When her medication got too expensive, Theresa Schrader just stopped taking it.

Schrader has anxiety, Type II bipolar disorder and post-traumatic stress disorder. She’s also struggled with addiction and takes medicine for diabetes and blood pressure.

When Schrader had a social work job in Toronto, her employer-provided drug plan covered her medication costs — over $200 per month for the psychiatric drugs alone.

Then she relapsed into addiction and her mental health spiraled. Schrader lost her job and her drug coverage.

Medication is often an integral part of mental-health treatment. But many Ontarians must pay out of pocket for their prescription drugs. And not all of them can.

Forced to choose between medication and rent for herself and her young son, Schrader stopped taking her drugs, even though it meant panic attacks and reckless behaviour brought on by her mental illnesses.

“I went without medication for a period of time,” Schrader says. “Until my psychiatrist insisted that I needed to get back on them (as) my mental health was deteriorating.”

OHIP generally covers drug costs for people in hospital, but not for outpatients. And while many employers offer drug coverage to their employees, a growing number of workers have no health benefits at all.

“Work has become more and more precarious,” Dr. Kwame McKenzie, CEO of the Wellesley Institute urban health think tank, says. “Low-paid, non-professional, non-unionized environments tend to be the environments that don’t have health coverage.”

When people can’t afford their drugs, they usually just go without it, McKenzie says.

Read Part 1 of this series: Patients suffer over gap between physical and mental health care

Read Part 2 of this series: Timely, affordable mental health therapy out of reach for many

“Prescribed medication is prescribed for a reason,” he adds. “If you don’t have that medication, you get ill.”

Cost is a factor for anyone taking medication, but mental-health patients experience some unique barriers to affording their drugs.

People with mental illness will likely need to stay on medication for years, McKenzie says, while many prescriptions for physical ailments may only be needed for a week or two.

Patients may also need multiple medications at once.

“Often people with mental-health problems are on one or two or three medications for their mental-health problem and then other medication because they’re more likely to have physical problems,” says McKenzie, a psychiatrist and Director of Health Equity at the Centre for Addiction and Mental Health (CAMH).

It can also take several months of experimenting with different medications before finding the right one.

“The brain is a very complicated organ,” Mood Disorders Society of Canada executive director Phil Upshall says. “Changing the brain’s behaviour, the chemistry in the brain, takes some time and it takes finding the right chemical formula.”

Meghan Coolen has depression, an anxiety disorder and an eating disorder.

In November 2015, her family doctor prescribed her an antidepressant similar to Zoloft. It helped alleviate some of her mental-health issues but also put her into a kind of dream state, she says, like she wasn’t experiencing her life first-hand.

The doctor gave her a new prescription for a different antidepressant, but Coolen was left with several tablets of the old drug, which she had paid for but now couldn’t use.

Coolen currently pays about $50 a month in medication costs. But she also pays about $480 per month for therapy, which is not covered by OHIP or her employer either. It all adds up.

“Some months it’s tight,” she says. “I’m spending money on medication that I could be spending on food, and I’m eating cereal for dinner.”

Coolen is a young professional with a university degree and a full-time job at a major media company in Toronto. But, because she is a contract employee, she does not qualify for her employer’s health benefits.

“There’s a ton of things I’m missing out on by working contract, yet I’m working the same hours as the [permanent] staff members,” she says.

Coolen is just one of the thousands of working Ontarians without health coverage through their jobs.

In 2015, the Wellesley Institute reported that 37 per cent of workers in the province have no employer-provided health coverage at all.

The government of Ontario has safety-net drug programs for people in dire financial need, but thousands of others are stuck in the strange situation of earning too much to qualify for drug coverage, yet not enough to comfortably afford their drugs.

“While Ontario provides a patchwork of health benefits that cover prescription drugs . . . to selected populations, people who are working but who have low earnings are likely to fall through the gaps,” the Wellesley Institute says in its report. “They are not eligible for public benefits and are less likely to have employer-provided benefits.”

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The Trillium Drug Program is for people whose medication costs are at least 3 to 4 per cent of their household’s after-tax income. Recipients of Trillium are still on the hook to pay the deductible for the drugs they take.

The Ontario Drug Benefit covers medication costs for senior citizens, patients in long-term care homes or receiving home care, people on provincial assistance for disability and people on the Ontario Works financial and employment assistance program.

To qualify for Ontario Works, a person must “need money right away for food and shelter,” and be willing to participate in “activities that will help you” find employment.

“Individuals that are on Ontario Works automatically qualify for the Ontario Drug Benefit,” Ministry of Community and Social services spokesperson Joshua Henry says. The ministry runs Ontario Works.

But McKenzie says that navigating government channels to get drug coverage can be prohibitively complicated, and that many patients may not even know what options exist.

“The problem is that we’re (dealing with) people that are really ill and vulnerable and rather than making it a really easy process, some people find it quite difficult,” McKenzie says.

And not all drugs are covered under these public programs, or even the private ones.

“When drug plans are assessing whether they’re going to cover (specific) drugs, they tend to look at whether the drug works or not rather than the side effects,” McKenzie says. “And so what you sometimes find is you get a new drug that’s much more expensive than the old drug . . . The side-effect profile is so much better, but it’s not going to get covered.”

Months after losing her job, Schrader got onto Ontario Works and qualified for the Ontario Drug Benefit. But the drug her psychiatrist had prescribed for her bipolar disorder was not covered by the ODB.

She tried an ODB-covered alternative but fell victim to one of its side effects, a severe skin rash that, in some rare cases, can be fatal.

Her psychiatrist kept her on the initial drug, getting free samples from the manufacturer a few weeks at a time, until the government added it to their list of covered drugs.

Steps are being taken at the federal and provincial levels to limit the cost of medication.

The provincial, territorial and federal governments have united under the Pan-Canadian Pharmaceutical Alliance, negotiating with drug companies to reduce the price of drugs under public drug plans, Ontario Ministry of Health spokesperson David Jensen says.

Jensen also pointed out that the federally run Patented Medicines Price Review Board works to cap prices of patented drugs across the board.

But for care providers, national drug coverage is the only solution.

“We need a national pharmacare plan right now to help Canadians access needed prescriptions, not just for mental health,” Dr. Vicky Stergiopoulos, physician-in-chief at CAMH, says.

“A national pharmacare plan should also provide guidance about which medications are effective at the lowest possible cost.”

In general, McKenzie says, governments should be taking greater steps to make mental-health treatment accessible.

“We’re in a position in mental health where we can do more for people than we ever could, but that doesn’t mean you can get it,” he says. “That’s a big frustration in Ontario. We could be doing so much more.”