which ideally, she would have prescribed. Since the young man was a walk-in patient, there is no guarantee she will see him again. "I want to be able to give them the care they deserve, and I know will benefit him, and I have no way of arranging that," she says. "It's a pretty helpless feeling."

Using technology to deliver therapy into the homes of Canadians It can be hard enough to get timely treatment if you only have to drive a few blocks to find it. But what if access to care for, say, an anxiety disorder requires traversing a sprawling wilderness, for hours by car, sometimes through a blizzard? These were the stories that Fern Stockdale Winder heard often from Saskatchewan patients, as the psychologist charged with developing the province's new mental health strategy. Even when mental health care was available, reaching treatment was often one more layer of stress. It doesn't have to be this way. Chief among the strategy's recommendations: a provincewide online therapy system. The evidence for tech-delivered therapy, with support over the phone, is strong - for many patients with depression and anxiety, it can be just as effective as face-to-face sessions. It allows patients to manage care around their work and school schedules, to maintain privacy and to take control of their own recovery in a way less likely to happen with medication.

And it's cost-effective, says Dr. Stockdale Winder, potentially reducing appointment no-shows and cutting down on travel time for patients and therapists to and from remote communities. Canadians have ready access to medication for mental illness not because it's the best option, but because it's the easiest - even though psychotherapy works as an effective early intervention, a standalone treatment or in combination with drugs, and to prevent relapse. This front-line treatment can also be delivered in a modern and increasingly convenient way that gives patients more choice in how they receive their care.

It's very much about how people like to learn. Whether for reasons of stigma or personal preference, many people like to work on life challenges by themselves," says Chris Williams, a psychiatrist at the University of Glasgow, whose self-guided program is used as a first-stage treatment in Britain's publicly funded psychotherapy system. It has also been adapted in British Columbia and is being piloted in other provinces by the Canadian Mental Health Association. Self-guided therapies vary - some use DVDs or booklets, others are delivered online - but the evidence is strongest for ones that also link patients to therapists, either by e-mail or with brief phone calls.

A separate online program at the University of Regina has already had promising results. (Even so, the government is taking a wait-and-see attitude: Health Minister Dustin Duncan said last week that the government is keeping an eye on the project and will consider whether to expand the service after the pilot concludes next year.) What Dr. Stockdale Winder envisions is a system in which family doctors could use depression and anxiety screening to easily steer appropriate patients away from medication and toward accessible, online therapy.

"She clicks a button, and the patient is in," she says. Such a system would also monitor the progress of participants and direct them into more intensive care if their conditions worsened. The need for early intervention is pressing, and the evidence for online therapy is already convincing. In a country of wide open spaces, with remote communities difficult to reach even in the best weather, it's necessary. What are policy-makers waiting for? Teaching the next generation about mental health

Mr. Rankin said that Ottawa should be working with the provinces, territories and municipalities to ensure they can provide an appropriate combination of services, treatment and support for those dealing with mental illness. He pointed to the national mental-health strategy developed by the mental Health Commission of Canada in 2012 as a roadmap for improving services.

We would obviously want to look at each of those recommendations [in the strategy], but the general thrust of those recommendations, we would implement, absolutely," Mr. Rankin said. Among other points, the strategy calls for increased access to qualified psychotherapists and counsellors and the removal of financial barriers for children, youth and their families.

Mr. Rankin also called for a revival of the Health Council of Canada and a new federal health accord to foster communication between the federal government and the provinces on health. Both expired last year. Dr. Fry said the Liberals, if elected, would work closely with the provinces to develop a more integrated approach to health-care services, including mental health.

She said the last accord, which expired in 2014, had begun to look beyond the physician and the hospital and toward health care that could be provided by multidisciplinary teams. "We want to integrate mental health, in a fulsome way, into our health-care system," Dr. Fry said. "And that would mean a lot of the things that the mental Health Commission talked about." However, she said the Liberals would not commit to specific actions before consulting with the provinces

We have to talk to the provinces about it," she said. "That's what we can commit to doing." Dr. Fry said a partnership between the federal government and the provinces on health care is necessary but declined to specify if a Liberal government would establish another health accord or bring in a different system. The length of the next partnership could also be up for discussion, she said.

Research suggests that psychotherapy, which is provided by a licensed therapist, is an effective treatment for many people struggling with anxiety and depression, the two most common psychiatric diagnoses. Therapy by private psychologists or social workers is not currently covered by any of the provinces. A spokesman for Health Minister Rona Ambrose said the provinces and territories are responsible for health-care delivery, including psychotherapy. The Conservative government created the Mental Health Commission of Canada and recently renewed its mandate for another 10-year period, he said.

A written statement from Ms. Ambrose, provided to The Globe and Mail, said the Canada Health Act does not preclude provinces and territories from extending public coverage to other services or providers such as psychologists. "Provinces and territories may choose to extend public coverage for such services," she said. With reports from Erin Anderssen in Ottawa This is part of a series about improving research, diagnosis and treatment

Sadly, the offerings in our health system are driven as much by tradition as they are by evidence. We needn't be prisoners of our outmoded structures. In the fifties and sixties, we created a system to provide care in hospitals and in physicians' offices and it's almost impossible to break that mould and innovate - for example, by putting psychological care on an even footing with psychiatric/medicinal treatment. What we really need to do is provide care where people bring their mental-health problems - in primary care. As most provinces try to transition from a solo, fee-for-service model to multidisciplinary teams, it provides a perfect opportunity to bolster mental-health care by integrating psychologists onto teams. Other countries have done so, notably Britain and Australia, and the early evidence is that it's paying off. The fear, of course, is that providing public funding of psychological care will cost more. Of course it will. Estimates range from $950-million to $2.8-billion a year.

But the offering of psychological care doesn't have to be an open buffet like other aspects of health care, and some of the hundreds of millions now paid for (not always trained) doctors to provide psychotherapy can be spent more smartly. If done right, the investment should pay off down the road, in lower health costs, disability-insurance payouts and absenteeism. Because the greatest costs of mental illness arise when it is left untreated, and festers. mental illness is common: 10 per cent to 25 per cent of women and 5 per cent to 12 per cent of men experience a major depression; 4 per cent to 7 per cent of Canadians suffer from anxiety disorder; 7 per cent to 12 per cent experience posttraumatic stress disorder; 10 per cent suffer from phobias; 5 per cent experience panic disorders; 2 per cent to 4 per cent suffer from obsessive compulsive disorder or eating disorders; 1 per cent to 2 per cent suffer from bipolar disorder or schizophrenia. For years, we have been focusing efforts on combatting the stigma, urging Canadians with mental-health disorders to come forward. But the care is not available for those who need it; waits stretch from months to years, and an estimated one in three adults and one in four children don't get care at all.

Psychotherapy can help fill the gap. There are 8,000 psychologists in Canada. About three-quarters are in private practice, charging $100 to $200 an hour, and roughly one-third work exclusively in the public system, where there is no charge to patients. Canadians spend about $950million on psychological care, most of it covered by private insurance and workers compensation; but a good chunk, about one-third, is paid out of pocket. We have a mixed health-funding model in this country, but when it comes to mental-health care, we don't have the mix right. Too many people are being denied care because they can't afford it, or because their workbased insurance provides paltry benefits for psychological care. As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care.

We need to stabilize the situation in Attawapiskat in terms of making sure they have the health support they need,” Mr. Angus (Timmins-James-Bay, Ont.) told The Hill Times last week. “We need a plan to get people who are needing help in any of the communities to get that help.”

A rash of attempted suicides prompted Mr. Angus, who’s also the NDP critic for indigenous and northern affairs, to call for an emergency debate on the ongoing suicide crisis in the James Bay community of about 2,000. As a result, the House of Commons convened until midnight last Tuesday for an emotionally charged discussion on mental health services following a string of incidents in northern reserves in recent months. Several MPs choked up during their statements, recounting suicide incidents in their ridings and personal lives.

Sometimes partisan politics need to be put aside and members need to come together to find solutions to prevent another unnecessary loss of life,” Conservative MP Todd Doherty (Cariboo-Prince George, B.C.) said during the debate. NDP MP Georgina Jolibois (Desnethé-Missinippi-Churchill River, Sask.) said the suicide rate went up in her home community of La Loche in northern Saskatchewan after a shooting spree that killed four people last January.

Liberal MP Robert-Falcon Ouellette (Winnipeg Centre, Man.) recalled visiting the northern Manitoba Pimicikamak Cree Nation, which declared a state of emergency over a series of suicide attempts last month.

Mr. Angus made an emotional appeal to action in his opening remarks during the emergency debate. “We have to end the culture of deniability whereby children and young people are denied mental health services on a routine basis, as a matter of course, by the federal government,” he said. Eleven people attempted to take their lives in Attawapiskat two Saturdays ago, prompting the First Nation to declare a state of emergency—the fourth one since 2006. There has been more than 100 suicide attempts in the reserve since the month of September, many of which involved children. The community has been plagued by flooding and several housing crises in recent years.

Eighteen mental health workers were dispatched to Attawapiskat on Tuesday, including two counsellors, one crisis worker, two youth support workers, and one psychologist. While there is no set timeline, they’re not expected to leave for at least two weeks, said Health Canada assistant deputy minister Keith Conn during a teleconference last week.

Some of the people treated for mental health problems last week had previously been airlifted out of the community for assessment before being sent back after their examination, according to Mr. Conn. This past Tuesday, at least 13 people, including a nine-year-old child, had made plans to overdose on prescription pills as part of a suicide pact. The Nishnawbe-Aski Police Service apprehended them before sending them to the local hospital for a mental health assessment.

Mr. Conn said he’s heard criticism of the mental health assessment process from Attawapiskat First Nation Chief Bruce Shisheesh. Individuals who are identified as likely to commit suicide are typically sent to a hospital in Moose Factory, Ont., to be psychologically evaluated by a psychologist or psychiatrist. They are then discharged and sent back to the community, where some try to take their life again. Mr. Conn said Health Canada does not “control the process,” but he personally committed to review the mental health assessment effectiveness.

No federally funded psychiatrists were present in the region prior to the crisis, despite reserve health-care falling under the purview of the federal government. Mr. Conn said the Weeneebayko Area Health Authority (WAHA), a provincial health unit servicing communities on the James Bay coastline, is usually responsible for the Attawapiskat First Nation following an agreement struck with the federal government about 10 years ago.

A mental health worker position for the reserve has been vacant since last summer, in part because there’s a lack of housing for such staff. The community has been left without permanent, on-site mental health care services. Since then, the position has been filled by someone already living on reserve. During the emergency debate in the House last week, Health Minister Jane Philpott (Markham-Stouffville, Ont.) emphasized the need for short- and long-term responses to the crisis.

We need to address the socio-economic conditions that will improve indigenous people’s wellness in addition to ensuring that First Nations and Inuit have the health care they need and deserve,” she said. Ms. Philpott pointed to the Liberal government’s budget, which includes $8.4-billion for “better schools and housing, cleaner water, and improvements for nursing stations.”

“Our department and our government are ensuring that all the necessary services and programs are in place,” she said during the debate. “We are currently investing over $300-million per year in mental wellness programs in these communities.” Yet, Mr. Angus said the budget includes “no new mental health dollars” for First Nations communities. In addition to allocating more funds for mental health services to indigenous communities, Mr. Angus said there needs to be a concerted effort to bring in the aboriginal youth in the conversation.

We need to bring a special youth council together,” he told The Hill Times on Wednesday. “We need to have them be able to come and talk to Parliament about their concerns, so we’re looking at those options now.” Emotion was audible in Mr. Angus’ voice when he read letters he received from Aboriginal youth during the emergency debate, which expressed a desire to work with the federal government to solve the crisis.

The greatest resource we have in this country is not the gold and it is not the oil; it is the children,” he said. “The day we recognize that is the day that we will be the nation we were meant to be.” Mr. Angus met with Indigenous and Northern Affairs Minister Carolyn Bennett (Toronto—St. Paul’s, Ont.) earlier in the week to discuss potential long-term solutions to the suicide crisis. “I’ve always had an excellent relationship with Carolyn Bennett, and as minister we’re trying to find ways to work together on this, to take the tension down, to start finding solutions,” Mr. Angus said. Mr. Angus criticized “Band-Aid” solutions that have been thrown at First Nations issues over the years and said there needs to be a “transformative change” this time.

That’s where we have to move beyond the positive language to actually the brass tacks,” he said. During the emergency debate, Mr. Angus supported the idea of giving more resources to frontline workers such as on-reserve police, and health and treatment centres. 0eMr. Angus’ riding sprawls from shores of the Hudson Bay to the Timiskaming district on the border with Quebec, an area roughly equivalent in land size to that of Guinea. He holds two constituency offices in Timmins and Kirkland Lake.

recommends that the proportion of health spending that goes to mental health should rise from seven per cent to nine per cent over 10 years

$4 billion over the next decade and

spending from social services budgets that goes to mental health should rise by at least two per cent

Shift policies and practices toward recovery for people living with mental health problems.Address critical gaps in treatment programs for youth and adult offenders.

Set standards for wait times for mental health services.Remove financial barriers for children and youth to access psychotherapies and counselling.Address barriers to access for medications.

not enough is being done to fund services or to address the problem of two-tier access to counselling

currently, 7 per cent of health dollars in Canada ($14-billion) are spent on mental-health care and recommends that be increased to 9 per cent ($18-billion).

changes are required in social services, education, housing and corrections.

CivicAction also lists income inequality and job insecurity as contributing factors for mental health issues. Wayne Lewchuk, a professor at McMaster University who has studied precarious labour extensively, said its strain goes beyond a worker’s schedule and employment status. “You’re less likely to have friends at work because you’re moving from workplace to workplace,” Lewchuk said. “Your support system is weaker.”

"deinstitutionalization," resulted in the virtual emptying, and subsequent closure, of many psychiatric facilities across the country (Can J Psychiatry 2012;57[2]:Insert 1-6).

The comprehensive community support systems that were meant to sustain deinstitutionalization never fully materialized.

In 1959, the nation had 65 000 beds in mental health facilities (Can J Psychiatry 2012;57[2]:Insert 1-6). Today, there are just 10 653 beds (www.who.int/mental_health/evidence/atlas/profiles/can_mh_profile.pdf).

But transinstitutionalization isn’t the sole factor at play in the disproportionate incarceration of the mentally ill, several experts say. They point to Prime Minister Stephen Harper’s "get tough on crime agenda" as also having had a substantial impact on the numbers of incarcerated.

As a corollary, the conditions of confinement essentially increase the rate of mental illness

Risk factors linked to increased mental health problems in children include unstable home environments, harsh or inconsistent parenting, parental mental illness and inadequate access to health care, says the Ontario report.

those from higher income brackets may be able to get help more quickly because they can access private practitioners without wait lists and coverage from health insurance companies

A family straining to make ends meet may not have extra dollars for trips to recreation centres, registration for sports teams or other social activities - experiences that connect children with their peers and keep them from being isolated and alone and therefore susceptible to mental health problems.

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

The Standing Senate Committee has asked Canadians to answer the question: Excluding increased funding, what are the three most important areas of government responsibility (either federal or provincial) that need to be improved to ensure adequate and timely access to needed mental health services?

Three Priorities for Action

1) Act outside of the traditional health care sector: Ensure access to housing, supportive housing, income, and employment.

2) Include mental health in health care reform initiatives.

Expand coverage under the Canada Health Act

include home care under the Act and to ensure public funding for the costs of medications prescribed outside of institutions

reinforce the work already underway by First Ministers to expand home care to people with mental illness

include people with concurrent disorders and addictions in any national home care program

3) Develop a National Action Plan on Mental Health.

Cavoukian found that 19,000 “mental health episodes" have been uploaded to CPIC. "The untenable practice of automatic or blanket sharing of police information related to suicide threats or attempts simply cannot continue," Cavoukian said. "The record of a person's suicide attempt is personal health information, that should be protected to the greatest extent possible," said Dr. Peter Voore, medical director at the Centre for Addiction and mental Health (CAMH). “I am calling upon all police services across Ontario to immediately cease the practice of automatically uploading or disclosing personal information relating to threats of suicide or attempted suicide via CPIC, by default,” Cavoukian said.