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Earlier discussion

Dr. Donald Milliken and hospitals

Psychiatrist talks about mental health and the hospital system

Globe and Mail Update

When it comes to care, mental health has always been the poor cousin of physical health, Globe reporter Andre Picard writes. This is partly due to a legislative anomaly: Half a century ago, when medicare was created and Ottawa started funding hospitals, asylums for psychiatric patients were excluded.

Those suffering from severe, persistent mental illness were warehoused in institutions paid for solely by the province. Then came the civil-rights movement, coupled with the advent of effective drug treatments, which led to policies of massive deinstitutionalization.

In the article Dr. Donald Milliken, president of the Canadian Psychiatric Association and a practitioner with nearly 40 years of experience, recalls his experience as a medical resident in 1970: "They gave me the keys to a ward and said, 'There are 100 patients in there. Discharge 50.' "

The number of long-term psychiatric beds in Canada plummeted from a high of close to 60,000 in the 1950s to just over 6,000 today. That, in itself, was not a problem. But mental illness did not miraculously disappear and governments did not invest in community supports for sufferers.

"The system is in chaos," says Dr. Milliken. He says patients might be getting good care but not appropriate care. The fundamental trouble is not necessarily a lack of money or a shortage of beds but a lack of organization.

"If you take the same amount we spend on ad hoc care and spend it on organized care," he says, "the care and the outcomes would be better."

What do you think? Do you have questions about the hospital systems? Have you or someone in your family had a brush with hospitals and the mental health system?

We're pleased to have Dr. Milliken join us online for a live discussion now, until 1 p.m. ET. Ask a question now and join us then to read Dr. Milliken's answers, which will appear below.

Dr. Donald Milliken has practiced both clinical and administrative psychiatry for almost 40 years. He trained in psychiatry at the University of Alberta and has an additional degree in health administration from the University of Colorado. He was the Chief of Psychiatry for the Misericordia Hospital, Edmonton, then the Clinical Director of Forensic Services, Alberta Hospital, Edmonton and taught at the University of Alberta with the rank of Clinical Professor.

In 1993, Dr. Milliken relocated to Victoria, British Columbia, where he was the Chief of Psychiatry for seven years. During this time, he developed a catchment-area model of services, integrating in-patient and out-patient systems with the belief that care must go to those most in need; that the system must provide continuity of care and support in a simple yet seamless manner, and that the organization of care must be seen as being clinically sensible by practitioners and recipients alike.

A past-president of the Canadian Psychiatric Association (CPA), Dr. Milliken advocates about the need of getting levels of care for patients with psychiatric illnesses that are equal to those provided to patients with other illnesses of equivalent disability.

Editor's Note: 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.

Christine Diemert, writes: Thanks for joining us today Dr. Milliken. In Andre Picard's story Tuesday about hospitals you were quoted saying the system is in chaos. I'm curious about how we can begin to fix a system that varies according to each province, but needs national attention.

Dr. Donald Milliken: The only way that I can approach your question is as a clinician. The needs of persons with depression, schizophrenia, OCD, anxiety disorders etc. do not vary from one province to another. As a clinician, I am very comfortable in saying that a person suffering with a moderate-to-severe depressive illness needs a combination of support at home and at the work place, proper medication management playing careful attention to doses, benefits and side effects, as well as the necessary education and rehabilitative psychotherapy to understand the illness and prevent relapses.

The needs of the patient do not differ from one part of the country to another. The local system, therefore, must be organized to address these needs. The tremendous contribution both of this Globe series, as well as the Senate report "Out of The Shadows" is that both are focused on clearly discussing the needs of the persons who suffer. By keeping these needs at the forefront of the discussion, I believe that we can, over time, bring order out of chaos.

Too often, however, I have sat in meetings when services are being planned or reorganized and I have been the only one there with recent clinical experience. My own belief is that this is part of what is wrong -- the system goes awry when we lose contact with those whom we are supposed to serve.

Mary Mary from toronto Canada writes: Being someone who has been through the system on a few occasions, I have encountered significant differences in my treatment level. Because of stigma that still surrounds mental illness, the highest priority in treatment should be health care professionals' ability to treat the patients as human beings that deserve respect. Personal interaction is important and probably the most difficult when dealing with the mentally ill. Is the system changing to a focus on qualitative education and aiding the transistion of the mentally ill back to society and prevention of future episodes, or are they still in the primitive quantitative approach? What changes are being made???

Dr. Donald Milliken: Mary, thank you for putting your finger on what is, to me, a really important point that must never be lost as we discuss system change. We must always remember that "the system" is there to serve people in pain and in distress. One of the mantras that I keep repeating both to the students I teach and to the patients whom I see is that we must cheat ourselves with "grace and dignity". Indeed, challenging the patient to treat himself or herself with grace and dignity is sometimes difficult, as they try to deal with their own personal feelings of stigma and shame.

Over the almost four decades that I have been in practice, I have seen many swings in the approaches used in this system. Certainly, for a while the drug companies would have had us believe that the only thing we had to do to help people with serious illnesses was to prescribe them the correct drug in the correct amount. While, for the patients whom I see, this is an important part of their care, nevertheless to help them lead in the most fulfilled and complete life that they can, I -- and other members of the treatment team -- needs to pay close attention to their own knowledge of the illness, their own aspirations, and help them as much as we can with counsel l ing and rehabilitative psychotherapy to lead full lives as parents, spouses, siblings, workers and community members. We can only do that by working with the individual in question, not by seeing them as someone who is easily labelled.

ZAKSTER from Canada writes: After 40 years of clinical practice, I would be very interest ed in hearing about Dr. Milliken's experience with patients who recover from clinical depression. I am not referrign to bi-polar, or schizophrenia, but unipolar and severe depression (not necessarily with delusions or voices).

As someone who is currently suffering from a severe episode of depression, I need to hear that there is hope. Many of the stories being profiled and being discussed in the forum suggest that once you have a mental illness, you have it for life. It's depressing! There was a time when I was 'happy'; I would like to know that there's hope of returning to that state.

I am taking anti-depressants, which help me get out of bed and get on with my day, but they do not instantly dissolve my negative thoughts. They just don't seem to overwhelm me as much--but they're still there. I'm going to counselling, but it is a slow process as I only see my counselor once every three weeks. I would also like your opinion on how much of depression is caused by brain chemistry and how much by the messages we heard in childhood.

Dr. Milliken: Zakster, The problem that you are describing is the one that I spend most of my working life trying to help. There was a recent (2 months ago) article doing a follow-up for up to 23 years of patients who had been diagnosed with serious major depression. The majority of these patients had one episode, got it treated and have so far had no relapses. A very small minority have proven extremely difficult to treat, and a slightly larger group have had an illness which has been recurrent.

So I must be very clear: for the majority of people who suffer from depression, it is not an illness that affects their life forever. Like people who suffer from any other illness, there are some things that have to be done to prevent relapses, just as there are some things that a person with type two diabetes must do to prevent problems in the future. Proper treatment (including more than medication) of the early episodes is essential.

Your letter mentions counselling to deal with negative thoughts, and asks the question of how much of a depressive illness is due to biochemistry and how much is due to messages we learned in childhood. The answer is, I think, that both make us vulnerable. The messages that we learn as children show us ways of dealing with stressful events, often ways that are not the best. Increased stress in a person who is vulnerable can then clearly lead to biological changes within the brain which can then be shown by the individual in a variety of different ways. For this reason I always say to the people whom I see that although it is necessary to try and improve the biology as much as we can, it is always necessary to look at the messages they have received as children, to figure out how those messages affect their ability to deal comfortably with stressful situations today, and what we must do to improve that. For vulnerable people who suffer from serious depressive illnesses, the best relapse prevention program involves both aspects.

Andre Picard 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, 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, 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.

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Return to Breakdown: Canada’s Mental Health Crisis

Face it. Fund it. Fix it.

In Breakdown, The Globe and Mail documents the enormous, unaddressed cost of mental illness to Canadian individuals, families and society. The series closes with a search for solutions.


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