Could a data-driven revolution be the answer to Canada's mental health crisis? In this episode of In Our VoICES, #ICESOntario scientist Dr. Paul Kurdyak and host Misty Pratt pull back the curtain on the systemic failures plaguing mental health care, revealing disparities between mental health and other medical fields. Join us as we explore the urgent need for change, the surprising power of lived experience, and the hopeful green shoots of progress that could finally transform mental health care in Canada!
Our Guest:
Dr. Paul Kurdyak joined ICES in April 2009 where he leads the Mental Health and Addictions research program. He is a senior scientist with the Institute of Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH) and Chair, Addictions and Mental Health Policy at CAMH and the Institute of Health Policy, Management and Evaluation at the University of Toronto. Since 2020, he has held the role of Vice President, Clinical, with the Mental Health and Addictions Centre of Excellence at Ontario Health.
Dr. Kurdyak studies clinical epidemiology and health service utilization. His work provides better understanding for the determinants of and barriers to treatment for mental illnesses; explores the relationship and interaction between chronic medical and mental illnesses; and develops methodology expertise in observational research design as it relates to the study of mental health epidemiology.
Read the research from Dr. Kurdyak:
Payment incentives for community-based psychiatric care in Ontario, Canada
Disparities in access to early psychosis intervention services
Misty Pratt
More Canadians than ever are reporting mental health challenges, self harm and suicide rates are on the rise, and opioid deaths have claimed the lives of almost 50,000 people since 2016. The crisis is real, yet millions of people can't access the care they need, and a patchwork system of services are available. Today on the podcast, we explore the state of mental health care in Canada and what needs to change so that we can take better care of each other. I'm joined by Dr. Paul Kurdyak, a psychiatrist and ICES scientist whose work sheds light on the barriers to treatment for mental illness.
Paul Kurdyak
It's really important that when they do make decisions here, I'm talking about policy makers, that they are armed with evidence to counter all the advocacy that they're faced with, because we know they're faced with advocacy that may not align with evidence.
Misty Pratt
Welcome to In Our VoICES, the podcast that takes you beyond the data to meet the people and hear the stories that help shape health and health care for all of us. I'm your host, Misty Pratt, and I'm one of the people behind the data who make the difference at ICES, a health research, data and analytics institute based in Ontario, Canada. ICES staff, scientists and partners are on a mission to make health care better and people healthier. In this podcast, we share our stories in our voices. A note that the opinions expressed in this podcast don't necessarily reflect those of ICES. Dr. Paul Kurdyak, welcome to In Our VoICES.
Paul Kurdyak
Oh, thanks very much for having me.
Misty Pratt
The Centre for Addiction and Mental Health, better known as CAMH, has a popular tagline that says, mental health is health. Do you believe this tagline has changed how we treat people with mental illness?
Paul Kurdyak
The question would be, why did CAMH feel that that was an important statement to say? And I think it really gets to the issue, a theme we're probably gonna be talking about this whole segment, which is, in what ways is mental health different from the rest of the healthcare system, and in what ways are they the same? I think that the salience of that statement speaks to the notion that for decades, mental health has been treated as a service as separate or other than the rest of the healthcare system and neglected accordingly. But more importantly, the individuals the system was meant to serve have always been less of a policy and funding preoccupation. And we have the, I don't call it a system. We have a sector that shows exactly that, and the consequences are, there aren't enough services. We actually have a hard time figuring out where services exist, what they do. People have a hard time figuring out where to go when they do go. It's not clear that the care is standardized or aligned with evidence, and this is not an indictment of the people who work in the sector, who are doing the very best. It speaks to the lack of attention from a system perspective that mental health services and providers have been afforded compared to other areas of the healthcare system.
Misty Pratt
Can you paint us a picture of that experience, what it's like for someone to navigate a physical health issue such as cancer, for example, versus somebody who's trying to navigate treatment for mental health issue?
Paul Kurdyak
Oh, absolutely. I have sort of lived experience in this regard. My wife was diagnosed with colon cancer in january 2020, while we were quite overwhelmed and stressed by the circumstances, from a system perspective, knowing my experience studying the mental health sector, knowing my experience trying to navigate on behalf of other people, just made me wonder, what is behind the discrepancy like, why does this system look like a system? Why does it work so well? And now, of course, being within Ontario health, I have a much better understanding of what has happened in cancer care and a much better understanding of all the things that have not happened in the mental health sector that perfectly explain the experiences and coming full circle, just the shame I think we should all feel at how poorly we serve individuals with mental illnesses and substance disorders. And and one of the goals, and in the work that we're doing is the only thing people have to worry about is whether or not they'll respond to the care. They don't have to worry about whether they can get access to care, whether the care exists, where it exists, whether it'll adhere to evidence like none of that was a concern in the cancer system and people with mental illness and substance disorders are really important point, not only do they have to worry about the impact of their illness, there's huge stress related to whether or not they'll get care and whether that care will adhere to a certain quality, which is really, like I said, it's shameful.
Misty Pratt
And that supply, obviously, is is a big issue, that it's just not there the services. But what are some of the other barriers to accessing any of the services that are available?
Paul Kurdyak
At the highest level when you speak to supply, when you look purely at a healthcare spend in Ontario, we spend, it's hard to know that the actual figure, but it's somewhere between four and five billion a year on mental health services writ large. That's not nothing. It's probably not enough. But you wouldn't know that there's four or five billion worth of services. And the reason is that they are so poorly organized that there is no way, no system, to access it. So in Toronto or whatever region you're in, whether you're somebody struggling with a mental illness or substance disorder or primary care physician, you have to somehow know the 80 to 100 agencies in your particular community who are doing the work. You have to know their eligibility criteria. You need to know what they do and what they don't do. And that just is not the case for other areas the healthcare system where you just have to show up and the system figures things out for you. So yes, it's a supply issue, but it's not just a supply issue. It is. It is an absence of system infrastructure that is so poorly optimized to provide care.
Misty Pratt
I can't imagine getting a cancer diagnosis, and then being handed a list of local providers in my area and saying, you know, have fun. Go see who's available, right? Call them all.
Paul Kurdyak
Good luck figuring out what you need before you get there, too, like all that stuff. Yeah, it's so getting back to the first question, you know, that's what I mean when I say that mental health is different, like mental health is health. Yes, mental health is health, but these are the differences that historically, it has not been treated like high-priority health concern, and we have the sector that goes with that kind of historical stigma.
Misty Pratt
How has Canadians mental health changed in recent decades? Have we seen rising rates?
Paul Kurdyak
That's what really interesting and tricky question, and it shouldn't be. And it's complicated by the pandemic. And it's complicated by social norms and generational differences. I think most of the evidence around the prevalence of mental disorders as measured by sort of like, you know, public health measures, suggests that there might be an increase in, say, anxiety disorders, as in younger generations, but for the most part, the prevalence of disorders has remained stable. So I think there probably were consequences of the pandemic, but I also think that there was a huge amount of sensationalism. I think there was a lot of measures of distress that got equated to mental disorder. The pandemic was a hugely stressful time for people. But that does not mean that that stress translated into mental disorder writ large, and our ability to measure distress with polling companies doing this side of the other compared to more real time measure of disorder, very different. We had a very hard time mapping changes in demand for services, and we have always had a challenge actually measuring population based need for services.
Misty Pratt
So this mental health moment that you say we're having could be helping with this stigma to the point that we may start to see further investment from public health and from other areas.
Paul Kurdyak
Yeah, I think the public mental health moment is an outcome of the stigma reduction. And I think as as youth get older and sort of so as like, some of the go back to 2009 some of those teenagers who were less stigmatized and reaching out for help, they're now in the workforce. They're now voting. They're now participating. Like, I just don't think there's any going back. That's my hope, and it's but it's my suspicion that in the ways that my generation blew it in terms of demanding functioning mental health system, I don't see that I just I just think there'll be such political pressure to continue to make the mental health system as accessible as an equity issue as the rest of the healthcare system.
Misty Pratt
You sound really hopeful.
Paul Kurdyak
Well, so it's something I reflect on a lot because, you know, my clinical work is challenging because I'm working in a sector that I know doesn't work. From an ICES perspective, much of the work that my team and I put out there, frankly, is not the best news, right? It's like for decades we've been crafting carefully articulated problem statements. But the hope comes from this growing generational destigmatization, this public mental health moment, which translates into political will, which translates into structures and processes like funding an ICES mental health and addictions program in 2013 and having it build and grow, and having an agency within Ontario Health, the sole purpose of which is to right size the mental health system and bring it up to speed with with higher functioning areas of the healthcare system. So it's going to take time, but compared to when I first became a psychiatrist, you know, nobody would have asked me to speak in a podcast. There never would have been the Globe and Mail articles about mental health. Nobody was talking about this. So I'm quite hopeful, but the amount of work and from where we are starting is daunting, but we have to remember that when Cancer Care Ontario started, cancer care in Ontario was a total shamble. People were having to be shipped out to US to get care. And that's like, you know, 25, 30 years ago. So it's, this will be a marathon, but I feel like we've started to run.
Misty Pratt
Is it just about money? Is that sort of the bottom line that we need to invest more money and that'll get us to the point that we can start to build this actual system that we need.
Paul Kurdyak
That's been the sort of the course from the sector. Why won't you provide us more funding? This might be a little bit sensitive to say, but I think I mentioned before, right now, we're spending about four, between four and five billion and know relatively little about that spend. So if you're a policy maker, I think it's a reasonable question to say, I don't know if I want to spend more money, if, if I don't know where it's going, if I don't know the outcome. So I think the investment is really important, but the investment has to address the how of how we go about delivering health care more so than the what. And our sector really is preoccupied with what. Let's do particular. Let's fund particular kinds of therapies. Let's make sure the particular kinds of drugs or new interventions get funded. The truth is that, you know, of course, all that's needed, but in the absence of system infrastructure, it's very difficult to put new technologies interventions into play. Whereas, you know, we're constantly talking about cancer, but it could be said for you know, cardiology, like with our provincial network of catheterization labs. If a new technology comes around, it just gets plugged in, like Lego like, it just gets integrated. So if there's evidence for it, if there's, if it seems to make good sense from a cost perspective, there's infrastructure to just plug it in. So what do we need? And what do we need to invest in? Some things we don't need to invest in, so we need to, and this is what like right now I'm gonna be telling you the work of the work of the provincial agency, we need to create advisory bodies of clinical experts who tell us what good care looks like, rather than have funding go to the squeakiest wheel. So that's the first thing so and we've started doing that, and we have, we have an advisory body of experts of all types, and I include in that set of expertise persons with lived experience as a specific type of expertise that we need critically to inform the decisions we make. So that's a big change that right now, the things that our agency are putting forward in the Ministry for funding are those things that have been fashioned, designed and developed by a committee of experts, which is a change, which is what happens in cancer care, and has never really happened in our sector. So that's the first thing. The second thing is, we need to be able to measure things in a much more succinct way, and that's been the work of our ICES Mental and Addictions program, but they're huge swaths of that four to five billion for which we know nothing like there's a bunch of community mental health and addictions care that data may exist, but we just don't aggregate it, centralize it. We don't really know what's going on there. We know that a whole bunch of mental health care occurs in primary care but we don't really have a good line of sight in that. So we really need to understand, have a much better understanding of what is currently being funded, and reckon with it. Figure out, you know, like, what it looks like. We need levels of accountability.
Misty Pratt
What do you mean by accountability?
Paul Kurdyak
So for me, as a psychiatrist, when I see a patient, I submit a billing and a fee schedule, and it's only really, all I really need to do is come up with a diagnosis and make sure the time I put in the chart that I spent with the patient is the same as the that I submitted for billing. And an oncologist has the same fee schedule, more or less, but there's a built in accountability with the oncologist in working with a system, and oncologist has to adhere to certain standards, not because of the fee schedules, because the system that he or she works in. So that's what we need, to build, levels of accountability and transparency that don't exist, that will come through the measurement phenomenon.
Misty Pratt
And that doesn't exist in psychiatry right now, the accountability.
Paul Kurdyak
No. So coming full circle. What, like, what we need to invest in. We need to invest in this system infrastructure. And that's really a hard sell, because, like everybody wants to say, Oh, we we pay for more therapists to do blah, blah, blah, or we pay for more hospital beds, or something that is much more retail. But none of that will change anything that it's really, we need parity in system infrastructure, in order to be able to do the work we really want to do. We need to play catch up. That's where we really need to invest. And our agency is focused on a certain clinical areas, because that's what resonates with people. And we have particular strategic reasons for why we chose these four clinical areas. But we could have chosen anywhere else, because there's need everywhere. But in the work that we do, we are obsessed with the system infrastructure, because we know that at the end of the day, that's what's going to be the sustainability proposition that's going to allow us to create business cases that are on par with with the business cases from the other healthcare sector. And during the pandemic, there was an unfortunate sort of backlog in surgery cases, right? For hips and knees, for cataracts and for cancer surgery, and we talked earlier about there was probably increased demand for mental health services. Well, while I was in Ontario Health, I saw the group overseeing the surgical backlog create the business case that they presented to the ministry. And it was here's how many people are waiting for surgery, and here's how long they're waiting, because they both measure the number of people in the wait times. You invest this much, we think we will get the wait time from A to B and the number of people from C to D. We will come, we will meet with you monthly and give you reports on progress. And if we're not meeting targets in terms of our progress, we will tell you our mitigation strategies, and when it came to me and whenever saying what's, what's the Centre of Excellence doing about the supposed increased need for service during the pandemic? I was like, I don't know. I don't know how, I don't know how many people need services. I don't know what they need. So in other words, the absence of infrastructure meant I could not fathom or contemplate creating a business case. And until we can create a business case, I think we will always be behind the eight ball compared to other areas, the healthcare sector. And we need to, as a sector, start thinking about what would make us competitive from a funding perspective. Policymakers want to fund mental health and substance use services because of the political moment we're in. We need to make it easier on them, and to do so, we need the infrastructure I spoke about.
Misty Pratt
And you mentioned before, having people with lived experience tell you also what they need. What are they saying? What do they feel like they need when it comes to treatment?
Paul Kurdyak
People with lived experience are incredibly important for a couple of reasons. One, when we add their voice to what we are putting forward, there's a measure of credibility that goes beyond what a provider or clinician can put forward. But they also have changed our submissions for funding in substantive ways. And so, for example, we've put forward and actually we've received funding to create evidence-based care pathways for people with substance use disorders to start in the emergency department. And all our clinicians said, you know, we need to have this evidence-based intervention, that evidence- based intervention, and then a person's lived experience said, don't disagree. We know about that evidence that's really important to include, but we really need peer support. We need to include funding for peer support. And our clinicians around the room said, you know, there's actually not a ton of evidence to support the funding of peer-support workers, and so we're not sure. And the person who lived experience stared them down and said, well, actually, I have been in the emergency department with a substance use disorder, and if I had somebody who I could relate to, I'd be more likely to, you know, settle in, stick with the program. And so for us at Ontario Health was like, that is really important evidence. It's not published in a peer-review paper, and so I'm very proud to say that peer-support workers was included in our funding submission and was a component of the funding. I can tell you that would not have happened were it not for the person's lived experience who were courageous enough to participate and give us their opinion. So it's so that's a really concrete example of what they bring to the table, and it's just a really concrete example of how important their contribution is.
Misty Pratt
Absolutely and I've heard people too talk about the need for community-based care, of which I think peer support might be included, that they feel more comfortable being able to access care close to home and easily with someone they trust. Have you heard that as well?
Paul Kurdyak
Mental health is health. I think that's true for anybody who's accessing a healthcare system, but perhaps more so for people with mental illnesses and substance disorders, but maybe over time, that might not be the case like but so the point is, yes, of course. But shouldn't we be striving that for all of our healthcare system, making it accessible, close to home, convenient? For sure, we're hearing that. I think what we're hearing more is just like, for God's sake, make these services more accessible, make the system more understanding, because, like, more understandable. Because we just don't, we don't know where to go. And so one of our initiatives is the thorniest and perhaps most important, is kind of a regional, provincial, coordinated access where in each of the six Ontario regions, and there were probably sub regions, because it's huge. But the concept is we have one front door, virtual or otherwise, behind which all the services reside. And much like in the cancer care, this one door does the work for individuals, they have to figure out the 80 doors behind. They just need to get to the front door, and then we take care of the rest. And if we can land this, and it's, like I said, it's really challenging work, and there's cultural issues and there's control issues, but if we can get this, I think that there are all sorts of positive spin offs. The most tangible and concrete is that having 80 doors to navigate is a structural barrier that means people aren't getting care so that will make things more accessible. But when you have one door, it also makes it much easier to measure need, because you're capturing information on everybody is coming through the door. So over time, as we start to more systematically measure the needs of individuals who are seeking care, we can start looking at what's behind the door and align the service behind the door more closely with what's coming to the door, if that makes any sense. So all of a sudden, you get information that allows us to right size the services to the needs of the individuals in an iterative quality improvement perspective, which is to me, incredibly exciting that's going to be, and that's going to be, you know, a decade or longer, of work, but the information afforded from this provincial coordinated access to better serve Ontarians is going to be a huge leap forward.
Misty Pratt
Is that what you're most excited about looking forward to the future, or is there any other treatments that get you excited these days?
Paul Kurdyak
As a clinician, one would expect me to be most excited about the clinical stuff, but for me, the most exciting pieces of this are the system pieces that those are the things that really get me excited. Because, you know, my clinical work is in the CAMH emergency department. And people come with all sorts of clinical issues, but the reason they're coming to the CAMH emergency department, and it's not not the primary care physician, or not a community agency, is because they didn't know where to go or they couldn't wait. And so anything we do to correct that massive issue is the thing that gets me most excited about.
Misty Pratt
You've talked about a lot of key players in our conversation. So who do you think is responsible for transforming the mental health you call it a sector, and we need to create a system. Who are the people that need to do this?
Paul Kurdyak
What is the job of the different stakeholders? Like the political will comes from the public, and we really need the public to keep up the pressure. It is our government's job to respond to that political will in ways that make sense for the people they serve. It is our job in Ontario Health to gather the input of persons with lived experience and our clinical experts and our system experts to advise our ministry colleagues and the government with our best advice. That's going to be one input among many firm politicians, as it always is. But it's really important that when they do make decisions here, I'm talking about policymakers, that they are armed with evidence to counter all the advocacy that they're faced with because we know they're faced with advocacy that may not align with evidence. So it's a distributed responsibility, but I think it's rather whose job is it, is not, I didn't really answer that question, but I kind of articulated, you know, what's the responsibility of everybody in sorting through the mess. And for me, you know, working in this sector that I know doesn't work for people and never has since, I've been practicing since 2003 working at ICES, where, over the past decades, producing hundreds of problem statements for which there was no solution. Being on the solution side now, and leveraging my great team at ICES to help us with that work, which is an interesting story in and of itself, is so important and so great at addressing what I started to experience. That's kind of like moral distress, like, nothing's nothing's happening, you know. I keep doing my emerge shifts. I feel like, you know, I'm just like trying to stop a flood with a cup, you know, and publishing these studies that are articulated in ways that are quite policy relevant, but not having any sort of traction because of the lack of political will. But to be on the solution side, it's an enormous challenge, but it's really moving. It's very gratifying to be doing this work. I'm hopeful I could just like, I just feel like I get up in the morning and in like, the day to day is really hard, but there are things that we have to show for the work. Like at the end of last year, we as a result of a provincial CBT program. CBT being a particular form of psychotherapy that is now.
Misty Pratt
Cognitive behavioral therapy.
Paul Kurdyak
Yeah, cognitive behavioral therapy is freely available in this Ontario structural psychotherapy program. We had treated 100,000 people in Ontario, and it's growing and growing. And so that's amazing, the work we're doing in the provincial coordinated access, starting to articulate this need, aligning it with other initiatives around centralized access in Ontario health so that mental health is part of the discussion on any initiatives around centralized intake and access. I can go on and on. But so the day to day is really hard, but I truly believe that in a couple of years, we're going to see these green shoots of the system growing. In five years, we're probably going to see a lawn, and in 15 years we're going to see a forest. And so that, you know, by the time I retire, I think it's just going to be with this very robust thing that the next generation is going to take and really make good on what we're starting on. And to me, that's so exciting to think about that. Mostly because the people I see in the emergency department, or we study at a population level, they have just been shortchanged for decades, and it's just not right. And they are paying such a high cost for that. And the flip side is if we could get to people early so that people can stay in their relationships so that they can finish their university degree, so that they can keep their job. That has huge consequences for the individuals, for the families, but it also has huge consequences for all of us, and I would argue, more so than the investments we're doing in other areas of the healthcare system.
Misty Pratt
And so how do you see ICES as part of that solution as part of that green grass growing?
Paul Kurdyak
I'll give you an example, but basically, what has happened is our research expertise and our really deep knowledge of our administrative data that has contributed to such sort of high-research productivity. There's a portion of our resources pivoting to support the work at the Centre of Excellence from a planning and performance monitoring perspective. And I'll give you an example. One of the first things I did when I when we launched the program, was to figure out a way to systematically identify every Ontario resident who had a diagnosis of schizophrenia. And we've done a ton of research around that. Like, if you basically have a like there, I don't know there's like, 200,000 people in Ontario that we can identify and then figure out all sorts of health outcomes. Well, we have been funding for a long time now in Ontario this early psychosis intervention program, and the program exists to provide services to people who have a first diagnosis of schizophrenia. And work by Kelly Anderson, an ICES scientist at London a while back, showed that, and it's all over, a bunch of studies showed that, at least in the London region, because she could identify in the London region, all the people who had a diagnosis that seemed to be eligible for the service, which was a regional service in London, and she had the data from the service. So she had the denominator of everybody who should have got in, and the numerator, which is everybody who did. And in the London region, only half of individuals got into care. But the next thing she showed is that the circumstances of access are dire, that if you don't get into care. You're four times more likely to die, and these are 16 to 30 year olds, and they die by suicide. So there's not too many healthcare interventions that reduce your likelihood to die between the ages of 16 and 34 fold. So what has we done with that information? Well, we now know because we're leveraging this ICES data, and we've quantified, like, how many individuals in each region have a first diagnosis of schizophrenia. And so that sounds pretty trivial, but it absolutely isn't, because now we can start quantifying the services in each each region and go, okay, like, here's how many cases you have in this region. Now, how much care are you providing in a given year? And how are you funded to do so? And it's there variation between these early psychosis interventions in terms of how much funding they get relative the volumes they conserve? Is there a way to standardize the care? So this is the first steps of like cancerifying cancer, clarifying early pychosis intervention, treatment. And that all started with the research we did at ICES, which is, I hope that makes sense, like we're pivoting to actually informing funding decisions, forming how much care show about planning and and figuring out. So this is, this is a game changer, like this, for our sector, there's never been this level of clarity transparency in what we should be doing relative to what we are doing. And it's raising the bar in terms of how we think about the services and how we fund them.
Misty Pratt
Well, it says people say, if you can't measure it, how can you ever change it? Yeah, so it sounds like we're starting with that those early steps of actually measuring it.
Paul Kurdyak
So yes, you can change it, but also you can't even have the conversation, right? So, like before we did this, you go to, like, an early psychosis intervention program. How many people did you see last year? This many? How many did you need to see? I saw as many as I as came. And now we know actually you're missing half the people. And why is that? Is it? Is it a part of your eligibility criteria, or do you have an age cutoff that is excluding people? Are you not doing enough outreach to primary care physicians? Because we know that if you're seen by a psychiatrist, you're more likely to be referred than primary care physicians like we know we're starting to get all this information. And so yes, it's in a more granular way, it is changing the conversation and empowering these providers to think more critically about the work that they do. And it's allowing us as an agency to change the way we're talking to the ministry about funding, right? So this is how much you're funding, and this is how this is the case, the number of cases we can serve. But like now, we know it's not enough, and that's that's starting to move inch towards the business case.
Misty Pratt
Thank you so much for being here, Paul and helping us to navigate this issue, and also for giving us so much hope.
Paul Kurdyak
Thanks, Misty. Appreciate it.
Misty Pratt
For anyone struggling with their mental health, help is available through Canada's suicide crisis helpline, call or text 988. The Centre for Addiction and Mental Health website also has resources, and we'll link to that in the show notes.
Misty Pratt
Thanks for joining me for this episode of In Our VoICES. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you've heard on in our voices, please email us at communications@ices.on.ca. And we'll be sure to get back to you. We might even share your feedback on a future episode. I'm Misty. Pratt in wishing you strong data and good health.