BC physicians not providing minimum treatment for half of patients with depression

Depressed British Columbians may not be receiving the care they need.

Half of patients in the province diagnosed with depression who seek help from a physician are receiving inadequate care. The other half are receiving the minimum adequate treatment, according to a new UBC study.

“We’ve always suspected that there are a lot of people that are not getting enough care for their depression,” said PhD candidate Joseph Puyat, the study’s co-author. “But it’s only now using the data we have that we were able to quantify the magnitude of the problem."

The researchers reviewed health data from almost 110,000 British Columbians diagnosed with depression by physicians between 2010 and 2011. Their possible treatments fell into two categories: talk therapy or drug therapy.

Minimum care for talk therapy is four sessions while minimum care for antidepressants is 12 weeks. The researchers found 13 per cent of patients in psychotherapy received a minimum level of care, compared to 47 per cent of patients in drug therapy. Overall, 53 per cent of patients received minimum care.

Puyat is quick to point out that his research doesn’t tell the whole story. The opposite of inadequate care is not optimal or even adequate care, his research has nothing to do with treatment outcomes. A 2012 Statistics Canada report found that only six of 10 people with depression in Canada are even in contact with the healthcare system.  

“So if I extrapolate my findings to those six people, it’s not 50 per cent who aren’t receiving the minimum treatment, it’s more like 30 per cent,” said Puyat, who also noted that more won’t be diagnosed with depression, often because of stigma associated with mental illness.

"None of us are surprised that only half of people are getting even minimally accepted level of treatment, unfortunately,” said Raymond Lam, a UBC professor and psychiatrist at the Djavad Mowafaghian Centre for Brain Health. “It’s something we still see all the time, people are just not getting evidence-based treatments or appropriate levels of treatment."

Lam points out that while Puyat’s study is an important piece of the puzzle, it’s limited by physician data. Physicians are the go-to stop for antidepressant treatment but “most people getting counseling or psychotherapy for depression are getting it from psychologists, social workers, or other mental health professionals.”

But Canada’s Medical Service Plan does not cover visits to mental health professionals as it does for physiotherapists, unless prescribed one. Referral visits can have wait times, ranging from months to a year. Paying for psychotherapy can cost around $150 a visit.

Before 2008, physician-led psychotherapy was more rare. Family physicians in Canada are paid by the visit, and visits with depressed patients cost money because they take longer than average. Plus, physicians were only allowed to bill four sessions of psychotherapy per patient per year, which only just meets that minimum standard of care.

In recognition of these factors, B.C. launched an $8 million community-based mental health initiative in 2008. Under this initiative, physicians would be paid an annual sum for each patient for whom they assumed the role of primary mental health caregiver. The initiative also allowed physicians to bill eight sessions instead of four. Family physicians are also increasingly being trained in cognitive behaviour therapy.

Lam and Puyat agree things are getting better, but they said it’s far from enough. In 1990, depression was the fourth leading cause of disability. In 2000, it was third. By 2013, it was second. In 2008, the Toronto-based Centre for Addiction and Mental Health published a study saying mental illness in general costs Canadians $51 billion a year.

Puyat said his research indicates provinces must review their mental health care systems and how patients access them. He also urged that better data must be collected. Treatments of depression aren’t often measurement-based, meaning physicians are often compensated for reporting a depressed patient’s visit, not the outcome of the visit. And patients can cease treatment without a word, leaving it unknown whether their symptoms improved or worsened.

The study was published on March 24, 2016, in The Canadian Journal of Psychiatry. Puyat is now studying the B.C. community-based mental health initiative to see if it has been successful in improving access to treatment.