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Dr. David Goldbloom took your questions

Psychiatrist talked about society and the stigma around mental illness

Globe and Mail Update

"The reality is that one in five Canadians over the course of their lives can experience mental illness in one of its many manifestations, and what that ultimately means is that every single family in Canada has in some way been affected by mental illness," psychiatrist David Goldbloom told The Globe's Carolyn Abraham in a recent interview.

"There's nobody in our country who can stand up and say, 'Not my family, not my aunts or uncles or cousins or grandparents, children, siblings, spouse or self.'

"And yet the reluctance to talk about it, to acknowledge it openly, to treat it as a form of human suffering like any other illness, relates in part to how threatening this set of illnesses is to our sense of who we are."

Dr. Goldbloom was responding to a question about why people are still reluctant to talk about mental illness, especially in this era where the personal is increasingly more public. He went on to explain that "... if you break your leg, you're still you. If your mind is somehow broken by mental illness, you're not you in the eyes of yourself and you're often not you in the eyes of other people."

What do you think? Has your family been touched by mental illness? What has your experience been with the system, the workplace or society in general?

We're pleased Dr. Goldbloom found time in his busy schedule to join us for a live discussion. Your questions and Dr. Goldbloom's answers will appear below.

David Goldbloom is the vice-chair of the Mental Health Commission of Canada, a professor of psychiatry at the University of Toronto and the senior medical adviser of education and public affairs at the Centre for Addiction and Mental Health, where he was also the inaugural physician-in-chief.

Dr. Goldbloom has worked in psychiatry for more than 23 years treating patients, teaching young doctors and schooling the public about mental illness and the stigma that it still carries.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Carolyn Abraham: Hello I'm Carolyn Abraham, medical reporter with The Globe and Mail and one of the contributing writers to the series on mental health the paper is now running. Joining us this evening to answer readers' questions is Dr. David Goldbloom, a well-known educator and psychiatrist with The Centre for Addiction and Mental Health in Toronto. Thank you for being with us this evening Dr. Goldbloom.

The first question comes from Trudy Boyle in Calgary: I am interested in your thoughts on how parents and grandparents, for that matter, can best 'innoculate' their children for good mental health. In this era of 'safety' we have all manner of practices that we hope will keep our children safe from disease and accidents. Our vulnerability to mental illness of one kind or another seems to be increasing, yet, we rarely speak about prevention. This conversation in The Globe may be a beginning. Obviously we have no recipe to protect us from illness, old age or dying but there are always things we can do to improve our quality of life while we are alive? I would love to see 'best practices' discussed, not as a guarantee nor as an obsession for some 'ideal way', but as a way to up our chances to be mentally and physically healthy. thank-you Trudy

Dr. Goldbloom: If we think about prevention in the arena of physical health, there are several components:

1. Knowing your family history to know areas of elevated risk (remember that risk is not the same as destiny); if you have a strong family history of depression, then being familiar with the illness and its presentation is important. And so is being able to talk about it in a matter-of-fact way, rather than treating it as a secret taboo.

2. Stress reduction and promoting things in our lives that give us both pleasure and a sense of competence.

3. Promoting healthy relationships- this is a lifelong task but there is emerging evidence from the work of Dr. David Wolfe of CAMH about the importance of this for mental health.

4. Allowing people to acknowledge difficulties and unpleasant feelings rather than looking on this as a sign of weakness or shame.

5. Family dinners: There is excellent evidence that this low-tech social intervention is associated with a whole variety of signs of good mental health and success in school and relationships. Families of adolescents that had 5-7 meals together per week looked very different than those who had 2 or fewer.

Clearly, these are very general approaches because we don't have specific evidence about interventions that successfully lead to avoidance of mental illness.

Rob Swanson from Edmonton writes: Thank you to The Globe and the good Dr. for attempting to raise awareness. From the perspective of a person who has been through the system a half dozen times and on as many as a dozen different and expensive meds at the same time, to little effect, and knowing that no wish list can or should be fully funded in an age of increasing costs, I question the ability of the existing system to measure its effectiveness going forward using existing methods. How do you suggest the industry measure itself and apply any increased funding in the most effective way for the patients and the taxpayers?

Dr. Goldbloom: There has to be a better emphasis on the quality of outcomes - from the perspectives of people with mental illness, their families, and health professionals. While it is easier to count numbers of beds filled, numbers of people seen, numbers of prescriptions written, this doesn't tell us about quality but only quantity. Increasingly, health care services are trying to measure both outcome and satisfaction (not always exactly the same thing) and eventually this will get linked to funding.

Emma Hawthorne from Canada writes: Why is it that in Canada only the well-heeled can afford the skilled psychotherapy provided by psychologists and social workers? Why aren't interested professionals from these groups invited to join OHIP?

Dr. Goldbloom: I can't speak for the decision-makers at OHIP. Some people are able to access non-MD therapists through benefits plans from work, but this leaves many Canadians unable to do so. In other jurisdictions, there has been public funding for skilled psychologists to deliver evidence-based treatments.

Cecilia Belcastro from Toronto writes: A huge barrier to the mentally ill is being adequately prepared for the workplace. In your years of dealing with patients, how often do you see those with serious mental illness (bipolar, schizophrenia) successfully transistion into a career? What has become the typical lifestyle of these patients?

Dr. Goldbloom: If you had asked me this 10 years ago, I might have said that very few of people with schizophrenia whose care I have been involved with made successful, sustained transitions to the workforce - and, to a lesser extent, people with bipolar disorder. Thankfully, that is starting to change but not fast enough. How can we expect people to recover a sense of well-being without the monetary and other rewards and feedback that the workplace provides? While some people with long-term illnesses will at times be too ill to work, our society has traditionally overestimated the inability of people with severe mental illnesses to work, depriving them of the dignity that work provides. People who are unemployed are at risk for loneliness, poverty, and physical inactivity.

Josiah Smith from Japan writes: Thank you for your time, Dr. Goldbloom. A lot of people seem to be under the impression that mental illness is something you should be able to overcome with an act of will, that you should be able to 'get over it and move on,' and that if you can't, you are weak and somehow contemptable. What do you suggest as a way to change this perception?

Dr. Goldbloom: This is a common perception - and yet it's one that people wouldn't have of others who are facing acute or chronic physical illnesses. Step one is getting people to understand it as an illness rather than a character flaw or sign of weakness.

Seana Tallon from Ottawa writes: Words cannot express how grateful I was to open up the Globe on Saturday morning, only to find a full front page bringing into light the devastating illness which is currently gripping and crippling our family; mental illness.Our close family member has Bipolar type 1. He is a husband, a brother, a son, a friend to many, an executive and a father to a little person who is devasted by his absence. The toughest part about this recent episode of mania, is that the man with the illness feels great; he is grandiose in his thinking and plans, he's on top of the world, though he completely lacks judgement and insight. When I pause to consider the gut-wrenching tasks of recent days; committing him to the safety of a hospital, the many discussions with nurses, mental health crisis line personnel, psychiatrists, psychologists, not to mention scrambling to prevent major financial devastation that often comes with this illness, I am dizzy. I know the hard work must be done when the person is well. Yet despite extrordinary effort to discuss this illness and to help to set plans in place for the day he would ever (never!) get sick again, the lurking problem was stigma and shame; lots of shame. He had a burden of shame and remorse about events from the past. Perhaps society can 'wake up' and realize that mental health must be discussed, openly, in order for those who are dealing with this burden to realize that what they are facing is an illness, like any other. Is this the missing piece in the treatment for mental illness, which is reaching a crisis proportion in our society?

Dr. Goldbloom: Thanks for that poignant account of a struggle. I would say it is A missing piece but not the only one by any means. I wish we had more effective treatments. The ones we have are better than the days when there was no effective treatment (e.g., more than 60 years ago).

Teresa Bradeau from Canada writes: I have a son 42 who is in denial that he is paranoid schizophrenic, or has a disability. He has been hospitalized several times and released as he refuses medication. Will not seek or agree to speaking to any more doctors and in fact wants to start a civil suit against the doctors in order to have his file sealed. Living in a fishhut type shed on a bush lot 5 hour drive north of where I live. He is without hydro or plumbing. Presently has the support of local Mental Health ACT Team of which I am grateful. Do you have any suggestions on how we might get him to realize he has a mental illness and agree to get medicated? I would like to send him the article on Jesse Bigelow. If he were to read it, do you feel that it might somehow get him to consider that he may in fact have an illness? Thank you.

Dr. Goldbloom: It can't hurt to send the article. In my experience, when people experience a mental illness, they often feel like the only person in the world going through that experience. And the distancing of others only leaves them alone with such thoughts. One of the powerful aspects of peer support is the special empathy and understanding that comes from lived experience - and even a written account of it can be helpful. ACT teams often work with people over the long term to develop a relationship that ultimately can lead to engagement in help.

Annick Aubert from Toronto writes: In November 2006, FMHA in partnership with CAMH,CMHA and OFCMHAP published ' Caring together : Families as partners in the Mental Healh and Addiction System .Is this paper known to CAMH practitioners ? What is CAMH's view of recommendation III on page 12 ..involving families as system partners ?

Dr. Goldbloom: This is an important initiative which other interested people can access here.

Getting families more involved at every level is an important issue for CAMH, for the mental health system in general, and for the Mental Health Commission of Canada, where family members sit on the Board of Directors and have their own advisory committee to the Board. I don't know what percentage of CAMH clinicians are familiar with the document but we can always do a better job in relating to families and engaging them at every level.

Anonymous from Canada writes: Dear Dr. Goldbloom, While I want to be compassionate, the reality is much more complicated. My partner has bipolar disorder. I find it extremely difficult to distinguish between symptoms of the disease and things that are his personality or his actual emotions. I'm never sure how to respond or even to whom/what I'm responding. I don't know at what moments I can say 'that's just his disease talking, not him' as people say you should, especially since the illness seems intertwined with his experiences, emotions and life events. Everything I read talks in broad generalities that don't address the nuances. It also suggests that this illness happens in discrete episodes, which does not match my sense of it at all. When we go to the psychiatrist, he rushes us in and out within 5 or 10 minutes. I'm struggling with this greatly, reading everything I can get my hands on in order to try to understand. And yet I still feel lost and desperate, bruised and frightened. Is there any forum anywhere where I can discuss these issues with someone with expertise and experience? It feels to me like there's nothing out there. I find myself disengaging emotionally in order to have some kind of stability, and yet it would also break my heart to leave. Thanks so much for your response.

Dr. Goldbloom: The challenge you face is not uncommon at all - distinguishing the person from the symptoms at times, experiencing the illness as less discrete episodes and more waxing and waning symptoms; for some people with bipolar disorder, episodes truly are discrete, while other people experience ongoing symptoms to varying degrees. In my experience, partners and family members often derive great benefit from support groups such as the Mood Disorders Association of Ontario or its provincial counterparts; there, you find how other people cope and deal with similar experiences. Sometimes that's alot richer than a book and more supportive. I also think you should ask the psychiatrist for more time than 5-10 minutes to understand his/her perspective, gain advice, etc. All of us can get angry and fed up at times when people we care about are ill, be it physical or mental. That's normal! But if it's the only reaction, it's a problem.

Liesel Nadela Aranyosi from Canada writes: I am a practicing Registered Professional Counsellor in private practice who is an active member of the Canadian Professional Counsellors Association. In Dr. Goldbloom's informat ive interview, he mentioned about re-skilling the other mental health professionals as one of moves to take to address the mental health crisis in Canada. What is the process for mental health professionals, like me, to be re-skilled so that we meet the skills and competencies to become a qualified resource for the community?

Dr. Goldbloom: There are a number of courses that are offered (including on-line courses at CAMH) and in local communities through professional associations.

Michael Mills from Vancouver Canada writes: How do you account for the rising rate of depression? There has been a 10-fold increase in reported depression since 1945. Surely a lessening of stigma related to mental disorders cannot account for such a large increase. Also, what percentage of your patients end up having a physiological trigger for their illness?

Dr. Goldbloom: One of the challenges relates to detection rates, which have improved dramatically with the use of standardized rating scales. This is quite separate from stigma. Additionally, the diagnostic criteria for depression have evolved, and this may have changed the rate. Depression can follow significant physical events, such as a heart attack, infectious mononucleosis, thyroid disease, etc. However, for many people depression can occur without any discernible trigger. We always look for the "why" when it comes to bad things happening to us; sometimes there is a reason but many times it just happens.

C.F. from Toronto Canada writes: A question for the doctor: How can we impact employers treatement of employees with mental health issues when the desginated employers (psychiatric hospitals, mental health and addictions facilities, etc) are intolerant of mental health issues in their own staff? It appears for employers it isn't the ''why'' of an employee absence from work but rather the cost of that absence. How can we influence this to change since so many workers are impacted by mental health issues?

Dr. Goldbloom: Stigma exists everywhere - in society at large, in the health professions, and in the mental health professions. We are trying to tackle that problem internally at CAMH and through education outreach as well. Employers have to think about BOTH the "why" and "the cost" of absence - but there is also evidence that the better the treatment for mental illness, the lower the cost to employers.

Neil Rankin from Toronto writes: With lost time disability claims due to mental health (i.e. panic attacks, depression) on the rise, what can people do to be more proactive in ensuring symptoms are addressed proactively to minimize time off work?

Dr. Goldbloom: All too often, people wait too long to get help or experience horrendous delays when they decide to get help. Both will add to disability time. Having a work climate that is aware and understanding of mental health problems and mental illness may make it more acceptable to get help - and get back to work sooner.

Scarablady from Ottawa Canada writes: My questions is about how families can support someone who refuses to get help. My brother has had difficulty forming relationships / personal and work, most of his life. He is a loner, hasn't had regular employment in many years, is brilliant, creative and engaging, but displays a lot of anger and sinks into depression. He has made reference to suicide, and last year we contacted a crisis hot line when he said he had thought of how he'd do it. As per their advice, we suggested that he contact them; he didn't. Although he refused to get help (says doctors don't know anything, quit a psychiatric assessment process when he was nearing getting the results, and won't take medication), when he learned that we had called the hotline, he stopped talking about suicide. He lives near my 82-year-old father, and is there all the time. His up-and-down and often agressive behaviour stresses my father and the rest of the family, and we're worried about Dad's stress levels and how my brother will cope on his own when dad is gone. Are there supports out there (we're near Ottawa) for families to help us learn how to support my brother and encourage him to seek help while taking care of ourselves? Thanks

Dr. Goldbloom: There are family supports available. I would suggest you contact the Canadian Mental Health Association branch in your area and/or the Royal Ottawa Hospital for some advice. You need to look after yourselves as well as your brother.

lee sjostrom from Toronto Canada writes: The biggest problem for most people with mental health issues is getting properly diagnosed and THEN getting the right kind of therapy for their illness. I fired my psychiatrist of several years a couple of months ago because he wasn't helping me get better at all. And now I can't find anyone to help me and I'm too confused and depressed. I need therapy NOT drugs! And therapists aren't covered under OHIP anymore.

I was told that I'd have to be admitted to a psych hospital before I even got a psychiatrist that specialized in my illnesses. How do we change this????

Tom Drummond from Ottawa Canada writes: I'd like Dr. Goldbloom to comment on the availability of Psycologists and Psychiatrists to the Public. It's my feeling that if there's a shortage of Family Doctors then what about Mental Health Professionals whom I believe would have many fewer patients on an individual or group basis. Thank-you Tom Drummond

Dr. Goldbloom: No one doctor is the right doctor for everyone — and the same goes for all types of mental health professionals. You need to be able to trust and have confidence in the person who is providing treatment and working with you. People can get a second opinion from a psychiatrist (either in private practice or in the Department of Psychiatry of almost every general hospital). However, there will never be enough psychiatrists to meet the mental health needs of all Canadians — nor should there be. Many mental health problems and mental illnesses are treated by primary care physicians (OHIP funded) and a variety of other professionals — psychologists, social workers, counsellors, and spiritual leaders. Family health teams in Ontario may provide some of the multidisciplinary resources needed, as do "shared care" models as best practiced in Hamilton where psychiatrists visit family practices regularly and provide direct and indirect care.

annick aubert from toronto Canada writes: In two of the stories on Saturday, the ill person could not have survived without the help of their loving parents, my question is are parents of the seriously mentally ill welcome as partners in care ?

Dr. Goldbloom: The answer is, "ideally, yes". However, there are times when relationships with parents or other family members have been highly difficult or even destructive — and other times when the person with the mental illness invokes his/her right to privacy in communication. In my experience, the earlier a family is welcomed by health professionals into the clinical relationship, the easier these problems are to navigate, the richer the understanding of the person, and the more extensive the range of supports needed for recovery.

Phil Gardner from Nanaimo, BC Canada writes: Hello Dr. Goldbloom, My question is about how we can begin in Canada to open up the conversation regarding the need for average people to recognize that mental health is a part of everyones' life. When problems of an emotional/ mental wellness nature do occur, we can openly discuss this without the shame and need for secrecy that so many people still feel. Do you think we could make a difference if we begin to do this when people are young- perhaps even in elementary school ? Phil Gardner Nanaimo

Dr. Goldbloom: You are right — we need to start this discussion early. It's one of the reasons CAMH has published two books for children — one called "Can I Catch It Like A Cold?" about having a parent with depression, and "Wishes and Worries" about having a parent with alcoholism. The goal is to explain and to reduce shame. The reality is that when the conversation starts — and it often still takes one courageous person in a social network — there is the realization that this is part of the experience of every family. I think The Globe and Mail's series is starting thousands of these important and necessary conversations across the country.

AE S from Halifax Canada writes: Dr. Goldbloom, If there was one thing that Canadians could do on a daily basis to help dispel the stigma and hurtful myths surrounding mental illness in our society - what would that be in your opinion? (I realize that it's much more complicated than this....) Thanks from Halifax...

Dr. Goldbloom: The best antidote to stigma is human contact — talking with someone who has experienced some form of mental illness and getting to know that there's a person in there, a person like you and me.

Carolyn Abraham: This is obviously a topic that strikes very close to home for a great number of Canadians. Thank you for taking the time to respond to so many questions during the past hour Dr. Goldbloom, it's much appreciated. I'm sorry we didn't have time for all the questions that have come in, but it's encouraging to see so many willing to share their personal experiences in this forum.

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