Mental health is costly

Is mental health care affordable?

I recently read an article about a U.S. national survey conducted during the summer with some interesting results concerning people’s perceptions of mental-health care in that country.

Just over 2,000 people aged 18 and older completed this survey for the American Foundation of Suicide Prevention, and 90 per cent of them said they viewed physical and mental health as equally important.

This is an encouraging finding and shows some progress has been made in battling stigma surrounding mental illness and its treatment. It has not been many years since a large segment of society viewed mental illness and mental health care with suspicion.

A third of those surveyed said they had been diagnosed with a mental health condition at some point, but almost half (47 per cent) said they thought they may have had a mental health condition. More than 10 per cent said they had missed work due to anxiety or depression.

Unfortunately, in spite of the prevalence of mental health issues and the perception of its importance, more than 40 per cent said they thought mental health care is not affordable for most people and 31 per cent viewed it as not accessible.

On the topic of suicide, more than half of respondents said they were affected by suicide in some way.

A majority said they believed measures to improve affordability and access to care, training for health care providers; research, and education could help to reduce the number of suicides.

Although this is an American survey and it’s easy to brush off issues of affordability and access when comparing our countries, I believe these perceptions are quite prevalent in Canada as well.

I often speak with people who say they delayed treatment for their mental illness because they thought they would not be able to afford it. Many are still surprised when I explain that psychiatric care is covered in our basic provincial health care.

This indicates we still have some distance to go in raising awareness about mental health care here in Canada.

This is not to say we have no issues with affordability or access here. Although visits with a psychiatrist are covered by our MSP, prescription medication is often only covered for those with extended health care plans. Many of the newer medications take years to be included in Pharmacare benefits in B.C.

When psychiatric medication is needed, it can be quite expensive. We do have some prescription coverage for low income Canadians, but costs for even regular working Canadians can be prohibitive in some cases.

Psychological testing may not be covered or easily accessible and counseling services are often not covered.

We have room for improvement when it comes to mental health care affordability and access.


Suicide risks too common

Suicide is a preventable tragedy, the worst outcome of mental illness and something we need to talk more openly about.

According to statistics on the Canadian Association for Suicide Prevention website, 11 people in Canada end their lives by suicide each day and an additional 210 attempt suicide.

That adds up to more than 4,000 lives lost each year in our country alone.

Suicide is most prevalent among older, white males and is associated with mental or other medical illness, loss, poor social support and functional impairment.

Suicide is also relatively common among seniors with 12 in every 100,000 people over the age of 65 dying from suicide each year.

More than 90 per cent of suicide victims are known to have one or more psychiatric disorders at the time of their death. Suicides may be preventable if psychiatric illnesses are managed properly and if supports are in place.

A 2015 European study examined 2,811 depressed individuals and found that 40 per cent of patients who attempted suicide experienced mixed state depression rather than depression alone.

The term "mixed state" is used to describe a patient who meets the full clinical criteria for depression, but also exhibits some of the hallmarks of mild mania.

In this study, researchers found a risk of attempting suicide is at least 50 per cent higher if a depressed patient presents with risky or impulsive behaviour or psychomotor agitation (such as pacing, hand wringing etc).

Sometimes when focusing on symptoms of depression, health-care professionals may not pay enough attention to these behaviours and could miss identifying a mixed state.

A mixed state may require the reduction or cessation of anti-depressants, the addition of an anti-psychotic or mood stabilizer and should probably be under the supervision of a psychiatrist.

Early identification and proper management of mixed states could make a big difference in suicide prevention.

Reducing stigma around mental-health issues, improving access to services, dealing with the social determinants of health such as poverty, and addressing substance abuse are other important ways we can all work to prevent suicide.

If you or a loved one are feeling overwhelming helplessness or despair or are feeling suicidal for any reason, seek help.

Talk to someone you trust and enlist the aid of a professional.

There are people in the community trained to help find solutions and who will work through these issues with you.

How bad is your memory?

As we age, concern about memory function increases. These days, thanks to increased attention in the popular media and the baby boom generation reaching their late 60s, we seem to hear a lot more about Alzheimer’s or dementia. 

We offer a free memory assessment clinic and the number of people who are interested in this service is a reflection of this increased awareness and concern about memory function and deterioration with age. 

Most people over the age of 60 become aware of deterioration in their memory and develop concerns about the possibility of Alzheimer’s – this is appropriate because the prevalence of dementia increases exponentially with age and doubles every five years starting at one per cent at age 60 and reaching 30 per cent by age 85.

Ninety per cent of diagnosed dementia is related to Alzheimer’s disease, which remains largely a diagnosis by exclusion.

In spite of this, memory assessment is not a routine part of a typical general medical practice. A family doctor can conduct a brief memory test when dementia is suspected, but these tests will typically only detect fairly large deficits and often do not detect the more subtle changes people notice before dementia would be diagnosed.

In our clinic, many of the people we meet have discussed memory concerns with their family doctor, but not received convincing reassurance. Some have fairly large impairments but have not received a realistic appraisal of their significance.

In reality, gradual memory loss is significant. Although a certain amount of decline in memory function is normal with aging,

Alzheimer’s also begins with small memory changes that gradually get worse.  

With normal aging, many people have difficulty remembering details of conversations or events that took place a year ago or more, whereas with dementia, they may not be able to recall details of very recent events or conversations.

Age-related memory loss may mean difficulty recalling the name of an acquaintance whereas a person with Alzheimer’s may not recognize or recall the names of family members.

A person with age-related memory deficits may have occasional difficulty finding words whereas a person with Alzheimer’s will have frequent pauses and substitutions when finding words. 

With this in mind, many Alzheimer research centres have begun offering regular memory assessments so that people can track the progression of their memory difficulties. These services are typically not covered by provincial medical services plans, but are relatively low cost and usually take only about 30 minutes. 

Just as most of us have to get our eyes checked periodically, so it may be appropriate for people over the age of 60 to have a regular assessment of their memory - particularly if they or their loved ones have concerns that their memory is failing.

Just like vision, memory tends to change so gradually that fairly significant impairment can develop insidiously.

Mild memory problems are typically labeled mild cognitive impairment and defined by a combination of: concern over a change in cognition:

  • evidence of lower performance in one or more cognitive domains that is greater than would be expected due to age or educational background 
  • objective evidence of cognitive decline.

This last one can only be determined if cognitive abilities have been periodically assessed over time. 

Impairment is considered mild as long as an individual is able to function independently for every day tasks like paying bills, preparing meals and shopping.

Memory assessments that can be repeated annually or more often can be obtained through our Memory Clinic at 250-862-8141.

We are also actively recruiting for clinical studies in Alzheimer’s disease.


Nocebo: placebo's evil twin

We are likely all familiar with the idea of a placebo effect. This occurs when we experience a response to a perceived treatment when the treatment itself is biologically active.

I have written several times about the power of placebo, so common and beguiling that it is controlled against in the majority of clinical research for new medical treatments.

The term nocebo effect has been used for something described as the placebo’s evil twin.  

Although there isn’t a standardized definition for nocebo effect, it really is seen as the flip side of the placebo.

It is thought to occur when patients attribute negative reactions they experience to a treatment intervention — even when they are given an actual placebo (or inactive medicine).

Symptoms are often nondescript such as headache or fatigue and seem to occur most often among women, those with pessimistic temperaments, or those with negative attitudes about the treatment being offered.

A study published in 2015 in the Journal of Clinical Psychiatry by researchers at Deakin University in Australia suggests the nocebo effect is quite common and should be considered in the design of psychiatric clinical trials.

Prevalence rates for nocebo effect vary depending on the clinical setting and type of therapy examined.

In this study, researchers examined data from 2,400 subjects in clinical trials involving antidepressants and found the nocebo effect could be responsible for more than 60 percent of treatment-emergent adverse effects and almost five percent of those who stopped treatment.

These researchers say the nocebo effect can impact a study by causing distress and treatment non-compliance among subjects. It can also potentially lead to a study medication being prematurely withdrawn from the market.

This information raises questions about how to avoid the nocebo effect in both research and clinical settings.

While some say providing too much information to patients of possible side effects may contribute to increasing the nocebo effect, we must respect a patient’s right to informed consent and autonomy and avoid taking a paternalistic role.

Gone are the days when the healthcare professional is the only source of medical information.

Increasingly, I see the phenomenon of someone with negative pre-existing attitudes about taking medication who then goes home and searches online for information from others who have had negative experiences and then are intolerant to the medication prescribed.

This happens with each medication in turn and sometimes the side effects experienced are very atypical and very difficult to explain on a biological basis. Some such individuals become impossible to treat for this reason.

Like the placebo, it will likely be impossible to eliminate the nocebo response. Our best bet is to identify it and do our best to minimize it.

More States of Mind articles

About the Author

Paul Latimer has over 25 years experience in clinical practice, research, and administration.

After obtaining his medical degree from Queen's University in Kingston, Ontario, he did psychiatric training at Queen's, Oxford and Temple Universities. After his residency he did a doctorate in medical science at McMaster University where he was also a Medical Research Council of Canada Scholar.

Since 1983 he has been practicing psychiatry in Kelowna, BC, where he has held many administrative positions and conducted numerous clinical trials.

He has published many scientific papers and one book on the psychophysiology of the functional bowel disorders.

He is an avid photographer, skier and outdoorsman.

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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet does not warrant the contents.

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