Open this photo in gallery Illustration by Domenic Macri

Data research by Matt Lundy • Graphics by Matt Lundy and Murat Yükselir

In London, Ont., a 20-year-old man waits a year to see a psychiatrist after he is hospitalized for suicidal behaviour.

In Prince Edward Island, even the most serious patients on the provincial triage list are told in November they will wait at least six months to see a psychiatrist.

When the only staff psychiatrist at Lake of the Woods District Hospital in Kenora, Ont. decides to move, the community is left begging for help from Thunder Bay, 500 kilometres away, where psychiatrists there already scramble to cover an area roughly the size of France.

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Across the country, Canadians tell similar stories of too few psychiatrists in places with too many patients in the queue. The results of the critical shortage: jam-packed emergency departments, long wait lists, stressed-out families, and burned-out doctors.

According to a Globe and Mail analysis, half of all Canadians live in parts of the country where the number of psychiatrists fall below the ratio recommended by a panel of experts with the Canadian Psychiatric Association; 2.3-million Canadians live in areas with no permanent psychiatrists at all.

The psychiatrists Canada does have are getting old fast. Half of the profession is over the age of 55 - making it one of the greyest medical specialties - and there aren’t enough young doctors filling the ranks to replace them.

The wear and tear is showing. In January, 2019, for instance, in Sydney, N.S., the head of psychiatry at the Cape Breton Regional Hospital quit to protest the unfair workload burdening his colleagues. For a month last spring, McMaster University withdrew its residents from the emergency department at St. Joseph’s Hospital in Hamilton, citing safety concerns and a lack of supervision due to overcrowding.

Meanwhile, the crowd keeps growing. More people are seeking help, as public awareness campaigns and corporate workplace-wellness initiatives reduce the stigma around mental illness. Self-reported anxiety and depression among youth continue to rise. Hospitalizations for mental illness have increased, and the rate of patients admitted involuntarily has risen. Wait times have grown, and the longer people wait, the sicker they often become, only to require more time-consuming and expensive care when they finally get help. The demand for psychiatrists will only increase.

The Ontario Psychiatrist Association raised the alarm last year, publishing a position paper that made the case for a series of fixes to the lack of access to psychiatrists.

The paper recommended creating more residency spots in psychiatry, and giving medical students more exposure to the specialty. It pushed for paying psychiatrists better, especially those who work in rural areas, or who treat underserved populations – noting that psychiatry remains one of the lowest-paid specialties in the public health care system.

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But research suggests that pay incentives, on their own, don’t always change the way doctors practice. And training more psychiatrists is a long term solution – one that takes nearly a decade, from start to finish. (Psychiatrists are medical doctors, who can bill the public system for talk therapy, as well as dispense medication, unlike others treating mental illness, such as psychologists and psychotherapists.)

What the OPA report didn’t address is the larger shift that mental health experts – including many frustrated psychiatrists – argue needs to happen, one that reimagines the role of the modern psychiatrist, especially how and where they work.

Should psychiatrists be able to bill the public health care system for long-term talk therapy to treat patients with more moderate symptoms of depression and anxiety, when so many complex, chronic patients with bipolar disorder and schizophrenia and other severe conditions can’t find specialist care? Should they work in solo practice, and choose who they see, when emergency departments are clogged, and research shows that team-based care is more cost-effective?

It’s a contentious debate – a battle between tradition and change, between what a public system needs and how the doctors want to practice.

“We have a long and cherished history that allows health professionals to do more or less what they want, in terms of who they see and the interventions they provide,” says psychiatrist Philip Klassen, the vice-president of medical services at Ontario Shores Centre for Mental Health Sciences in Whitby, Ont. This can’t continue, he suggests. “At first blush, you can say we lack resources. But I think the first order of business is to ask, what are we doing with our resources?”

‘Psychiatrists should stop pretending that we can fix this problem on our own.’ How readers would fix Canadian mental health care

Number of psychiatrists per 100,000 population, by census division 5 10 20 30 40 BRITISH COLUMBIA There are no psychiatrists based in grey areas Vancouver Victoria ALBERTA Broad regions of northern Alberta have no permanent psychiatrists Edmonton Calgary SASKATCHEWAN Among the provinces, Saskatchewan has the second-lowest supply of psychiatrists (adjusted for population) Saskatoon Regina MANITOBA Winnipeg ONTARIO Kingston, Ont., has the highest population-adjusted supply of psychiatrists in the country Ottawa Thunder Bay Toronto isn’t lacking for psychiatrists, but surrounding cities are Toronto QUEBEC Quebec has the highest number of child psychiatrists Quebec Montreal NEW BRUNSWICK Fredericton PEI PEI is rapidly growing, but its psychiatric resources remain limited Charlottetown NOVA SCOTIA Halifax NEWFOUNDLAND AND LABRADOR St. John’s TERRITORIES There is not a single psychiatrist based in Nunavut Iqaluit Yellowknife Whitehorse Note: Maps are not to scale. GRAPHIC BY MURAT YÜKSELIR, RESEARCH BY MATT LUNDY / THE GLOBE AND MAIL, SOURCE: GLOBE ANALYSIS OF DATA FROM EACH PROVINCE AND TERRITORY’S COLLEGE OF PHYSICIANS AND SURGEONS; 2016 CENSUS Number of psychiatrists per 100,000 population, by census division 5 10 20 30 40 BRITISH COLUMBIA There are no psychiatrists based in grey areas Vancouver Victoria ALBERTA Broad regions of northern Alberta have no permanent psychiatrists Edmonton Calgary SASKATCHEWAN Among the provinces, Saskatchewan has the second-lowest supply of psychiatrists (adjusted for population) Saskatoon Regina MANITOBA Winnipeg ONTARIO Kingston, Ont., has the highest population-adjusted supply of psychiatrists in the country Thunder Bay Ottawa Toronto isn’t lacking for psychiatrists, but surrounding cities are Toronto QUEBEC Quebec has the highest number of child psychiatrists Quebec Montreal NEW BRUNSWICK Fredericton PEI PEI is rapidly growing, but its psychiatric resources remain limited Charlottetown NOVA SCOTIA Halifax NEWFOUNDLAND AND LABRADOR St. John’s TERRITORIES There is not a single psychiatrist based in Nunavut Iqaluit Yellowknife Whitehorse Note: Maps are not to scale. GRAPHIC BY MURAT YÜKSELIR, RESEARCH BY MATT LUNDY / THE GLOBE AND MAIL, SOURCE: GLOBE ANALYSIS OF DATA FROM EACH PROVINCE AND TERRITORY’S COLLEGE OF PHYSICIANS AND SURGEONS; 2016 CENSUS Number of psychiatrists per 100,000 population, by census division 5 10 20 30 40 BRITISH COLUMBIA ALBERTA There are no psychiatrists based in grey areas Broad regions of northern Alberta have no permanent psychiatrists Edmonton Calgary Vancouver Victoria SASKATCHEWAN MANITOBA Among the provinces, Saskatchewan has the second-lowest supply of psychiatrists (adjusted for population) Saskatoon Regina Winnipeg ONTARIO Kingston, Ont., has the highest population-adjusted supply of psychiatrists in the country Thunder Bay Ottawa Toronto isn’t lacking for psychiatrists, but surrounding cities are Toronto QUEBEC NEW BRUNSWICK Quebec has the highest number of child psychiatrists Fredericton PEI PEI is rapidly growing, but its psychiatric resources remain limited Quebec Charlottetown Montreal NOVA SCOTIA NEWFOUNDLAND AND LABRADOR Halifax St. John’s TERRITORIES There is not a single psychiatrist based in Nunavut Iqaluit Yellowknife Whitehorse Note: Maps are not to scale. GRAPHIC BY MURAT YÜKSELIR, RESEARCH BY MATT LUNDY / THE GLOBE AND MAIL, SOURCE: GLOBE ANALYSIS OF DATA FROM EACH PROVINCE AND TERRITORY’S COLLEGE OF PHYSICIANS AND SURGEONS; 2016 CENSUS

Notes on the data • Read more below on the methodology for this report

Psychiatrists, like almost all medical specialists, are concentrated in Canada’s biggest cities, leaving smaller communities, and more northern parts of the country with few to none. This makes it harder for those places to recruit new doctors, who will have to work long hours on call, and leaves an already wobbly system especially vulnerable to a single departure, work leave or retirement.

The problem is especially acute in the North, where many communities rely heavily on dedicated substitute psychiatrists willing to work short stints or rotations in underserved areas. But care still depends on a limited pool of doctors, and often means drawing from places with their own access issues.

A 2010 position paper by the Canadian Psychiatric Association recommended that the standard ratio for full-time licensed psychiatrists should be one for every 6,548 people – with the caveat that the number does not account for geography or higher needs of the population.

But it’s not only small towns that fail to come near this ratio. Brampton, Ont., one of the fastest-growing – and youngest – municipalities in the country, has about one psychiatrist for every 24,000 people, one of the worst ratios in Ontario. By comparison, Toronto, just 40 kilometres away, has a ratio of one psychiatrist for every 2,754 people.

But even in Toronto, Montreal and Greater Vancouver -- where more than one-third of Canada’s psychiatrists are based -- access is fitful.

On a recent afternoon, a family doctor in Vancouver consulted Pathways, an online list of specialists who have volunteered that they’re available to see new patients; only one psychiatrist was accepting referrals in the clinic’s catchment area without any diagnostic restrictions. Even then, the wait was two to four months. Many family doctors say they rely on personal connections and word-of-mouth to find psychiatrists, or just give up.

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Open this photo in gallery Rita McCracken, shown in 2015, is an assistant professor in family medicine at the University of British Columbia. Andru McCracken/Handout/The Canadian Press

“Honestly, we don’t even bother [looking] anymore," said Rita McCracken, a family doctor in East Vancouver and an assistant professor in family medicine at the University of British Columbia.

Recently, a psychiatrist in Vancouver retired, leaving about six patients at Dr. McCracken’s group practice with no referral to a new psychiatrist. These are patients, she says, who have complex disorders, often with substance abuse issues and suicidal behaviour, who have been previously hospitalized.

When one of her colleagues called the only psychiatrist accepting referrals on Pathways, Dr. McCracken says he was told by the receptionist, “we don’t take complicated patients.”

Yet these are precisely the kind of patients who need a specialist to get better, she says. Otherwise, the options are limited. Her team will try to manage by “checking in” with the patient more often or by sending them to an emergency department. Sending them to the hospital may result in a new prescription, she says, but no follow-up care to make sure it works. And while psychotherapy might be helpful in some cases, access to publicly funded therapy is limited, and most of Dr. McCracken’s patients can’t afford to pay for it.

Across the country, psychiatrists in private office-based practices bill the public system for their services, but can treat who they choose with few limitations – a practice that contributes to the most difficult patients often having the longest waits.

Dr. Lena Palaniyappan, a psychiatrist in London, Ont., and professor at Western University, says that there are a number of community-based psychiatrists in the city who have built up their roster of patients until “they have enough to keep running the mill, so to speak.” Then, as far as the system is concerned, their practice is closed to new business.

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“This cannot happen,” he says. “More people are seeking help, and we need to have a system that incentivizes seeing more patients, rather than seeing the same patient again and again.”

The problem on campus As more Canadian students seek mental-health care, they face long waits or more out-of-pocket costs. Victoria Gibson takes a deeper look at how universities are struggling to cope with demand.

When Renata Villela became a psychiatrist, she opened the practice she’d always wanted: a solo office in Thornhill, Ont., providing specialized long-term psychotherapy. On average, she sees patients for two years, sometimes once a week. They are referred to her by family doctors or other psychiatrists; on rare occasions, they walk in off the street. For patients who don’t want to make the trip to her office, she sees them by video in their homes.

For most Canadians trying to get help for a mental health problem, receiving this kind of personal care would be like winning the lottery, and just as unlikely.

Dr. Villela’s type of practice is mostly exclusive to Canada’s big cities, and most common in Toronto. Small-volume practices account for more than one-third of psychiatrists in Toronto and Ottawa, the two cities where the province’s psychiatrists cluster in bulk. Dr. Villela and psychiatrists with practices like hers say they are keeping people out of hospital, where those patients would cost the system more. That may be true, but there is no way of knowing: Psychiatrists don’t have to demonstrate that the people they’re treating are benefiting from intensive psychiatric care, or even that they require it in the first place. Meanwhile, research suggests that many patients do just as well with shorter-term therapies that cost the system less.

Open this photo in gallery Paul Kurdyak is an emergency department psychiatrist at Toronto’s Centre for Addiction and Mental Health. Fred Lum/The Globe and Mail

This issue – too much care for those who may not need it, and too little for those who do – would be a good place to start fixing the system, according to Paul Kurdyak, an emergency department psychiatrist at Toronto’s Centre for Addiction and Mental Health.

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A series of studies that Dr. Kurdyak has co-authored, primarily using a database of Ontario health statistics, found that, in Toronto and Ottawa, 40 per cent of full-time clinicians saw fewer than 100 patients a year. (Ten per cent saw fewer than 40 patients.) Additionally, the patients seen by those smaller-volume psychiatrists were more likely to live in higher-income neighborhoods, and less likely to have been previously hospitalized for psychiatric issues. When some psychiatrists suggested to Dr. Kurdyak that this practice style would be eliminated as aging psychiatrists retired, he went back to the data. The trend persisted even with younger psychiatrists, a 2017 paper reported – in fact, “there had been little change in practice patterns despite an increasing awareness of substantial unmet need for psychiatrist services.”

A February, 2019, paper found that nearly one in three Ontario psychiatrist sees fewer than two new outpatients a month. The patients they do see, the study concluded, also tend to be wealthier and healthier than those seen by psychiatrists with much larger practices. An upcoming study by Dr. Kurdyak, which has been accepted for publication and is based on more recent data, suggests that the trend continues.

Perhaps this wouldn’t be a problem if everybody was getting timely psychiatric care. The system could support different modes of practice. But a study published last year found that 40 per cent of Ontario youth discharged after an emergency department visit for their first psychotic episode received no outpatient mental health care for 30 days – despite research showing that follow-up is a key factor in preventing re-hospitalization. A 2017 paper found that the majority of people treated in an Ontario emergency department after a suicide attempt were not seen by a psychiatrist within six months; two-thirds of those hospitalized didn’t see a psychiatrist one month after being discharged, even when the province offered a financial incentive to specialists to assess these patients quickly. The incentive, the study concluded, made little difference in the way psychiatrists practised.

“I would like our profession to have as much autonomy and flexibility as possible,” says Dr. Kurdyak. “But the choices being enacted now are at the expense of patient access.”

One idea he floats would be a central registry that could steer patients to psychiatrists. Quebec has recently experimented with regional centralized registries -- an ambitious undertaking that has been hindered by staffing shortages and too few options for patients with mild symptoms who may only need brief counselling, according to Karine Igartua, the president of the Quebec Psychiatric Association. Plus, she said, it is not mandatory for psychiatrists to participate.

Providing specialist care to as many high-needs patients as possible in the most cost-effective way should be the ultimate goal, says Dr. Kurdyak, who argues that psychiatrists should become part of a collaborative care team in which they can provide both rapid consults and follow-up care, ideally supported by psychiatric nurses, psychologists and social workers. In the ideal system he envisions, there would be more public funding for therapy and patient progress would be measured, so treatment could be adjusted, based on need.

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He argues that a team-based system like this would not only get patients in cities to the right level of care more quickly, it would also help ease the burden on overworked psychiatrists in smaller locations. To improve access to psychiatrists, build a better system around them.

Open this photo in gallery 'I would like our profession to have as much autonomy and flexibility as possible,' Dr. Kurdyak says. 'But the choices being enacted now are at the expense of patient access.' Fred Lum/The Globe and Mail

Introducing innovation isn’t always easy, as Bill MacEwan, the former head of psychiatry at Vancouver’s St Paul’s Hospital, learned the hard way. A few years ago, Dr. MacEwan teamed up with another psychiatrist, Ron Remick, to begin treating patients in groups as part of the outpatient mental health services at St. Paul’s. In 2016, the new clinic completed 15,000 patient visits, according to the pair’s presentation at the Canadian Psychiatric Association’s annual conference this fall. By comparison, in 2014, the hospital-based outpatient clinic had 400 patient visits, Dr. MacEwan says, and operated with a budget three times larger.

Wait times for patients went down. Patients were seen regularly by a specialist, but after an initial one-on-one assessment, they saw the psychiatrist in group visits as needed.

In a group setting, other patients could also offer their own insights – coping with symptoms, what lifestyle changes have worked for them – with the psychiatrists providing the medical expertise. Psychiatrists at the new clinic also practised measurement-based care, in which patient progress was tracked electronically, helping clinicians to spot when treatment is working.

In a small-scale study published in the Canadian Journal of Psychiatry in 2014, 99 patients at Dr. Remick’s clinic were surveyed. They had all participated in group sessions – on average about five – for roughly a year. On average, the patients rated care in the group sessions as very good to excellent. Although one third said they would rather receive individual care, another 38 per cent said they preferred the group appointment, and 30 per cent said they had no preference.

Group medical visits would seem to be a natural fit for a specialty with a long history of group therapy, but only a handful of psychiatrists are practising this way across the country. Billing for it can be complicated, providing it isn’t financially incentivized, and residents usually aren’t trained in it. But proponents say these types of innovations need to be considered to improve access.

For instance, at the Joseph Brant Hospital in Burlington, Ont., group sessions led by psychiatric nurses are now being used to educate new patients about mental illness, and to collect patient information so psychiatrists can move more quickly to treatment options during appointments.

Despite the success in Vancouver, the partnership with St. Paul’s didn’t last. A key reason, says Dr. MacEwan, is that psychiatrists resisted practising in a new way. Seeing one patient at a time, he says, is far easier than seeing seven, especially if it means changing the way you’ve practiced for decades. “It is hard work, plain and simple," Dr. MacEwan says. Two years later, the program was cancelled.

Dr. MacEwan gives this weary assessment of his own specialty: “Cardiologists are all about ‘that was last year, what are we doing this year.’ Psychiatrists are all about, ‘well, if I have been doing this for 30 years, and it’s always been good, why am I changing?' " But the status quo, he says, is unsustainable.

“It just isn’t the way we can deal with the masses of patients in the future.”

Open this photo in gallery Cape Breton psychiatrist Yvonne Libbus is shown in Halifax after an unofficial recruiting meeting with recent psychiatry graduates at a friend's home. At the hospital where she works in Sydney, N.S., she has a caseload of 300 patients, plus people waiting at an emergency department. Darren Calabrese/The Globe and Mail

In Sydney, N.S., psychiatrist Yvonne Libbus tries to squeeze more patients into her day at the the Cape Breton Regional Hospital, even though she already has a caseload of 300, not counting people waiting in the emergency department, and the demands of a 46-bed inpatient ward. Today, there are four staff psychiatrists at the hospital; a few years ago, she says, there were 15.

Dr. Libbus isn’t going anywhere, but she thinks about it. Doctors in smaller communities and rural areas often earn less than their urban peers, whose salaries can be boosted by being attached to a university - a situation the province of Nova Scotia recently attempted to remedy with a $30,000 bonus for rural psychiatrists. But even with a pay bump, going to a small hospital that promises long on-call hours, little peer support and few resources, as well as the danger of aggressive patients in an understaffed emergency department, is often less enticing than taking a job in a big-city hospital or hanging their own shingle in a wealthier neighborhood.

Psychiatry is already one of the lowest paying medical specialties, in Canada. In part, this is because provincial fee scales tend to pay more for procedures than consultations, even though many medical procedures have been made easier and faster by technological advances.

On top of this, psychiatry still suffers from a stigma among doctors, as a less prestigious specialty. One Toronto psychiatric resident interviewed by The Globe described being actively discouraged from wasting her talent by pursuing the field.

Requiring medical students to do stints in rural locations is one solution. For instance, Ozotu Abu, a psychiatrist in Smithers, B.C. and one of three psychiatrists managing a large swath of northern British Columbia, came over from Ireland; after serving part of her residency in her native country in small towns, she sought the same experience in Canada. The Northern Ontario School of Medicine, with campuses in Sudbury and Thunder Bay, is also credited with training more physicians more likely to work in smaller communities after graduating because they come from or did their training in those types of places.

Given that most psychiatrists will stay in urban settings, provinces are working to expand telepsychiatry to improve care, both for patients who can receive consultations via video and family doctors who can dial in for advice. Ontario Shores Centre for Mental Health Sciences, for example, recently implemented a program that allows family doctors anywhere in the province to consult, on the phone, with psychiatrists at the hospital.

Psychiatrists also point to the need for service to cross provincial lines, to fill gaps in care across the country. Nachiketa Sinha, a psychiatrist in Moncton, N.B., says he has long-term patients, who, having moved west to work or study, book appointments when they are home to visit family. Living in Alberta, they can’t find a psychiatrist, but Dr. Sinha, who is not licensed to practise there, can’t even write them a new prescription to fill at the pharmacy if they run out of medication.

In a November, 2018 survey of the Canadian Medical Association’s general membership, 47 per cent of doctors said if such a national licence program existed, they would be “likely or very likely” to practise in a remote location, and 36 per cent said they would provide virtual support to patients in other provinces. (Those percentages were even higher for residents.)

In Kenora, after the hospital’s only psychiatrist left, efforts to recruit new ones to the northern Ontario region were slow to produce results. Getting help from Winnipeg, only two hours away, is complicated by provincial licensing rules. Psychiatrists in Thunder Bay, five hours away, were willing to pitch in, and the hospital was able to cover off the mental health unit with shifts by temporary doctors, called locums. But the loss of a veteran psychiatrist prompted a larger discussion among those handling mental health services in the meeting.

The result: a boundary line between the hospital service areas was eliminated, and a mental health team, which includes a doctor and social worker, was created that would assess patients arriving at any of the region’s hospitals, and triage them into the first available bed, wherever it was located in the region. The new process is designed to make better use of psychiatric resources so clinicians see the patients whose conditions require their expertise.

Ultimately, a system upgrade would make the psychiatrist’s job more efficient and more focused. As advocates for change such as Dr. Kurdyak suggest, that means moving out of solo practice and into spaces with other doctors and mental health professions, embracing technology to spread their clinical reach, and concentrating on the toughest cases they are best trained to handle.

The modern psychiatrist can’t be everywhere. So they should be where Canadians need them most.

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Notes on the data

The Globe and Mail conducted its analysis using 2019 data provided by each province and territory’s College of Physicians and Surgeons. The numbers include licensed psychiatrists by location, but not all of these may work full-time.

In cases where psychiatrists listed more than one workplace address – as many do – the first address was selected. In most cases, psychiatrists worked within one census region.

Quebec was the only province that refused to provide the names of psychiatrists, so there may be some double-counting in the province.

The map also only identifies psychiatrists in their permanent locations. Some psychiatrists travel to work in remote parts of the country, particularly the North, either occasionally or on a regular basis, but this is not reflected in the map due to data limitations. Nunavut, for instance, which has no permanent psychiatrists, is served entirely by a group of locum specialists.

As well, psychiatrists may move within the year to a different location. Where this was discovered, the data was updated by the Globe.

The map should be taken as an estimate based on an analysis of the best available data.

Editor’s note: An earlier version of this article referenced a hospital in Northern Ontario as being in Kelowna, when it is Kenora. This version has been fixed.

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