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My list: 10 things to do improve mental health care in Canada

Globe and Mail Update

A long-time advocate for people with mental illnesses gives his prescription for curing what ails mental health care in this country ...Read the full article

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  1. EL CANN from Toronto, Canada writes: I was astonished by your comment: "There is evidence that people with serious mental illness are likely to die 25 years earlier than the general population." I think the average life span is 85? So this to me might mean the average life-span of what you call the 'seriously mentally ill' would be 60? I'm thinking of people I know who have been mentally ill - I think you'd have to say they had 'serious' illnesses, but many of them have gone well beyond 60. Can you clarify or cite some sources or statistics? If you take what you say at face value, and you have a close friend or family member with a mental illness, then I think you could come to the conclusion that some people close to you likely have very shortened life spans. But I'd somehow suspect this is not the right thing to consider.
  2. Brenda Mathieson from Canada writes: Although I think some of your points are valid, I think that the biggest problem is lack of legislation to ensure those that are too sick to make competant decisions can still be treated. I feel that the Canadian Mental Health Association is definately a powerful advocate for the mentally ill on many fronts, but has missed the mark on this point. When my family needed assistance in finding the best path to find psychiatric care for a family member with paranoid schizophrenia, we contacted the Canadian Mental Health Association. Turns out, the organization is an advocate for the rights of the patient, but also advocates the patient's right to be sick. Many patients have little or no competency to seek medical help for themselves and the law has no teeth to allow family and friends to pursue a legal path to obtain medical assistance for them. The sick remain sick. The longer this disease remains untreated, the more damage to the brain due to out of control brain chemistry, not to mention the financial implications, family breakdowns, etc. If it were not for the Schizophrenia Society of Alberta, my family member would be going on year 30 with untreated schizophrenia. Fortunately, they were able to provide us with assistance and advice. My family member has been stable for 12 years and is now just starting to find joy in life again and taking up hobbies and interests that were dropped during 17 years of chronic illness. Perhaps you could provide the Globe and Mail and its readers with the current opinion of the Canadian Mental Health Association on the subject of Canada's current legal system as it pertains to psychiatric care.
  3. EL CANN from Toronto, Canada writes: I can sympathathize with Brenda Mathieson because I know of family members who have been in her position. Its a very painful spot to be in, for sure. But on the other hand I've known of people who've had mental health treatments that they were either pressured into or coerced into that actually did them great harm. When they stopped the treatments they were much better, and stayed that way for years. I think they were depending on some community and family support, but mostly they were off drugs and not seeing mental health practitioners. I don't have any real expertise in the area of mental health, but I wouldn't be surprised if the solutions lay not so much in increased funding of present treatment options, but in finding the most appropriate treatments through service re-organization and better research. I would also guess it to be very important that both the families and the patients themselves feel they can be responsible and at least to some extent make their own decisions. Seems to me that no matter who we are, it's essential that we have some feeling of control. To feel like you have no control, would seem to me either a state of being very like mental illness, or at least something that would contribute to great mental distress. I'm sure that it is sometimes necessary to impose treatment, but hopefully in future a way will be found that is careful of both the rights of family and patient alike.
  4. Kathy Boyda from Atikokan, Canada writes: I agree with Brenda, the patient has more rights and families have none. I believe that if a medical practioner knows the person has
    mental health issues they should be forced into treatment for their
    own health and well being. Families end up having to deal with the
    person and as she said it is not an easy path. Families should have
    rights to see that the patient gets appropriate care and support. I
    realize that the patient has rights but the healing cannot begin until
    they get medication/therapy. People with mental illness do not realize that they are ill and they refuse meds and therapy but they really are not capable of making decisions to help themselves. I also
    think that when an individual is hospitalized for their first psycotic episode that families be informed and assigned a case worker to help the family and patient make the best choices for the patient and develop a follow up plan to help the patient and family. I believe that the family should be involved. It is unfortunate that there are many patients without family support.
  5. june Conway Beeby from Kingston, Canada writes: I know Steve Lurie. He is a fine fellow. His ten steps are terrific for the easy to serve mentally ill. But many families have a different experience than Steve and his organization serve. Families of the most severely mentally ill deal with relatives whose sickness prevents them from making a decision in their own best interests, They refuse the only hope of allieviating their suffering . Parents must watch their beloved children,, lost in their delusions, live on downtown streets, in a dingy rooming house, kill themselves or maybe someone else. This is a reality for many mentally ill. They remain without places to live because no one wants to let them in. If they do find a place they are soon booted out because of their psychotic behavior. So many families live lives in danger and legitimate fear of their own children ,knowing the family is the most likely target ofr violence. Not because as uninformed people have foolishly said-- because the family caused the illness-- but because the family is handy and unprotected. They cannot simply cannot give up on their children and cannot turn them out. Where in your ten steps is your help for this group of citizens? The concept of freedom of choice (meaningless in these cases) is condemning innocent mentally ill people-- as one family called it--to living in a Picasso painting. I urge everyone to read Dr. E. Fuller Torrey's recent book INSANITY OFFENSE to appreciate the terrible social tragedies that flow from the belief that the severely mentally should not be forced to take restorative medication. The moral and ethical wrong is in NOT enacting this legislation. Families need advocates too, Steve..
  6. Patricia Forsdyke from Kingston, Canada writes: I am sad to hear Steve Lurie reiterate what he has said for well over a decade. More housing more community support all good in themselves, but he still misses out the most important part of the equation and that is stabilizing treatment is needed first. For those who are afflicted with a serious mental illness it is essential and it is often more humane that this take place in a safe hospital setting. Every thing follows from stabilization. I have watched while Lurie and his kind have siezed the high ground but they have left much tragedy in their wake. If I were a cynical person I would say that his kind had secured jobs for themselves without doing a really good job. Steve Lurie is probably well meaning in his attempt to help the mentally ill, but I believe that he and his ideology are part of the problem. The Canadian Mental Health Organization is libertarian and will not take an honest look at why the Mental Health Legislation fails so many who are so vulnerable. Yes Steve , a decent place to live is essential for those who are afflicted by a mental illness and yes most of those afflicted want to work,but sadly they often find work too stressful and relapse. Top of your list should be timely MEDICAL INTERVENTION for those with a serious diagnosis hospital in the safest place possible There is ample evidence to support hospitalization. The Canadian Institute of health has a paper on this. Again he argues how the community care teams cost less and avoid hospital inpatient costs. But so many of these teams do not cope well with those who are not yet stabilized. Why is Mr Lurie so blatantly anti- hospital. There is an enormous cost to the taxpayer... court costs and prison costs for those who are still not stabilized and go by default inappropriately into the justice system .
  7. steve lurie from Toronto, Canada writes: I want to thank the readers who have responded so far. Regarding treatment, my comments on access to mental health services includes access to treatment. The data I provided on the success of ACT teams in reducing hospitalization, is an example of integrated mental health treatment that gets results. Over 80% of the people served by ACT have psychotic disorders such as schizophrenia.
    According to studies by SAMHSA in the US, premature death for people with serious mental illness ranges between 15 and 25 years, with heart desease being the leading cause of death. Brian Miller's study (2006) found links to obesity, hypertension and diabetes
  8. F Coolen from Gatineau, Canada writes: I was extremely pleasantly surprised to read through Steve's list, namely that it actually includes more health services and more money for mental health as well as a HR strategy, rather than social services only. I would reinforce that this investment must be for 'PUBLIC' services delivered using a COLLABORATIVE COMMUNITY care approach with good accountability mechanisms. Since new investments are going to be a struggle to get, we must be sure that they are not fettered away for extending fee for service payments to private unaccountable practices. For skeptics about the need for more services and those who would prefer an emphasis on social programs only, it is noteworthy that availability of adequate health services is in fact a social determinant of health. The fact that the mortality and morbidity rate gap between people with psychiatric conditions and general population is going up should be a reminder that the medical elements are an important part of any effective and JUST strategy.
  9. Brett Knoss from Rockglen, SK, Canada writes: If employment is number 2 onthe list one thing to consider is that provinces end minimum wage. Minimum wage is well intentioned but it is a tax on employers to subsidze low income indeviduals, if it was ended employers could charge people with mental illnesses less for basic tasks. As there are more people with severe mental illness in the workplace employers would be able to prote some to job which make or exceed the curent minimum wage.

    Some of the problems outlined with lack of care are problems with the Canadian health system in general.
  10. Patricia Forsdyke from Kingston, Canada writes: Steve Lurie cites an American study to support his belief that community care can take care of everything if it is well funded enough and extensive enough. I am certainly not against community support but there are certain things that it does badly. In fact he should pay attention to a much more disturbing figure, that around thirty percent of the homeless people in the U.S have a serious mental illness. It is unlikely that the figure is any different here in Canada, if Kingston is anything to go by. Perhaps googling CFACT ... Citizens for Appropriate and Treatment ... would point him in a more solid direction. Some of the community care programs fall far short of being comprehensive and money alone will not fix them. There have be more hospital beds in the system in order for community care to work well. When he admits that then he can have my support.
  11. Brett Knoss from Rockglen, SK, Canada writes: Three things can help the homeless I belive. 1 improve house by removing rent control, excessive regulation, and by providing more shelters for the homeless where they can recive mental health service, addictions counceling, and job training. 2 end squatters rights as this does not allow the homeless to seek help and hurts the communities which are forced to allow people to live in building which are vandalized, graffitied and not up to code. 3 encourage people not to panhandle with a poster and bumpersticker campaign as well as homeless meters, a parking meter which is bright orange and collects money to fight homelessness and give people a place to put change rather then to panhandelers.
  12. RI Brown from London, Canada writes: I can’t understand F. Coolen’s comments. Is there any chance these could be explained in easier language? I would really like to know what is meant. I’m an ex-patient doing quite well now very thankfully, but in my spare time, I try to read and find my own perspective on mental health. I do this as something of a “hobby” and not to advance any particular philosophy or way of doing things. From my point of view (and my family’s who helped me immeasurably using mostly their own resources, self-sacrifice and unconventional methods) the present system seems seriously fractured and dysfunctional. So much so, that I have to admit that even if the greatest minds in mental health were to implement the greatest system in the world, I for one would never use it -- unless I was forced to. In past years, as far as I can tell, there have just been so many ideas put forward for improved mental health. But then maybe 20 years later each of these grand schemes seems to discredit itself and expose its serious weaknesses. All I can say is that I hope I stay healthy, because if I ever need help, it will be nearly impossible to trust any treatment given to me -- I’ve seen just too many bad outcomes. Apparently Senator Kirby envisions a broad social movement to help implement mental health reform. What a great sounding thing! But if the movement comes knocking at my door, sorry, but I’m not answering. Individual solutions, I have found, like the investments of contrarian investors, may be the best way to weather organizational chaos. Mental illness is hell, and not everyone will be lucky enough to find their own solutions, but please don’t forget about these when making up the next grand plan.
  13. steve lurie from Toronto, Canada writes: Patricia Forsdyke is correct about the the number of homeless mentally ill in the US. We have similar figures here. In 2002 Morrissey and colleagues evaluated programs in 18 communities to respond to homelessness and found that evidence based care , such as case management and ACT along with access to supportive housing reduced hospitalisation and homelessness. Here in Ontario Tim Aubry did a study as part of the CMHEI which was funded by the Ontario Mental Health Foundation, that showed dramatic reductions in hospitalisation, visits to emergency departments and reduced homelessness, when people who were homeless received case management, and were able to access supportive housing in Ottawa. There is lots of evidence that when housing and community services are in place, hospitalization can be reduced. In Trieste, Italy where they spend 94% of their funds providing treatment in the community, they have the lowest involuntary hospitalization rates in the country. Similarly in Osaka Japan where the SAWA hospital has created supportive housing and visitiing clinical teams, their length of stay in hospital has declined dramatically over a 10 year period.
  14. june Conway Beeby from Kingston, Canada writes: Steve, with respect, perhap a reduction in hospitalization is because so many beds are closed. People can't get into them anymore.

    The same is true of emergency room visits. Families say their relatives are so frequently turned away--again, probaly due to a lack of beds or maybe some gate keepers dislike dealing with their psychotic behvior..

    Families tell us they approach general hospital emergeny rooms with little hope of getting help for their lioved ones. They called it a crap shoot but they had to gamble anyway.

    Studies that show there is less use of hospitals where researches assume it is a resulit of more and improved community treatment cannot know this. It could be a spurious relationship.

    A reduction in hospitalization could be the natural result of not enough beds.

    Studies cannot be simply accepted at face value. They need to be questioned and evaluated by the realities of life.
  15. Patricia Forsdyke from Kingston, Canada writes: Steve you are still avoiding the issue as to whether it is sometimes best to give early stabilizing treatment in hospital. For many, as I know well, it led them back to a reasonable life. Clearly at present the system is in tatters and many cannot benefit. It is bankrupt. It needs pruning root and branch. More inpatient beds need to be allocated to give the afflicted time to get back on track. Please keep in mind that there are an increasing number of people with very serious diagnoses who keep revolving through the courts and prisons, seldom being given the inpatient care they need. Many of these would not have become so chronically ill had they been given timely medical intervention. You must add these to your figures when attempting to show that community care is working. It is easy to quantify this here Kingston. We are host to prisons and jails. Many who have been given timely care and treatment avoid the jail route, and go on to contribute to the community; e.g educating the public, the universities, and hospital clinical learning departments. They educate the next generation of professionals caregivers, and the general public. This does far more to lessen the stigma and the discrimanation attached to serious mental illness than much of the other double speak. The honest way is to tell the truth about serious mental illness, and it pays off in spades. I know many in Kingston who began this work years ago and continue this work. Their illness has not gone away, but they have given of themselves to the benefit of others. I rest my case.
  16. steve lurie from Toronto, Canada writes: The studies I have cited are peer reviewed research studies. As well the Ontario ACT data shows which has been collected for over five years shows that hospital days decline by 82% and 66% of ACT clients across the province (n= 4325) spend no days in hospital when they averaged 60 days per year prior to enrollment in ACT, and have long histories of living with schizophrenia.

    There is a role for hospitals in the system, to help stabilize people and we know that wait times to see a psychiatrist are intolerable(three months in some places). It is our failure to invest in a full range of community supports, including supportive housing that can divert people from hospital, that results in overcrowded emergency rooms and psychitraitc units. Canada spends less than most OECD countries on mental health care and Ontario has some of the lowest per pcaita spending in the country according to a recent study by Jacobs and colleagues. There is evidence in Ontario that the recent investments in community mental health services for people involved with the justice system is reducing demands on forensic beds.
  17. Jung Frau from Switzerland writes: RI Brown - Thanks for your comments. I couldn't agree more. I would be very interested if you could share with us what "unconventional methods" your family used to help you.
  18. K B from to, Canada writes: create a mental health for patients act. mhap. support funding to the law society for lawyers to fight against harmful detainment, restraint, racism, privacy of information, forced care and treatment, workplace health and safety. a new criminal code where medical people have no inherent right whatsover to another persons body or mind, and anonymous genetic, disease other diagnostics for women who want to have a family. good luck.
  19. RI Brown from London, Canada writes: Hi Jung Frau, thanks. I'll try late tomorrow to respond to your question re "unconventional methods." For some reason, either technical or due to the Globe's automatic editing screen for "semi-moderated" comments, my first attempt to answer was not accepted by the system.
  20. RI Brown from Canada writes: Here Jung Frau are my comments on “unconventional methods” The main thing my family seemed to do was talk to lots and lots of people they knew or were connected with to find anything relevant to helping me from their experience. I had been high functioning previously and suddenly my behaviour and emotional responses changed radically. Amongst their connections they found some medical people and some high school guidance teachers who volunteered various kinds of information, based probably more on their real beliefs than what they may have had to do within any particular venue they worked in. The ironic thing was that it was a medical doctor who provided the most holistic and spiritual advice. He was distantly related to me and so I knew he had served in various disaster areas in the world and was familiar with all kinds of “broken” people. He just listened to me, and told me he understood but then insisted I would find the necessary courage if I looked harder for it. While in the depths of despair he reminded me that I and any human being deserved to get the best treatment possible and that it was wrong to give up. The psychiatric facility I was in appeared very disorganized and frightening, and it seemed impossible to get any real information from them. However, my family (an aggressive and gregarious lot I guess) insisted on seeing the medical people in charge to get frequent run-downs of what was happening to me. When I was discharged they again had to insist vehemently on getting proper information about what to expect and how to care for me at home. Through an independent psychiatric consultant they miraculously found, a way was discovered to wean me off many strong drugs that were interacting badly for me. Various teachers my family were in touch with (and perhaps paid?), kept an eye on me at home, and set up a round of activities that kept me occupied and not thinking about my problems. (to be continued)
  21. RI Brown from London, Canada writes: (continued from previous comment) Thoughout there was an emphasis on how it was possible to improve to at least near normal, and that attitude never let up. In retrospect I think that being offered a lot of hope and being able to do lots of familiar things in a familiar environment helped me over my illness the most. Other than that I was encouraged to use meditation techniques, long walks and good nutrition. I think there was also a negative spur, and that was the idea that it was likely my family and I would have to figure it all out ourselves if we were to survive. This by the way is not a put down of institutions, because I think really good institutions (if you can find them) will help. Later on it was very important for me to understand what had happened to me and to find a variety of information sources that were unbiased. Again, Jung Frau, hope this helps in some way, although I know everyone's different and has different circumstances to cope with.
  22. Patricia Teskey from Kawartha Lakes, Canada writes: Steve Lurie's list to help people with mental illness begins with a home, a job and a friend. These supports may be needed by some people who are already stabilized and on the road to recovery. However, they are useless for someone who is seriously ill with psychosis and doesn't know they need help. After all, many psychotic people already HAD a home, a job and many friends before they became ill, but LOST these things because of their psychotic behavior. I agree with June Beebee and Pat Fordsdyke that a psychotic person must be fully stabilized first in a hospital before they can benefit from social supports in the community. Families and friends who have lived under the same roof as a psychotic person know that this is a harrowing experience. Nothing they say or do can change the person's delusional and paranoid thinking and behaviour, and supportive housing units won't admit someone who is not relatively well for the same reason. Families can't administer crisis-level medical treatment and neither can social workers on the street or mobile crisis teams that visit on occasion and do not have psychiatrists. A psychotic person needs to be in a protected, specialized environment where a qualified medical practictioner can diagnose, treat and monitor them on a continuous basis until they are in a stable state - and that place is called a hospital. Once the individual reaches a stable state, he or she often regains cognitive insight and understands they need support and help. At this point, they are ready to be discharged. The discharge plan should always include their primary caregiver (usually a family member) and ensure the social and psychoeducational supports in the community that the individual needs - possibly a home, a job and a friend, but not necessarily as they may already have these things.
  23. RI Brown from London, Canada writes: I’m a little puzzled by Patricia Teskey’s energetic response. As I read Steven Lurie’s article again, I see no mention that aggressive treatment of psychotic individuals by hospitals as necessarily a bad thing. And I see nothing unsympathetic to the needs of the caregivers of the mentally ill. Perhaps elsewhere he has expressed unsympathetic views I’m not aware of, but I don’t see this in his article. As for my previous comment, this is just my individual opinion as arrived at through my particular experience. I admit I could be wrong and never advocated it for everyone. The only thing I would advocate is some freedom to choose, because it appears that there is no real professional consensus as to how the mentally ill and the severely mentally ill should be treated. I also feel that as much as possible patients and families should have a right to choose. I realize that this could be very tricky if a person has obviously “broken with reality” but I think a lot of care should be taken before taking someone’s rights away to force treatment. It is afterall a drastic step. The hospital cannot possibly be always right, and there are indeed alternative treatments. Please see the following from “The Independent,” a well known newspaper in the U.K. And also please see the following research article:
  24. Patricia Teskey from Kawartha Lakes, Canada writes: My concern with Steve Lurie's list is that it addresses ONLY the needs of people living with mental illness who are already stabilized, thinking clearly and are willing to work with people wanting to help them. I agree that this group of people deserve support and choices to recover. However, Mr. Lurie's list doesn't address the needs of people in a psychotic state (yes, out of reality) who do not understand they are ill and need help. For example, an individual who thinks he is Christ, or that the FBI is talking to him through the pictures on the walls is not going to keep a job. If a person runs up and down the stairs shouting all night, the other tenants in supportive housing vote them out. My concern is that this high-risk group is in danger of being left out of a national mental health strategy because their needs are relatively very difficult to meet, and because our sensitivity to human rights makes us afraid to address the issue of incapacity. But we are doing a psychotic person no favour to pretend they can make rational choices in their own best interest. That is why we family caregivers, who deeply love this person, struggle desperately to get medical treatment for them. But Mr. Lurie's list does not mention supporting families in this effort. Mr. Lurie argues for diverting money from hospitals and into community supports such as ACT teams. By my observations, ACT teams do a great job of supporting a person who knows they need help. However, if a psychotic person refuses medical help, the ACT team must either leave them to deteriorate, or resort to forms and hospitalization the same as their family and everyone else. So I maintain that we do need hospitals to keep the money and beds to stabilize psychotic people. Once stabilized and thinking clearly, the person's discharge plan must include community supports for continuing their treatment out of hospital. I agree with Mr. Lurie that the ACT teams do this particular piece of recovery very effectively.
  25. K B from ottawa, Canada writes: Insect repellent. The psych wards are teaming with mosquitos.
  26. Betty L from toronto, Canada writes: Just shave and get a haircut and don't complain.

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