Is there an app for that? This little line has aptly defined the recent age of smart phones, tablets and related technological toys. We truly do carry our ‘life in our pockets’ these days and chances are, if you’ve thought of it there is an app for it.
Psychiatry and mental health are no exception to this growing trend. A search under ‘mental health’ in the app store brings up 250 options. Psychiatry brings up almost 100.
There has been some media attention paid the so-called therapy apps and speculation about their usefulness as tools in the treatment of psychiatric conditions – even questions about whether these may one day eliminate the need for face-to-face therapy altogether. Will anyone need to visit a doctor when they can receive therapy anytime, anywhere using their phone?
Some of the available apps are designed like video games where a user practices a behaviour designed to help them with a given symptom in a technique called cognitive bias modification. There are exercises for a variety of issues ranging from decreasing an anxiety response in certain situations to learning not to drink too much.
Another set of therapy apps are tools designed to help people keep track of their condition, treatment or progress. There are electronic diaries for mood or anxiety disorders where individuals can keep track of their symptoms every day and share this information with health care providers.
In my opinion these complementary tools such as the electronic mood diaries can be very helpful to assist in managing a mental health condition. While not providing therapy in themselves, they are a convenient, portable way to track treatment progress between appointments. Many psychiatrists and counsellors have been assigning this kind of ‘homework’ to patients for years. Electronic tools such as these apps simply make this easier.
As for the apps claiming to truly offer therapy in some sense – the video games with cognitive behavioural goals etc – some of them may prove to be useful, but I believe many will simply be a passing phase or a gimmick with little therapeutic benefit in the long run.
Certainly, continued research into their individual effectiveness will be the test of exactly how much weight to give therapy apps when it comes to the management of mental health conditions.
In the meantime, a trained and certified mental health professional can provide education, lifestyle recommendations, tips and exercises along with therapy or medical treatment to help minimize the negative effects of mental health issues.
If you are experiencing mental health symptoms, I strongly urge you to speak with someone about it. Help is available and you needn’t sort it all out on your own.
I have often heard myself and other doctors referred to as pill pushers. In my experience this is usually from someone who disagrees with treatment recommendations that involve medication – and the term is always used pejoratively.
Many patients will not accept the use of psychiatric medication under any circumstance even if they do not hold the same beliefs when it comes to other areas of medicine. If they were to have a heart attack, they would be right at the head of the line for medication.
I actually started my career as a behavior therapist and for many years did not use medication at all. In the practice I had at the time, at a behavior therapy center, most of the patients I saw could be treated solely with behavioral therapy or what is now referred to as cognitive-behavioral therapy.
After moving into a general psychiatric practice, however, I soon had to broaden my tool kit. There are many problems in psychiatry for which the optimum treatment is not behavioral. That is not to say that education, discussion and even cognitive behavioral techniques have no place, but without medication they will be weakly beneficial at best.
Sometimes patients refuse medication on philosophical grounds. In a situation where medication is clearly the best choice and failure to use it will be unsuccessful or greatly prolong the process, others and I may elect not to participate.
It is certainly an individual’s right to refuse medication but there is likewise no obligation on a physician to proceed with treatment they don’t believe is appropriate. This is especially true in a publicly funded health system. When patients choose less effective or more costly options over the recommendations of their caregivers, this affects the community at large and may reduce services to others. I see this sometimes with those who are off work on disability but who refuse recommended treatment. Should the insurer be responsible for ongoing disability payments when available recommended treatment is being refused? People have a right to their choices but also some responsibility for the consequences of those choices.
If you asked a cabinetmaker to build you a piece of furniture and then made it a condition that he not use his specialized finishing tools, he would likely refuse. You would be free to find someone else to agree to your terms.
With respect to treatment options there is certainly room for informed people to disagree, but there are also professional standards and guidelines that help to establish the best choices. Only when these have failed would most professionals move on to less well-established or more costly alternatives.
Last week I talked about the difficulties that exist across Canada in accessing psychiatric services. The realities of finding a suitable psychiatric referral in a timely manner are often frustratingly difficult.
The issue has been addressed by the Mental Health Commission – which has stated a need for some system of coordinating mental health services.
Here in Kelowna, coordination could go a long way toward helping patients access the services they need without the headache.
Right now we have the hospital, the mental health centre and many private practitioners all running their own programs and offering different services to patients. Individuals in private practice – such as psychiatrists, psychologists and counsellors – do not necessarily have any affiliation with the hospital or mental health centre. Not only is there no affiliation, but there is absolutely no coordination between private practitioners and the other components.
When programs or personnel change, those of us in private practice may only hear about it from patients – there is no official communication from the institutions. Likewise, the hospital and mental health centre currently have no way of knowing what other services are going on in the community at large.
Professionals in each setting see only their own reality depending on their patient population and none has the overall picture.
When a patient needs a referral, it is up to that person and his or her family physician to learn who is accepting referrals and what the wait times will be – this takes time, which many physicians simply don’t have enough of.
A different service delivery model or an additional one may be necessary to solve this problem.
For example, a psychiatric clinic with psychiatrists, psychologists, social workers and nurses who could see patients on a walk-in basis could go a long way. At this intake clinic, staff could do an initial assessment, initiate treatment and make appropriate referrals for ongoing support. The staff positions would likely have to be salaried and ideally the clinic would be a 24/7 operation to divert psychiatric patients from the emergency room at the hospital – of course it would need to have a close working relationship with not only the ER but inpatient psychiatric services and the mental health centre.
In order for a clinic like this to be effective in delivering services efficiently, it would need a minimal amount of bureaucracy – often a challenge in government funded services. From my long experience I think the taxpayer would get more bang for the buck if the funding for this type of clinic was made available through private clinics. It cannot be done with the current fee-for-service funding because there is no way to fund the other professionals who could take some of the work load off the psychiatrist. I think that in the long run it would be much cheaper than waiting for a crisis that necessitates hospitalization, or other expensive institutional interventions.
Whether a clinic such as this or some other system to coordinate mental health services, it is clear that something needs to be done to improve things both here and in many communities.
If you have tried to get a referral to see a psychiatrist in recent years, you may not be surprised to learn that it can be difficult.
In our region the wait time for an appointment is typically greater than six months.
Across Canada, access to psychiatric services is proving to be an issue of concern. A National Physician Survey had most Canadian family physicians rating access to psychiatrists as poor – worse than all other specialists addressed in that survey.
One study published in the Canadian Journal of Psychiatry showed that this problem of access is indeed a problem in a BC urban setting.
In this study, an adult male patient with depression was referred for psychiatric assessment by a family physician. Calls were made to almost 300 psychiatrists in Vancouver to determine wait times and availability for this kind of referral.
The results of this attempt show a system in need of serious change if we are to provide required services to the population. Of the 297 psychiatrists who were called, the researchers successfully contacted 230 – and 70 percent of those contacted indicated they were unable to accept the referral. The remaining 30 percent who would consider the referral could not give estimates of their wait times and required detailed written referral information before accepting the patient. Only six psychiatrists offered immediate appointment times with wait times ranging from four to 55 days.
With this information, researchers concluded that substantial barriers exist for family physicians attempting to refer patients for psychiatric help. They recommend efforts to consolidate and improve access to psychiatric assessment.
There is no good national data on wait times for psychiatric assessment. It clearly varies widely depending on the number of psychiatrists and their style of practice. It is not necessarily true that where there are more psychiatrists per capita there are shorter wait times. Large urban centres typically have more psychiatrists per capita but often have long wait times due to style of practice issues. Psychiatrists conducting long-term psychotherapy, for example, will see fewer patients.
Since family physicians are in short supply, they are often extremely busy and may not have the time to do an exhaustive search such as this for the best psychiatric access. More and more, patients need to be proactive and do their own legwork in this regard. This isn’t always easy for someone in the midst of a mental illness.
You may contact a psychiatrist directly and can certainly call to ask about availability – however psychiatric care is only fully covered under MSP if you are referred by another physician.
If you would like an immediate psychiatric assessment and are having difficulty getting a referral, you might consider looking into what clinical trials are currently taking place in the community. If you meet the criteria for an ongoing study, there are generally no wait lists and there is never any cost to you.
In an effort to ease some of the pressure in our local area, I run a psychiatric walk-in clinic, which takes place every Tuesday from 8:00am to 12:00pm. A referral is needed but otherwise there is no wait time. Frequently patients come from their family doctor or walk-in clinic with referral in hand. This is not intended for medico-legal or third party assessments. It is also not intended for those in need of hospital admission. If you are in acute crisis, you should go to the ER.
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