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Mental health in the national
spotlight
After
perhaps the shortest public consultation ever
— it lasted just 10 days in January —
the Canadian Mental Health Commission may finally
be getting off the ground. Primary care physicians
and psychiatrists frustrated by the current fragmentation
of services have high hopes for this brainchild
of Senator Michael Kirby. Senator Kirby's famous
'booze tax for mental health' might not make it
out of Parliament alive, but advocates are hopeful
the Tories will look kindly on the Commission
when they unveil their March budget.
URGENT
APPEAL
In 2006 a Standing Senate Committee on Social
Affairs, Science and Technology led by Senator
Kirby issued a report resulting from a year of
consultations and hearings. It recommended the
establishment of a Canadian Mental Health Commission
to provide a "much needed national focal point
to keep mental health issues in the mainstream
of public policy debates until effective solutions
are developed and implemented." The proposed term
of the Commission was 10 years.
Key
points from the Standing Senate Committee report:
- Mental illness is a
national concern
- No single level of
government has the resources to deal with mental
health issues on its own and issues span ministerial
boundaries
- Mental illness and
addiction cost Canadian companies about $18
billion a year
- There is no mechanism
available to exchange knowledge and best practices
- Education about and
tolerance of mental illness and addiction need
to be encouraged
The
recent public consultation by Stephen Harper's
Conservatives asked people:
- What should be the federal
government's priorities in mental health?
- Would a commission help to
address mental health issues?
- Which activities should the
commission undertake?
- Should the commission have
an advisory committee and which groups should
be represented on that committee?
An
umbrella group of mental heath advocates called
the Canadian Alliance for Mental Illness and Mental
Health (CAMIMH) anticipates playing a significant
partnership role with the Commission. "We see
it aligning closely with our efforts," says Dr
John Service, member and former chair of CAMIMH.
The Canadian Mental Health Association (CMHA)
also expects to play a key role once the Commission's
up and running. "The Senate Committee produced
a first rate report," says Glenn Thompson, Interim
CEO at CMHA. "Now we need to move on and create
a Commission that can develop a strategy, identify
best practices and use seed funding to propagate
them across the country." Both men say they fully
expect the Commission to become official when
the budget is announced in March.
— Susan Usher
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Quebec's plan to drastically restructure
much of its mental healthcare delivery system is getting
a cool reception from the province's family physicians
and psychiatrists.
The reform, originally suggested
in June 2005, calls for two big changes. First, about
100,000 of 170,000 stable mental health patients' care
and about 70% of hospitals' mental health teams (nurses,
psychologists and social workers) will be moved out
of hospitals and into community health centres. And
second, more responsibility for these patients will
be transferred to family physicians.
DOCTORS'
DEFIANCE
Both the Quebec Federation of General Practitioners
and the Quebec Psychiatrists Association have demanded
that the province revise the plans before they are set
in motion in the fall. The current projected start-date
is six months later than had originally been planned
due to the strong opposition from doctors, according
to Health Minister Philippe Couillard's office.
The battle has become increasingly
heated. Doctors and patient advocacy groups say the
dearth of family physicians could make this reform unfeasible;
there may simply not be enough GPs available to handle
a transfer of patients from hospital care. Quebec Psychiatrists
Association president Dr Brian Bexton told the Montreal
Gazette the plan could threaten some patients' access
to doctors. "It's hard to get a physical exam once a
year," he said. "So how can you get [a family physician]
to treat complex mental illnesses? It's a pipe dream
— it's not realistic whatsoever."
Quebec Federation of General Practitioners
president Dr Renald Dutil pointed out that nearly a
third of Quebecers can't find a family doctor in the
first place, and asking them to take on the role of
substitute psychiatrists is untenable.
The provincial government has countered
that moving mental healthcare to the communities where
the patients live will expand and hasten access to care.
"The point is to avoid individuals getting onto waiting
lists for long periods of time if they are in crisis,"
explained Dr Fiore Lalla, chief of psychiatry at Montreal's
West Island community health centre, who is involved
in implementing the plan. "Mental health wait lists
in Canada are very long. This is a change in philosophy
to get more timely services provided." (For more on
national mental health reform, see "Mental health in
the national spotlight" right.)
AT
WAR
There is a great deal of anxiety about how the change
will affect already-overbooked family physicians. Dr
Mark Yaffe, a family physician at St Mary's Hospital
in Montreal and an experienced mental health clinician
and researcher, said, "There is a limit to which physicians
can be asked to extend themselves to ensure care is
not only there by virtue of having a patient's name
attached to a doctor's, but also by making sure the
doctor has sufficient time to spend to provide competent
and compassionate care. That is a major concern.
"To use an unfortunate analogy,
many people felt the Iraq war was justifiable —
but people didn't know the exit plan. This reform is
also justifiable, but what is the community management
plan?"
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The scope of mental illness
in Canada
20%
of Canadians will personally experience a mental
illness during their lifetime
3.8%
of all admissions to general hospitals were due
to mental illnesses
8%
of adults will experience major depression during
their lifetime
1%
of Canadians suffer from schizophrenia
12%
of Canadians have some form of anxiety disorder
3%
of women will be affected by an eating disorder
(hospitalizations increased by over 30% between
1987 and 1998)
24%
of deaths in 15-24-year-olds are from suicide
The
onset of most mental illnesses occurs in adolescence
and young adulthood
Source: A Report on Mental
Illness in Canada, The Canadian Alliance for
Mental Illness and Mental Health, 2002
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HARD
CHANGES
"The reform is a good idea, but its success will depend
on the way it is implemented," agreed Dr Marie-Josée
Fleury, a psychiatric public health researcher at the
major Montreal psychiatric facility Douglas Hospital.
"Theoretically it is a very interesting way to go...
but it will take time for things to work well. In the
short run, it will be difficult for everyone."
If anyone knows about mental healthcare
organization, Dr Fleury does. She has spent years studying
different models of mental health delivery networks.
Her results seem to lend support to the Quebec plan.
"When services are more integrated," she summarized,
"the system gives better care." In other words, moving
mental healthcare into the communities and encouraging
shared care between family physicians and psychiatrists
should result in improved care.
The controversial new reform has
already kicked off in Quebec City — and it has
proven to be a very good model of care, said Dr Fleury.
LOCAL
CARE
This move towards community healthcare and away from
a hospital-centric vision of mental healthcare has been
a trend in Quebec since the 1990s. They call it "virage
ambulatoire," which means a move towards outpatient
care. Naysayers like Dr Yaffe call it "mirage ambulatoire."
"Now we have a well-intended reform, in large measure,"
he said, as was seen in the 90s, "but no manpower to
pick up the patients."
The reform's effects would be huge.
An internal memo obtained by La Presse in late
January revealed that Louis H Lafontaine Hospital, one
of the largest psychiatric hospitals in Montreal, will
have to close 249 of its 531 beds if the reform goes
through. Psychiatrists fear that patients who need long-term
care will be released without appropriate plans for
future care.
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