August 14, 2019
WINNIPEG – A Manitoba Liberal Government will cover clinical psychological therapy and invest in training mental health professionals in order to provide better mental health care for all Manitobans, says Manitoba Liberal Leader Dougald Lamont.
“As some have put it, we have a two-tier mental health care system in Canada — where people with private insurance get treatment but people who can’t afford it often do without,” said Lamont. “Mental health care is health care, and everyone should have access to it.”
Lamont said he has heard from many families who have struggled to get their children into therapy because they don’t have insurance and waiting lists for public mental health care can take months. Even those with private insurance have to cover cost overruns.
Manitoba Liberals will:
1) Cover the costs of psychological assessments and treatments for children with learning and behavioural disabilities under Medicare. Currently, waiting lists for assessment are up to two or three years in places in Manitoba.
2) Ensure that approved clinical psychology and therapies are covered under Medicare.
3) Implement Improved Access to Psychological Therapies (IAPT), a training and mental health delivery program, based on UK models, to ensure that mental health services and counselling are available province-wide.
4) Work with universities and colleges to increase the number of fully licensed psychologists in Manitoba.
Under the NDP and PCs alike, Manitoba spends less on mental health care than the national average. Across Canada, 7% of health care budgets are dedicated to health care. In Manitoba it is only 5%.
In 2018, Manitoba had 19 psychologists per 100,000 people — less than half the national figure of 49 per 100,000. For months, the Pallister government delayed signing a new federal health care funding agreement that offered $400-million, including funds earmarked for mental health care.
There is a major need for psychological therapies in Manitoba with twenty-three percent of adult Manitobans having a mood or anxiety disorder. The costs of depression and anxiety to Manitoba are estimated to be $2.8 billion a year, with an estimated net benefit to our provincial economy from the widespread availability of effective treatments being estimated at $1.8 billion a year to Manitoba.
Liberals estimated the cost IAPT that could treat 10,000 adults a year would cost $7-million in the fourth year and psychological counselling would be $15-million.
“There is plenty of evidence that these investments in mental health care pay off because people are able to get back to work. It also prevents a downward spiral that keeps people out of crisis and the ER,” said Lamont. “It’s also important to give people hope that things can better — but we need to ensure that help is there when people need it.”
Psychologists are an important part of addressing mental and brain health issues including depression, anxiety and addictions. For children, psychologists have an important role in assessing and treating behavioural and learning disabilities as well as preventing and treating depression and anxiety.
Much evidence shows that psychological therapies, such as cognitive behavioural therapy and dialectical behavioural therapy, are as effective as medications in the short run and more effective in the long run. Economic analyses show that it is cost-effective to fund improved access to psychological therapies, with costs, including up-front costs, being more than compensated for by savings in other areas of health care and increased revenue from increased productive employment.
A Manitoba Liberal government will address the shortage of psychological therapy in Manitoba by taking the following steps:
1) Cover the costs of psychological assessments and treatments for children with learning and behavioural disabilities under medicare. Currently, waiting lists for assessment are up to two or three years in places in Manitoba. This is not acceptable as it means children can lose the full benefit of years of schooling.
2) Will implement a program for improved access to psychological therapies (IAPT) where evidence has shown these to be effective. There is a major need for psychological therapies in Manitoba with twenty-three percent of adult Manitobans having a mood or anxiety disorder (2). The costs of depression and anxiety to Manitoba are estimated to be $2.8 billion a year (see analysis and comparison to England below), with an estimated net benefit to our provincial economy from the widespread availability of effective treatments being estimated at $1.8 billion a year to Manitoba (3). The Manitoba IAPT program will be modelled on the IAPT program in England which was begun in 2008 and which has been called one of the most successful implementations of an evidence-based health care therapy in the world. The journal Nature described it as “world-beating”. Based on the experience in England – where funding reached 170 million pounds in the third year and delivered psychological therapy treatment services to 400,000 people annually by its fourth year– the Manitoba IAPT program is expected to cost $7 million in its third year and to provide treatment to 10,000 Manitobans annually by year 4. A more in-depth description of this program is provided below. The IAPT program will involve training individuals in delivering psychological services in the province to make sure the services are available province-wide. Following the English IAPT program, centres will be required to meet quality standards and to report on outcomes from more than 90 percent of those treated. As with the English IAPT program, the program is expected to reduce costs in other areas of government services so that it is essentially cost-neutral over time.
3) Establish a Trauma Centre specializing in Psychological Trauma to reduce the post-trauma impacts to include publicly funded psychological services for individuals with trauma.
4) Fund research into improved applications of psychological therapy. This program is to be complimentary to the IAPT program. The IAPT program will fund psychological therapies only where they have been proven effective. This research program will test new psychological therapeutic approaches where evidence is promising but not sufficient to prove effectiveness. It will fill in a gap which results from funding only evidence-based programs under IATP and will allow the development and testing of new psychological therapies. In essence, this is equivalent to a major sports team having a “farm” team to develop promising new athletes.
5) Fund additional training positions to increase the number of fully licensed psychologists in Manitoba.
1) Layard R and Clark D: “Thrive” Penguin Books, 2014.
2) Chartier M et al: 2018. Mental Illness Among Adult Manitobans. Manitoba Centre for Health Policy.
3) Sutherland G, Stonebridge C: 2016. Healthy Brians at Work: Estimating the Impact of Workplace Mental Health Benefits and Programs. Conference Board of Canada.
Improving Access to Psychological Therapy (IAPT) Program in England
This program arose from the realization that there are effective psychological therapies, but because there are not enough psychologists to deliver them, they needed to make a major change in how psychological services are delivered in England. It was also realized that there was a major imbalance between the availability of treatment for physical illness (good availability) in contrast to mental (brain) illness where only a fraction of those needing help were able to get it. “While nearly everyone who is physically ill get treatment, two in three of those who are mentally ill do not.” (1)* The situation as it was in the United Kingdom is very similar to the current situation in Manitoba and Canada.
IAPT “only started in late 2008, but by 2013 it was treating some 400,000 people a year, nearly half of whom had recovered by the end of treatment. Since the model has worked so well and is transparent, it has generated major interest in other countries …and Norway and Sweden have already started to introduce their own version of the system.”
Key to introducing IAPT in England, and in making the case for introducing IAPT is England’s National Institute for Health and Care Excellence (NICE). “Its job is to review the scientific evidence about the different treatments available for every problem, physical as well as mental. So it assembles widely representative panels of experts, and the National Health Service is obliged to provide the treatments which they recommend.”
David Clark and Richard Layard initially wrote a paper for Tony Blair’s Policy Unit called “Mental Health: Britain’s biggest social problem. This argued that to implement the NICE Guidelines we should be able to treat at least 15% of the diagnosable population each year, and this would require some 8,000 more therapists in England, most of whom would have to be treated. The paper made its impact through three simple points. The first was the scale of suffering and the injustice of denying people the NICE recommended treatments they preferred. Second (and very important) there was the economic argument that mental illness cost the government billions of pounds, and treatment would therefore have no net cost to the Treasury. And third, routine outcome measurements would show what the system was really achieving.” As a result of the paper and a follow up seminar for politicians, Labour’s election manifesto included a commitment to “improve our services for people with mental health problems at primary and secondary levels, including behavioural as well as drug therapies”. Following the election, IAPT was implemented.
The IAPT program has six main criteria which a service has to satisfy if it is to be an IAPT service:
1) It has to deliver only evidence-based, NICE recommended therapies. This includes not only CBT (Cognitive Behavioural Therapy) but interpersonal therapy, brief psychodynamic therapy, couples therapy and counselling for depression.
2) It has to employ therapists who are fully trained in how to deliver the relevant treatment. (the IAPT program worked with post-secondary education institutions throughout England to train about 6,000 people in six years (by 2015). Most training programs were one year.
3) It has to measure patient outcomes on a session-by-session basis, with at least 90% completeness of data.
4) Each patient receives a professional assessment when she or he arrives and is then allocated to high or low-intensity treatment as appropriate. About 46% get low intensity only, 34% get high intensity only, and 20% get both – having been stepped up to high intensity after low intensity failed.
5) Each therapist must have weekly supervision, and each trainee must have a well-qualified supervisor.
6) The service must be open to patients who refer themselves, without going through their general practitioner. This broke with the normal arrangements in the National Health Service. When it was proposed, some people argued that it would attract the “worried well”. On the contrary, it was found that patients who self-refer are as ill as those coming through their GP. They have also been ill longer, and recover as well (often with fewer sessions, reflecting their high level of motivation). They also include a higher proportion of people from black and minority ethnic groups than patients referred by GPs, and this helps to ensure that IAPT patients have a more similar ethnic balance to the population at large.
(Note on numbers: With England having a population of 56 million and Manitoba having a population of 1.3 million, training 147 people in Manitoba would be equivalent to training 6,000 people in England). The annual funding allocation in the third year was 170 million pounds. This would represent for Manitoba about $7 million in the third year based on current exchange rates between the UK and Canada.)
Note on the Economic costs of mental health problems:
In the book “Thrive” the authors make the case for the economic cost to England as a result of mental (brain) illness. They break this down into the lost economic productivity as a result of mental illness. This cost is estimated at 4% of GDP. For Manitoba, 4% of GDP (2017) is $2.84 billion. The estimate is that about half of this lost cost ($1.42 billion in Manitoba) is due to lost economic productivity because individuals with mental health problems are not working, working part time or not working efficiently. It is estimated that the other half is due to the combination of lost taxes to government and increased costs of social assistance and other supports for those who are not employed. The second component of economic cost is the cost of crime which results from the mental illness. This cost is estimated at 2% of GDP ($1.42 billion), half of which is a cost to government. The third component of the financial cost is estimated at 1% of GDP ($0.71 billion) as a result of the additional costs of physical illness due to mental illness. The authors estimate that those with mental health problems have 60% greater costs related to physical illness that that who do not have mental health problems. More than half this cost is a government cost. In total, the economic burden of mental illness is 7% of GDP. This would represent $4.97 billion in Manitoba for 2017.
4) * Quotes are from the book “Thrive” by Richard Layard and David Clark, published by Penguin Books, 2014
5) Chartier M et al: 2018. Mental Illness Among Adult Manitobans. Manitoba Centre for Health Policy.
6) Sutherland G, Stonebridge C: 2016. Healthy Brians at Work: Estimating the Impact of Workplace Mental Health Benefits and Programs. Conference Board of Canada.