Who delivers mental health care?

Dr. Suzanne Koven has just written a great blog post that is required reading for anyone who cares about mental health care in North America, called "Should Mental Health Care be a Primary-Care Doctor's Job?"  She points out the degree to which medical mental health care has been downloaded to primary care docs who may or may not feel up to the task. 

I’m comfortable helping people get through life’s more common emotional challenges, like divorce, retirement, disappointing children. If you’re hearing voices, or if you walk into my office and announce that you’ve decided to kill yourself, as someone did not long ago, I know exactly what to do: escort you to a psychiatrist. But what about the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder? Or the businesswoman whose therapist told her to see me about starting an antidepressant? Or the civil servant trying to shake his Oxycontin addiction? They’ve all asked me to treat them because they don’t want or can’t easily access psychiatric care.

Here in Quebec, the recent Bill 21, which regulates the act of psychotherapy, gives physicians automatic access to the title of psychotherapist though their training in mental illness and mental health may be limited depending on what their experience in medical school and residency was.  While there are many doctors who are great psychotherapists and who have taken the time to get trained, becoming a doctor involves training in diagnosis of mental illness and some psycho-pharmacology and only a cursory understanding of different forms of psychotherapy.  (The purpose of Bill 21 is to protect the public by ensuring a minimum of training for psychotherapists.  It has serious ramifications for people who use mental health services but remains largely unexamined in French or in English media). 

Dr. Koven points out that fewer medical students are going into psychiatry in the US (sorry, I can't give Canadian stats) so both the public and general physicians have less access to doctors who specialize in mental health.  I also have seen that there is a feeling among patients that psychiatrists are pill-pushers while a GP may be more accessible and take the time to know a patient better ad this may make people even more likely to rely on generalists.  (My experience of psychiatrists has actually been that they are more likely to prescribe talk therapy with or without medication than GPs, but that is very impressionistic.) 

Recent changes to the way health care is delivered in Quebec make it harder to access a psychiatrist directly through the public system.  In order to see a psychiatrist you must first go to a public health clinic, a CLSC, rather than go to a psychiatrist in the public system directly (except for emergencies).  This can be good because people can be seen by a social worker or psychologist at a CLSC which may be what they need, but it re-enforces the model of psychiatry being practiced only with the very seriously mentally ill or the very wealthy.  Finding a psychiatrist to really follow someone with obsessive compulsive disorder, for example, to ensure that medication is appropriate and effective and to consult with the therapist, whether s/he is a GP or a social worker, is very hard.  It may account for why fewer people want to go into the field, too.  After all, who wants to go into a medical specialty where you are supposed to fathom the mysteries of the human heart and human relationships but are unable to form relationships with patients because you see them on an assembly line, and on top of that, you will mostly see people whose illnesses can at best be managed but are without cure?