To the Editor: I am writing in regard to Steven Sharfstein's Taking Issue commentary in the March issue, "Some Interesting Lessons From Canada," and his discussion of a study by Leah S. Steele and colleagues (2), which was reported in the same issue, that found a gap in service use by socioeconomic class, even in Canada, a country with universal access to care. Although I can appreciate Dr. Sharfstein's idea of requiring individuals from higher socioeconomic strata to pay for their greater use of services, that focus is much too narrow, as is any focus on language and cultural barriers, stigma, or the psychiatrists' preferences that he mentioned.
The real gap is in the difference in the specific needs of patients with chronic psychosis, addiction, or other serious mental illnesses, who constitute a far greater proportion of the lower socioeconomic population compared with the higher strata. Most of these patients have been so beaten down by their illnesses and their life experiences—and by the gaps and failures of the care system—that they cannot advocate for their personal needs. Most are cognitively compromised, and most have little motivation. They often have no family to urge them to treatment, nor do they have any support network—and many are homeless as well. Such individuals simply cannot navigate the system on their own, even when services are available for the asking.
For true access to and utilization of services, what this population needs, in addition to psychiatrists, is a set of other proactive services that include very aggressive outreach, case management, personal advocacy, frequent and systematic use of involuntary outpatient commitment and court-ordered treatment with follow-up, integrated medical and surgical care, engagement in activities, and social and occupational rehabilitation.
I entirely agree with Dr. Steele's conclusion that "eliminating financial barriers through universal health care coverage is insufficient." To consider service use in any universal health care or single-payer system in the simple terms of coverage and access is to ignore the basic problem of persons with chronic illnesses: most are uniquely unable and in no position to use that coverage or access.
Dr. Robinson is in private practice in North Easton, Massachusetts.
1.Sharfstein SS: Some interesting lessons from Canada. Psychiatric Services 57:297, 20062.Steele LS, Glazier RH, Lin E: Inequity in mental health care under Canadian universal health coverage. Psychiatric Services 57:317-324, 2006