In Canada, public mental health care consists of three types of care. Primary mental health care (first-line services) includes simple diagnostic procedures, basic treatment, and referral to more specialized services as needed. Secondary care is more specialized care that provides more extensive and complicated procedures and treatment; it may be provided within hospitals, clinics or office-based practices, on an inpatient or outpatient basis. Tertiary care is a set of specialized interventions delivered by highly trained professionals to help individuals with problems that are particularly complex and difficult to treat in primary or secondary settings.
Access to mental health services in Canada varies from each province and territory. Generally, seeing a psychiatrist requires referral via a family doctor and is covered by provincial and territorial health plans. Individuals may access services of other mental health professionals within the community such as counsellors, helplines, social workers, mental health services within educational institutions and psychologists. These services, however, are not covered by provincial or territorial health plans but may be offered at no cost if operated through government-funded hospitals, clinics or agencies. Mental health services delivered through private practice such as a psychologist or psychotherapist are also not covered by provincial or territorial health plans. In Ontario, for example, fees for private psychologists or psychotherapists practitioners may range from $40-$200/hour, which may be an unaffordable expense for those experiencing homelessness.
Experiencing homelessness makes it difficult or impossible to access general health care services. Issues such as the inability to book an appointment due to a lack of a stable address or telephone number are elements of accessing health care that often go unnoticed to housed individuals. Further challenges to accessing mental health care may include wait times for referral to specialized services, like psychiatry.
For instance, an Ontario study found that wait times to see a psychiatrist via family doctor referral was approximately 50 to 60 days. Furthermore, wait times may significantly impact those who face lower socio-economic status. One Toronto study found that individuals from affluent backgrounds with less severe psychiatric disorders had regular access to psychiatric treatment and often accessed treatment without a referral. On the other hand, individuals from a lower socio-economic status and experiencing more severe and persistent mental illness had longer wait times and received less treatment.
In addition to long wait times, individuals who are unhoused and facing mental illness tend to face quite a few barriers to accessing the services they need:
- People experiencing homelessness and mental illness are admitted to hospitals 5 times more than the general population, with mental illness accounting for 52% of ER visits.
- 25% of individuals experiencing homelessness cannot access health care or treatment due to missing health cards, no proof of health insurance coverage or cannot afford prescriptions for medication.
- Only 45% of individuals experiencing homelessness have a family doctor (compared with 94% of the general population), acting as a barrier to care considering a family doctor referral is usually required to access psychiatric services.
- When accessing the ER, studies have found that unhoused individuals with addiction issues often face stigmatization due to the criminalized status of certain illicit substances.
- Individuals facing mental illness and homelessness might also face barriers of ageism, racism, sexism and discrimination when visiting the ER.
- Indigenous Peoples experiencing homelessness in particular have found issues with accessing services due to racism and lack of cultural understanding on the part of health professionals.
- Homophobia and transphobia are cited as barriers to care, where LGBTQ2S individuals may feel stress, anxiety or fear in disclosing their sexual orientation with their physician due to fear of being ‘treated’ for their sexual orientation, rather than their mental health needs.
- Accessing care is particularly difficult for those in remote communities, where individuals cite long wait times, difficulty finding or booking a family doctor and an inability to afford transportation to larger cities as barriers.
- For youth experiencing homelessness, difficulty in navigating health care systems, distrust of adults, stigma associated with homelessness, fear of judgment and fear of being reported to child welfare services all act as barriers to accessing services.