Mental health strategy still seems elusive

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

What’s the difference between "excited delirium" and "autonomic hyperarousal state?"

Not much. In fact, in the provincial government’s response to the Hyde Inquiry report, the second term is used as a replacement for the first.

The inquiry, headed last year by provincial court Judge Anne Derrick, studied the death of Howard Hyde, a Dartmouth man who died in custody in 2007 at the Central Nova Scotia Correctional Facility in Dartmouth. Hyde suffered from mental illness and the cause of his death was initially identified by a coroner as "excited delirium."

Derrick rejected that as a "red herring." She found that Hyde died as a result of a restraint technique used on him by guards during a struggle.

Hyde had been repeatedly shocked with a stun gun during his 30 hours in custody. Derrick found that while the use of the stun gun did not cause Hyde’s death, the repeated shocks contributed to his deteriorating mental state.

Derrick’s report also strongly called for improved training for law enforcement officers who come in contact with people suffering from mental illness. The judge painted a clear path towards the use of de-escalation techniques in advance of the use of stun guns.

But the province seems to be struggling to find the right balance between public safety issues and the use of stun guns by officers. It has yet to finalize its guidelines for stun gun use, though Justice Minister Ross Landry said Thursday they will be released within a few weeks.

The minister did not explain why there has been a delay in issuing the guidelines or why, if only a few more weeks were needed, the province’s response to the inquiry report was not delayed so the documents could be released together.

But it speaks volumes that the use of the stun guns has already dropped by over 70 per cent since Hyde’s death in 2007, as The Canadian Press reported on Thursday.

In addressing what is now being described as an "autonomic hyperarousal state," the report released Thursday did not rule out using a stun gun on a person who may be mentally ill. But plenty of work remains to be done on the training side of the equation.

"Law enforcement officers must have appropriate tools to assist them in maintaining public safety," says the report. "At the same time, people living with mental illness may already be experiencing a high level of anxiety and the use of restraint could escalate the situation.

"The province and policing partners agree that the use of conducted energy weapons should only occur when a person’s behaviour is aggressive or violent and could harm the person or the public or the police officer. Additional direction is required regarding the restraint of individuals with mental illness."

The delay in providing that direction is not explained but Landry is clearly not comfortable with the current level of knowledge and training.

"It’s very difficult in situations where . . . there’s a high level of disturbance for the police officer to determine whether the person is suffering from mental illness," the minister told reporters on Thursday after the response was released.

In fairness to police, officers are often called on to make very quick decisions about the use of force in highly charged situations. But the death of Howard Hyde, among other cases, provides a reminder of the responsibilities that accompany the use of force, including the use of stun guns and other various forms of restraint.

There are federal guidelines available to help officers make those judgment calls and the province has said its stun gun rules will consider the federal document as well as expert advice provided by a panel of psychiatrists.

Derrick was clearly on the right track in emphasizing the need for much better levels of training. And in fairness to the province, some progress has already been made in addressing areas of concern raised in the inquiry report.

But the wheels continue to grind slowly towards the judge’s most important recommendation, adopting a provincial mental health strategy. The government is still waiting for a report from stakeholders.

It has been nearly two years since the NDP formed government and promises to improve mental health policies and services are growing stale.

(mstephenson@herald.ca)

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Culture shift needed in society, system

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

In the end, who failed Howard Hyde?

Perhaps, to some degree, we all did.

There is really no way to dress up the realities of mental illness. It is not pretty, and it can be a very tough challenge to support people in crisis. The people who live closest to those who suffer from mental illnesses are victims of the illnesses, too.

There is also no way to disguise or excuse how our society has continued to respond to people who experience mental illnesses. The stigmas are clear and well understood, even by young children in our schools. The branding begins early.

Hyde is the Dartmouth man who died in custody in 2007. He suffered from schizophrenia. The police were told of his mental illness when he was taken into custody over allegations of domestic abuse. He later died after an intense struggle with prison guards.

Provincial court Judge Anne Derrick released the fatal inquiry report into Hyde’s death on Wednesday. She firmly rejected a previous finding by a pathologist that he had died due to a condition termed "excited delirium."

Derrick dismissed that finding as a "red herring" that did not exist in Hyde’s case.

She also found that while the repeated use of a Taser on Hyde during his time in police custody "worsened the situation," it was not the cause of his death. She did, however, remind justice officials that so-called stun guns are to be used as an alternative to lethal force rather than as a front-line option to subdue suspects who are emotionally disturbed.

His death was accidental, Derrick found, but it came as a direct result of his struggle with prison guards.

In the comprehensive list of 80 recommendations, Derrick tossed the ball firmly into the hands of the provincial government.

She begins by calling for the establishment of a long-promised, but still absent, mental health strategy. It is clearly not by accident that this basic framework is at the top of the list as a necessary building block from which other improvements would naturally evolve.

The judge also calls on the province to increase funding for mental health, but not to do it by reallocating funds from within the existing envelope of health-care funding. This reflects the fact that mental health issues have for too long languished on the list of health-care priorities.

We are left with a fractured, often inaccessible mental health system where vanishing waiting lists are proudly waved around by government as proof of treatment for patients. Improvements are being made, and Derrick’s report makes note of policy changes that have already occurred in the justice system in the wake of Hyde’s death.

But it is hard to comprehend that none of the guards involved in the struggle with Hyde minutes before he died had any training to help them deal with prisoners who suffer from mental illness.

One seemingly innocuous recommendation, No. 49 on Derrick’s list, speaks volumes. Directed at justice system staff and other front-line officials who are in contact with prisoners who suffer from mental illness, it is brief and to the point:

"Training should have, as its overarching purpose, the development of a culture of respect and empathy for persons with mental illness in the justice system."

This is a statement that reaches beyond the justice system and into our society as a whole. While mountains have been moved in reducing the acceptance of stereotypes linked to mental illnesses, many of the most basic government services — justice and health among them — are still handcuffed by systemic ignorance.

The judge called for alternatives for people with mental illness who come in conflict with the law, and says the responsibility reaches well beyond the justice system.

"As the evidence before the inquiry has vividly illustrated, grasping this nettle is not just the responsibility of the justice system; creativity and commitment to change are required of the health system and the community, too."

The principles of respect and empathy provide a good place from which to start.

( mstephenson@herald.ca)

Also see:

Howard Hyde Inquiry Ignores Ableism As Cause of Death


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Focus on training, not terminology

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson [pictured]

A DEBATE OVER whether so-called "excited delirium" is a valid condition is a waste of time. What is more significant — in terms of how police and jail guards react to it — is the risk of death for a person in this state and how to best respond when high-risk situations unfold.

Last week Justice Minister Ross Landry released a report from an expert panel struck to review the condition last year. The panel was formed in response to the 2007 death of Howard Hyde of Dartmouth. He died in custody after a struggle with police. He had been shocked with a stun gun by them 30 hours earlier.

A death inquiry, led by Judge Anne Derrick, is already underway and its outcome is separate from the report. A pathologist has already concluded that Hyde died of excited delirium — a condition the panel says would be better labelled autonomic hyperactivity syndrome (AHS) — and not from the stun gun shock he received the day before.

We can expect from the inquiry, at the very least, another truckload of recommendations targeting how first responders deal with mentally ill people. A doctor who checked out Hyde after he was shocked with the stun gun has already testified that she would never have released him to the police had she known he would not receive the psychiatric assessment she had requested. Hours later, he was dead.

Dr. Stan Kutcher, a psychiatrist at Dalhousie University, served as chairman of the panel. He told The Chronicle Herald in an interview that "the most important thing here is to realize that this is a medical emergency and that this situation requires the combined efforts of law enforcement and medical first responders."

Police and jail guards will get extra training to ensure they are better equipped to recognize the symptoms of AHS and to call in medical assistance in those circumstances, says Landry. This is one of the key recommendations in a report that contains many useful guidelines for moving forward towards better responses to people experiencing AHS.

Symptoms — which can lead to hyperthermia, cardiac arrhythmia and sudden death — include extreme agitation, aggressive behaviour, paranoia or delirium, incoherent and rambling speech, extraordinary strength, numbness to pain, and profuse sweating.

The report says that "mortality rates are increased in the presence of the signs and symptoms of excited delirium — even with medical intervention or in the absence of use of restraints by law enforcement."

The panel also found that "it is reasonable to consider that, when further stressed by physical struggle or the application and continuation of physical restraints (including the CED), an individual exhibiting the syndrome of excited delirium may be at increased risk for sudden death.

"Similarly, the pre-existence of a medical or psychiatric condition (such as a psychotic illness, pre-existing cardiac condition, delirium with or without the use of psychostimulant drugs) may increase the risk for sudden death in an individual showing signs and symptoms consistent with excited delirium."

That is the nub of the issue: People who suffer from mental illnesses that end up in a state of excited delirium are at an increased risk of death. While police and jail guards may well be the people who are first required to be on the scene of such a situation, additional training is clearly needed to ensure they know when it is paramedics, rather than restraints and a physical struggle, that is more likely to bring a safe outcome to the situation.

Police officers and jail guards are often in very challenging, high-stress situations, where public safety, their own safety and the safety of the person they are trying to subdue must be judged at lightning speed.

They must be provided with every tool possible to make the right decisions in those moments. If that means more training to properly assess, arrest and/or subdue people with mental illness, then it should happen as soon as possible. Calling for medical assistance should be considered a first option, not a last resort.

Even one Howard Hyde outcome is one too many.

Also see:

Vulnerable targets

Mental health court long overdue

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson [pictured]

THE TORIES MAY have promised it, the NDP may have delivered it and the Liberals may have backed it. But credit for this week’s announcement that Nova Scotia will finally establish a mental health court goes to the many justice system officials who have pushed for years, and then finally said enough is enough.

Remember the story of Jean Roberts, the 70-year-old Dartmouth woman who ended up in court for setting fire to her own apartment?

She was unable to properly care for herself, could not be cared for in a traditional nursing home and found herself in trouble with the law. She had been in and out of jail over an 18-month period after what her family described as a slow slide into dementia and mental health problems.

Sadly, during a court appearance, Roberts had asked to be returned to jail because she had nowhere else to go. But is jail really the right place for people like Jean Roberts?

In 2006, Judge Bill MacDonald said no, it was not. After releasing her from custody on a series of relatively minor charges, he ordered sheriff’s deputies to delivery her to the Health Department and to leave her in their care.

"Why should the criminal justice system have to come up with all the options?" the judge asked at the time.

"I don’t want to take the responsibility of putting her out in the parking lot. There needs to be a facility in our society to deal with people like Jean."

Since then, the previous Tory government did move to establish a transition shelter for people with mental health problems, though with just a handful of beds I doubt it is able to accommodate the needs that exist. Still, it was a start.

More recently, Nova Scotians have heard the disturbing testimony at the inquiry into the death of Howard Hyde, the Dartmouth man who died in custody in 2007 after police shocked him with a stun gun.

He suffered from paranoid schizophrenia, but was not sent for a mental health assessment as one doctor had requested after he had been taken into custody on a domestic assault charge.

But the long-promised mental health court has been slower to materialize.

The Tories had finally promised to have it in place April 1 of this year, but a delay was soon announced. Summer or fall was the new target. Of course, an election and a change in government soon followed.

Finally this week, Justice Minister Ross Landry, under the new NDP government, announced that it will open in Dartmouth in November.

Once a week — guess who? — Judge Bill MacDonald will hear cases that are recommended by a provincial mental health court team.

They will be diverted from the regular provincial court case stream, but will not include more serious crimes such as murder or sexual assault.

Landry says the new court will help to balance public protection requirements and the needs of those who suffer from mental illness and find themselves in trouble with the law.

"It ensures public safety, and at the same time ensures the accused’s health needs are met," said Landry.

The court will not hold regular trials. Those who appear in the mental health court will have given either an admission of guilt prior to a regular trial, or have received a guilty verdict in a regular court.

The intent will be to work out treatment options, and in some cases, charges could be withdrawn once treatment is complete, says Landry.

With the closures in past years of mental health residential facilities, more people have found themselves without the care options they need.

For some folks, this had led to life on the streets and an absence of needed medications. Landing in court on charges, followed by jail, should not be the only option our society can offer.

The new court is a long-awaited initiative that will require offenders to be responsible for their crimes, while offering a helping hand to those with mental illnesses so they can get on the road to better health.

Also see:

Mental health court: Delivering on Tory promise

B.C. stun gun report applies here, too

An opinion piece published in today's edition of The Chronicle Herald:

By Marilla Stephenson [pictured]

WHILE THE DEATH of Howard Hyde in a Dartmouth jail remains an incident of confusion and contradiction, the report from a British Columbia public inquiry this week was crystal clear: stun guns can kill.

The fatality inquiry called into Hyde’s death by the Nova Scotia government and the B.C. inquiry are different in many ways but they also have much in common: both deal with the death of a disturbed man who had earlier been Tasered by police officers.

The two men died about a month apart in 2007.

Robert Dziekanski died on the floor of the arrivals area of the Vancouver International Airport in October 2007 after officers used a stun gun to subdue him. The Polish man, who spoke no English, had been wandering the terminal for hours before becoming disruptive and exhibiting erratic behaviour. The RCMP were called in to deal with him, eventually delivering five Taser shocks before he collapsed and died.

Hyde died 30 hours after he had been Tasered by Halifax Regional police officers in November of the same year. The medical examiner ruled that his death, after a scuffle with guards at the jail a day after being arrested, was a result of "excited delirium" caused by paranoid schizophrenia.

The fatality inquiry into the Hyde case has different parameters from the B.C. inquiry. Judge Anne Derrick has not been tasked to assign blame in her findings.

In B.C., former judge Thomas Braidwood found that stun guns can kill or cause serious injury. As a result, the B.C. government has ordered the use of stun guns to be "severely restricted," but stopped short of an outright ban on the weapons, which have often been used to bring unruly suspects under control.

"Conducted energy weapons are unique — they are the only weapon designed to cause intense pain and to incapacitate through an electrical current," Braidwood said at a Vancouver news conference.

In releasing his report on Thursday, Braidwood noted that Tasers were introduced without prior independent government testing, relying instead on information from the manufacturers, the Canadian Press reported.

Braidwood issued 19 recommendations, including that police only use the weapons when someone is causing or is about to cause bodily harm. He said 25 people have died in Canada after being subjected to electrical shock from a stun gun.

He undertook a detailed review of existing research into Tasers. He concluded they are a better option for police than guns, noting the threat of a Taser has enabled some police forces to resolve up to 80 per cent of incidents.

But he also found that they can cause heart irregularities and are an especially high-risk weapon for those who are medically or emotionally compromised, particularly if they receive repeated shocks.

"Deploying a conducted energy weapon against an emotionally disturbed person is, in most cases, the worst possible response," said Braidwood.

Among his recommendations is a call for additional training to help police officers deal with emotionally disturbed people.

These findings will be of particular interest to the family and friends of Hyde, who have heard testimony at the Halifax inquiry from police officers and medical officials that seems, at times, at odds with common sense.

The inquiry has been told of procedural errors relating to Taser use by the officers involved in the incident, acknowledgement that written reports about Hyde’s time in custody are in conflict with what appears on security tapes, and a written doctor’s order that called for Hyde to receive a psychiatric assessment.

That never happened. Communication about Hyde’s condition appears to have been minimal among the police, medical staff who cared for Hyde after he was initially Tasered, and corrections staff. While the confusion that existed is apparent from testimony at the inquiry, there seems to have been little effort made to seek clarification.

One day later, Hyde was dead. Suggestions that jurisdictional limitations and ignorance of proper procedures may have prevented Hyde from getting the help he needed are far from good enough.

Bold emphasis in the text of the article is mine.

Also see:

Hyde lawyer: Adopt Taser guidelines

Three cheers for outspoken health bureaucrat

From the August 28th edition of The Chronicle Herald:

By Marilla Stephenson (pictured)

CHERYL DOIRON is one of those bureaucrats who, happily for us, is more concerned about doing the right thing than she is with fawning over her political masters.

That’s why the deputy health minister is on the top of my Three Cheers list for her honest assessment of the dismal state of mental health services in Nova Scotia.

Even better, Doiron’s explosive missive was delivered in public, damn the torpedoes and other potential consequences.

She is exactly the kind of bureaucrat Nova Scotia could use more of.

At the Canadian Mental Health Association’s national conference in Dartmouth last weekend, Doiron issued a plea for mental health organizations and the public to push harder to have politicians direct more money into mental health services.

"It’s very hard to get it to be the primary issue, particularly for politicians who are making budget decisions . . . because they are not getting the same pressure about mental health as they get about cancer and coronary disease and diabetes," Doiron told delegates in a speech.

"We, working from the opportunity we have within government, organizations such as (the national association) and the Nova Scotia (association) and other groups, and all of us, collectively need to be doing something much more significant to make this a burning-bridge issue for decision-makers."

Doiron’s primary concern is the long wait times for psychiatric care for people suffering from mental illness, especially children. She noted that while spending for mental illness by her department has increased in recent years, the percentage has decreased in proportion to the total health-care budget.

To read the entire article, click here (as of February 8th, 2010, the entire article is no longer available).

Photograph of Marilla Stephenson courtesy of The Chronicle Herald.