For years, Emmanuel Lopez wrestled with a “dark demon.” He roamed self-help aisles in bookstores searching for the answer to why he was crippled with despair.

Feelings of low self-worth wreaked havoc on his work, relationships and health. His illustration business collapsed. He declared bankruptcy. He lost his home. And he struggled with thoughts of suicide.

Lopez finally sought psychiatric help at the Centre for Addiction and Mental Health (CAMH) in 2015 and was diagnosed with major depression. His psychiatrist suggested he try group psychotherapy — so-called talk therapy — led by a social worker at CAMH.

He signed up. His life depended on it.

“I was so hungry for help,” says the 54-year-old, who also grappled with anxiety. Lopez participated in a cognitive-behavioural therapy (CBT) program, which is one of the most common forms of psychotherapy for depression and anxiety. It helped him develop strategies and skills to cope with daily problems.

“It was amazing ... It gave me the tools to stop the negative thinking and negative moods.”

It’s the kind of treatment that should be readily accessible and widely available in a timely manner, according to Health Quality Ontario , a provincial agency that monitors the health system and recommends whether or not health-care services and medical devices should be publicly funded.

But it isn’t. For those with depression and anxiety there are a lot of barriers. Only psychotherapy provided by a physician, such as a family doctor or psychiatrist, is covered by OHIP, which means people end up on wait lists or simply go without treatment.
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Psychotherapy services by non-physicians, such as psychologists and social workers, are covered by some private health insurance plans. Otherwise people pay out of pocket, which can cost up to $200 an hour. Sometimes they’re offered for free in government-funded clinics, agencies or hospitals, such as CAMH, but they typically have long wait lists and are not meeting demand.

Furthermore, there are geographical inequities. Urban dwellers have better access to services than those in rural areas, and even within the same community, some will have access to publicly funded psychotherapy, while others don’t.

It all adds up to big gaps in service. That’s why Health Quality Ontario in November sent a report to the Ministry of Health and Long-Term Care recommending that evidence-based, structured psychotherapy in individual or group settings delivered by non-physicians — such as nurses, psychologists, psychotherapists and social workers — be publicly funded for depression and anxiety. Such a change, the report notes, would provide “clinical benefit and represents good value for money.”

“Right now, it’s hit or miss in Ontario — and we hope our recommendation leads to consistent access to evidence-based psychotherapy for every Ontarian who needs it,” says Dr. Irfan Dhalla, vice-president of Evidence Development and Standards at the agency.

The ministry directed the agency to put together the report and is now considering the proposal, which will inform its development of a provincially-funded psychotherapy program. Typically, the province follows Health Quality Ontario’s recommendations.

According to the agency, about 11 per cent of Canadians will experience major depression and 6 per cent generalized anxiety disorder, which are among the most common mental illnesses. Health Quality Ontario is suggesting funding three common types of psychotherapy treatments: CBT, interpersonal therapy and supportive therapy. It estimates that funding psychotherapy by non-physicians could cost the province between $11 million and $68 million per year over the next five years.

“The evidence is quite persuasive that these psychotherapies work,” Dhalla says. “They improve the quality of life for people with depression and anxiety. They help people function better. They help reduce the risk of suicide, which is obviously something we want to prevent.

“The goal is that any patient with depression or anxiety who stands to benefit from psychotherapy would be able to receive it, paid for publicly, in a timely way.”

He notes that the Health Quality Ontario report isn’t about the benefits of psychotherapy versus medication. Some patients benefit most from medication, others from psychotherapy and some from a combination of the two. Rather, this is about making psychotherapy one of several available treatment options.

Dr. Vicky Stergiopoulos, the physician-in-chief at CAMH, the country’s largest mental health and addiction teaching hospital, welcomes the recommendation, noting “access to mental health treatments is dismal.”

“We have a significant access challenge and we have a significant quality of care challenge. We need to address both,” says Stergiopoulos. “Mood disorders are becoming the No. 1 cause of disability worldwide ... Both the individual suffering and the societal costs need to be taken into account when we fail to provide timely access to treatment.”

In Lopez’s case, the depression was extremely debilitating and a prescribed antidepressant only worsened his symptoms. But psychotherapy helped. He did a 15-week CBT program, and months later did an eight-week CBT relapse prevention program.

“Part of the severe end of symptoms with my clinical depression was having suicidal thoughts,” says Lopez. “But thanks to the tools I learned from CBT the frequency and duration of these episodes were greatly reduced.”

CBT focuses on how negative thinking affects behaviour and feelings. If a person learns to change their thoughts and behaviours, it impacts how they feel, says Karen Fournier, a CAMH social worker who runs CBT group sessions for mood and anxiety disorders.

For example, she says, if you send someone a text message, but don’t get a response, you may think you’re being ignored or that you’re not liked. You might then avoid the individual and ruminate on why they didn’t respond. That makes you feel lousy and reinforces feelings of low self-esteem, which may even bring on physical discomfort, such as sore muscles, fatigue and an upset stomach.

Fournier provides strategies on how to challenge negative thinking and change behaviours. For instance, why not ask that individual why he didn’t message you back? Perhaps his phone was broken, or the battery was dead, or he’s been too busy to respond. A simple explanation could alleviate destructive feelings of low self-worth.

She also urges people to look at the evidence, so they can arrive at a more balanced view of the situation. For instance, maybe the person did actually forget about you, or was avoiding you. If so, is this an unsupportive person who should be cut out of your life? Or, did he just mess up this once, but is otherwise supportive?

“They’re skills to live by,” Fournier says. “What we say in CBT is you become your own therapist ... If you come every week, if you do the work and you practise outside of the group you will see a shift in your mood.”

It’s a sentiment echoed by Lopez. CBT helped him to challenge distorted thinking and keep from slipping into negative patterns. And he’s learned to find comfort in pleasurable activities, such as cooking healthy meals, going for walks and taking hot showers. He loves watching movies, deriving inspiration from feel-good flicks.

He says he’s feeling more energized than he has in years. He’s now a motivational speaker and has a movie blog called Movies That Motivate: The Adventures of Motivatorman.

Lopez still monitors his mood and has learned to talk about how he’s feeling.

“I was in such a dark place before that I no longer have a fear of talking about this. Talking has given me a new lease on life,” he says. “It really feels like I’ve been getting back to living again, both with relationships and work ... I feel like I’m part of society again.”

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