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Andre Picard globeandmail.com writes: The Globe series has featured some horrific stories of mental health patients' encounters with the health system. How can we ensure people are getting treated? Getting treated appropriately? And getting treated in the right place?
Dr. Milliken: Andre, First of all let me say thank you to The Globe and Mail for, in my opinion, making a very significant contribution to answering all three of your questions. Community surveys (done, for example, by Statistics Canada) show that there are many more people in the community suffering from -- and disabled by -- moderate forms of depressive and anxiety disorders than are currently in treatment. People may choose not to seek treatment for their illnesses for a variety of reasons. What we, as a community, have to make sure is that the reason for not seeking treatment is fear of stigma or rejection because they are ill. We, as a community, have to accept and act on the belief that brain-based illnesses are no more fearsome than kidney-based illnesses, along-based illnesses or pancreas-based illnesses. By discussing these illnesses openly I believe that we are contributing to changing attitudes.
To make sure that the individual is getting treated appropriately, or in the right place, he, she or his loved ones have to ask questions. What are the alternatives? What is the success rate of this type of treatment? What are the side effects -- and all treatments, including counselling, have side effects? There are in most communities reasonably good resources. For patients with serious illnesses, contact with the local Schizophrenia Society or Mood Disorders Association or Canadian Mental Health Association may give information about questions to ask, and resources to be explored. Each of these organizations runs websites with useful information -- the Canadian Psychiatric Association / Schizophrenia Society of Canada publication: "Schizophrenia, the journey to recovery. A Consumer and Family Guides to Assessments and Treatment" is an excellent one. Many professional organizations -- psychiatrists, psychologists, social workers, clinical counselors -- also run websites giving valuable guidance about treatment options.
Armed with as much information as one can get, one can then have the best type of discussion with the family practitioner about the problem, and how it can best be addressed.
Christine Diemert, globeandmail.com writes: Dr. Milliken, some of the questions we have received during this series have been troubling, including a few for your discussion. It's obvious the person is in crisis, but it's difficult to know how to respond. You must encounter similar situations through your work with the Canadian Psychiatric Association.
Dr. Milliken: Thank you, Christine. This is one of the more challenging things than I ever have to do as a psychiatrist -- how to offer assistance to an individual who is obviously in distress, yet not recognizing that they are unwell. Every psychiatrist who works in an emergency department of a hospital and sees people brought in by their relatives, or by the police, for floridly psychotic or disturbed behavior faces this challenge.
First, we have to recognize that this is a human being who is distressed. We must acknowledge and respect that distress, while being clear that we may not share their beliefs. Thus, I may end up saying to the patient "I don't share your belief that the sound of the car horns outside mean that you are being targeted by the Mafia, but certainly if I did believe that, I would be frightened just as you are." Doing this in a respectful way will often allow the individual to start building some trust, and allow them to accept advice and treatment.
When I was the President of the CPA, I would sometimes get similar concerns expressed to me in letter form. These are much more difficult to deal with, because there isn't the same ability to develop a personal contact. However, I think the same principles apply. What I would try and do was make it clear to the person that I acknowledged and respected their feelings, didn't necessarily share their beliefs, and direct them towards talking about the problems with someone whom they trusted, hopefully a family doctor who could then initiate an appropriate treatment program, if indicated.
Heather Bruce from Ottawa Canada writes: Hello Dr. Milliken -Do you see a time in the future when psychiatric patients will be asked for their expertise regarding what treatment works best for them? Hospitals and mental health agencies here in Ottawa are now doing WRAP (Wellness Recovery Action Plan) groups and I would like your perspective. Just as obstetrics is now very different from a generation ago (all pain/no pain/doula/midwife/jacuzzi/whatever!), I wonder if psychiatry will go the same way? Thanks, Heather
Dr. Milliken: Heather, I don't see this as starting in the future, because it should be happening now. I say to all of my patients that in the interview room there are two experts: hopefully I know more about the illness and its treatment than the patient, for otherwise why would I be there? Likewise however, the other person in the room knows much more about the patient, how he or she responds to different medications, what his or her goals and aspirations are, which side effects are tolerable and which are not, etc.. When dealing with a relapsing illness, the patient, their family or those who know them well are the experts in the early signs of things going awry, bringing much greater knowledge to the table about that particular individual than I have.
If I don't use this wealth of knowledge, then I will be missing extremely important information and guidance that will lead me to successful treatment. The results will not be as good, the patient will feel slighted, I will know that I have not done the best that I can, and because of the poor results, my reputation will not be as good either.
I am fortunate because I work with a group of colleagues who all think the same way that I do. Clearly, each of us brings our own different personalities to the table, so we may approach matters slightly differently. However, the fundamentals of the same: we bring our expertise, the patient brings her expertise and by combining these we get the best results. Although we may be using a slightly different program than the one in Ottawa, the essentials are, I hope, the same.
Christine Diemert, globeandmail.com: Dr. Milliken, thanks for joining us today. Before we close, I'd like to ask one question and it's one we have been asking everyone involved in the series. When it comes to mental health, what single change in society or policy would help the most?
Dr. Milliken: Thank you very much. It has been fun to participate, and I hope has been helpful to your readers.
When one is as immersed in the system as I am, it is difficult to think of only one thing to put the emphasis on. I suppose that -- I'm groping for words -- it would be a change in attitude towards persons with psychiatric illnesses, or maybe a loss of fear of persons with psychiatric illness. These illnesses are serious, disabling, sometimes crippling, and all too often fatal. They deserve to be treated with respect, and those who suffer from them should not experience prejudice.
If we treat both the illness and the individual with respect, without fear and in a straightforward manner then we will legitimately look at trying to provide a range of options to help those individuals recover and resume their place in our families, our friendships and our society, just as we do for other medical conditions. That would be my wish.