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A 12-step program for Canada

Setting priorities and solutions to address the mental health crisis

From Saturday's Globe and Mail

Canada does not have a mental-health system, for all intents and purposes. Rather, it has a patchwork of programs that have left the three million Canadians afflicted with mental illness the orphans of medicare and relegated them to the shadows.

For the past week, The Globe and Mail has delved into the plight of the mentally ill and their family members. Today, we offer a dozen recommendations to create a basis for the comprehensive system that is so desperately needed.

As Michael Wilson, the Canadian ambassador to the United States, whose son, Cameron, suffered severe depression and committed suicide, has said so eloquently: “We should care for the mentally ill as a matter of good conscience and good public policy. Those living with mental illness are not a lost cause – they are a just cause.”

1. Commit to a national mental-health plan – now

Canada is the only Group of Eight country without a mental-health strategy. We need a plan that lays out specific goals on 1) how to reduce the impact of mental illness on individuals, families and the community, 2) how to prevent mental disorders and 3) how to promote mental health and wellness.

Drafting a strategy – a blueprint for co-ordinating services and setting priorities – is the raison d'être of the new Mental Health Commission of Canada. The plan probably will be complete around 2011. But the government can take steps earlier.

2. Conduct public-education campaigns to combat stigma

The single biggest barrier faced by people with mental illness is the social stigma their illnesses carry and the discrimination it causes.

A number of countries have launched large-scale anti-stigma campaigns, such as Beyond Blue in Australia and See Me in Scotland. As they have learned, the more blunt the message and the more focused the target group, the more effective the campaign.

Canada needs to focus its anti-stigma efforts on debunking myths about particular groups that face the most discrimination, such as aboriginal people, the inner-city homeless and the elderly. It also needs to target professions in which changing attitudes will have the most impact – health professionals, senior corporate executives and the media.

3. Create a $10-billion, national mental-health fund

Mental health has, since the inception of medicare half a century ago, been treated like a poor cousin to physical health. There is now a yawning care gap. To bridge the gap, substantial investment is required.

Two years ago, a national $5.5-billion fund was established to reduce medical wait times in five priority areas (cancer and cardiovascular surgeries, hip and knee replacements, vision restoration and medical imaging).

A similar, targeted fund should be created that provinces can tap to bolster mental-health care, from prevention to housing. At least $10-billion should be put in the kitty for a five-year program.

While this may seem like a lot of money, it is a trifling amount given that mental illness costs the economy an estimated $51-billion a year in direct treatment costs, lost productivity and diminished quality of life.

4. Set up community-treatment programs in every health district

In the past 50 years, Canada has gone from 60,000 long-term beds for people with mental illness, to about 6,000 beds. Most people with mental illness are better off in the community, but only if treatment is available. In the current non-system, the sickest of the sick often end up on the streets, in jail or spiralling downward in grungy rooming houses.

There are proven, cost-effective ways of delivering care outside the institutional setting, including assertive community-treatment teams (mobile teams that directly oversee patients taking their medication, help them manage activities of daily living and help find employment), crisis-intervention units (an alternative to making police deal with mental-health patients) and intensive case-management programs (assigning case workers to those with chronic mental illnesses to keep them from being stuck in a revolving door, going in and out of the hospital).

Time and funds must also be set aside to ensure there are culturally appropriate services to suit the particular needs of immigrants, refugees and aboriginal people. Investing in community care does not mean hospital programs will disappear, but that institutional care will be more specialized and designed for acutely ill patients.

5. Build tens of thousands of supportive housing units

For community treatment to be effective, patients needs stability. They need housing. But an estimated 140,000 people with mental illness are precariously housed in Canada. The $110-million the federal government has announced for a research project on mental health and homelessness is a welcome initiative, but it's not enough.

Tens of thousands of supportive housing units – including subsidized apartments and houses, group homes and nursing homes that specialize in caring for mental illness – need to be built. The investment required is massive, but it is a wise use of tax dollars. Living in a safe, secure place will keep many people with mental illness out of hospital or jail, publicly funded facilities that are far more costly than supportive housing.

Some health regions in British Columbia have begun building lodges to house those with severe mental illness – cottage-like facilities where patients can learn practical skills such as cooking and managing money while they are being cared for. Those projects should serve as a model.

6. Double the amount Canada spends on research

Canada spends about $250-million on brain research each year, but less than half of that is related to mental health. The amount needs to be at least doubled. The capacity exists and the need is great: Compared with other common chronic illnesses like heart disease and diabetes, we know comparatively little about how brain diseases function and should be treated.

Research funding should be increased in all aspects of mental health and illness, from genetics to quality of care. Focusing on research provides practical benefits – psychotherapeutic drugs, for example, have helped revolutionize care – but it also builds hope, as it has done so remarkably in the cancer field. In addition, it helps to demonstrate that mental illnesses are diseases like any other, which reduces the stigma.

7. Establish mental-health courts in every province

The behavioural problems that are often symptoms of mental illnesses – public intoxication due to addiction to drugs or alcohol, failure to respect private property, indecent exposure, violence in response to psychotic hallucinations – often land people in conflict with police.

In fact, about one in five prisoners in Canadian jails suffers from a diagnosable mental illness, making our jails de facto asylums – a travesty for those who are sick and a huge waste of resources.

Every province needs to establish mental-health courts so people can be diverted from the penal system and “sentenced” to treatment, not incarceration.

As well, the forgotten victims of the criminalization of mental illness are the families of people with mental illness. They desperately need help navigating the justice system. The Justice and Mental Health Program of the Schizophrenia Society of Ontario is a gem that should be copied around the country.

8. Set up advisory groups to represent affected families in every district

Mental-health problems do not just affect individuals. They devastate entire families. Severe mental-health problems most often arise in a person's late teens or early adulthood, so sufferers usually turn to their families first and foremost. These families, from all walks of life, are brutally thrust into the health, justice and social-welfare systems.

There are inordinate demands made on these families and virtually no support. They need advocates and they need navigators.

Every health region should have a mental-health family-advisory committee to tap into the hard-earned expertise of those who have been there. These cannot be token positions: They need to have real power to shape the mental-health system.

But the reality is that most care is delivered by family caregivers. Every patient experiencing a first psychotic episode should be assigned a navigator to ensure rapid, aggressive treatment and support and to ensure family members are not kept in the dark – which they too often are.

9. Implement early-intervention programs in all schools

Canada has a good system to care for sickness, but it does a poor job of disease prevention and health promotion. Nowhere is that more true than in mental health. About 70 per cent of adults with mental illness had signs and symptoms in childhood or adolescence. Yet most realize this only in retrospect.

Prompt diagnosis and treatment can make a tremendous difference – for individuals and the health-care system. Early-intervention programs should be implemented in all schools so teachers and parents can be taught to spot problems early. Currently, only one in six children with a diagnosable mental illness gets treatment and the wait time for initiating care stretches into months.

Mental health is also more than the absence of mental illness: Public health campaigns promoting good nutrition and physical activity should tout the benefits not only to the body but to the mind. What people desire in life is a sound mind in a sound body – mens sana in corpore sano, as the Roman poet Juvenal wrote.

10. Push the business community to lead the way on workplace support

Most adults suffering from mental illness have jobs, making the workplace the ideal venue for anti-stigma campaigns, prevention programs and peer support. Canada's economy cannot afford to have a $51-billion hit every year. It cannot afford the productivity losses, the costs of disability and the lost opportunities that flow from turning a blind eye to the problem.

The business world (including private companies, non-profits and government) needs to step up to the plate with employee-assistance programs, more flexible disability programs, rehabilitation programs and reasonable accommodations for workers with mental-health problems.

Efforts must also be made to change the workplace culture to reduce the stress that is a common trigger for mental illness.

11. Radically reduce wait times for both emergency and therapeutic care

According to medical guidelines, people with symptoms of severe depression, bipolar disorder and schizophrenia should not wait more than 24 hours for treatment in the emergency room or elsewhere. People with less-acute illness should not wait more than four weeks to see a psychologist or psychiatrist after a referral from a family doctor.

Reality is far removed from these modest goals. People with mental-health problems fester in emergency rooms, often waiting up to 72 hours. Wait times to see a psychiatrist or psychologists stretch into months.

Britain and Australia, as part of their mental-health strategies, have substantially increased the number of psychologists and general practitioners offering cognitive-behavioural therapy, an approach Canada would do well to follow.

Also, Canadians are currently the biggest consumers of psychotherapeutic drugs in the world. While these medications are useful, they should not be the sole method of treatment: When drugs are combined with counselling, the results improve dramatically.

12. Invest in peer-support groups

For those with mental-health problems, isolation is a killer. Having a vibrant social network is a key element in recovery and peer support is one of the most effective tools for sufferers.

Every new mental-health patient should be referred to a peer-support group, either online or in the community. Considerable investments should be made to bolster initiatives that facilitate sharing of practical information among patients and families.

Different treatments work for different people. Effective care may include various combinations of medication, counselling, nutrition, exercise, meditation, spirituality and other therapies and lifestyle choices. But almost no one can recover from mental illness alone.

Across the country, there are countless disparate groups toiling in the shadows. They are on the verge of coalescing into a social movement with a powerful voice – akin to what happened in the cancer field a generation ago.

Therein lies hope. And that's the most important thing we have to offer people who suffer from mental illnesses.

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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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