The Importance of Insuring Mental Health Care

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In 2006, a research paper was published in the Canadian Journal of Psychiatry, where the authors argued for greater public access to psychotherapy - specifically Cognitive Behavioural Therapy (CBT). To make their point, the authors did not rely on emotional appeals to compassion or empathy for those in need. Rather, they examined the very thing that directs much of the decision-making in government - the cost.

I have no idea whether any government officials read this paper, but recent changes in mental health benefits for federal employees in Canada suggest someone must be paying attention to the research. As of October 1, 2014, members of the Public Service Health Care Plan will now be reimbursed up to $2000 per year for psychological services.

Given the results of research on the cost-effectiveness of therapy, such an increase should be viewed as an investment.

The Costs

The alarm bells for mental illness having been sounding for some time in public discourse, and the research supports every bit of the hand-wringing. The prevalence of mental illness is fairly high (the 1 in 5 people estimate is likely too low), costs the Canadian economy $14.4 billion annually, and leads to the occupation of more hospital beds than cancer. Let me give a more concrete example of the costs - in 1999/2000, mental illness in Canada accounted for 9,022,382 of days spent in hospital - an average of 45 days per person.

The considerable price tag of mental illness comes at a time when the provincial governments in Canada are having to brainstorm ways of containing unsustainable health care costs.

Which brings us back to the 2006 article examining the cost-effectiveness of CBT.

CBT is now the most popular form of psychotherapy in the Western world, which is due in large part to the tremendous amount of research on its effectiveness. Hundreds of outcome studies have shown that CBT is just as effective as medication for depression and anxiety, and tends to have a lower relapse rate than medication for depression.

In terms of cost-effectiveness, the research shows that CBT is more cost-effective than medication. A major reason for this outcome is due to the fact that patients who use CBT instead of medication make less use of health services following treatment.

For example, patients with clinical depression who receive CBT have been found to relapse around 29% of the time, whereas those who take antidepressants have a relapse rate of 60%. Similarly, panic disorder (PD) tends to respond very well to CBT, but can also be effectively treated with medication. Those who are treated with the medication for PD (ex: imipramine) may have lower costs than CBT after 1 year of treatment, but after two years the cost of medication surpasses therapy. This long-term cost-effectiveness occurs arguably because people who are successfully treated with CBT no longer need treatment (or at least need less ongoing treatment), whereas people prescribed medication continuously require treatment over the years.

Given that CBT is at least as effective as medication and costs less, any effort to increase access to such care seems to be the most fiscally prudent option available to the government, employers and insurance agencies alike.

Moving Forward

Ideally, the increase in benefits to federal employees represents only the beginning of such change across the country. Employers would be wise to make comparable changes to employee insurance packages where possible. Trying to save on premiums and having employees rely solely on medication to manage mental illness is a sub-optimal approach, and likely results in greater long-term costs via sick days and lost productivity.

Increasing insurance benefits increases access to private care, which has become a necessity in Canada. Those wanting psychological treatments must either choose between public care (ex: psychologist in a hospital) or private care (ex: psychologist in private practice). Unfortunately, there tend to be unreasonable wait lists for access to public care (typically one year or longer). Access to a psychologist or counsellor in private practice tends to be much faster, which is ideal when dealing with mental illness. However, private practice can be expensive (it is common for costs in Ontario to be around $200 per hour).

The increase in insurance coverage for private, evidence-based psychological care would pay dividends not only to the patient, but also to the employer, economy and society at large.

The economic and societal costs of mental illness are not going to change on their own - and we can no longer consider therapy to be a luxury.

It is an investment -- in every sense of the word.

What You Should Know Before Starting Anti-Depressant Medication

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The Problem

My new patient sits down to start our first therapy session.

Me: "So, what can I help you with."

Patient: "I've been feeling nauseous, panicky and depressed lately."

Me: "I'm sorry to hear that. When did this start?"

Patient: "Well, I recently tried to stop taking my Paxil...."

This fictional encounter is an approximation of the conversations I have had with many clients over the years. The symptoms my clients describe are directly due to a reduction in, or complete termination of, their antidepressant medication.

These situations can be particularly difficult when the patient was not aware of the possibility of withdrawal effects, and only becomes aware when medication is stopped. As such, I hope that what follows is useful to patients and potential patients alike.

SSRI Withdrawal Symptoms

The most popular antidepressants used today are SSRIs (short for Selective Serotonin Reuptake Inhibitors). Although designed to be an antidepressant, SSRIs are commonly prescribed for anxiety as well. Common brand names include Prozac, Effexor, Paxil and Zoloft.

Antidepressant prescriptions have been on the rise for the past few decades, such thata 400 per cent increase in usage has been observed in the US, while Canada currently ranks among the global leaders of antidepressant use.

Needless to say, SSRIs have become a household name and most people possess at least some knowledge of their function and place in our society. When someone says "I'm taking Prozac," most people would instantly understand what is meant.

However, knowledge has its limitations and there is important information that users of SSRIs should be aware of. For example, suicidal thinking and behaviour can occur among children and adolescents taking SSRI medications.

As such, it is obviously very important that health care providers and patients (including parents of minors) consider such information when making a treatment decision involving these medications. This specific example of the link between suicide and SSRIs among younger users was well covered in the media.

Unfortunately, I fear that a different issue involving SSRIs -- one not as popular in the media -- is also worthy of more attention. The problem concerns what is sometimes termed "Discontinuation Syndrome" or "SSRI Withdrawal Syndrome."

Essentially, this refers to cases where people reduce or stop taking their SSRI medication, and usually within a few days start experiencing a range of symptoms, including nausea, dizziness, anxiety, depressed mood, electric shock sensations, and insomnia to name several (there have been over 30 documented symptoms).

Withdrawal symptoms are common, although certain SSRIs are more likely to cause problems than others. Withdrawal is more likely to occur with Paxil and Effexor, which also produce more severe symptoms, perhaps because of their shorter half-lives.

For all SSRIs, the higher the dose and longer the duration of treatment, the more likely that withdrawal symptoms will occur. Most withdrawal symptoms are mild to moderate, but clinical trials have shown that a drug like Paxil causes severe withdrawal symptoms in 15 per cent of users. Fortunately, most withdrawal symptoms disappear after two weeks, but can last much longer in some patients.

One of the more difficult decisions for patients with severe withdrawal symptoms is whether to resume the drug and eliminate the negative withdrawal symptoms, or "stick it out" and wait until the symptoms remit on their own.

Professionally, I have seen plenty of cases where the patient re-starts the medication again, and indeed there are people who would like to stop taking medication, but cannot deal with the withdrawal symptoms, so in a sense are dependent upon them.

I want to tread lightly on the issue of addiction, as it has been debated in the research literature, with some professionals arguing that SSRIs can and should be considered addictive. Whether they are considered to be addictive relies heavily on how one defines addiction. Interestingly, a representative from pharmaceutical giant Eli Lillyonce suggested to a medicine review committee in the UK that the termdiscontinuation reactions be used instead of withdrawal reactions -- presumably because the latter implies the potential for addiction.

Hence discussions about addiction and medications can be complicated not only in terms of science, but also politics. In any case, it should be noted that SSRIs are generally not considered to be an addictive drug and have been deemed by a professional review committee as having a low risk of dependence.

What To Do?

The take home message is that SSRIs commonly lead to withdrawal symptoms (depending on the type of SSRI) and can pose significant problems for only a minority of patients trying to stop their medications. My primary concern is not that these drugs are being prescribed. In fact, the research data show that SSRIs can be a useful treatment option for depression and anxiety.

Rather, the central issue is with informed consent -- specifically, I am concerned that patients are not always aware of these issues, and may experience unexpected problems when it comes to stopping a medication, particularly the more notoriously difficult drugs to discontinue -- Paxil and Effexor.

My overall sense is that physicians and psychiatrists tend to do a good job informing patients about these issues, although there has been reseach showing that a number of GPs are not sufficiently aware of withdrawal symptoms. However, this data comes from studies conducted in the 1990s when SSRIs were still relatively new, and it is likely the case that awareness has significantly increased since then.

Nevertheless, one of the motivating factors for me to write about this issue were recent cases involving patients who were not told, or at least do not remember being told, about the withdrawal symptoms. As such, I am hoping to raise awareness of the issue so that the appropriate conversations can be had with health care providers, and the issue is sufficiently addressed.

I want to be clear that I am in no way trying to slander the use of psychiatric medication. I am quite confident in the professional ability and values of Canadian physicians and their ability to manage the medications of their patients.

At the very least, I am hopeful that my writing will at least serve two functions. First, I hope it provides some education to those currently taking, or considering taking antidepressant medication. Any readers with additional questions should direct them to their GP, psychiatrist or pharmacist.

Second, I am hopeful that an increase in awareness will produce fewer instances of patients trying to abruptly stop the medication on their own, either because they are unaware of the withdrawal effects or underestimate the importance of having a plan with their doctor to stop or reduce their meds. I am also hoping to help people avoid holding negative attitudes toward their GP or psychiatrist. When patients believe that their health care provider has not informed them of such potential issues (whether accurate or not), it can create resentment and frustration with both doctors and with medications.

Knowing more about antidepressants and developing a plan to stop the medication (if desired by the patient) with your doctor will ultimately save time by avoiding future appointments devoted to dealing with problematic withdrawal symptoms, and to problems with relapse of the disorder.

Some Mental Health Tips for Students

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I have been fortunate enough in my career to work with many university students throughout Canada. Sitting across from these students in therapy has certainly provided me ample opportunity to get a handle on some of the more pressing issues facing them during their college years.

I thought I would pass along some advice that might be helpful to university and high school students hoping to make this year a good one. While I could offer a lot of things to bear in mind, let's focus on just a few that are especially important:

1. Stay Connected

Although there exist some rare exceptions, everyone needs to have social connections and relationships. Witnessing the impact that relationships (or lack thereof) can have on the psychological well-being of students prompted me to write a book (The Need to be Liked) about this and related issues. It is no coincidence that Tip #1 on my list is related to making and maintaining relationships during the academic year. I have seen too many young adults in my office over the years dealing with problems in this area not to highlight its importance.

Psychologists have studied people's need to associate with others and have found that we all differ in how much social interaction is needed. So, don't feel you have to be a social butterfly with loads of friends and parties to attend. Some people only want and need a few connections, which is fine. Knowing (and respecting!) your social and relationship preferences is important.

Unfortunately, learning to cope with the loss of a relationship is also often a part of student life, as is rejection and sometimes exclusion. These types of events cause real pain and can lead to depression and serious anxiety. Use your friends and family to get through these tough times, and if you feel you need some extra help, see Tip #3 below.

Finally, a significant proportion of students describe themselves as shy. If you are looking for ways to meet new people, I would recommend clubs and organizations at your school. Most universities have at least some such organizations (ex: law society; psychology club), and the big universities will have many. I can't think of a more perfect way to meet new people -- you already have a common interest and odds are the people who are joining are looking for other people to connect with as well.

2. Know the Difference Between Healthy and Unhealthy Perfectionism

Perfectionism tends to get a bad rap as something to be avoided for those who want to maintain good psychological health. However, it is possible to have healthy perfectionism, which basically refers to having standards that are at the high end of what you can reasonably attain. It is a good idea to set some goals in terms of grades and averages, but try to think of them as general targets rather than hard and fast requirements. Golfers who tee up their shots do not expect to get a hole in one -- their main goal is to get as close to the hole as they can. Similarly, trying to get a specific grade, and treating anything below this mark as a failure (known as "all or nothing" thinking), is unhealthy. Choose a reasonable grade average and anything within a decent range would be considered a success (ex: if you aim for an 85 and get an 82, you've basically hit the mark).

Unhealthy perfectionism involves rigid, unrealistic goals that result in lots of self-criticism if they are unmet. Such perfectionism affects many students, not only in terms of grades, but also things like body image and social performance. It is OK to be self-critical, but the amount of self-criticism should be proportional to the mistake. For example, your level of self-criticism for receiving a grade slightly below your goals should probably be minimal.

3. Make use of Psychological Services

Many universities in Canada have counselling and psychological services available to students*. This is a tremendous way to receive great mental health care for FREE! I emphasize the FREE part because once you leave university and have to pay psychologists' fees out of pocket, you will miss this option.

University is stressful and students can develop mental health disorders at this time. I used to work at the First Episode Mood and Anxiety Disorders Program at University Hospital in London, Ontario. This program's main mandate was to identify and treat adolescents and young adults experiencing their first significant problems with mood and anxiety. In fact, the majority of these disorders tend to develop around this age group. Not surprisingly, we saw many students from the local university and associated colleges. Getting help early on for mental health problems is always a good idea. For example, it is ideal to prevent problematic shyness from becoming Social Anxiety Disorder and normal sadness from becoming clinical depression.

In terms of stigma, some students worry about their peers knowing that they see a psychologist. First, all sessions are confidential. Second, more people than ever are seeking the services of psychologists, and there are many public campaigns that target the stigma of seeking treatment. This means that more and more people are talking about mental health and accepting the fact that it is necessary for many people to attend therapy at some point. The catastrophic worry of "everyone will think I'm crazy" is simply not true.

Furthermore, not everyone in therapy has a serious mental health problem. Many of my clients do not have a mental illness. They use therapy for support, decision-making, proactive coping, etc. I think we are getting closer to the day when going for a psychological assessment will be considered on par with a physical check-up with your GP. And by the way, if your friends learn that you are seeing (or saw) a psychologist, that might empower them to seek help as well.

4. Avoid Overreactions

Inevitably, at some point this year you will have an argument with a friend or significant other, a conflict with a professor, or experience some sort of rejection. As a result, your immediate emotions of anger, shame, embarrassment, anxiety and/or sadness might motivate you to do something impulsive to address the issue (ex: leave a voice message you really shouldn't leave; decide that a relationship is over; write yourself off as a loser).

I have seen enough of these situations to offer the following tip: wait until some time has passed and the emotions have decreased in strength before deciding to act in some significant way. Generally speaking, people don't stay angry for long, they forgive, you forgive, and life returns to normal. Many people tend to catastrophize (i.e., think of the worst case scenario) following stressful events, and they feel like they have to act NOW! Breathe, slow down, and wait until things have calmed down. Nine times out of ten, things are not as bad as you think and life will return to normal sooner than you think. If not, see tip #3.

5. Stay Active

There is just too much evidence that exercise reduces stress and contributes to increased physical and mental health -- both published and anecdotal -- not to include this final piece of advice. Between intramural sports (which is one of the things I miss most about university) and the university gym, there is ample opportunity for you to exercise and keep active. And these things tend to be free or very low cost. The impact this will have on stress, anxiety and mood is well worth the time it takes out of your day. It is also a great way to have some social time.

*Due to high demand, university counselling services can sometimes have long wait lists. If you need to see a professional sooner than later, consider seeing a psychologist in private practice. You might have some insurance coverage to help pay for private sessions (speak with an administrator at your school about such coverage). Also, some psychologists have a reduced rate for students, so inquire about which psychologists provide this option. There might also be programs at the local hospitals or clinics that take new clients. The intake coordinator at the university counselling center can usually offer information on such local services.

If your mental health issue is an emergency (ex: suicidal thinking), go immediately to the nearest emergency room.