Mental-health strategy calls for complete overhaul, $4-billion commitment

An article published in today's edition of The Globe and Mail:

By André Picard — Public Health Reporter

Canada’s mental-health system is underfunded and poorly co-ordinated and needs a complete overhaul to meet the needs of patients and their families, the Mental Health Commission says in its long-awaited national strategy.

The 152-page document recommends an immediate infusion of $4-billion annually for mental-health care; calls on employers to implement psychological health and safety standards to protect workers; says efforts to divert people with severe mental-health problems out of the justice system and into care need to be accelerated; and embraces a “housing first” philosophy to get homeless people suffering from mental illness off the streets.

The Globe and Mail obtained a copy of the strategy, entitled “Changing Direction, Changing Lives,” under embargo but is publishing before the Tuesday release date because of leaks to other media outlets.

Until now, Canada has had the dubious distinction of being the only G8 country without a mental-health strategy but the Mental Health Commission of Canada says it now has a “blueprint to translate aspiration for change into action.”

An estimated 6.7 million Canadians suffer from mental illness at any given time. Last year alone, spending on mental-health services totalled $42.3-billion and the impact on the economy was even greater.

“This is an ubiquitous Canadian problem and an ubiquitous global problem,” said David Goldbloom [pictured], a psychiatrist and chairman of the MHCC. “There are significant barriers – in the health-care system, in the workplace and in the community.”

To break down those barriers – and address the problem of stigma in particular – the strategy proposes six “strategic directions” that should be pursued, and makes numerous recommendations in each area:

• Promoting mental health and prevention of mental illness;

• Fostering recovery and upholding rights;

• Providing access to the right services, treatments and supports;

• Reducing disparity and addressing diversity and those suffering mental-health problems;

• Working with first nations, Inuit and Métis, communities where addictions and suicide are major problems;

• Mobilizing leadership and fostering collaboration.

Dr. Goldbloom stressed that the commission is not a funding agency so its role is to promote a vision and promote buy-in by putting forward good research, highlighting best practices and facilitating co-operation between various stakeholders.

“We’re not an advocacy organization, we’re a catalyst,” Dr. Goldbloom said.

To underscore the approach, the strategy is peppered with examples of successful mental-health programs from around the country, such as Partners For Life, an innovative suicide prevention program that has reached 750,000 high-school students in Quebec, and the Seniors Mental Health Outreach Team that follow up on referrals from police, social services and physicians to ensure seniors with mental-health problems get follow-up care.

The strategy does not deal much with monetary issues, with one exception; it says that, currently, 7 per cent of health dollars in Canada ($14-billion) are spent on mental-health care and recommends that be increased to 9 per cent ($18-billion).

“We need more money for mental health, but we also need to spend it more wisely,” said Louise Bradley, the chief operating officer of the MHCC and a psychiatric nurse by training.

She stressed too that the needs of mental-health patients cannot be met exclusively by the health system, that changes are required in social services, education, housing and corrections.

A draft of the strategy, released in 2009, was met with sharp criticism, particularly from families of people living with severe mental illness. They complained that too little attention was paid to neuroscience and the right to treatment, and too much credence given to the civil libertarians and anti-psychiatry activists.

Dr. Goldbloom said that the final version of the strategy is very different and, in particular, pays far more attention to the needs of those with severe mental illness and their families. The report states that “treatment of people with severe illness is a gauge of system success.”

The MHCC chairman conceded, however, that it is impossible to create a blueprint for change that will please everyone. “My hope is that everyone will see they like 80 per cent of the strategy and support the overall thrust. That’s the only way we’ll be able to mobilize and move forward.”

The Mental Health Commission of Canada was created in 2007 in response to a damning Senate report on the state of mental-health care entitled “Out of the Shadows at Last – Transforming Mental Health, Mental Illness and Addiction Services in Canada.”

The MHCC has an annual budget of $15-million.

Mental health strategy draft doesn’t go far enough

An article published in today's edition of The Globe and Mail:

By André Picard (pictured)

Copies of the “confidential” draft of Canada’s highly anticipated mental health strategy are circulating widely among “targeted stakeholders.” So let’s take a look at what’s being offered up.

Canada is the only G8 country without a mental health strategy, so the document – and, more important, the underlying philosophy that we need to make life better for those with psychiatric and psychological illnesses – is long overdue.

After all, one in five Canadians will suffer a bout of mental illness; it is the principal cause of absenteeism and disability, and costs the economy a staggering $51-billion annually.

A strategy is essentially a way of setting priorities, of ensuring that no group is overlooked or neglected, that services are co-ordinated and that voices are heard in the corridors of power.

The Mental Health Commission of Canada, whose role it is to draft and implement the strategy, more or less has its priorities right, as evidenced by its six “strategic directions”:

1. Shift upstream and across sectors. This means emphasize the promotion of mental health (not merely the absence of mental illness), intervene early when people are sick – at school, at work or wherever – and tackle the stigma of mental illness.
2. Transform relationships and uphold rights. The draft document emphasizes recovery (most, but not all, people with psychiatric illnesses get better) and the need to get the sick out of the criminal justice system.
3. Strengthen capacity in the community. The strategy calls for a shift to community-based care and underscores the importance of housing and income support to aid the recovery of those with mental illnesses. 
4. Improve equity. Access to mental health services varies markedly across the country and among various age groups (with access to care for children being particularly abysmal), and the gaps need to be closed. 
5. Seek innovation with first nations, Inuit and Métis. Some communities, such as aboriginals, have specific challenges like sky-high rates of addiction and suicide that need particular attention. 
6. Mobilize leadership. The strategy calls for a “whole of government” approach, meaning mental health is not strictly a health issue – it affects the workplace, housing, justice and so on. The draft also calls for a strengthening of the mental health infrastructure.

The commission and the strategy have their genesis in a landmark 2006 Senate report entitled Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada. The 567-page report was thoughtful, reasoned, forward-looking and, sometimes, even bold in describing the shortcomings of mental health treatment, dubbed the orphan of the health system, and in proposing solutions.

The committee, headed by then-senator Michael Kirby (who now heads the MHCC), made 118 recommendations, most of which find echo in the new document.

But there are some subtle, yet important differences between the tone and content of Out of the Shadows at Last and the draft strategy.

First, the language is more bureaucratic and wishy-washy. Mr. Kirby and his senatorial colleagues were refreshingly blunt on what needed to be done; the anonymous drafters of the strategy are far more circumspect.

Far more troublesome is what you can read between the lines of the proposed strategy. There is far too much emphasis on the “recovery model” – the notion that everyone will get better with support – and not enough emphasis on brain science. It’s a legitimate approach for those with mild and moderate mental health problems but not those with severe conditions such as schizophrenia.

In fact, reading the draft strategy, one is left with an unpleasant aftertaste: the distinct feeling that psychiatry and medications have no place in Canada’s approach to tackling mental illness.

There are distinct – and sometimes clashing – views in the mental health field. But the strategy gives too much credence to social science and not enough to neuroscience.

It also pays far too much attention to the views of “psychiatric survivors” who hide their vehemently anti-treatment views in the promotion of “peer support” and the language of “rights.”

But hope – and false hope – cannot be allowed to take the place of care. Where in the strategy, for example, is the call for investment in brain research, psychiatric beds and more addiction treatment facilities?

The draft also gives short shrift to the sickest of the sick, those with severe (and often intractable) cases of schizophrenia and bipolar disorder, who often suffer from anosognosia (where people don’t even recognize they have a mental illness).

This group, while small (less than 1 per cent of those with mental illness), are those who populate our streets and prisons. They don’t need the right to refuse treatment, they need the right to be well. And their families need to be empowered to help them, not cast aside.

Susan Inman, author of the memoir After her Brain Broke: Helping my Daughter Recover her Sanity, offers up a detailed critique of the strategy’s shortcomings in this regard in her article Suppressing Schizophrenia, published this week by The Tyee.

One of the MHCC’s key goals has been to help create a social movement, one that empowers people living (or having recovered from) mental illness. This is how women with breast cancer, men with prostate cancer and people living with HIV-AIDS have brought their issues to the forefront and made great strides.

But the mental health movement has to learn an important lesson from these other movements: You have to be inclusive, you have to embrace science, you have to be mainstream and you cannot allow those with ulterior motives to set the agenda.

There is a lot of good in Canada’s draft mental health strategy. But it’s not good enough yet.

Also see:

An open letter to Canadians from the Mental Health Commission of Canada

North Shore Schizophrenia Society Advocacy Bulletin (September 2011)

‘I've gone through a metamorphosis'

An article published in yesterday's edition of The Globe and Mail:

Stability is the key to managing mental illness, experts suggest. André Picard looks at a Montreal project that puts housing first, providing troubled homeless people a stable home of their own

By André Picard

Ricardo Maddalena has lived in many places over the past four decades: fleabag apartments, a psychiatric hospital, prison, rooming houses and on the streets.

Four years ago, he finally found a home.

The 58-year-old, who suffers from severe schizophrenia and has struggled with alcoholism since his teens, moved into an innovative housing project in downtown Montreal that is operated by Chambreclerc, a non-profit group in the city that offers housing to long-time homeless men and women with severe psychiatric disabilities.

“Since I moved here, I've gone through a metamorphosis,” Mr. Maddalena says.

To read the entire article, please click here.

Also see:

Homelessness: By the numbers

Harm reduction: Contentious, but experts say it works

Photo Credit: John Morstad for The Globe and Mail

Patients' rights frustrate families

An article published in the March 12th edition of The Globe and Mail:

By André Picard (pictured)

The trial of Vince Li, the so-called "Greyhound bus killer," garnered a lot of media attention. There is no need to rehash the gruesome details.

But let's linger on one aspect of the case, because much was made of the fact that Mr. Li suffers from a severe mental illness, schizophrenia.

This is the story of someone else who suffers from schizophrenia.

His name is Matt. Like most [people with schizophrenia], he has never harmed anyone physically - except himself.

But he and his illness have caused his family and friends untold pain - a pain made more searing by the coverage of Mr. Li's trial. The descriptions of him as "psycho," a "sicko," a "nutcase" and so on hurt profoundly; so, too, did the focus on Mr. Li's "crazy" symptoms and the lack of attention paid to the fact that he was untreated for a treatable condition.

"Nobody deserves to die like that young man on the bus. But seeing the way schizophrenia was reported made me sick," said Steve, Matt's father.

They have a last name, but have asked that it not be used. There is a lot of stigma surrounding mental illness, and vilification of the mentally ill. "I'm self-employed and I can't afford having people think of me as the father of a 'freak.' That's the sad reality," Steve says.

But, at the same time, Steve wants the public to see another side of schizophrenia, one that will never be front-page news.

It is a story of frustration with Canada's patchwork mental-health system, one in which care is not available until there is a crisis. It is the story of the devastated family of the person with schizophrenia.

It is a story of anger with a legal system that gives people with severe mental illness the right to refuse treatment, and affords families no right to help their loved ones get well.

The family has lost count of how many times Matt, who is only 20, has attempted suicide, how many times he has overdosed.

Matt will ingest any drug he can get his hands on, from NyQuil to ecstasy. When he does, the demons that haunt him recede into the shadows for a while.

Like many people with severe, untreated mental illness, Matt has an ever-lengthening criminal record, most of it related to shoplifting over-the-counter drugs at pharmacies and public intoxication.

He spends nearly as much time in prison as he does in hospital - essentially jailed for being ill.

Who could have imagined it would come to this?

At one time, Matt lived a comfortable middle-class existence in suburban Toronto. He was a star athlete, a gifted musician, an army cadet, a popular classmate. But things began to unravel in high school.

He became withdrawn. Smoked and drank and did drugs with a little more gusto than his peers. Began acting weird. Dropped out of school. At first, it was dismissed as the growing pains of adolescence, but his behaviour soon spiralled out of control.

Matt bounced around various group homes and court diversion programs. The stress and frustration were such that his parents' marriage almost collapsed.

Then the diagnosis came - schizophrenia.

"Finding an explanation for his behaviour was a relief," Steve says. After all, parents tend to blame themselves.

"But then you find out what it really means - a mind-altering disease destroying a person you love - and it's heartbreaking," Steve says.

Trying to get his son the care he needed was more heartbreaking still.

The wait to get Matt into a psychiatric bed in the region of Ontario where he lives was 12 weeks or more. He bounced from crisis to crisis. When there was a glimmer of hope and the young man was willing to be treated, care was not available.

After a suicide attempt, Matt was treated in the emergency room then sent home. Not because he didn't need help, but because all the hospital's psychiatric beds were full.

Matt has now deteriorated to the point where he is hospitalized against his will; he has been committed, or "formed" as they say in the jargon of the milieu.

But he can still refuse treatment and he can still wander away from hospital to shoplift and get high. "He has lost the capacity to make rational decisions, but he still has the legal right to make those decisions," Steve says.

He is exasperated by this paradox, as are many parents of adult children with severe mental illness.

"In the end, all I want is my son back," Steve says mournfully.

He has nothing but praise for the health professionals who have cared for his son. The nurses and doctors, he says, have been phenomenal. So are the volunteers and staff from the Canadian Mental Health Association.

"But their hands are tied by consent forms and legal nonsense," Steve says. "The Charter of Rights and the Mental Health Act give my son the right to be sick."

Vince Li, too, had the right to be sick, the right to be guided by psychotic visions, the right to refuse treatment. In that case, the tragic consequence was the senseless death of Tim McLean on a Greyhound bus.

Two more victims of untreated schizophrenia, of a mental-health system with screwed-up priorities.

But there are many more victims of untreated mental illness, of a profoundly flawed system.

Far from the headlines, they are dying deaths by a thousand cuts, deaths by a thousand pills, deaths by a thousand missed opportunities to treat.

Also see:

The mentally ill who break the law deserve 'all mercy and humanity'

Freedom to be sick leaves families feeling chained

From today's edition of The Globe and Mail:

Caregivers who can't get mentally ill loved ones to seek help grapple with laws designed to protect civil rights

By André Picard

Mary Liz Greene [pictured] was in the midst of an animated conversation with her son when he suddenly lunged, grabbed her by the neck with two hands, then pushed his thumbs into the soft flesh of her throat, using the full force of his 6-foot, 200-pound frame.

Gasping for air, she felt the pressure let up for an instant, shoved him with all her might and fled to a neighbouring apartment to call 911.

“I'm lucky to be alive,” Ms. Greene said later, “although sometimes I doubt that.”

Her son, 24-year-old John Candow, suffers from severe bipolar disorder and, when untreated, is consumed by the delusion that he is Tony Soprano, the TV mobster. He has been living with his mother and, since he was diagnosed three years ago, has thrown knives at her, burned her with cigarettes, punched and kicked her repeatedly.

Last week's incident was the most violent yet. When police arrived, they were confronted with a psychotic young man holding a knife to his throat threatening suicide. They tasered, subdued and arrested him – and found 10 more knives in his knapsack.

When Ms. Greene, a Halifax social worker, visited her son at the East Coast Forensic Hospital a few days later, he reminded her, matter-of-factly, that he plans to kill her and chop her body to pieces.

“When John's not sick, when he's being treated, he's very loving. He's a sweet, beautiful boy,” Ms. Greene says tearfully.

But the central fact of the sordid tale is this: Mr. Candow refuses to get treatment, as is his right under Canadian law.

That right presents a dilemma for countless caregivers across the country whose loved ones have such severe mental illnesses as schizophrenia, bipolar disorder and addictions, especially when they also suffer from anosognosia – an inability to recognize they are sick.

To read the entire article, click here.

Photograph by Sandor Fizli for The Globe and Mail.

Mental illness - past or present - is not a crime

From the August 28th edition of The Globe and Mail:

By André Picard (pictured)

Is having a bout of mental illness something that should result in a police record?

Astoundingly, that is the reality in much of this country.

It is an egregious breach of civil rights, yet the practice continues because people who suffer serious mental illnesses such as depression, bipolar disorder and schizophrenia are all too often voiceless, powerless and victims of well-entrenched stereotypes.

To understand this story, a little background is in order. In the post-9/11 era, police checks have become the norm in our society; it is a simple way of weeding out pedophiles and other "bad" people, or at least giving the illusion of doing so.

If you apply for a job or a volunteer position - fundraising at the local hospital, coaching a peewee hockey team, helping out with the school choir or any other of those innumerable, thankless tasks - you will have to agree to a police check.

These checks come in two forms.

The first is a search of the computerized records maintained by the Canadian Police Information Centre. If you have a criminal record, the information is likely to show up in CPIC.

The second is a police records check. In addition to CPIC, local, municipal and provincial police forces maintain their own computerized records.

These records contain all manner of information about any contact you have with police, whether you are a criminal, a victim or a witness.

When you have a loud party and the neighbours rat you out, both your names are in the system. A Good Samaritan calling 911 is in there, and so are the people they are calling about, even if they are harming no one but themselves.

People who suffer bouts of mental illness tend to have a lot of encounters with police. They make suicide attempts and threats of suicide. Sometimes they starve themselves, drink or drug themselves silly, make paranoia-spewing phone calls and trash their cars. And these are the "respectable" people with nice homes and good jobs, not the stereotypical "crazy" street people.

These encounters all result in a police record.

"So what?" you may ask.

Aside from the principle that we should not accept gratuitous violations of civil rights, there are practical harms being done every day. Take the example of Ontario, where the Mental Health Police Records Check Coalition has done a wonderful job bringing this issue to light.

If you apply for almost any volunteer post in Ontario working with children, the elderly, people with disabilities etc. you must undergo a Vulnerable Person Screening.

This report will tell the volunteer agency if there are red flags on a person's police record. Some police forces simply make the vague statement
that there is "information of concern," while others provide details such as "suicide attempt" or "arrest under the Mental Health Act."

(Incidentally, when people are detained under the terms of the Mental Health Act, it is not an arrest. Police have the legal right to take people who are a danger to themselves for treatment at a medical or psychiatric facility, but police tend to use the misnomer "arrest.")

Mental illness is a medical issue. What business do police have disclosing this information to potential employers? Some police forces retain and release this information for up to 25 years after an "encounter."

To read the entire article, click here.

A 12-step program for Canada

From today's edition of The Globe and Mail:

Setting priorities and solutions to address the mental health crisis.

To read this excellent article by André Picard, click here.


From www.andrepicard.com:

André Picard is the public health reporter at The Globe and Mail and one of Canada's top public policy writers.

He is the author of the best-selling books CRITICAL CARE: Canadian Nurses Speak For Change and THE GIFT OF DEATH: Confronting Canada's Tainted Blood Tragedy. He is also the author of A CALL TO ALMS: The New Face of Charity in Canada.

André has received much acclaim for his writing, including the Michener Award for Meritorious Public Service Journalism, the Canadian Policy Research Award, and the Atkinson Fellowship for Public Policy Research.

In 2002, he received the Centennial Prize of the Pan-American Health Organization as the top public health reporter in the Americas. In 2005, he was named Canada's first Public Health Hero by the Canadian Public Health Association, and in 2007 he was honoured as a Champion of Mental Health.

André is also a four-time finalist for the National Newspaper Awards – Canada’s Pulitzer Prize.

He has been the recipient of the Canadian Nurses' Association Award of Excellence for Health Care Reporting, the Nursing in the Media Award of the Registered Nurses Association of Ontario, the International Media Prize of Sigma Theta Tau (Nursing Honor Society), and the Science and Society Book Prize.

His advocacy work has been honoured by a number of consumer health groups, including Safe Kids Canada, the Canadian Mental Health Association, the Canadian Alliance on Mental Illness and the Canadian Hearing Society.

He lives in Montréal.

Photo of André Picard courtesy of www.andrepicard.com.