People with substance use disorders are up to three times more likely to have a mental health issue in their lifetime, compared to those without a substance use disorder. Navigating concurrent disorders – a term used to refer to co-occurring addiction and mental health issues – can be overwhelming, but a clinic at St. Michael’s Hospital is working to help. 

The Pathways Clinic provides outpatient psychiatric care aimed at identifying and treating mental health disorders in the context of substance use disorders. The clinic was established in September 2023 after psychiatrists at St. Michael’s noticed a steady increase in the number of psychiatric referrals for patients with concurrent disorders. 

“Our clinicians used to receive one-off assessments for patients with concurrent disorders but the number of referrals and the rate at which patients were presenting with comorbidities became more consistent in recent years,” says Samantha Boumeester, Clinical Leader Manager of Addictions and Withdrawal Management Services at St. Michael’s. “It got to a point where we realized that having easy, dedicated access to psychiatric care for these patients was urgently needed.”

The clinic is led by a multidisciplinary team comprised of a registered nurse, case manager, peer support specialist and two psychiatrists. It offers time-limited individual and group supports for up to one year, with the goal of mental health and addiction stability and referral to a community clinic or provider, such as a family physician, who can provide ongoing care on a long-term basis. 

Upon receipt of a referral, a nurse reaches out to the patient to determine if they are still interested in receiving treatment. The patient is then booked for a consultation with one of the clinic’s two psychiatrists and other recommended team members, who can clarify lingering questions about the referral.

“Our clinic provides access to psychiatrists but also an allied health team, which includes a peer support specialist who has lived experience with both addictions and mental illness,” says Dr. Anita Kang, one of the psychiatrists in the Pathways Clinic. “Our case manager helps us navigate addictions resources in the city, which can be challenging for patients to find on their own.”

In the clinic’s early days, referrals were limited to St. Michael’s clinicians. Today, the clinic accepts referrals both inside and outside of Unity Health Toronto, provided that the patient lives within the St. Michael’s catchment area and has a health care provider who will resume care following the program’s one year duration. People experiencing homelessness are also welcome at the clinic.

“We’ve learned a lot from previous clinics with regards to the referral process,” says Kang. “It’s important to keep it low barrier, to help people attend. I think we’re doing a good job branching out, not just in the hospital, but in the community as well.”

The frequency of follow-up appointments is dependent on the patient’s psychiatric illness and the type of treatment required. While the program offers supports for up to one year, it’s flexible for patients who require further assistance, says Boumeester.

“The goal is stabilization of patients’ mental health concerns and their substance use disorder,” she says. “That could be done with a stable medication regimen, therapy, connecting them to a family doctor if they don’t already have one, or setting them up with any other kinds of services that they might need.”

Support from the Rapid Access to Addiction Medicine Clinic (RAAM)

Recognizing how the stigmatization of mental health and substance use disorders may prevent patients from receiving care, the Pathways Clinic works collaboratively with other addictions services at Unity Health.

It’s this coordination between services that distinguishes Pathways from other similar clinics in the Greater Toronto Area, says Dr. Karen Shin, Chief of the Department of Psychiatry at St. Michael’s.

“We’re fortunate at St. Michael’s to have a complement of services, including inpatient addiction medicine consultations, a rapid access addiction medicine (RAAM) clinic and an emergency department that frequently supports patients with acute substance use intoxication and withdrawal,” she says. ”These teams work closely together to move suitable patients into Pathways for further care.”

RAAM is an urgent care drop-in service for people with substance use disorder. Many of the Pathways team members also support the RAAM in the hopes of building trust with RAAM patients who may later attend Pathways for ongoing
personalized services.

“It can be a challenge to provide care for patients with severe substance use disorders and mental illness, because those patients are often the ones that have the hardest time coming to the clinic,” says Kang. “Our allied health teams in RAAM and Pathways are so knowledgeable and reliable, and they’re really good at forming deep relationships with their patients.”

Consultations for new patients occur every Tuesday and Thursday. While the average wait time for an appointment with a psychiatrist can take many months, the Pathways clinic triages patients urgently – the current wait time is about one month.

Though the clinic hasn’t yet established a formal channel to receive patient feedback, this hasn’t discouraged patients from expressing gratitude for the clinical team.

“I think a lot of patients like having additional supports from our multidisciplinary team – at least that’s what I hear from my patients,” says Kang. “We’d love to expand the clinic across the city one day, but we’re taking baby steps for now.”

By Shaelyn Winters

Shaelyn Winters works in communications at Unity Health.