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OUT OF THE SHADOWS AT LAST 

Transforming Mental Health, Mental Illness and Addiction Services in Canada

The Standing Senate Committee on Social Affairs, Science and Technology


PART III
Service Organization and Delivery

CHAPTER 5:
TOWARD A TRANSFORMED DELIVERY SYSTEM

5.1        CONSENSUS ON THE DIRECTION FOR MENTAL HEALTH REFORM

Chapter 3 of this report described the Committee’s underlying vision of how a transformed mental health system should be organized. At the core of this vision is a recovery-oriented, primarily community-based, integrated continuum of care. Text Box: At the core of this vision is a recovery-oriented, primarily community-based, integrated continuum of care.

 

 

In the course of its hearings, the Committee was pleased to learn that this vision reflects a strong national consensus on the broad outlines of what a transformed mental health system should look like. This consensus of so many of the key “players,” providers and consumers alike, provides a strong springboard from which to pursue transformation of the way in which mental health services and supports are organized and delivered.[147]

Text Box: Three key elements must be part of a transformed mental health system: the system must be recovery-oriented and person-centred; it must be predominantly community-based; and it must be integrated across the full continuum of care and across all age groups.In some jurisdictions, the goal of establishing a recovery-oriented, community-based, integrated continuum of care that places people living with mental illness at its centre has been in effect for some time. For example, in October 1988, the Government of New Brunswick created a Mental Health Commission with a mandate to reform mental health delivery. The Commission completed its work in 1996, creating a province-wide mental health delivery system inspired by a vision that aligns closely with that the Committee has outlined.

Table 5.1 presents brief excerpts from documents produced during the past few years that demonstrate the pursuit of a similar approach to mental health reform across the country. It contains direct quotes from each report referring to three key elements that must be part of a transformed mental health system: the system must be recovery-oriented and person-centred; it must be predominantly community-based; and it must be integrated across the full continuum of care and across all age groups. The last row in the Table contains excerpts from a recent British Columbia document that focuses on transforming services to address substance use and addiction problems, highlighting the same three key elements.

Text Box: Relying primarily on services and supports delivered in the community does not cost more than mental health delivery systems that rely predominantly on institutions for the provision of services.Text Box: People living with mental illness can live productive and meaningful lives in the community.The policy consensus set out in Table 5.1 is based on consistent and compelling Canadian and international evidence that increased provision of services and supports in the community is highly beneficial for people living with mental illness. It indicates also that relying primarily on services and supports delivered in the community does not cost more than mental health delivery systems that rely predominantly on institutions for the provision of services. A recent paper produced for the World Health Organization (WHO) noted that “community-based mental health services generally cost the same as the hospital-based services they replace.”[148]

It is now widely recognized that people living with mental illness can live productive and meaningful lives in the community. That is not to say that people with a serious mental illness will not require intermittent periods of institutional care. Rather, it points to the need for policies to be put in place to make certain that the right conditions are in place to support as many people as possible living in their communities.

As Elliot Goldner pointed out in summarizing the results from a number of mental health studies financed by the Health Transition Fund:

Up until recently, hospitalization for psychosis was seen to be the safest route for the patient and society. It was believed to be too risky to try to treat psychotic patients at home. But Home-Based Program for Treatment of Acute Psychosis in Victoria added further weight to previous studies (e.g., Wasylenki, Gehrs, Goering, & Toner, 1997) that showed these patients can be safely managed, stabilized, and returned to a reasonable level of function without the disruption of admission to a psychiatric unit.[149]

In fact, many people achieve better outcomes when the proper services and supports are provided in the community. A recent report by the Community Mental Health Evaluation Initiative (CMHEI) in Ontario concluded:

 

Table 5.1 Excerpts from Provincial Documents

 

Recovery/person-centred

Community-based

Integrated continuum of care

Nfld.

2001[150]

Person-Centered and Participatory:

§     [the system is] responsive to the unique needs of the individual, across all age groups 

§     individuals and communities define their own needs and participate in the planning and delivery of services

Community-Based [system:] 

§     supports the individual living in the community 

§     provides the least restrictive form of care as close to home as possible

 

A Comprehensive Continuum:

§     provides a continuum of services and supports, including informal supports, focused on well-being and recovery 

§     encompasses promotion, prevention, crisis intervention, acute and continuing care, case management and support…

2005[151]

The person/family receiving services must be the central focus of any intervention. Consumer knowledge, expertise and leadership are key components of the mental health and addictions system.

 

Approaches to be adopted include:

§     Establishment of a range of community-based, best practice, specialized mental health/addiction services in each region that best meets the needs of the population.

 

The nature of mental illness and addictions often necessitates a comprehensive team approach that involves access to a variety of treatment and support interventions. No one service is usually adequate to meet the diverse needs of this population. Cooperation and collaboration among a range of service providers is essential.

Que.

2005[152]

Recovery: the action plan reaffirms the ability of individuals to take control of their lives and play an active role in society. 

Recovery invites us to support individuals with mental illness by helping them resume their role in society, in spite of their symptoms or handicaps, since social interaction is usually how individuals learn that their efforts give them power over their environment.

The mental health network must offer quality services to the entire population (children, youth, adults, cultural communities, Aboriginals etc.). To support this vision, the measures in the plan focus on establishing front-line services in local communities, utilizing the expertise of local workers. An organization encouraging a smooth transition to specialized services is the basis for this plan.

Continuity: The action plan focuses on the importance of meeting individuals’ needs by breaking down the barriers in our work and providing the necessary liaison to limit interruptions in service.

Ont.

1999[153]

The consumer is at the centre of the mental health system;

 

People with serious mental illness will achieve greater independence; that is, the ability to live in the community with the least intervention from formal services and, to the greatest extent possible, make their own decisions.

 

Mental health services and supports:

§     Are provided within a comprehensive service continuum developed to meet consumer needs and based on best practices.

2002[154]

A critical success factor for implementing mental health reform in Ontario is the philosophy that recovery — as defined by the individual, not by service providers — is possible for all people living with mental illness. With the appropriate treatment and supports in place, people living with mental illness can take charge of their lives, create new goals and aspirations, and engage in society as productive citizens.

The Provincial Forum believes the recovery philosophy must be embraced and endorsed as an integral tenet of a reformed mental health system.

A system that creates local systems of care where people living with mental illness, and their families and support networks, can get access to a range of community-based services and supports that are tailored to their needs.

Central to the recovery philosophy is the idea that mental health services should be developed within a natural community, not replicated by the mental health system. The community should enable those with mental illness to find gainful employment, participate in supported education programs, and volunteer or participate in society in meaningful ways.

 

A system that delivers, without fail, a continuum of care — with programs, services and supports available at every stage of life and as close to home as possible.

 


 

 

Recovery/person-centred

Community-based

Integrated continuum of care

Alta.

2004[155]

Clients and their families will come first. The first and primary purpose of mental health services, plans, research and support is to improve the outcomes for people with mental illnesses and their families. That means services must be appropriate to the circumstances of the people served and that they are treated with dignity and respect. …  And most important, it means people with mental illnesses and addictions are able to live productive and positive lives.

All Albertans should have optimal access to the best mental health care options regardless of where they live in the province. The right services will be delivered to the right clients in the most appropriate setting, whether that’s in communities, in community hospitals, or in specialized facilities.

 

Instead of the fragmented system we see today, mental health services will be fully integrated with the health system and the importance of mental health will be recognized and included in the health care system. Care plans will be in place so people with mental illnesses receive seamless care from multiple service providers and supports provided by a range of health care providers, health authorities, community agencies and provincial ministries.

BC

2004[156]

 

The term “client-centred” refers to the unique needs, strengths, motivations and goals of individuals. Client-centred responses “meet people where they are” by removing barriers to access and respecting individual readiness to change.  Given the co-morbidity of substance use disorders and mental disorders, client-centred also means providing an integrated and evidence-based system of mental health and addictions care.

 

Enabling people and groups at the community level to be active participants in, rather than passive targets of, efforts to address problematic substance use is another component of an effective response. Community organizations provide critical support by engaging members of groups most vulnerable to problematic substance use, fostering social inclusion, supporting individuals and families, and by providing a vital bridge for knowledge transfer.

 

System integration can minimize the fragmentation that allows people to “fall through the cracks”. An effective response to concurrent disorders and multiple diagnoses requires a comprehensive, integrated and evidence-based continuum of addictions and health services.  These services include health promotion, prevention, harm reduction, early identification, treatment, long-term rehabilitation and relapse prevention, community re-integration and support.

 

 


Findings from the CMHEI projects clearly show that community mental health is making a difference in the lives of people with serious mental illness, their families, and caregivers. Data indicate that community-based services and supports can help reduce symptoms and increase the ability of people with serious mental illness to live in the community, rather than in hospitals and institutions. Many clients are showing improvement in their daily lives, community functioning, symptoms, and abuse of substances. They also are experiencing fewer crisis episodes and days in hospital.[157]

Text Box: While a transformed system must be predominantly based in the community, institutional services also constitute an essential component of the continuum of care. It is the over-reliance on certain kinds of institutional services that has long been the problem.While the Committee believes that a transformed system must be predominantly based in the community, institutional services also constitute an essential component of the continuum of care. It is the over-reliance on certain kinds of institutional services that has long been the problem. What is required is the right blend of institutional and community-based supports and services. In this regard, the Committee agrees with the approach presented in the paper produced for the WHO cited above:

In the last two decades, there has been a debate between those who favour providing mental health treatment and care in hospitals, and those who prefer providing it in community settings, primarily or even exclusively. A third alternative is to utilize both community services and hospital care. In this balanced care model, the focus is on providing services in normal community settings close to the population served, while hospital stays are as brief as possible, promptly arranged and used only when necessary. This balanced interpretation of community-based services goes beyond the rhetoric about whether hospital care or community care is better, and instead encourages consideration of what blend of approaches is best suited to a particular area at a particular time.[158]

Text Box: Community-based services must be accessible, appropriate, in the right place at the right time, and the least restrictive possible while, of course, achieving good clinical outcomes. Many hospitals run excellent community-based programs that meet these criteria.Many of the services that people need to live successfully in their communities may well emanate from institutions such as hospitals. The key issue is to ensure that those services are accessible in the community and that the people who need them are not admitted unnecessarily as in-patients. Community-based services must be accessible, appropriate, in the right place at the right time, and the least restrictive possible while, of course, achieving good clinical outcomes. Many hospitals run excellent community-based programs that meet these criteria.

Moreover, it is important to ensure that as many service providers and stakeholders as possible join together in a common purpose. While in-patient resources must be valued and continue to be available, the reform process should result in the reorientation of all services to support community living and the avoidance of hospitalization.

5.2       SOME ADVANTAGES OF COMMUNITY-BASED SERVICES

5.2.1     Many Community-Based Services can Save Money

As already noted, the evidence suggests that “community-based models of care have been shown to be largely equivalent in cost to the services they replace, so they cannot be considered primarily to be cost-saving or cost-containing measures.”[159] On the other hand, a community-based system need not be more expensive than an institutional one. In fact, there are many specific services and supports that can be provided more cheaply in the community than in hospital.[160]

Consider the following example.[161] Five years ago, a high-support housing program opened its doors to 30 of Ontario’s most severely disabled people.  The residents ranged in age from 41 to 69 and had been ill, on average, for 27 years. They all had a serious mental illness as well as other serious medical conditions:

§         9 had diabetes;

§         8 had a history of substance use problems;

§         6 were developmentally delayed;

§         6 had been ordered into treatment by the Ontario Review Board;

§         5 had serious arthritis;

§         3 had chronic obstructive pulmonary disease;

§         3 had seizure disorders;

§         1 had cancer.

Previously, all had been long-term in-patients in provincial psychiatric hospitals; many of them, despite repeated attempts, had been unable to manage in non-hospital, non-institutional accommodation.

In the housing unit, the program itself provided the support services that the residents required to cope with their mental illness.  Another service provider took care of the residents’ medical needs.

Despite the severity of their conditions, these residents have fared remarkably well since entering the program.  They have developed a sense of community; they support each other and achieve goals that they could not have previously.

The residents have spent very little time in hospital, saving the health care system an estimated $4,400,000 annually (or $146,000 per resident).  This estimate was derived from the number of days each resident would have spent in hospital had he or she not moved to the residence, multiplied by the hospital per diem, minus the current cost of the person’s residential program. 

The cost saving illustrated in this example is by no means unique.  In Ontario, for example, the 3,130 clients who received Assertive Community Treatment (ACT) services in 2003-2004 spent 26 days in hospital compared with an average of 77 days in the previous year, a reduction of 87%. In 2003-2004, 66% of ACT clients in Ontario were not admitted to a hospital. It is estimated that ACT achieved a cost avoidance of $82 million in 2002-2003 and $77.6 million in 2003-2004.[162]

In addition:

§     Steve Lurie, Executive Director, Canadian Mental Health Association (CMHA) Metro Toronto, has demonstrated a decrease in total hospitalization costs from $1,358,136 to $172,692 for 56 people receiving comprehensive case management services;

§       Wendy Czarny, reports an 89% reduction in the average amount of time residents spend in hospital after enrolling in the supportive housing programs of the Waterloo Regional Homes for Mental Health.[163].

The same types of savings are also achieved in programs that focus on the treatment of  substance use disorders based in the community.  For example:[164]

§       89% of people with a substance use problem who were treated in a community-based withdrawal management service showed continued positive outcomes six months after treatment in terms of significantly reduced substance use and improvements in self-esteem and self-confidence;

§         Without community-based withdrawal management services, 5% of potential clients are likely to be in jail and 11% in hospital;

§       Each dollar spent on community-based treatment of alcohol use disorders saves between $4.00 and $12.00 in long-term societal, economic and medical costs;

§        The scarcity of withdrawal management services in the community forces many people to turn to hospital emergency rooms for service.  Indeed, research suggests that, by a very conservative estimate, alcohol-related problems account for between 10% and 30% of all emergency room visits.

 

5.2.2    Other Advantages to Basing Services in the Community

It is clearly easier in a community-based system to incorporate community input and to adapt the system to community needs and values than in a system that is institutionally based. Locating services and supports as much as possible in the community also makes it easier to hold those who are responsible for organizing and delivering them accountable to the community itself.

Text Box: Moving towards a community-based system thus opens the door for Aboriginal communities to be fully involved in the design and implementation of the mental health programs they require to meet their needs.Text Box: Locating services and supports as much as possible in the community also makes it easier to hold those who are responsible for organizing and delivering them accountable to the community itself.The Committee believes that these features of community-based systems are of particular importance in ensuring that the care, services and supports that are available to Canada’s Aboriginal peoples are fully adapted to their traditions. Moving towards a community-based system thus opens the door for Aboriginal communities to be fully involved in the design and implementation of the mental health programs they require to meet their needs.[165]

Text Box: Basing services in the community allows volunteers and family members to play a larger role in their organization and delivery.Moreover, community-based services offer many additional opportunities to integrate those services and supports in a way that puts the consumer at their centre. It becomes easier to avoid the creation of “silos” by making the delivery of community-based services the focus, regardless of the source of their funding.

Finally, basing services in the community allows volunteers and family members to play a larger role in their organization and delivery; this can both help to expand the range of services and supports that are available to people living with a mental illness, and gear them as much as possible to fostering recovery.

5.3       AN INTEGRATED CONTINUUM OF CARE

Before making specific recommendations on how to put in place an integrated continuum of care that is primarily community-based, it is necessary to look more closely at what such a system would look like. The final report of the Provincial Forum of Mental Health Implementation Task Force Chairs in Ontario contained a succinct description of the difference an integrated continuum of care would make in the lives of people living with mental illness. It deserves to be cited in full:

 

What will be different

 

Individuals with a psychiatric disability live in integrated housing that they have selected in their community; work in jobs and/or participate in meaningful activities that they have chosen; have positive relationships with their families; and have friends who rely on them for support and on whom they can rely.

 

Individuals have services and supports available that they have had a central role in developing, selecting among, and evaluating. These services and supports are focused on supporting people in their recovery processes in their local communities, and are delivered as close to home as and in the least intrusive way possible.

 

Individuals have access to a comprehensive, well-integrated and balanced range of community, ambulatory and inpatient services and supports, offered by both professionals and peers.

 

Services and supports are offered in the context of and are responsive to people’s economic, cultural and social situations, are based on the latest relevant knowledge and are oriented toward successful coping, empowerment, self-direction and recovery.

 

Efforts to change negative public attitudes and their resulting behaviours, such as discrimination, are in place in local communities and are working. Local community resources and the responsibility to include all citizens in community life are seen as an integral part of the community framework for support.

 

Users of services have the resources and authority to hold service providers and funders accountable for the quality of mental health treatment, services and supports they receive.

 

Individuals with a psychiatric disability are not defined by their disability or illness, are recognized for their strengths and are empowered and have the resources to define and live the lives they want to lead to the absolute best of their ability.

 

Source:  Government of Ontario. (December 2002) The time is now: Themes and recommendations for mental health reform in Ontario. Final report of the Provincial Forum of Mental Health Implementation Task Force Chairs.

 

The key types of services that are required to make such a system a reality are presented in graphic form in the diagram “The Continuum of Care.” This diagram is drawn from one of the Ontario Mental Health Implementation Task Force reports (Toronto-Peel Implementation Task Force Report).[166]

Text Box: As discussed in Chapter 3, the Committee believes strongly that mental health issues should be approached from a variety of perspectives, only one of which is the “medical” model.This framework does not present a definitive listing and categorization of services and supports; those listed are not exhaustive but are illustrative of the services and supports that are needed. Thus the model should be regarded as one useful way of depicting the range and types of services and supports that are required in a transformed mental health system.

One advantage to this framework is that it is able to encompass the full range of services and supports, listed under three “levels of need” (first-line, intensive and specialized), with a fourth category that cuts across the three levels. This terminology moves away from commonly used terms that some associate with an overtly medical approach, i.e., primary, secondary and tertiary care. As discussed in Chapter 3, the Committee believes strongly that mental health issues should be approached from a variety of perspectives, only one of which is the “medical” model.

 

Text Box: First-line refers to prevention, assessment and treatment provided by frontline providers.Each level of need is associated with a particular array of services and supports. People will usually receive most of their services from within a particular level, but they are not limited only to the services within that level.

 

a)         First-line

Text Box: First-line services and supports therefore must be easily accessible to people no matter what their specific needs.First-line refers to prevention, assessment and treatment provided by frontline providers, including family physician, primary care clinics, and the providers of mental health services, social services, and hospital emergency services. For most people with mental health problems, the first-line level will be their first contact with mental health services, usually through their family physicians or primary health care teams. When someone’s illness is not too serious or of short duration, the provision of first-line services will usually be enough to meet the person’s needs.

 

Text Box: First-line services and supports must be well connected not only to each other, but also to more intensive and “cross-level” mental health services and supports that can be called upon as needed.

First-line services and supports therefore must be easily accessible to people no matter what their specific needs. Providers at this level must to be able to respond to a very wide range of needs, and be extremely sensitive to the confusion, fear, and concern of those experiencing symptoms of mental illness, perhaps for the first time. They need also to be culturally sensitive so that they can respond appropriately to the needs of people from a diversity of backgrounds.

First-line services and supports must be well connected not only to each other, but also to more intensive and “cross-level” mental health services and supports that can be called upon as needed. Individuals who are diagnosed with serious and ongoing mental illness will usually be referred by first-line service providers to intensive or specialized services for further assistance.

 

b)         Intensive

Text Box: Intensive refers to mental health assessment, treatment and support services that are provided in community or hospital settings for people with serious mental illness.Intensive refers to mental health assessment, treatment and support services that are provided in community or hospital settings for people with serious mental illness. People living with serious mental illness will often require ongoing, long-term support from service providers, but not necessarily daily contact. Intensive services and supports are designed to provide continuous contact and support for people who, without them, would be at risk for repeated or prolonged institutionalization in health care or correctional facilities. The needs of most people living with a serious mental illness should be met by community-based intensive services and supports. People who suffer from acute, severe impairment in personal functioning and are at significant risk, such as someone with a severe post-partum depression, could also require these kinds of intensive services.

 

Text Box: Services at this level address the serious and complex mental disorders most common among the general population.

Services at this level address the serious and complex mental disorders most common among the general population (including concurrent disorders, eating disorders, first episode schizophrenia, and personality disorders). Service integration can be facilitated through intensive case management. Intensive services and supports must be well connected to first-line and “cross-level” services and supports and must be able to access, and be backed up by, specialized services and supports so that together they can address people’s unique and/or particularly complex needs effectively.

 

c) Specialized

Text Box: Specialized refers to highly specialized mental health programs provided in community or hospital settings that focus on serving people whose serious mental illness is characterized by complex and unstable mental disorders.Specialized refers to highly specialized mental health programs provided in community or hospital settings that focus on serving people whose serious mental illness is characterized by complex and unstable mental disorders. Only those very few people with serious mental illness who require ongoing, daily contact with service providers will need to access such specialized services and supports. As these services are the most specialized, least available and most expensive resources in the mental health system, they must be reserved for those who truly need them and used only when intensive and cross-level services and supports have failed to work for a given individual.

The following are among those whose problems require that they be addressed at this level:

§         elderly people suffering from dementia, psychosis and medical illness,

§         people who are developmentally disabled with psychiatric disorders and who often display aggressive behaviours,

§         people living with schizophrenia who are chronically psychotic, aggressive or suicidal,

§         people with complex, treatment-resistant mood disorders.

Text Box: Specialized services are not synonymous with long-term, institutionalized care.Specialized services are not synonymous with long-term, institutionalized care. Rather, treatment, rehabilitation and support services can be provided by multi-disciplinary teams that work in ways to enable many people living with these illnesses to continue to live in the community.

Individuals who use specialized services and supports will not always need this level of care. The need of individuals for the whole range of services and supports must be monitored and reassessed continuously as they progress through the recovery processes and as their needs change.

d) Cross-level

Text Box: Cross-level services include housing and housing supports, educational and vocational services and supports, drop-ins and other social/recreational supports, as well as consumer and family peer/self-help supports.Cross-level services and supports is a term used by the Toronto-Peel Implementation Task Force to refer to those services and supports that may be needed regardless of whether someone is being served at the first-line, intensive or specialized level of the mental health system. They include housing and housing supports, educational and vocational services and supports, drop-ins and other social/recreational supports, as well as consumer and family peer/self-help supports. Cross-level services and supports are typically — and most effectively and efficiently — delivered in the community, and are amongst those services and supports most often identified by people living with mental illness and their families as being fundamental to the recovery processes.

 

5.3.1     The Continuum is Local and Complex

The preceding section described the types of services and supports that must be in place for people living with mental illness to live meaningful and productive lives in the community. In the real world, however, what is available will depend on many factors that are unique to the history and circumstances of each community; each will have its own particular mix of services and supports. These will vary not only from province to province, but from region to region and municipality to municipality.

This inescapable regional variation was noted in the mental health plan issued recently by the Quebec government:

The situation in each particular region, as well as available expertise and experience, may mean that the continuum of mental health services differs from region to region. Services must be tailored to suit local needs. At the same time, it is necessary to ensure that a continuum of basic services (what we have called “required services”) is in place.[167]

Text Box: The Committee does not believe it wise to attempt to dictate a uniform model that could be implemented somehow across the country.During its cross-country hearings, the Committee was impressed by testimony that described the integrated provision of community-based services and supports in Brandon, Manitoba. Further investigation by Committee researchers, who visited Brandon during the summer of 2005, confirmed the Committee’s initial impression that Brandon stands out as an example of how hard work and careful planning can yield effective results. But, as noted in Chapter 3, the Brandon experience also illustrates also how efforts to provide an integrated continuum of care are both complex and fundamentally local in nature.

Text Box: …we had to go through a process of shifting the beliefs of patients and staff to one that supported the principle that people could live with mental illness disability in the community…
— Albert Hajes

The Committee does not believe it wise to attempt to dictate a uniform model that could be implemented somehow across the country. It is not even possible (or desirable) to do this on a province-wide basis because the effectiveness and efficiency with which services are delivered depend critically on a number of local particularities, including the history of local institutions and the number and characteristics of the people who live in each community. The Brandon experience illustrates this critical point. While it cannot serve as a template or uniform model, many valuable lessons can be learned from Brandon’s success in integrating mental health services, lessons that can be creatively applied throughout the country.

Southwest Manitoba is largely rural farming country, with Brandon, a city of 45,000, as its major urban centre.  Health care in Manitoba is managed through Regional Health Authorities (RHAs).  The Brandon RHA serves the city and, in addition, provides referral and other services to the surrounding Assiniboine RHA (112,000 square miles, population 80,000) and to four other RHAs in rural areas to the north and east of Brandon. 

Text Box: Key principles included recruitment and training of proctor paraprofessional staff to provide close and frequent contact with clients to assist with their independent living.
— Albert Hajes
For most of the 20th century, mental health services for Brandon and the western portion of Manitoba were delivered from the Brandon Mental Health Centre (BMHC), a large psychiatric institution dating from the early 1900s.  Mental health leaders in Brandon started planning in the 1980s to transfer the centralized services in the BMHC to the community.  The number of beds in the aging BMHC buildings started to decrease in the 1980s, and the BMHC was closed in stages between 1994 and 1999.

Albert Hajes, Regional Coordinator, Mental Health Program, Brandon Regional Health Authority, described to the Committee how key aspects of this transition were managed.[168] In the first place, attitudes had to change:

A very important point is that with the closure of BMHC we had to go through a process of shifting the beliefs of patients and staff to one that supported the principle that people could live with mental illness disability in the community and have good quality of life including a greater participation and full citizenship. It required a shift in thinking away from the traditional institutional model not just in terms of the staff and the patients, but also in the general community.

As well, Mr. Hajes spoke of the need for advance planning:

A transition of this magnitude was not possible without the development of strong community-based services within the general community to support clients. Considerable work was done prior to the implementation of mental health reform and the transition of services to strengthen the capacity of the service structure and the community to sustain clients.

Mr. Hajes then described some of the measures that were taken:

Key principles included recruitment and training of proctor paraprofessional staff to provide close and frequent contact with clients to assist with their independent living. We worked for the establishment of skill development and capacity building for clients to acquire the abilities to function with relative autonomy. We helped our clients to gain access to resources and have greater participation within the community. We established the full spectrum of services that are needed to support clients in a normalized community setting.

Brent White, Program Manager, Residential and Support Services in Brandon, elaborated on the proctor program:

In Brandon, we have developed something we call a “proctor service,” which has been likened to home care service, if you will, for mental health clients.  Those individuals provide support services to individuals supporting long-term goals.  It involves the client in terms of an empowerment process, engaging them in working towards their goals, which might be living goals, educational goals, vocational, or social goals.  We have paid a lot of attention to the provision of supportive social programming as well for people.[169]

Text Box: We have paid a lot of attention to the provision of supportive social programming as well for people.
— Brent White
The proctor program has since been adopted by other regions of Manitoba. In Brandon, the proctors, who are mostly employed part-time, each help approximately 150 clients.  Proctors are drawn in approximately equal proportions from health professional or psychology students, from people trying to enter the job market, and from retired people looking for part time work; approximately one-third of proctors are themselves former or current clients of mental health services.

Text Box: …there was the need for formation of strong partnerships with other health and social service agencies, hospital services, physicians as well as police, school divisions, property owners and housing authorities and others. …
— Albert Hajes

Mr. Hajes also stressed the importance of broader community involvement:

Additionally, there was the need for formation of strong partnerships with other health and social service agencies, hospital services, physicians as well as police, school divisions, property owners and housing authorities and others. …   If we were asking community partners to share in responsibility for service to mental health clients, we also needed to provide a backup service to them.

Finally, Mr. Hajes explained how the lack of doctors in Brandon served as a catalyst for innovation:

We have a large generic workforce of community mental health workers that have credentials of psychiatric nursing, psychology and social work. The Brandon Mental Health Centre employed a similar staff that did not include many psychiatrists and physicians.

In fact, truth be told, we went through a period of very lean years. At one point in time, we actually had one psychiatrist who came from Winnipeg two or three days a week to sign the documents, and we had a couple of physicians with some mental health experience. That developed the capability and the capacity of the non-medical workforce to be able to respond to the needs. The competencies of our workforce are significantly better, I believe, than what you would see in most other mental health regions.

Text Box: First contact with the system can be through a readily accessible and visible “store front” location centrally located in downtown Brandon, close to public transportation and other services on which mental health clients depend.Currently, the various programs in Brandon are coordinated by a management team that meets every two weeks.  Mental health programs receive approximately 10% of the total funds of the Brandon Regional Health Authority, which has preserved the mental health budget allocation even in years when deficits loomed.

 

 

Text Box: Intensive Case Managers serve people who are living in the community but need continuing support to manage their daily lives.First contact with the system can be through a readily accessible and visible “store front” location centrally located in downtown Brandon, close to public transportation and other services on which mental health clients depend. This community-based centre also has close working relationships with several allied services and agencies. One of these is the Brandon Friendship Centre, an Aboriginal peoples’ organization to which people can be referred for traditional culturally appropriate treatments, with funding provided through a services contract with the mental health program. Text Box: There are also programs for people at both ends of the age spectrum.

Intensive Case Managers serve people who are living in the community but need continuing support to manage their daily lives. The Psychosocial Rehab-Residential Services helps them find accommodation in the rental market, where they have access to the proctor service described above. The Westman Crisis Services is a nurse-run, 24/7 telephone response centre that operates a mobile crisis intervention service as well as a crisis stabilization unit that can accommodate up to eight people for approximately five days. Those who need acute in-patient psychiatric care can be referred to the Centre for Adult Psychiatry, a 25-bed acute care psychiatric hospital facility connected to the Brandon Regional Health Centre.

There are also programs for people at both ends of the age spectrum. Mental Health Services for the Elderly serves seniors in their homes, while those elderly clients who need acute in-patient care can be referred to the Centre for Geriatric Psychiatry. The Centre operates a 22-bed acute care psychiatric unit connected to the Brandon Regional Health Centre and manages to return 70% of people who are admitted from their home environments to their homes after discharge. The Brandon Mental Health Program’s Child and Adolescent Treatment Centre (CATC) is located in its own building next to a high school; it also focuses on enabling each young person affected by a mental illness to return to his or her school, family and community.

 

5.4       COMPLETING THE TRANSITION TO COMMUNITY-BASED SERVICES

Although community-based services are being developed in many regions of the country, such as Brandon, the Committee believes that there is still much to be done to allow people living with mental illness to have access to the services and supports they require to live productively in a community setting. Of those who responded to the Committee’s second e-consultation, 80% indicated that the services required by people living with mental illness were not available in their communities.[170]

The consequences of not having access to services and supports in the community are that people living with mental illness must rely on institutional services that are generally much more expensive, and often not as beneficial. Nancy Beck, Director, Connections Clubhouse in Halifax, recounted the case of a 72-year-old veteran with schizophrenia: 

[Clyde] requires a couple of hours a week of personal care and a couple of hours to help prepare meals.  As a mental health client, he is not able to access home care and against his wishes, the recommendation is that he receives long-term care.  We estimate it would cost $400 a month to honour Clyde’s wish and help him remain in an apartment that he has lived in for 15 years.[171]

Text Box: Of those who responded to the Committee’s second e-consultation, 80% indicated that the services required by people living with mental illness were not available in their communities. The consequences of not having access to services and supports in the community are that people living with mental illness must rely on institutional services that are generally much more expensive, and often not as beneficial.Other witnesses stressed the importance of accessible and appropriate housing not only as the necessary foundation for people living with mental illness to remain in the community, but as a cornerstone of reform of the entire mental health system. In the words of Stephen Ayr, Director of Research, Capital District Health Authority in Halifax:

The next issue is housing. I need not say anything more than if the issue of housing is not addressed, then it is unlikely that any provincial mental health reform will have an impact on the problem.[172]

Witnesses told the Committee that the money that had been spent previously on providing institutional care was not always transferred to the community. Jocelyn Greene, Executive Director, Stella Burry Community Services in St. John’s, spoke of the impact of funding cuts to health care during the 1990s:

In particular, in 1995, the cutbacks from the federal government funding resulted in cutbacks in this province in health care and, in particular, the closure of 97 out of the 127 long-term beds at the Waterford Hospital, which is our provincial psychiatric facility.  It is not too strong to say that none of those savings realized from the closure of those beds went back to the community.  Wherever they went, they certainly did not come to those of us who work in the community.[173]

Further evidence of the difficulties confronted by community-based mental health services can be found in a survey of its members conducted by the Ontario Federation of Community Mental Health and Addiction Programs in 2002. It concluded that:

§         Since 1992, most of the Federation’s 212 member organizations have experienced a net decrease of 20% in provincial funding for core programs, taking into account the increased cost of operations since then.

§         Eighty percent of respondents have had to close programs temporarily to cope with fiscal pressures. Twenty-five percent of them have closed programs permanently.

§         Almost half of the people who need the services of the Federation’s member organizations must wait for 8 weeks or more to access them.

§         For a significant number of programs (18%), the waiting time can be a year or longer.[174]

Text Box: The pattern of use of hospital resources by mental health patients, as revealed by a recent Canadian Institute for Health Information (CIHI) report, suggests that there is still considerable scope for shifting treatment to the community.The Committee was told that the Ontario government is currently making significant investments in mental health services in the community, as are most other provinces. Over the past two years in Ontario, core budgets for community mental health programs have been increased for the first time in 12 years. Despite these efforts, it is clear that there is still a long way to go. For example, Carrie Hayward, Director, Mental Health and Addictions Branch, Ontario Ministry of Health and Long-Term Care, told the Committee that:

Ontario has 6,750 supportive housing units for people with mental illness or addictions, but the Provincial Forum of Mental Health Implementation Task Forces called for 10,000 more across the province, so continued federal support for affordable and supportive housing is welcomed.[175]

More generally, the pattern of use of hospital resources by mental health patients, as revealed by a recent Canadian Institute for Health Information (CIHI) report, suggests that there is still considerable scope for shifting treatment to the community. The report’s analysis of inpatient hospitalizations indicates that mental health patients are more likely to be hospitalized for extended periods than any other patient group. According to the report:

While the Mental Health patient group made up the smallest percent of all hospitalizations, at just over 3%, it had the third highest contribution to total number of days (7.4%), and had the highest average length of stay of all patient groups, at 14.0 days, more than double the national average length of stay.[176]  

And:

In contrast to all patient groups, only 50% of patients in the Mental Health group stayed in hospital for seven days or less. Nearly one-quarter of Mental Health patients stayed in hospital for 19 days or more; almost three times higher than all patient groups combined (7%).[177] 

Text Box: The nearly one-quarter of mental health patients in acute care hospitals who are there for 19 days or longer are, in fact, long-term care patients who are occupying beds in acute care hospitals.According to the Organisation for Economic Co-operation and Development (OECD), acute care inpatients are defined as those patients with an average length of stay in hospital of 18 days or less; those required to stay in hospital for longer than 18 days are classified by the OECD as long-term patients. The nearly one-quarter of mental health patients in acute care hospitals who are there for 19 days or longer are, in fact, long-term care patients who are occupying beds in acute care hospitals. While part of the explanation for longer stays in hospital by mental health patients may relate to the nature of their illnesses, it is nonetheless reasonable to assume that many are being kept in expensive acute care hospital beds because there are no alternatives available in the community. Text Box: Many are being kept in expensive acute care hospital beds because there are no alternatives available in the community.

In fact, witnesses told the Committee as much. Roy Muise recounted his experience:

 

I remember the time when I was ready to leave hospital and I had nowhere to go because I had no income and I had no money.  I spent 13 days in hospital only because I had nowhere to go.  It is very difficult, given the gaps in our employment history, first, to get a place to live and, second, to come up with the damage deposit and things like that while we are trying to turn our lives around.  So, yes, there needs to be something done in housing, that is for sure.[178]

Text Box: The use of acute care hospital beds to accommodate mental health patients for an extended period represents a serious misallocation of scarce and valuable resources.The use of acute care hospital beds to accommodate mental health patients for an extended period for reasons similar to those that kept Roy Muise — completely unnecessarily — in hospital, represents a serious misallocation of scarce and valuable resources; in all probability, the patients’ recovery will likely have been substantially delayed to boot! The Committee believes, unfortunately, that this is precisely what is happening right across the country now.

 

5.5       THE NEED FOR A MENTAL HEALTH TRANSITION FUND

Text Box: The savings that will eventually accrue from downsizing the institutional sector do not materialize all at once; they accumulate gradually as institutional services are phased out.As noted earlier, the evidence suggests that, while the transition to community-based services should not be looked on as a cost-saving measure, it will not cost government any more to fund a predominantly community-based system than it does to run one heavily dependent on the institutional sector. The question then arises as to why governments have not been able to complete the transition to a community-based system, given that it offers so many advantages to people living with mental illness and yet costs no more once the transition is complete. There are a number of reasons to explain the uneven progress that has been made across the country in moving towards an integrated continuum of mental health care based predominantly in the community.Text Box: The two systems must operate in parallel over a considerable period of time; this too costs money. There is never a guarantee that the money saved by closing a big institution, for example, will find its way back into the mental health sector.

The most important of these relates to the dynamics of transferring existing financing from the institutional to the community-based sector. A recent article on the restructuring of mental health policy in Ontario noted that:

 

Closing psychiatric hospitals, however, takes political will and seed money to develop an infrastructure of community services on which such closures rely. A circular argument lies at its core: while the funds needed to develop community services are tied up in hospitals, hospitals cannot close in the absence of community programs. Transitional funds must thus be allocated to develop a community infrastructure.[179]

There are three points to bear in mind in this regard. First, the savings that will eventually accrue from downsizing the institutional sector do not materialize all at once; they accumulate gradually as institutional services are phased out. The practical problem, therefore, is that there are no immediate savings available from within the mental health system to finance the creation of new community-based services. Second, because the phasing out of the old system and the introduction of the new one both take time, the two systems must operate in parallel over a considerable period of time; this too costs money. Third, there is never a guarantee that, over the period of time necessary, the money saved by closing a big institution, for example, will find its way back into the mental health sector.

Text Box: The Committee believes that a Mental Health Transition Fund (MHTF) must be established.For these three reasons, the Committee believes that a Mental Health Transition Fund (MHTF) must be established. Such a fund would allow the Government of Canada to make money available to the provinces and territories for investment in services and supports that contribute to the transition toward a community-based, integrated continuum of care for Canadians living with a mental illness. This Fund would be a time-limited investment to cover the costs of the transition and to accelerate the process of developing the community-based system.

Text Box: This Fund would be a time-limited investment to cover the costs of the transition and to accelerate the process of developing the community-based system.

Once a new “steady state” has been achieved — when the community-based services and supports, integrated along the full continuum of care, are fully in place — the provinces and territories will be able to sustain the new community-based system with the same level of government spending as was devoted to the old system with its heavy reliance on institutional delivery. Thus, any federal funding directed at helping the provinces and territories move in this direction would be a genuine transition fund; it would not constitute an ongoing obligation for the federal government, nor generate increased costs for the provincial and territorial governments.

 

Text Box: It is a genuine transition fund in that it is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another that will cost the same once the transition is complete and the transformed system is up and running.The Mental Health Transition Fund is unlike many other federal initiatives called “transition funds,” including those such as the Primary Care Transition Fund. Too often, such federal initiatives have resulted in the creation of new programs that must either be supported by new provincial money or disbanded once the federal programs that sparked their creation come to an end. Such initiatives are not truly transitional in that once they are started they place ongoing obligations on provincial and territorial governments to fund them with “new money” on a continuing basis.

 

Text Box: The Transition Fund approach is the most appropriate way for the federal government to invest in what is a provincial responsibility - the delivery of mental health services.The Committee has been very careful in crafting its recommendations to ensure that this does not happen in the case of the Mental Health Transition Fund. It is a genuine transition fund in that it is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another that will cost the same once the transition is complete and the transformed system is up and running.

 

The Transition Fund approach is the most appropriate way for the federal government to invest in what is a provincial responsibility - the delivery of mental health services. Because the federal government is not responsible for the delivery of mental health services in the provinces and territories, it cannot determine which specific services and supports are most appropriately funded with federal money. That requires a detailed understanding of what is needed, which can come only from doing the job day in and day out. Therefore, the provinces and territories must decide how to allocate the money to be transferred.

This, of course, is nothing new. It is in line with many recently negotiated health-related agreements between the federal and provincial/territorial governments. In fact, since the creation of the Canada Health and Social Transfer in 1995 the provinces have been masters of how they spend federal transfer payments related to health and social affairs.

The need for flexibility in relation to federal funding to assist with the diverse local needs of mental health service providers was highlighted by Bonnie Arnold from the Canadian Mental Health Association of Prince Edward Island, who used the example of home care:

However, home care has a very different interpretation from province to province.  We believe that it is critical that the federally transferred funds must be sufficiently flexible that they can be used in the most creative and effective ways to best deliver mental health services to P.E.I. and not be tied to one type of service.[180]

Text Box: It is legitimate, however, for the federal government to expect some form of accountability for its funding, in keeping with its responsibilities to Canadians to properly manage public funds.It is legitimate, however, for the federal government to expect some form of accountability for its funding, in keeping with its responsibilities to Canadians to properly manage public funds. In this case, the federal government, and Canadians generally, should be assured that the money is: (a) spent on mental health projects; and (b) used to increase the total amount each jurisdiction spends to enhance mental health and treat mental illness.

Text Box: To be sure new federal money will be used for its intended purposes, it must be “ring-fenced” in some fashion.Moreover, the Committee intends that these funds must not only be incremental to the existing level of provincial or territorial spending. The amount allocated must also take into account the increases in mental health funding that would occur with the overall growth of health care spending in each province and territory. In other words, the new funding must be over and above provincial mental health spending, which should increase at the same rate as the rest of health care spending in the province concerned.

It is important to clarify two points with respect to the Committee’s insistence on the need for new federal money to be used to supplement provincial or territorial spending. First, the Committee does not specify the new or expanded services in which the provinces and territories should invest. It will be up to each province or territory to allocate the new funding to those particular services it needs most, whether to expand or enhance existing services or to create new ones. Second, if individual provinces and territories are able to save money by enhancing productivity, it is entirely up to them to decide how these productivity savings are best spent.

Many believe that to be sure new federal money will be used for its intended purposes, it must be “ring-fenced” in some fashion. As Christine Davis, President, Canadian Federation of Mental Health Nurses, told the Committee:

When money is given to ministries of health and then to health authorities, health authorities do what is most pressing, and that is to reduce wait lists for hip surgery, knee replacement, cardiac surgery and that kind of thing.  If it is not earmarked for mental health, it is not put into mental illness and addictions.  Mental illness and addictions are at the bottom of the hierarchy of health care, and people with those problems are seen as less deserving than others.  It almost needs to be earmarked for mental health from the get-go.[181] 

Text Box: This type of ring-fencing was used in the initial phase of implementing the National Mental Health Policy in Australia.Some witnesses were concerned that ring-fencing funding for mental health could set restrictive limits on the total amount of funding that was available. But even these witnesses agreed that, given the pressing needs to accelerate change in the mental health sector, ring-fencing was a good idea.

This is how Dr. John Service, Chair, Canadian Alliance on Mental Illness and Mental Health, expressed it:

You put it best yesterday, Mr. Chairman, when you said you are between a rock and a hard place with these ringed funds.  On the one hand, it can be cherry-picked in tough times.  We know that has happened across the country.  I have been in the game for 30 years and it has happened many times in my experience.  Ringed funds are very vulnerable.  They also are in a ghetto by themselves; they accentuate separation.  One of the things that ringed funds and targeted funding can do is kick-start change.  It can buy change.  If it is done right and it is tied into the longer term and structural change that is needed, it can be helpful.[182]

The Committee noted in its report on “Mental Health Policies and Programs in Selected Countries” that this type of ring-fencing was used in the initial phase of implementing the National Mental Health Policy in Australia.[183] All levels of government in that country made a commitment to some form of budget protection so that new injections of federal funds would not be negated by a concurrent reduction in state and territory funding. Specifically, the agreement between governments to protect mental health resources had two components:

§         a commitment to maintaining the level of expenditure on mental health services; and

§         a commitment to reinvest any resources released from closure or rationalization of services back into mental health programs.

Text Box: The Canadian Mental Health Commission’s expertise on mental health policies and best practices and its arm’s-length relationship to government make it better placed than Health Canada to oversee the administration of the Transition Fund.The Committee was told by Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia, that efforts to protect mental health spending had been successful, to the point that they were no longer needed. He said that:

 

 

In fact, one of fears of the federal government 10 years ago was that if we were to give money for mental health, then the states and territories would simply take it and spend it somewhere else. We had an agreement with them that they would maintain their level of funding if the federal government added to the pie. We actually tracked the dollars and the states and territories had to report to a system of monitoring expenditure. We do not need that system now, 10 years later, because governments, realizing how important this is at a jurisdictional level, would not use the money for something else because it has become such a political issue in the communities.[184]

Despite these arguments in favour, it does not appear to the Committee that it is possible to develop at this time a system of ring-fencing that would allow for robust accountability down to the local level. In fact, the Committee commissioned research on the viability of ring-fencing funding for mental health at the level of the Regional Health Authority. The study concluded that not only is there a “lack of coordination of mental health information provincially and nationally, there is limited population needs assessment, service profiling or links between health, social services, justice and education along the journey of care.”[185] In short, the health information system available to track spending on health care, including mental health, is inadequate for the purpose.

The Committee believes, nonetheless, that it is possible to establish a set of procedures, overseen by the Canadian Mental Health Commission, that would ensure that Transition Fund money was spent as intended. Disbursement of the fund should be managed by the Canadian Mental Health Commission, the establishment of which was agreed to by all the Ministers of Health (with the exception of Quebec) and officially announced by the federal Minister of Health on 24 November 2005.[186] The Commission’s expertise on mental health policies and best practices and its arm’s-length relationship to government make it better placed than Health Canada to oversee the administration of the Transition Fund.

The Committee believes that priority should be given to initiatives directed at improving the lives of people living with serious mental illnesses, children and adults alike. Those living with these conditions will benefit most from the delivery of a fully integrated continuum of care. But at the same time, this continuum will make a range of services available in the community that will also assist those living with mild to moderate mental illness.

Text Box: The Committee is also particularly concerned that the mental health needs of children be a consistent and strong focus in the development of community-based mental health services and supports.For example, accessible first-line services are needed as the first point of contact both for those with serious illnesses who will need referrals to intensive and specialized services, and for those who can be cared at the first-line level. Similarly, the development of cross-level services will benefit everyone living with a mental illness, although priority access to such services as supportive housing should clearly be given to people coping with serious illnesses.

The Committee is also particularly concerned that the mental health needs of children be a consistent and strong focus in the development of community-based mental health services and supports. As reviewed in greater detail in the next chapter, the needs of children and youth are too often an afterthought, left to the end even in discussions of how to improve the overall mental health system. The Committee believes strongly that this must be rectified.

The Committee recommends:

 

 

9

That the Government of Canada create a Mental Health Transition Fund to accelerate the transition to a system in which the delivery of mental health services and supports is based predominantly in the community.

That this Fund be made available to the provinces and territories on a per capita basis, and that the Fund be administered by the Canadian Mental Health Commission that has been agreed to by all Ministers of Health (with the exception of Quebec).

That the provinces and territories be eligible to receive funding from the Mental Health Transition Fund for projects that:

 

 

·      Would not otherwise have been funded; that is, projects that represent an increase in provincial or territorial spending on mental health services over and above existing spending on services and supports, plus an increment equal to the percentage annual increase in overall spending on health; and that

·         Contribute to the transition toward a system in which the delivery of mental health services and supports is based predominantly in the community.

That in allocating the resources from the Mental Health Transition Fund priority should be given to people living with serious and persistent mental illness and that a strong focus should be maintained on meeting the mental health needs of children and youth.

 

5.6       THE COMPONENTS OF THE MENTAL HEALTH TRANSITION FUND

This section discusses some of the key services and supports that would be eligible for funding under the Mental Health Transition Fund (MHTF). The total funding required for these initiatives will be discussed in Chapter 16.

To repeat the Committee’s opinion, the MHTF should have two main components: a Mental Health Housing Initiative (MHHI) that will provide federal funds for the development of new affordable and appropriate housing units as well as for rent supplements to allow people living with a mental illness, who could not otherwise afford to do so, to rent accommodation at market rates; and a Basket of Community Services (BCS) that will assist provinces in providing to people living with mental illness a range of services and supports in the community.

 

5.6.1     The Mental Health Housing Initiative (MHHI)

Text Box: Somewhere between 30% and 40% of homeless people have mental health problems, and that 20-25% are living with concurrent disorders, that is, with both mental health problems and addictions.It would be hard to overestimate the importance of adequate housing for people living with mental illness, in particular those whose illnesses are serious. The scale of the problem is indicated by studies showing that somewhere between 30% and 40% of homeless people have mental health problems, and that 20-25% are living with concurrent disorders, that is, with both mental health problems and addictions.


The Committee heard a consistent story everywhere. Christine Davis, President, Canadian Federation of Mental Health Nurses, put it this way:

Housing is protection from illness.  Housing is protection from the vagaries of mental illness, from the voices, from the fears.  The federal government must address the lack of affordable housing.[187]

Finding suitable housing is an ongoing challenge. Carol Solberg, Executive Director, Schizophrenia Society of Saskatchewan, explained to the Committee that: 

Most people on social assistance live in very small homes, which are not always in safe parts of town; they may be dingy and do not promote good mental health.  I believe that if a person with good mental health had to live in some of those situations they probably would become ill or, if nothing else, depressed.[188]

Jan House told the Committee of her experience trying to find adequate housing for her daughter in Halifax:

Physical environment is especially important for those with mental illness; however, because they often have little or no income, they are often forced to live in the worst possible neighbourhoods filled with high crime, drugs and violence.  In order to ensure she is living in a safe and positive environment, my daughter has been forced to move three times in one year.[189]

Text Box: Between 1980 and 2000, the number of affordable housing units created by the Government of Canada dropped from 24,000 to 940.Witnesses noted the impact that reduced federal funding has had on the availability of affordable housing. According to the CMHA, between 1980 and 2000, the number of affordable housing units created by the Government of Canada dropped from 24,000 to 940.[190] Linda Chamberlain, of The Dream Team in Toronto, spoke of the shortage of available housing:

That is the whole problem. We do not have enough housing. Most times there is a waiting list of 10 years. Sometimes, some of us have taken five years to get in. That is why [we] need more housing. There is just not enough built.[191]

Bonnie Arnold, of the CMHA in Prince Edward Island, recounted the challenges that confront agencies in the wake of reduced government housing subsidies, as they continue to strive to assist people living with mental illness to secure adequate housing and the services they need. 

While I am speaking about housing, another concern that has come up at the working group level is the fact that subsidized housing programs that were once supported by the federal government no longer exist.  It is true that new money has been made available to assist in building housing, but it is impossible for agencies to be able to make the rents affordable to the tenants, who are often single with low income…[192]

The Committee was also presented with evidence that programs designed to provide support to people living with mental illness do in fact accomplish this goal. Darrell Burnham, Executive Director, Coast Foundation Society/Coast Mental Health Foundation, told the Committee:

We serve well over 2,000 people.  I want to highlight two categories of services.  One is that we provide an array of supported housing.  Indeed, we pioneered supported housing for people with mental illness in 1974 and now serve over 544 people in many different forms of housing throughout the Lower Mainland in decent neighbourhoods in the community.  We have found that it is not only a cost-effective means, in that it keeps people healthy and out of hospital, but also they blend well into the communities.  They are not places that stand out and cause any concern in the neighbourhoods, so supported housing works.[193] 

Text Box: Programs designed to provide support to people living with mental illness do in fact accomplish this goal.Suzanne Crawford, Program Manager, LOFT Community Services in Toronto, elaborated on the strengths of the supportive housing model:

 

Why does supportive housing work? We think it works because we promote recovery and independence.  We have heard this over and over. We focus on safety.  We focus on the physical space.  We focus on the 24-hour hands-on support.

As I said, we need our psychiatrists.  We need our clinicians, but you know what? They come into the home.  They are there for an hour and they leave.  Who is there for the 24 hours a day?  It is the supportive housing, and it is the supportive housing in a very psychosocial model.  It offers security.  It offers peace of mind.  It offers flexibility.[194]


Phillip Dusfresne of The Dream Team spoke to the Committee from personal experience:

I used to live on the street and now I am a member of The Dream Team which is a project that was created by the boards for Mental Health Services and Housing Services back in 1999. …

We demonstrate the life-altering benefits of supportive housing by telling our stories to politicians at the various levels of government, social service agencies, service clubs, high school and university students, consumer groups and other institutions. …

People who live in supportive housing live independently. Each of us is assigned a support worker that we could go to whenever we need help. The support workers could help us get on social assistance. They could help us with résumés if we want to go looking for a job. They could help us with doctor and dentist appointments or day-to-day activities if we are not feeling well, but for the most part, we live independently. We do our own cooking, cleaning, grocery shopping and that. Most of us do not have 24-hour support.[195]

Text Box: The Committee was convinced by the testimony it heard that there is need for a major federal investment in housing. More housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people can live in the community.The Committee was also told about a variety of innovative projects that are under way across the country, both in the governmental and the non-governmental sectors. Audrey Bean, Co-President of L’Abri en Ville in Montréal, told the Committee:

 

 

 

We work with the psychiatric institutions to identify people who would benefit from our particular kind of living arrangement. We deal with two things that are essential to stability for someone with a mental illness. One is permanent housing, a home, a place where they can invite people to, a place that reinforces a sense of identity, and a place from which they can then re-relate to their families. 

Then, what we provide is social support, so that we have dinners, people go to one another’s houses and we provide that bridge back to the community for a person who has suffered the isolation that those with a mental illness so often suffer.

It is a model that is simple and can be done by any community. We are about … 100 people, with 30 residents, about 60 or 70 volunteers, and a working board of 20 people. We now have a grant. We had one from Human Resources Development Canada, and now one from the McConnell Foundation, to replicate our model in other communities in Canada.[196]

And David Nelson, Executive Director, CMHA, Saskatchewan Division, told the Committee of

…a positive new initiative in this province that is, I believe, groundbreaking.  It is the Saskatche­wan Rental Housing Supplement. … It will assist persons with all types of disability to improve their housing situation, and extends well beyond the stereotypical ramp and washroom modifications generally needed by the physically disabled.  It will provide resources to those with mental health problems on a continuing basis to assist with renovations such as larger windows, enhanced security, noise control and housing closer to services. ...

The supplement is strictly for people who are in the rental market and it will not go to the landlords. It will follow persons when they change homes.[197] 

The Committee was convinced by the testimony it heard that there is need for a major federal investment in housing. Moreover, the testimony points to three interconnected dimensions to be taken into account with respect to this investment: more housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people can live in the community. All three dimensions must be addressed.

The investment required in new supportive housing and supportive services for people living with mental illness cuts across areas both of federal and provincial/territorial responsibility. The provision of the necessary supportive services is a provincial responsibility. Thus, the Committee believes that federal support for these services and supports should be channelled through the Transition Fund to be administered by the Canadian Mental Health Commission. The Committee recommends:

 

 

10

That services and supports directed at enabling people living with mental illness to be housed in community settings be eligible for funding as part of the Basket of Community Services component of the Mental Health Transition Fund and administered by the Mental Health Commission

 

The Committee believes that the first two interconnected dimensions described above (to build new units and to provide rent supplements) should also be channelled through the Transition Fund. However, in managing the housing portion of that Fund, the Canadian Mental Health Commission should make use of existing structures and bodies at the federal level that are already responsible for affordable housing initiatives, such as the Canada Mortgage and Housing Corporation.

The Committee notes that, in March 2005, the federal Minister of Labour and Housing announced that rent supplement programs would henceforth be eligible for funding under the existing Affordable Housing Initiative launched to fund the construction of new affordable housing units. The Committee believes that a similar approach should be used with respect to federal financing of housing initiatives for people living with mental illnesses.

The Committee therefore recommends:

 

 

11

That, as part of the Mental Health Transition Fund, the Government of Canada create a Mental Health Housing Initiative that will provide funds both for the development of new affordable housing units and for rent supplement programs that subsidize people living with mental illness who would otherwise not be able to rent vacant apartments at current market rates.

·         That in managing the housing portion of the Mental Health Transition Fund, the Canadian Mental Health Commission should work closely with the Canada Mortgage and Housing Corporation.

 

The recommended size of the Mental Health Housing Initiative is discussed in detail in Chapter 16, along with a financial accounting of other recommendations in this report.

 

5.6.2    The Basket of Community Services

In addition to housing, many services and supports are needed in order to enable people living with serious mental illness to live safely in their communities. Those described below have all been demonstrated to improve the lives of people living with mental illness by making it possible for them to live productively in the community. They are within the Basket of Community Services that are widely recognized by governments as being at the core of a community-based mental health system:

§         Text Box: In addition to housing, many services and supports are needed in order to enable people living with serious mental illness to live safely in their communities.Assertive Community Treatment (ACT) teams that provide continuous and comprehensive treatment, rehabilitation and support services to people with serious mental illness who have multiple and complex needs that cannot be met with less intensive levels of support.

 

 

§         Crisis Intervention units that provide accessible and mobile crisis response services and supports, 24 hours a day and 7 days a week, to clients of all ages.

§         Text Box: It is the particular circumstances of each community that should determine the content of the basket of services that will be most effective.Intensive Case Management that enables people to meet their treatment, support and recovery objectives, maintain positive change, and live as independently as possible in the community.

The Committee is aware that these three by no means constitute all the services that should be eligible for funding under the Mental Health Transition Fund. Many others, such as early psychosis services, services for people with mental illness involved with the justice system, consumer drop-ins, peer support, employment support programs, concurrent disorder programs, services aimed at the mental health needs of refugees and immigrants, could be funded through the Basket of Community Services. But, as we have already noted, it is the particular circumstances of each community that should determine the content of the basket of services that will be most effective. Therefore, the recommendation below is not intended to be prescriptive; it recognizes explicitly the need for local flexibility, subject only to the condition that the services be community-based.

The Committee recommends:

 

 

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That a Basket of Community Services that have demonstrated their value in enabling people living with mental illness, in particular those living with serious and persistent illnesses, to live meaningful and productive lives in the community be eligible for funding through the Mental Health Transition Fund.

That this Basket of Community Services include, but not be limited to, such things as Assertive Community Treatment (ACT) Teams, Crisis Intervention Units and Intensive Case Management programs, and that the only condition for establishing the eligibility of a particular service for funding through the Mental Health Transition Fund be that it be based in the community.

 

The recommended size of the Basket of Community Services is discussed in detail in Chapter 16.

 

5.6.3    Promoting Collaborative Care

Text Box: It is important to encourage implementation of collaborative care initiatives in the development of an integrated, community-based continuum of care.Most people who seek professional help for a mental health problem will likely see a physician first, rather than a psychologist, social worker, or other provider. This is due primarily to the relatively larger proportion of physicians practising in the community and the manner in which the health insurance systems operate in the provinces and territories — in general, only the cost of seeing a physician is paid for by public funds, while the services of other mental health professionals, such as psychologists, often require private out-of-pocket payment.

 

Text Box: Collaborative care seeks to widen “the collaboration to include a wide variety of mental health providers, consumers and family members in the partnerships.The Committee believes it important to encourage implementation of collaborative care initiatives in the development of an integrated, community-based continuum of care. Collaborative care is the most promising strategy to improve both access to, and the quality of, treatment and services at the first-line level. A recent American study of “Evidence-Based Mental Health Treatments and Services” reported on the success of collaborative care projects:

For example, the evaluation of one model of collaborative care using non-physician mental health specialists shows that patients with depression treated with the collaborative care model in primary care settings experienced a significantly greater reduction in symptoms over a one-year period than did patients treated with usual primary care.[198]

The idea of collaborative care builds on “shared care” initiatives that were developed to promote greater cooperation between psychiatrists and family physicians. Collaborative care, in the sense intended by the Canadian Collaborative Mental Health Initiative (CCMHI) seeks to widen “the collaboration to include a wide variety of mental health providers, consumers and family members in the partnerships.”[199]

Dr. Nick Kates, Chair of CCMHI, explained to the Committee that

…there are a number of benefits to this kind of integration. The first is that it can increase access to mental health services for a large number of individuals who otherwise would not reach services. We know that 72 per cent of individuals with a mental health problem receive no mental health care over the course of a year, but 80 per cent of these individuals visit their family physicians.[200]

Dr. Kates went on to describe the range of services that could be provided in a primary care setting, including:

…early detection, health promotion and prevention, consultation, treatment, monitoring, and even some rehabilitation services, but we would stress the need to see mental health and primary care systems as complementary. One will not replace the other.[201]

Dr. Kates also told the Committee:

We also see the benefits of pharmacists, dieticians, care navigators, peer support programs, as well as the greater involvement of consumers and family members. We believe in a model of client-centred care. We think that primary care is in a unique position to be able to do this. Our concept of client-centred care includes the development of collaborative care plans, seeing the consumer as an active partner in treatment, the development of peer support mechanisms, and involving consumers in all aspects of planning, delivering and evaluating mental health services in primary care.[202]

In its published material, the CCMHI further notes that:

Providing mental health services in primary health care settings can be accomplished through various means, for example: providing direct mental health care in primary health care settings, or providing indirect mental health support to primary health care providers in primary health care settings. In the first instance, mental health care is provided by a mental health specialist; in the second, mental health care is delivered by a primary health care provider who is supported by or consults with a mental health specialist.[203]

It further notes that:

Collaborative mental health care takes place in a range of settings including community health centres, the offices of health care providers, an individual’s home, schools, correctional facilities, or community locations such as shelters. Settings vary according to the needs and preferences of the individual, and the knowledge, training and skills of the providers. Collaboration may involve joint assessment or care delivery with several providers present with the consumer, families and caregivers, when appropriate, or it may take place through telephone or written communication. In other words, effective collaboration does not require that the health care providers be situated in the same physical location.[204]

Funding for the CCMHI project expires in March 2006. The Committee believes that the work begun by the CCMHI should be pursued in two ways, and therefore recommends:

 

 

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That collaborative care initiatives be eligible for funding through the Mental Health Transition Fund.

That the Knowledge Exchange Centre to be established as part of the Canadian Mental Health Commission (see Chapter 16) actively pursue the promotion of best practices in the development and implementation of collaborative care initiatives.

 

5.6.3.1   Human Resource Issues

Text Box: It is abundantly clear that the kinds of human resource shortages that pervade the health care sector generally also affect the mental health sector.In its final report on the acute care, or hospital and doctor, system,[205] the Committee highlighted overall shortages in human resources in the health care system. Anecdotal evidence suggests that these same shortages affect the mental health sector. Throughout the health care system, an aging workforce, along with long lead times for educating and training new providers, mean that existing shortages are likely to get worse over the coming years.

Text Box: The absence of national human resource planning affects the mental health sector as much as the rest of the health care system.The human resource issues raised during the Committee’s hearings intersect with the need to foster collaborative care models in mental health. Although there are few hard statistics on human resources in the mental health field, it is abundantly clear that the kinds of human resource shortages that pervade the health care sector generally also affect the mental health sector. Encouraging the development of collaborative care practices that make more efficient and effective use of existing human resources in mental health is one way of addressing this shortage. Text Box: It is particularly important to increase the numbers of all mental health providers because so many services and supports that are critical to improving the lives of people living with mental illness are provided outside the health care system as such.

Unfortunately, most recent human resource studies do not provide a detailed breakdown of the human resource shortages in the mental health sector. A CIHI report on health care providers has noted, however, that psychologists have the highest mean age of the regulated health professions.[206]

Another example is provided by the National Symposium on Gaps in Mental Health Services for Seniors in Long-Term Care (April 2002), in which shortages of professional and non-professional participants were described as one of the most important problems in the provision of mental health services in long-term care.[207]

The absence of national human resource planning affects the mental health sector as much as the rest of the health care system. In its final report in October 2002, the Committee made several recommendations aimed at increasing the number of health care providers across the complete spectrum of health care professions and occupations. Should these recommendations be implemented, the numbers of mental health providers would increase as well.

The Committee wishes to stress that it is particularly important to increase the numbers of all mental health providers because so many services and supports that are critical to improving the lives of people living with mental illness are provided outside the health care system as such. As elsewhere in the health care system, shortages of health care providers is one of the main factors that contribute to unacceptably long wait times for access to mental health services. The Committee notes that the Canadian Psychiatric Association recently issued benchmark wait times for care for a number of psychiatric illnesses, and believes that this represents a further step towards ensuring that people have timely access to the mental health care they require.[208]

Several other human resource issues specific to the mental health field are given prominence by the need to move toward greater use of collaborative care models. The potential for widespread implementation of collaborative mental health initiatives depends to a considerable extent on the broader health care landscape - the creation of multi-disciplinary primary care teams in particular. The slow pace of primary care reform across the country is cause for particular concern.

In practical terms, the difficulties associated with reforming primary care mean that, for many years to come, many solo-practice general practitioners will continue to provide the bulk of the mental health care that their patients receive. It is well known that the fee-for-service model of physician remuneration discourages physicians from spending the extended periods of time that their patients require to help them with their mental health issues. Dr. Richard Goldbloom, Professor of Pediatrics, Dalhousie University, put it this way in his testimony to the Committee:

I happen to function currently as a consultant.  Most of the children I see are referrals from primary care physicians.

It did not take me long to learn that the number one reason for referral is that the primary care physician realizes this will take more than 10 minutes.

Sir William Osler once said that when doctors speak of matters of principle, they invariably mean money.  There is a practical problem in mental health.  That is, that people are paid by the number of patients they see.  As long as that is the case, you will not see much mental health care in primary care.[209]

Text Box: Three years ago the Australian government had introduced a program designed to facilitate the delivery of care to people living with mental illness; it rewards primary care physicians financially for spending more time with people with mental health problems. Similar initiatives should be encouraged in Canada.One measure that could help family practitioners who continue to be remunerated by fee-for-service arrangements, but who wish to enhance their capacity to assist patients with mental health issues, was described to the Committee by Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia. Mr. Casey told the Committee that three years ago the Australian government had introduced a program designed to facilitate the delivery of care to people living with mental illness; it rewards primary care physicians financially for spending more time with people with mental health problems.  He explained how this program came about and its main features:

We have been told that if you are a GP and someone comes into your consulting room and you think they have a mental health problem, you keep quiet, because if you open the dialogue, you will still be there 20 or 30 minutes later, and of course, fee for service is the treatment model. We have encouraged them by saying that if it will take 20 minutes, we will pay them extra for taking the time. Currently, about 15 per cent of our GP workforce has enrolled in this program. We have about 3,500 GPs who are now enrolled in this program and recognize themselves as people who can offer slightly more and better mental health care. That is a new program.[210]

Text Box: The Committee strongly encourages provincial and territorial governments to pursue initiatives designed to remove this financial barrier and facilitate the easy flow of mental health service providers between institutional and community settings.The Committee believes similar initiatives should be encouraged in Canada. Provincial and territorial governments should work closely with the medical associations in their jurisdictions to adjust the fee schedules to reward primary care physicians who increase the time they spend with patients who have mental health problems. Some provinces have already taken measures in this direction. For example, in New Brunswick, fee-for-service physicians can bill for psychotherapy, patient counselling, and family counselling up to 4 hours per day per patient. They can also be reimbursed for time spent case conferencing with allied mental health service providers.

A study of human resource issues by the Canadian Collaborative Mental Health Initiative pointed to another issue the Committee believes must be addressed. The CCMHI report notes that “differences in compensation are especially apparent for providers who shift between institutional and community care practice environments”;[211] those practising in the community setting are paid less. The Committee believes that such inequities are simply wrong and are likely to inhibit the full development of community-based services. The Committee strongly encourages provincial and territorial governments to pursue initiatives designed to remove this financial barrier and facilitate the easy flow of mental health service providers between institutional and community settings.

5.7       OTHER INITIATIVES

5.7.1     Support for Family Caregivers

Family members play an essential, at times lifesaving, role in caring for persons living with mental illness.  Almost 60% of families of people living with serious mental illness are estimated to be serving in the capacity of primary caregivers, usually with little guidance, support, relief or respite.[212] These family members often must also contend with the difficulties of navigating through a fragmented mental health system on behalf of their loved ones.

Recognizing their importance and the value of the care they provide, family caregivers were sought out and invited by the Committee to appear at public hearings in every province and territory.  We have given “voice” to their concerns in Chapter 2 and have sought to respond to their input. This report addresses two key matters here:  income support and respite care services.

5.7.1.1  Income Support

The Committee was told that family caregivers are being financially affected in a number of ways.  For example, they often have to take time off from their jobs to care for a family member living with mental illness.  In this regard, Dr. Kellie LeDrew, Clinical Director of the Newfoundland and Labrador Early Psychosis Program, noted that:

I think many times we underestimate the burdens that are placed on families. If you want to look at the cost of mental illness, oftentimes we underestimate the indirect cost of mental illness. Many of these mothers — and oftentimes it is the mother — have had to take time off work. I have had to give numerous notes for mothers who had to take time off work to stay home so that the son does not have to go into the hospital. They do not want to leave him because they are afraid something will happen.[213]

The Committee believes that caregivers should receive some form of financial assistance from government when they have to leave work temporarily to care for a family member who is mentally ill.  A number of compelling reasons lead us to this belief:

§         Text Box: Caregivers should receive some form of financial assistance from government when they have to leave work temporarily to care for a family member who is mentally ill.Persons living with mental illness benefit by receiving long-term help from a familiar source, outside an institutional setting.  With this help they may also be spared contact with the criminal justice system or homelessness.

§         Caregivers benefit by maintaining stable employment over time.  They are also better able to maintain a supportive relationship with the affected family member.

§         Employers benefit from being able to retain valued staff and avoid costs associated with other forms of leave (e.g., sick leave) that may be relied on when leave to care for a family member is unavailable or available only for brief periods of time.

§         Governments benefit by keeping caregivers in the workforce and persons living with mental illness out of hospitals, long-term care facilities, prisons, and off the streets, all of which will result in cost savings to the public purse.

The Committee is aware that Compassionate Care Benefits are currently available to eligible Canadians through Employment Insurance (EI).  However, these benefits are restricted to persons who have to be absent from work to provide care or support to a gravely ill family member at risk of dying within six months.[214]  Recent reports suggest that this program has been seriously under-utilized by its target constituency, in part at least because of the restrictive eligibility criteria that are currently in place.

Given the enormous surplus in the EI account[215] and the recent decision of the Supreme Court of Canada[216] affirming Parliament’s constitutional authority to adapt the EI plan to the new realities of the workplace, the Committee believes that it is appropriate to make Compassionate Care Benefits more widely available.  Therefore, the Committee recommends:

 

 

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That compassionate care benefits be payable up to a maximum of 6 weeks within a two-year period to a person who has to be absent from work to provide care or support to a family member living with mental illness who is considered to be at risk of hospitalization, placement in a long-term care facility, imprisonment, or homelessness, within 6 months.

That eligibility for compassionate care benefits be determined on the advice of mental health professionals and that recipients of compassionate care benefits be exempt from the two-week waiting period before EI benefits begin.

 

5.7.1.2               Respite Care Services

Text Box: To avoid caregiver burnout, the Committee believes that respite care services available to families must be significantly improved.The responsibility of providing care and support to a family member living with mental illness can place caregivers at risk of burnout.  Brenda McPherson, Provincial Coordinator of Psychiatric Patient Advocate Services for New Brunswick, testified that:

…many of our caregivers or parents of these [psychiatric] patients are literally burnt[out].  They have been caring for these individuals since the age of 12, 13 or 14. The caregivers have gone through the justice system, they have gone through foster home systems, and so on. By the time their children are 25 and 30…the caregivers are … burnt[out], and they have access to little or no resources. That is why I think it is important that the federal government play a role, and partner with the provincial government to enhance the services and the resources that the province has.[217]

To avoid caregiver burnout, the Committee believes that respite care services available to families must be significantly improved.  A variety of models were suggested, including: 

§         having a public health nurse make home visits to the families of persons recently diagnosed with mental illness to offer information and support;[218]

§         providing in-home respite care that frees caregivers to go to their own medical or other appointments, attend support groups, or shop for groceries;[219]

§         establishing adult daycare services;[220]

§         improving institutional respite care by making it available more often and for longer periods.[221]

Given the diverse needs of family caregivers, and recognizing that these needs may shift over time, it seems logical to make a variety of respite care services available.  Therefore, the Committee recommends:

 

 

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That initiatives designed to make respite care services more widely available to family caregivers, and better adapted to the needs of individual clients as they change over time, be eligible for funding through the Mental Health Transition Fund.

 


 

CHAPTER 6:
CHILDREN AND YOUTH

6.1        INTRODUCTION

The greatest omission in the work that I see is that it fails to stress the reality that most of the mental health disorders affecting Canadians today begin in childhood and adolescence. Failure to recognize this fact leads us to dealing with a stage-four cancer, often with major secondary effects, instead of a stage-one or stage-two disease. Like obesity, mental health issues, if not addressed early in life, threaten to bankrupt our health care system.  —Diane Sacks[222]

Text Box: …a total of some 1.2 million young Canadians live with anxiety, attention deficit, depression, addiction, and other disorders.There are a great  many children and youth who are living with mental illness.  It is conservatively estimated that as many as 15%[223] are affected at any given time, a total of some 1.2 million young Canadians who live with anxiety, attention deficit, depression, addiction, and other disorders.[224]  Further, given that families are usually directly involved in the care and support of their younger members, the impact of these high rates of illness is compounded.  When a child or young person lives with mental illness or addiction, so too do his or her family caregivers.

Although one might expect that these high rates of prevalence, coupled with the ready supply of advocates (i.e., parents), would have resulted in a well organized, appropriately funded mental health system capable of attending to the needs of children and youth, this is not the case.  The Committee learned from those who appeared before it that the system is fragmented and under-funded, that intervention occurs far later than is necessary, that there is a critical shortage of mental health professionals, and that young people and their families are not being involved in workable, long-term solutions to their serious mental health problems. 

Children and youth are at a significant disadvantage when compared to other demographic groups affected by mental illness, in that the failings of the mental health system affect them more acutely and severely.  The Committee believes it is imperative to move aggressively to tackle key problems now — with other changes to follow.


6.2       EARLY INTERVENTION

Text Box: The importance of early intervention cannot be overstated.  The importance of early intervention cannot be overstated.  When symptoms of distress or illness first appear in a child or young person, regardless of age, family caregivers, health professionals and educators should intervene immediately. 

Also, these interventions must be sustained, where necessary, through the transition into school, and thereafter into adulthood.  The Committee shares the view of Dr. Ian Manion, a psychologist, who emphasized the importance of reaching children and youth in all stages of their development:

If you focus solely on one area you create another garrison. You are saying that that is where the funds should be directed, and that means that a generation of middle-year children and youth lose out, or a generation of adolescents loses out. Of course, if you lose a generation of adolescents you are actually losing the next generation of parents, who will parent those zero-to-three-year-old children down the road. Therefore, you need to have a full appreciation of the continuum of care along a developmental continuum.[225]

Text Box: …we advocate an end to the practice of terminating mental health or social services when the client has reached a predetermined age (e.g., 16 or 18 years), after which he or she is expected to seek help through the adult system(s).Mental illness and addiction do not respect arbitrary cut-off ages.  For this reason, the Committee does not support targeting mental health funds for children and youth in a narrow age range.  Instead, our focus will be on the establishment of a fully integrated and seamless continuum of services through to and including adulthood. 

Further, we will advocate an end to the practice of terminating mental health or social services — both of which are important to good mental health — when the client has reached a predetermined age (e.g., 16 or 18 years), after which he or she is expected to seek help through the adult system(s).

6.2.1     The Pre-School Years

While much of the testimony heard by the Committee emphasized the importance of early intervention, most often it was discussed as applicable to school-age children.  The logic and convenience of locating mental health interventions within the education system must not blind us, however, to the reality that problems can and do arise prior to enrolment in school.  As Sharon Steinhauer, a member of the Alberta Mental Health Board, explained:

We know that the risk factors come out of the kinds of family and community environments that kids live in….  The question is: Do we have ways of identifying children who are at risk, and do we have ways of capturing them into support networks so that, in fact, we are mitigating some of the risks that may make their family vulnerable?

The first place is where kids are raised, of course, and that is families; secondly, is in school. Thus those early years, which the ECD [Early Childhood Development] strategy is trying to address, is the preschool piece. We are trying Head Start programs and a number of other avenues to try to identify those kids who may need more support than is naturally available to them.[226]

As children mature, they will bring their emerging mental health problems with them into the school environment.  Michelle Forge, Superintendent of Student Services at the Bluewater District School Board, noted that:

When they do, they will be better for having had a teacher who has been able to help them understand what school looks like and how to make those transitions. It also helps the preschool team to navigate the system. We are a system, and we are very different from anybody else. We know it, and we need to provide the navigation tools and people to do that.[227]

The pre-school years present two challenges.  The first is to identify and provide services to those children who are living with, or who are at risk of developing, mental illness.  The second is to manage effectively the transition from early childhood (0-5 years) into the school system.  The Committee recommends:

 

 

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That school boards mandate the establishment of school-based teams made up of social workers, child/youth workers and teachers to help family caregivers navigate and access the mental health services their children and youth require, and that these teams make use of a variety of treatment techniques and work across disciplines.

 

6.2.2    The School-Age Years

Text Box: Many of the Committee’s witnesses spoke of the need to ensure that schools are better equipped to handle children’s mental health issues than they are now.  Many of the Committee’s witnesses spoke of the need to ensure that schools are better equipped to handle children’s mental health issues than they are now.  Dr. Richard Goldbloom, Professor of Pediatrics, went so far as to remark that, “I see the school as the most underdeveloped site for effective health care of any in the country.”[228]  He went on to suggest that:

…we need a major move of mental health services from their present locations in most communities into the schools. The school is children's natural habitat. For six or eight hours a day, it is where they are, it is where their parents often come and it is where you can deal with the problems in collaboration with the teachers.[229]

Dr. John Service, Chair of the Canadian Alliance on Mental Illness and Mental Health, echoed these comments:

If we look at just one group, that is young adults, and we ask young adults why they do not access mental health services, they will often tell us it is because they are in large hospitals, because they are in settings that they feel very uncomfortable going to. … The way we position our services often dictates that they will not use them very effectively. That is a serious issue. …

Another example that I could use from my own experience as a psychologist for 15 years with children, adolescents and families in Nova Scotia, is that we had difficulty getting children and their families to feel comfortable coming to the hospital. We negotiated with the county school board an agreement where we would offer our mental health services in the schools. That was much more effective. People felt much more comfortable coming and we had access to the teachers.[230]

Text Box: The Committee stresses the importance of teachers having the training necessary to recognize better mental health issues in their students and to help them find effective treatment.There was agreement also regarding the importance of teachers having the training necessary to recognize better mental health issues in their students and to help them find effective treatment, rather than, as now, referring students to already overburdened emergency rooms or relegating them to long waiting lists. 

 

Text Box: Development of the school as a site for the effective delivery of mental health services is essential.Dr. Mimi Israël, Psychiatrist-in-Chief at the Douglas Hospital (Montreal), called for investment in the training of non-mental health professionals, including teachers.  Specifically, she stated that “we should produce a mental health curriculum that would be integrated into the educational programs of teachers, daycare workers and other health professionals.”[231]

Judy Hills, Executive Director of the Canadian Psychiatric Research Foundation, described one such initiative undertaken by her organization in recognition of the fact that “…research shows that the first person youth go to for help is the teacher.”[232]  She commented that:

…teachers were having problems coping with things changing [in the school system] so quickly. They asked if we would put together a guide to help them until they could get help for the children they were working with. They were facing waiting lists for referrals of up to a year and a half for children in their classrooms.

The foundation gathered together a group of experts in the field of education. We had principals, teachers, special education people and youth themselves involved in putting together a handbook entitled “When Something's Wrong.”[233]

Ms. Hills went on to clarify that:

We know that teachers cannot be diagnosticians, and we do not want them to be that, but we do want them to have some skills in early identification and to understand some of the mood and behaviour disorders that might be caused by mental disorders. With that, they have a basis on which to go forward.[234]

Development of the school as a site for the effective delivery of mental health services involves several key steps.  First, its potential must be recognized.  Second, those services must be relocated from other hospital or community-based sites, or established as new services.  Third, teachers must be provided with the time and resources to take on this new, more involved role.  Therefore, the Committee recommends:


 

 

 

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That mental health services for children and youth be provided in the school setting by the school-based mental health teams recommended in previous section 6.2.1.

That teachers be trained so that they can be involved in the early identification of mental illness.

That teachers be given the time and the practical resources and supports necessary to take on this new role.

 

 

6.2.2.1  Mental Health Screenings

It was suggested to the Committee that another way of involving schools could be through their administration of screening tools for mental illness.  This is a matter of some debate.  For example, in her testimony to the Committee, Carolyn Mayeur, recounting her daughter’s experience, argued in favour of general screening programs:

I believe there should be regular screening for mental health through all the grades. Danielle had a chemical imbalance that started when she was very young, but there was no screening mechanism. We could have maybe prevented a lot of what happened if we had caught it early.[235]

Others, including Dr. Diane Sacks, Past President of the Canadian Paediatric Society, favour a more targeted approach:

It is positive to recognize that services need to be involved in the school system. The next step is to recognize that we are now able to offer available, inexpensive, easy-to-apply and validated tools for identifying many of these disorders in children. These tools need to be utilized [with] a high risk, definable population identified within the school system.

What is this population? These are the children who are frequently absent, failing or dropping out. They need to be tagged and automatically screened for mental health disorders. We do not need to wait until they are in prisons to test them and find out, as they did in the U.S., that up to 80 per cent of prison residents have diagnosable conditions.[236]


Dr. Norman Hoffman, Director of the Student Mental Health Service at McGill University, was more cautious.  He stated that:

We see a trend towards wanting to make these fast diagnoses. Screening programs such as depression screening may increase awareness of the problem of depression, but often all it does is support the idea that depression is a singular biological entity. This idea is highly promoted by the pharmaceutical industry, but has no support in the literature.

 Depressed moods are a complex problem. Twenty years ago, students would come to see us and they would say, “I feel depressed, I feel down.” Now they come in and say, “I think I have depression.” We say, “What do you mean? How are you feeling? What is going on in your life?” They answer, “No, I have depression.” People want fast answers and fast solutions, but they do not work.[237]

Later, he continued by offering an alternative to general screening programs:

We need to have school systems where the teacher-to-student ratio is small enough that teachers know their kids. We do not need to do a depression screening in a school if a teacher knows their kids. They will know which kids are troubled.[238]

Text Box: While we are very strongly in favour of early diagnosis, we are mindful of the roadblocks to implementing screening programs in schools.The Committee acknowledges the support shown for a variety of approaches to screening programs.  While we are very strongly in favour of early diagnosis, we are mindful not only of the criticisms, but also of the roadblocks to implementing screening programs in schools.  These fall into two general categories.

 

 

6.2.2.1.1           Legal Roadblocks

As discussed in Chapter 4, Section 4, mental health services are primarily a responsibility of the provinces and territories, whose collaboration would therefore be essential to the implementation of any national strategy of mental health screening.  In addition, each jurisdiction’s laws regarding the provision of health services in a school setting, consent to medical care, privacy of personal information, and admitting a student for treatment for a specific illness would also have to be followed.

The Committee believes that, to screen students for possible mental health concerns, informed consent is necessary, even though, depending on applicable provincial and territorial legislation, a mental health screening may or may not be among the medical services that require consent. Consent should be obtained from the appropriate person, the student in some cases and his or her family caregiver in others.

Text Box: The Committee believes that, to screen students for possible mental health concerns, informed consent is necessary.Provincial and territorial legislation varies with respect to the age at which a person is considered capable of consenting to, or refusing, treatment.  Legislation notwithstanding, age is not determinative; a minor or person below a statutory age may well be capable of consenting to medical treatment if he or she understands its nature and consequences. 

 For consent to be valid it must be both free and fully informed, the latter meaning that the nature, gravity and any risks of the mental health screening must be conveyed to the person to be screened.  Understandable answers must also be given to specific questions asked by the person concerned about the procedure or process.  A requirement that consent be given without undue influence or coercion may be particularly important when a student who has not yet reached the age of consent is asked to agree to a mental health screening in the presence of school authorities, health professionals and peers.

Mental health screenings in schools would require appropriate measures to be taken to protect the confidentiality of each student’s personal information.  If a student is competent and capable of providing his or her own consent, it becomes a legal question whether the mental heath screening and its results may be disclosed to the student’s family caregiver.  The law is not consistent across Canada. In any given situation a family caregiver may be precluded from receiving, being entitled to receive, or being required to receive information about the student’s health status and care.

Treatment that might follow a mental health screening would also be subject to significant legal implications.  The law relating to consent and confidentiality of information would remain applicable, but the legal requirements with respect to treatment would not necessarily be the same as for the initial mental health screening.  Because the nature and consequences of mental health treatment are usually more serious than assessment itself, it is possible that a person who is capable of consenting to a screening, and to controlling the disclosure of its results, would not be capable of consenting to follow-up treatment, or of preventing others (his or her family caregiver, for example) from being advised of the treatment options available.

 

6.2.2.1.2           Practical Roadblocks

Text Box: It seems unlikely that there would be a sufficient number of mental health professionals available in the near term to assist these children and youth.  Given this situation, nothing would be accomplished by the screening; indeed, more harm could be done.In addition to the inconsistency of the law pertaining to mental health screenings, there is also the question of what school authorities or family caregivers would do with the information the screening might reveal.  At present, only a small percentage of people with mental illness or addiction, including children, actually seek help from health professionals.[239]  Yet the existing system is already overburdened.

If mental health screenings were widely administered in schools, one could reasonably expect that significantly more children and youth would be diagnosed as living with mental illness.  Carole Tooton, Executive Director of the Nova Scotia Division of the Canadian Mental Health Association, cautioned the Committee that:

We are somewhat hesitant now to do presentations in the schools. We get many calls especially for grade 11 classes, where part of the curriculum deals with psychology. We worry that after our presentation that the school does not have a system in place to deal with any problems that arise out of the presentation. We need to know that the teachers and guidance councillors have the proper strategy to deal with a student who realizes he or she might have a problem with depression or thoughts of suicide.

We are hesitant because we know that a proper follow-up strategy is essential to the success of our program. If the school does not have a strategy, it struggles to find the proper professionals in the system.[240]

Indeed, even if the suggested strategy is in place, for reasons discussed in Section 6.3 of this chapter it seems unlikely that there would be a sufficient number of mental health professionals available in the near term to assist these children and youth.  Given this situation, nothing would be accomplished by the screening; indeed, more harm could be done.

In summary, while the Committee believes that mental health screenings in schools may offer benefits, there are two reasons why a large-scale screening program should not be started at this time.  First, existing inconsistencies among provincial and territorial laws render a national initiative unworkable; unfortunately, there appears to be no current appetite for the extensive law reform needed to resolve these inconsistencies on a Canada-wide basis.

Second, while approaches targeted at specific groups of the student population offer somewhat more promise, the existing shortage of health professionals remains a significant impediment.

Perhaps once the mental health system has been reformed, and either its capacity or efficiency or both have been increased, some limited screening programs — carried out within individual jurisdictions — could be considered.

 

6.2.2.2 Stigma and Discrimination

The issue of stigma and discrimination arises throughout this report and is examined in greater detail in Chapter 16.[241]  Nonetheless, the Committee feels it is necessary to emphasize here the importance of implementing early education and awareness about mental illness in schools.

Text Box: “We have learned that it is relatively simple to destigmatize mental health with youth.  I do not think the same is true of adults.”   Dr. Simon Davidson
When resources are scarce, it is best to target information at those who are most receptive to it.
 Often, stigma comes from a lack of knowledge.  This ignorance is pervasive among all Canadians.  The rationale for targeting educational programs at younger people is simple.  As Dr. Simon Davidson, Chief of Psychiatry at the Children’s Hospital of Eastern Ontario, pointed out, “we have learned that it is relatively simple to destigmatize mental health with youth.  I do not think the same is true of adults.”[242] 

In short, when resources are scarce, it is best to target information at those who are most receptive to it.  Therefore, the Committee recommends:

 

 

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That students be educated in school about mental illness and its prevention, and that the Canadian Mental Health Commission (see Chapter 16) work closely with educators to develop appropriate promotion campaigns in order to reduce stigma and discrimination.

 

 

6.2.3    Post-School — Making the Transition to the Adult System

As stated earlier in this chapter, there is no end date for mental illness.  The same cannot be said for the mental health and social services available to children and youth.  This common problem is one which the Committee believes must not be allowed to continue.

 

6.2.3.1               Mental Health Services

Text Box: When young people reach a predetermined age, set out in law or policy, at which they become ineligible for “children’s” mental health services.  One day they are eligible, the next day — their birthday — they are not.Abrupt termination of essential services has been rightly characterized as akin to falling off a cliff.  Yet this is what happens all too often when young people reach a predetermined age, set out in law or policy, at which they become ineligible for “children’s” mental health services.  One day they are eligible, the next day — their birthday — they are not.  As Dr. Ashok Malla, Head of Research at the Douglas Hospital, noted:

…separation of child/adolescent from adult services I think is artificial and it is counterproductive. While resources for this age group [should] be protected at all costs, disorders with onset during adolescence must be treated within a system that is continuous, so that the expertise is available where the person needs care, as opposed to the person going for…X-number of years to this unit and then being transferred when they turn that magical age of 18 to another set of programs.[243]

Some of the situations described to the Committee were quite nonsensical.  For example, Dr. Linda Bayers, Executive Director of the Self Help Connection, told us that:

As for this business of 17 and 18, one time they opened up a mental health clinic next to a high school, which was a hop, skip and a jump away but the kids could not access it unless they were 19 years old. What is wrong with this picture? We have to get a lot smarter about helping people in that age group.[244]

While one might be tempted to just shake one’s head at whatever rationale might underlie decisions of this type, the consequences are very real.  Phyllis Grant-Parker described her son’s experience this way:

When you are young and you have mental illness, it is like the system expects you to immediately be an independent adult. In Ottawa, where we live, we could not find him the necessary age-appropriate treatment. The Children's Hospital of Eastern Ontario — CHEO — had no program. The Ottawa First Episode Psychosis Clinic at the Ottawa Hospital had a six-month wait. As a result, my son was hospitalized in a tertiary care hospital housed with chronically ill adults and no rehabilitation program. It is a pretty bleak forecast for a teenager and for his family.[245]

Text Box: The current practice of “guarding one’s own turf,” a habit that has resulted in individuals and organizations operating alone, in silos, must cease.Children and youth require specialized mental health services.  But there is no good reason why such services should exist in isolation from the larger mental health system.  The current practice of “guarding one’s own turf,” a habit that has resulted in individuals and organizations operating alone, in silos, must cease. 

It is the responsibility of mental health professionals to work in concert to tear down barriers within and between the adult and children’s systems.  All treatment services, be they community-, school- or hospital-based, should be fully integrated to ensure children and youth receive age appropriate interventions for as long as they are needed.

Therefore, the Committee recommends:

 

 

 

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That provincial and territorial governments work to eliminate any legislative, regulatory or program “silos” that inhibit their ability to deal in an appropriate fashion with the transition from adolescence to adulthood, and that they adopt the following measures:

·         Determine age cut-offs for mental health services for children and youth by clinical, rather than budgetary or other bureaucratic, considerations.

·         Where age cut-offs are employed, link services for children and youth to adult services to ensure a seamless transition.

·         Where age cut-offs are employed, avoid any “gaps” of time where individuals are ineligible for treatment under both the children and youth and the adult systems

 

 

6.2.3.2              Social Services

While age cut-offs have resulted in certain nonsensical outcomes in the context of mental health services, those in the arena of social services at times defy belief.  Reproduced below, in full, is an exchange between Andy Cox, Mental Health Advocate at the IWK Children’s Hospital in Halifax, and the Committee’s Chair.  This discussion occurred at the Committee’s public hearings in Halifax.  While not involving a person living with a mental illness, it is illustrative of the gaps in services such people face on an ongoing basis:

Mr. Cox:  For the first part, I will explain by giving an example. We have a young fellow who is 18 on our inpatient unit. He has been there since October [seven months]. He does not have a mental illness, or any mental health issues. Community services would not house this young man. He came to the ER at the IWK, was admitted, and we have been fighting to find him a place to live. We have three or four cases like that on our inpatient list.

The Chairman:  Why was he admitted if he did not have a problem?

Mr. Cox:  Community Services gave up on him. He is blind.

The Chairman:  You gave him a bed in a hospital because the Department of Community Services, to use your words, gave up on him?

Mr. Cox:  Yes, and we have been fighting it, appealing it.

The Chairman:  He is occupying a hospital bed because there is nowhere else to go and yet he is not sick?

Mr. Cox:  No, he is not.

The Chairman:  He has not committed a crime?

Mr. Cox:  No, he has not.

The Chairman:  You understand how, to ordinary people, this sounds absolutely ridiculous, as well as extremely expensive.

Mr. Cox:  That is not rare.

The Chairman:  This is not totally unique?

Text Box: No person living with a mental illness should be left to languish in a legislative void between the children and youth and the adult systems.Mr. Cox:  No, it is not.[246]

The problem appears to originate in the wording of certain provincial statutes.  As Christine Brennan, Supervisor of Youth and Senior Services at the Office of the Ombudsman for Nova Scotia, explained:

…you have to understand that under the Children and Family Services Act in our province [Nova Scotia], it says the minister, until the age of 15, shall provide services, and between 16 and 18 the minister may provide services. “Shall” has been legislatively interpreted to be “you have to.” We have noticed a service gap for those youth aged 16 to 17 because the act says the minister “may.”

Generally, a lot of the youth that need those types of services do not follow case plans that are set for them so they are problem youth. It is easier to terminate a care agreement or not provide those services, which is problematic because the youth that need the services are not getting them because of their problem behaviour.[247]

The Committee is of the view that both mental health and social services are critical to staying well.  While a seamless continuum of either type of service is beneficial to children and youth, tying the two systems together augments their positive effects. 

No person living with a mental illness should be left to languish in a legislative void between the children and youth and the adult systems. 

Therefore, the Committee recommends:

 

 

 

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That provincial and territorial governments coordinate mental health and social services, and pay particular attention in this regard to ensuring that age cut-offs for social services for children and youth be synchronized with those established for mental health services.

6.3       SHORTAGE OF CHILD AND ADOLESCENT MENTAL HEALTH PROFESSIONALS

Canadians have grown accustomed to hearing about a shortage of health professionals in this country.  Neither the mental health system, nor the sub-system serving children and youth, has escaped these shortfalls.

The Committee was told repeatedly that there is a need for a much greater number of mental health professionals across Canada, particularly those who specialize in treating young people.  Dr. Nasreen Roberts, Director of the Adolescent Urgent Consultation and Inpatient Service at Hotel Dieu Hospital in Kingston, provided one example of this in her testimony:

Providing very quick care, providing an urgent consult service, is important. I have just done a waiting list from across the country for all the 16 medical schools. The waiting list for triage is two weeks to four weeks. The waiting list to see somebody varies between eight weeks to 18 months.

There are less than 500 child and adolescent psychiatrists in the country. If you look at only 14 percent of the severely disordered kids in the general population, that translates to 800,000 kids across Canada. That is taking just the severe disorders; I am not including the 22 percent that I [think] should be [treated]. Those are very important numbers.[248]

Given that only ten fully trained child psychiatrists graduate from medical school each year,[249] the problem Dr. Roberts refers to will likely be with us for some time. 

It is not just a question of increasing the number of psychiatric specialists, however.  Shortages of other mental health professionals who specialize in treating children and youth, including psychologists, nurses and social workers, must also be addressed.  Therefore, the Committee recommends:

  

 

 

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That governments take immediate steps to address the shortage of mental health professionals who specialize in treating children and youth.

 

 

6.3.1     Transitional Measures

Text Box: It is not just a question of increasing the number of psychiatric specialists, however.  Shortages of other mental health professionals who specialize in treating children and youth, including psychologists, nurses and social workers, must also be addressed.  While the Committee agrees that waiting times must be reduced, we realize that increasing capacity within the system, particularly the training capacity for those mental health professionals who specialize in treating young people, will be a very lengthy process.

The Committee believes it important, therefore, to explore remedies that will bring some relief in the near term.  We believe that tele-psychiatry, the use of alternative treatment models, and case conferencing, have that potential.  These transitional measures will help to bridge the gap during a period of restructuring designed to enhance the ability of the mental health system to assist children and youth.

 

6.3.1.1  Sharing Existing Resources — Tele-Psychiatry

The Committee has heard testimony regarding the benefits offered by new technologies.  One of these — tele-psychiatry — will be examined in detail in Chapter 12.  However, the Committee raises the matter here as it has particular application to mental health services for children and youth.Text Box: Tele-psychiatry will permit the sharing of existing resources with under-serviced regions only if a basic level of mental health service is already available in those communities.

Shortages of mental health professionals are usually experienced most acutely in rural and remote areas.  Those living in communities with limited or no access to mental health services may be forced to travel great distances for treatment.  One of the suggestions put to the Committee to deal with the situation in such communities was increased use of tele-psychiatry.  Michelle Forge explained that:

We do not have a children's psychiatrist in our jurisdiction. Quite frankly, the wonderful access that we have had through tele-psychiatry…I believe it is over 200 psychiatric consultations, has allowed us to do things at the community level that we would not have been able to do otherwise. We need that access. We do not necessarily need it all the time, but we need the access and we need a pediatric community that is willing to support it.[250]

The key here is access to external expertise by local health professionals, be they psychologists, nurses, social workers or primary care physicians.  Tele-psychiatry will permit the sharing of existing resources with under-serviced regions only if a basic level of mental health service is already available in those communities.  Also, local health professionals and their clients must be willing and able to make use of the technology and the advice provided by consultants at a distance.

Therefore, the Committee recommends:

 

 

22

That the use of tele-psychiatry be increased in rural and remote areas, to facilitate the sharing of mental health personnel who specialize in treating children and youth with these communities.

That tele-psychiatry be employed both for consultations and for the purposes of education and training of health professionals who work in rural and remote areas.

 

 

6.3.1.2  Emphasizing Alternative Treatment Models — Group Therapy

A number of experts proposed the use of alternative treatment models, particularly group therapy, as a way to reduce waiting lists.  Andy Cox stated that:

…my top solution is more groups have to be organized. We have youth sitting on a wait list when we can bring them together and start talking earlier about mental illness and, therefore, we will know in what direction to refer these youth.[251]

Text Box: The shortage of mental health professionals who specialize in treating children and youth is clearly critical.His view was echoed by Dr. Richard Goldbloom, who presented a case described by the British Paediatric Association in which group therapy was used with children living with Attention Deficit and Hyperactivity Disorder.  According to Dr. Goldbloom:

The waiting list of children referred for assessment of possible attention deficit disorder had tripled over a one-year period. To deal with this, they held patient information sessions targeted at parents who had been on the clinic wait list for nine months or more.

They reduced the wait list. Many of these children were put in treatment through group sessions. They reduced the wait list from 20 months to zero over a period of only seven months. It can be done.[252]

The shortage of mental health professionals who specialize in treating children and youth is clearly critical.  However, by educating practitioners in how best to manage waiting lists, particularly through the use of alternative therapies, it may be possible to lessen the impact of the shortage.  Therefore, the Committee recommends:

 

 

23

That standardized, evidence-based group therapies be used, where clinically appropriate, to reduce wait times for children and youth who need access to mental health services.

 

 

6.3.1.3  Working Cooperatively — Case Conferencing

As the information in this chapter clearly shows, children and youth are not well served by the mental health system.  Hence, all options for improving service levels must be explored, including case conferencing.

Barbara Whitenect, then Acting Director of Child and Youth Services for the New Brunswick Department of Health and Wellness, put it this way:

One approach we have used in New Brunswick is comprehensive case conferencing. We talk about case conferencing a lot. … Often, because of demands for service, wait lists or mandates, people do not make the time.

We have to look at mandating that and linking it to funding. People have to come together and bring their resources for children, their issues, to the table. … It is important that we know and understand the dynamics. We will if we are sitting at the same table.[253]

Ms. Whitenect went on to describe the positive impact flowing from the implementation of the Youth Criminal Justice Act:

When a young person commits an offence, the judge orders the community partners to have a case conference before sentencing. It is too bad that the young person has to commit an offence before we can legislate case conferencing. …

People say, “I have waiting lists,” and this and that. If a judge says “You will do it,” you do it. We have seen some positive results. It has not overtaxed our people because it is only in those very difficult cases, those high-need situations that we all encounter that we throw our resources onto the table.

I will not overemphasize that, but if we start acting strategically and say our funding dollars are linked to doing these case conferences, thus reshaping the way people do their work, then we can achieve that.[254]

Text Box: The Committee believes that case conferencing has the potential to increase the efficiency of the mental health system, while also reducing costs.  The Committee believes that case conferencing has the potential to increase the efficiency of the mental health system, while also reducing costs.  It is a further example of a transitional measure that may be of some assistance in compensating for the existing shortage of mental health professionals who specialize in treating children and youth.  Therefore, we recommend:

 

 

 

24

That provincial and territorial governments encourage their health, education and justice institutions to work closely together in order to provide seamless access to mental health services for children and youth.

That greater use be made of case conferencing so as to coordinate and prioritize mental health service delivery to children and youth.

 

6.4       INCLUSION OF YOUTH AND FAMILY CAREGIVERS IN TREATMENT

Text Box: The Committee believes that it is important to include children and youth and their family caregivers at every stage of the process.  Children and youth pose a particular challenge to mental health professionals.  Their bodies and minds are continually growing and changing.  Adapting treatment interventions to this reality is a delicate process, one that must be approached with a healthy respect for the client and his/her family caregivers.  Where the family unit is dysfunctional it should be treated as a whole, with all family members provided the assistance they need.

The Committee believes that it is important to include children and youth and their family caregivers at every stage of the process.  Judy Finlay, Chief Advocate for the Ontario Office of Child & Family Services Advocacy, provided the following rationale:

If we begin to view parents and children as collaborators in assessment, planning, delivery and evaluation of mental health services, it will force a family-based intervention, with the child and the family at the centre. As long as we have a provider-driven system, we will always have the families on the periphery. We need to move to a family-driven model that enables the child and the family to do well in their community.[255]

 

Text Box: Shifting to this model of service delivery will not be easy.  It will require a change in mindset that, to date, has resulted in the mental health system being structured to suit the needs of institutions and providers, not clients.  Shifting to this model of service delivery will not be easy.  It will require a change in mindset that, to date, has resulted in the mental health system being structured to suit the needs of institutions and providers, not clients.  As a first step, it must be recognized that children and youth, and their family caregivers, are full and equal partners — capable of defining the solutions that best meet their own needs.  The Committee strongly supports this approach and therefore recommends:

 

 

 

25

That evidence-based family therapies be employed so that all family members are provided the assistance they need.

That professionals interacting with children and youth with mental illness be offered training opportunities to ensure that they can properly address the mental health needs of their younger clients.

That family-based treatment of mental illness be integrated into the curriculum of mental health professionals and primary care physicians.

That professionals interacting with family caregivers be compensated for this time, in addition to the time spent with the young person living with mental illness.

That all practitioners working with children and youth be trained in children’s rights.

 

6.5       AUTISM

In its first report, the Committee described hearing from mental health professionals who outlined barriers to service delivery, and from family caregivers who spoke of the emotional and financial toll associated with caring for those living with autism.  Their statements, in conjunction with a review of the literature, led us then to characterize autism as a “mental disorder.”  In retrospect, we should have consulted with persons living with autism before taking this position.

During the public hearings that followed the release of our interim reports on mental health, mental illness and addiction, the Committee again heard testimony on this issue.  This time, however, we heard sharply divergent views on what autism is and how the mental health system should respond to it.

Norah Whitney, whose child is living with autism, stated that:

Without effective treatment, autism is a lifelong disorder that results in the placing of over 90 per cent of untreated children in group homes and residential facilities. Only 1 in 64 children will improve without treatment.[256]

Later she noted that:

…almost 50 per cent of children with autism who receive treatment before they enter school, ideally at age 2, will go on to become completely indistinguishable from their peers. In other words, with this treatment, there is a 47 per cent recovery rate. Now, I know many people do not believe in recovery when it comes to autism, but I have seen these children with my own eyes, and if I did not know better, I would never be able to detect one trace of autism in their little bodies.[257]

Ms. Whitney is of the view that autism is an illness[258] that if left untreated will have serious consequences for affected individuals, and their family caregivers.  She advocates the early use of Intensive Behavioral Intervention (IBI), describing it as “the only effective treatment that we have for autism.”[259]  Also, she points out that family caregivers are experiencing financial hardships associated with the high cost of IBI and the fact that often only limited assistance is available under provincial health plans.

Persons living with autism, such as Michelle Dawson, took strong exception to these arguments.  She countered that:

Autistics have been portrayed by autism advocates in the most dire and horrific terms. We destroy ourselves, our families, and the economy, and there are promises that we will shortly ruin the entire country, so long as we are not expensively fixed. Our continued existence, as ourselves, as autistics, is held to be an affront to the whole idea of Canada.

At the same time, autism advocates claim that this impending national catastrophe can be averted if there is unlimited funding for intensive interventions based on applied behaviour analysis, ABA, Lovaas-type or otherwise, for autistics of all ages. …

Autistic abilities and traits are assumed to be non-existent or destructive, useless, and wrong. There is everything to gain and nothing to lose if our lives are dedicated to striving every minute to be normal, that is, non-autistic. The goal of this kind of intervention, Ivar Lovaas has repeatedly written, is to build a person where none exists.[260]

Ms. Dawson is of the view that autism is not a mental illness.[261]  She suggests that what is truly needed is “an accurate and unbiased source of information about autism in Canada.”[262]  In her view, this report is not the appropriate forum for dealing with this issue.

The Committee recognizes that family caregivers are struggling to provide the best care possible for persons living with autism.  Their emotional and financial hardships are very real, and a solution must be found.  However, we do not believe that the Committee is well placed to make recommendations at this time.  Further study is required if we are to do justice to an extraordinarily complex issue where even the most basic question — “is autism a mental illness?” — remains contentious.[263]

In its earlier report, The Health of Canadians — The Federal Role, the Committee laid out the thematic studies to be investigated in future.  We are committed to this work, as evidenced by this study of mental health and addiction.  In future, we hope to have the opportunity to undertake a thematic study on autism.  Meanwhile, we advocate a fuller debate among all stakeholders.  In particular, the Committee believes that persons living with autism must be recognized as full and equal partners in the discussion.

6.6       CONCLUSION

The Committee is deeply concerned about the capability of the mental health system to respond to the needs of children and youth.  Fragmentation, coupled with under-funding, a shortage of mental health professionals, and a failure to involve younger people, and their families in long-term treatment solutions, has resulted in the delayed application of  inadequate treatment interventions.  Simply put, this is unacceptable.  A much greater investment in children’s mental health is required if it is to shed its label as the “orphan’s orphan” within the health care system.  By using the Committee’s recommendations as a guide to restructure the system on an urgent basis, it is our belief that an investment in early intervention will result in significant long-term savings within the health care system, and beyond.


 

CHAPTER 7:
SENIORS

7.1        INTRODUCTION

When we talk about serious and chronic mental illness, we are not [only] talking about Alzheimer's and dementia, which everybody automatically assumes. We are talking about the older adult and senior who have lived their life with schizophrenia, bipolar disorder, or a personality disorder. Because people are aging, obviously we are going to see that more often. These people are probably the most difficult, the most vulnerable and the most forgotten people that we serve.  —Suzanne Crawford[264]

Text Box: Specialized treatment programs and support services for seniors are lacking, as are the research and knowledge exchange necessary for their development and improvement.Today, Canadians have a life expectancy of close to 80 years.[265]  Increased lifespan, coupled with a declining birth rate, has meant that seniors, aged 65 and over, now represent a large and growing proportion of our population.[266]  Of these, 20% are living with mental illness.[267]

Text Box: Efforts to address deficiencies in existing treatment and support services are consistently hampered by the application of a philosophy of simply “warehousing” those who suffer the disadvantage of being both aged and mentally ill.

While this rate of incidence is comparable to other age groups, it masks alarming problems such as the 80-90% of nursing home residents who are living with mental illness[268] or some form of cognitive impairment.[269]  It also fails to reveal the fact that more elderly seniors are facing particularly acute challenges that include high rates of Alzheimer’s disease and related dementias, and for men, a significant incidence of suicide.[270]

In the course of its consultations, the Committee identified a series of significant problems that, while particular to seniors, are simultaneously interwoven within the broader failings of the mental health system.  Regrettably, the Committee found that for seniors, as for other population groups, the available treatment and support services are, in general, inadequate.  More specifically, specialized treatment programs and support services for seniors are lacking, as are the research and knowledge exchange necessary for their development and improvement. 

As well, mental health services are often not available to seniors where they live, an important consideration given the limited mobility of this population.  In addition, the fact that seniors often shift from community-based to institutional-based care is often not taken into account and planned for, making the transition both troublesome for the person affected and inefficient.  Finally, efforts to address deficiencies in existing treatment and support services are consistently hampered by the application of a philosophy of simply “warehousing” those who suffer the disadvantage of being both aged and mentally ill. Sadly there is little focus on the recovery of seniors affected by mental illness.

 

7.2       SPECIALIZED TREATMENT NEEDS

Text Box: …seniors are a distinct group. They deserve strategies, programs and policies that address their particular issues…
—Jennifer Barr
Seniors are not just older adults whose mental health problems can be addressed within generic treatment programs that are supposedly suited to all ages.  They are a demographic segment with unique attributes that distinguish their mental health needs from those of other groups.  A participant in the Committee’s on-line consultation described it this way:

 

 

Seniors with chronic mental health problems are a seriously under-serviced population. They often do not “fit” mental health services/ residential programs developed for adults (they may have physical/functional/cognitive impairments related to aging in addition to their chronic mental health problems), nor do they necessarily “fit” in long term care programs (they may be very physically and functionally well).  —Anonymous

This perspective was echoed by Jennifer Barr of the Centre for Addiction and Mental Health, who stated that:

…seniors are a distinct group. They deserve strategies, programs and policies that address their particular issues, as other groups need idiosyncratic programming across the lifespan. We cannot paint everybody with the same brush.[271]

Also, it is important to recognize that seniors are not a homogeneous group.  They encompass a broad range of ages, and their mental health needs vary within these age-groups from youngest to oldest.

The prevalence of Alzheimer’s disease serves to illustrate this point.  It is widely known that Alzheimer’s disproportionally affects seniors.  However, while this disease touches 1 in 13 persons over the age of 65, its prevalence increases sharply to 1 in 3 in persons over the age of 85.[272] 

Mental health service delivery, and the research that ought to underpin it, must take this diversity into account.  As Faith Malach, Executive Director of the Canadian Coalition for Seniors’ Mental Health, emphasized in her testimony to the Committee:

When we talk about “seniors”, I am not sure whether there is an assumption that we are talking about a large range of people…. There are vast differences between 65-year-olds and 95-year-olds, and when we are collecting indicators and looking at statistics, we need to remember that even within the seniors' population, there is a huge range.[273]

The failure of the mental health system to recognize the uniqueness and diversity of seniors’ needs may be attributed in part to the lack of knowledge exchange amongst researchers in gerontology, as well as between those who provide care to geriatric populations and the broader community of mental health and addiction care providers.  Witnesses went so far as to claim that Canadian researchers working in seniors’ mental health “have no idea who each other are,” despite their small numbers.[274]  The remedy, as Jennifer Barr described it, is that:

We need to provide gerontology information to mental health and addiction providers. We need to provide mental health and addiction information to gerontology providers. That is putting it very simply. Of course, all this material has to be targeted to the individual setting. Again, it has to be particular to the individuals involved and the particular roles that they play. In terms of knowledge exchange, it has to be complemented by broad public awareness campaigns, and peer and consumer support.[275]

Having this in mind, the Committee recommends:

 

 

26

That the Knowledge Exchange Centre to be created as part of the Canadian Mental Health Commission (see Chapter 16) have as one of its goals to foster the sharing of information amongst gerontology researchers themselves, and also between providers of specialist care to seniors and other mental health and addiction care providers.

That the Canadian Mental Health Commission encourage research on the broad ranges of ages, environments (i.e., community versus institutional), co-morbidities and cultural issues that have an impact on seniors’ mental health, and that it promote best practices in senior-specific mental health programs in order to counter the marginalization of older adults within treatment programs that claim to be suited to all ages.

7.3       LOCATION OF SERVICES

7.3.1     The Reality:  A Provider-Driven Model

Text Box: The seemingly obvious solution to this dilemma is to provide mental health services where older adults live, be it in their homes, the homes of their caregivers, or in acute care or long-term care facilities.The mental health system is provider-driven in that it is generally structured to suit primarily the needs of individual and institutional service providers, not their clients.  For example, many mental health services are available only in hospitals or other facilities where health service providers are based.  Other characteristics of this provider-centric model were described by Charmaine Spencer, Adjunct Professor of Gerontology at Simon Fraser University, who testified that:

…they [seniors] are being limited to things such as a 10-minute visit, or …one visit, one complaint. They see signs that say that. That is not conducive to good mental health service at any level or to any kind of health service for older adults. For older adults in these circumstances, focusing on one issue at a time leads to a crisis-type of approach….[276]

The challenge posed to seniors by the provider-driven service model varies, depending on their role as caregivers to another family member, their personal financial resources, and the extent to which their mobility is restricted. 

Mobility may be impaired by a variety of factors. Individual seniors may not be comfortable driving or may be incapable of doing so. In many communities, public transportation may be poorly designed or simply unavailable, especially outside of urban centres.  Even walking may be impeded by poor sidewalk maintenance, particularly in the winter months.  Further, even if transportation is available, seniors often have caregiver responsibilities for a spouse or partner that may hamper their ability to leave the home, and they may lack the necessary funds to make use of respite care or to hire a taxi.  In short, the service provider-driven model poses significant structural barriers to the use of services by seniors.


7.3.2    The Ideal:  A Client-Driven Mental Health System

The seemingly obvious solution to this dilemma is to provide mental health services where older adults live, be it in their homes, the homes of their caregivers, or in acute care or long-term care facilities.  Jennifer Barr put it this way:

…similar to your [the Committee’s] recommendation around school-based programming for young people where you want to provide programs that are easily accessible, for example, having an addiction counsellor or a mental health support group in a school setting. Similarly, because older adults are, for a number of reasons, not as likely to reach a treatment service, we need to provide the addiction and mental health services where older adults are found, in all that variety of settings.[277]

It is not sufficient, however, simply to locate mental health services where seniors live.  It is necessary as well to provide a full range of services that are suited to the population in question.  As Penny MacCourt noted in her brief, submitted on behalf of the British Columbia Psychogeriatric Association:

For many seniors, the factors that affect their mental health are often related to…deficits in their social support system or environment.  Current policy and services…are typically situated within a biopsychosocial model…with an emphasis on the biomedical component.  The biomedical model…focuses on individual pathology and leads to the organization of services and programs that focus primarily on the diagnosis and treatment of mental illness.  There is a narrow focus on cure and acute care.  The biomedical paradigm has led to the neglect of…broader non-medical interventions and community-based services required to support seniors’ mental health.[278]

Thus, services need to be both shifted to the client location and expanded to fit the needs of each particular on-site population. Even once this is done, however, a final step is needed. The gap between the different places in which seniors live must be bridged — that is, the transition of seniors from one location to another over time must be taken into account.

 

7.3.2.1  Tailoring Services to Where Seniors Live

Text Box: The Committee believes that, like those with physical health problems, seniors living with mental illness should be provided treatment and support services in their own homes.Life as a senior is often a series of transitions.  While some individuals may remain in their homes in comfort until they die, many will shift between their own homes, the homes of family caregivers, acute care and long-term care facilities.  The exact details of these transitions are very hard to predict, although we do know that many seniors experience them in some fashion. Seniors may move back and forth between many locations during a period that often extends over three or four decades. 

 

7.3.2.1.1           Seniors Living in Their Own Homes

The Committee believes that, like those with physical health problems, seniors living with mental illness should be provided treatment and support services in their own homes.  This should include in-home treatment services by an appropriate mental health service provider and low- or no-cost delivery of medications. 

But, as discussed above, the delivery of medical or psychotherapeutic services alone is insufficient.  Seniors have additional needs, be they physical (e.g., assistance with the activities of daily living — home maintenance, shopping, cooking, cleaning, or bathing) or social (e.g., visitors or access to library services).

While some recognition has been given to the advantages of maintaining seniors in their own homes, current options are limited.  As Terry McCullum, Chief Executive Officer of Leap of Faith, Toronto (LOFT) Community Services, has indicated:

There are virtually no supportive housing resources if you are an older adult with mental illness and/or addictions….  Your only options are a hospital or a nursing home, but these are expensive, institutional and often not necessary.[279]

The near-absence of supportive housing resources is not attributable solely to financial constraints.  Instead, as Dr. Martha Donnelly, Head of the Division of Community Geriatrics at Vancouver General Hospital, pointed out:

…most seniors I meet want to stay in their own home, and that is a good place as long as you can get support services in. The problem is there are sometimes policies that do not allow you to bring in the appropriate support services for mental health clients. For instance, in B.C. [British Columbia] right now we can get homemaking help for people who need help to take a bath. However, if people are suspicious and isolating themselves, we cannot get the homemaking services in. Their physical health is considered important, but not their mental health to the same degree.[280]

This should not be the case.  The Committee strongly supports the principle that a full range of treatment and support services should be available for both the mentally and the physically ill.  We also support the creation of affordable (i.e., subsidized) and supportive housing (i.e., housing options where assistance with the activities of daily living is available on-site).  Therefore, the Committee recommends:

 

 

 

27

That money from the Mental Health Transition Fund (see Chapter 16) be made available to the provinces and territories for initiatives designed to facilitate seniors with a mental illness living in the community; these initiatives could include, amongst other things, the provision of:

·         home visits by appropriately compensated mental health service providers;

·         a range of practical and social support services delivered in their homes to seniors living with mental illness;

·         a level of support to seniors living with mental illness that is, at a minimum, equivalent to the level of support available to seniors with physical ailments, regardless of where they reside;

  • a more widely available supply of affordable and supportive housing units for seniors living with mental illness.

 

7.3.2.1.2           Seniors Living With Family Caregivers

 

Text Box: Caregiver responsibilities place seniors themselves at risk for mental illness.The issue of support for family caregivers was examined in Chapter 5.  Nonetheless, the Committee believes it necessary to refer here to the particular pressures experienced by those who care for seniors living with mental illness.

First, seniors living with mental illness are often cared for by spouses or partners who are themselves seniors.  These caregivers may have their own physical or mental limitations, which place an added strain on the relationship and heighten the need of both parties for mental health and support services.  As Penny MacCourt pointed out in her submission to the Committee, caregiver responsibilities place seniors themselves at risk for mental illness:

Caregiving women, especially those caring for an individual with dementia…are at increased risk for depression.  Caregivers who receive little social support and who feel burdened and/or lonely are more likely to also experience depression than caregivers with good social support.[281]

Text Box: Caregivers should not be expected to stand in or substitute for services and supports that should be available to ill family members living alone in their own homes.  Second, seniors living with mental illness often have many concurrent physical and mental incapacities.  As a result, they may demand more of their caregivers than a younger family member might.  This reality was described by Karen Henderson in her article entitled “The Dichotomies of Caregiving:  Mental Health Challenges of Informal Caregivers.”  She wrote that:

My caregiving experience taught me that because of the long list of physical and cognitive deficits endured by my father, I ended by adding spouse, parent, personal care aide, friend, chauffeur, decision-maker, advocate, personnel manager, financial manager and funeral planner to my role as daughter.  How could anyone fill all these roles and emerge unscathed?[282]

Although not a senior herself, eventually the responsibility of caring for an older adult living with mental illness resulted in Ms. Henderson herself becoming clinically depressed. 

In addition to recognizing the value of family caregivers and assisting them in that role, steps must be taken to minimize the risk of their developing mental illness.  In particular, caregivers should not be expected to stand in or substitute for services and supports that should be available to ill family members living alone in their own homes.  Therefore, the Committee recommends:

 

 

28

That seniors with a mental illness who are living with family caregivers be eligible for all of the health and support services that would be available to them if they lived alone in their own home.

 

7.3.2.1.3           Seniors Living in Acute Care and Long Term Care Facilities

 

Text Box: Many older adults are being inappropriately “housed” in acute care facilities.  The solution lies in making alternatives to hospitalization more widely available.Under the service provider-driven model, one might expect seniors to receive appropriate mental health services in the acute care hospitals in which most service providers are based.  However, all too often they do not. One reason for this is the widespread perception in acute care facilities that older adults suffering from mental illness should be accommodated in long-term care facilities and thus “spare” the hospital’s limited resources for higher-priority patients. 

Dr. Elizabeth Drance, a geriatric psychiatrist, addressed this perception and the consequences for seniors, in her submission to the Committee:

…our frail elders are still considered “bed blockers” and “placement problems” by our acute care environments due to the stresses within the system for beds.  The importance of elective admission for geriatric medical and psychiatric assessments, thereby avoiding emergency room admissions, is not well understood by our acute care system caregivers.

Many feel that these frail elders do not require admission to hospital at all, and that these beds should be purely utilized only to decant [transfer] patients out of overcrowded emergency rooms.  The stress on the acute care system pushes us further away from creating elder-friendly acute care environments, adding to the stress of hospitalization for our frail older adults [and] worsening their mental health.[283]

Text Box: Today 75 per cent to 85 per cent of the population of personal care homes are persons with cognitive disorders or mental health disorders.
—Annette Osted

…The consequences of this change have not been adequately addressed.
The Committee believes that all Canadians should have access to the acute care system, when and where they need it.  There are circumstances where seniors living with mental illness require hospitalization, and this service should be readily available to them.  We also recognize, however, that many older adults are being inappropriately “housed” in acute care facilities.  The solution lies in making alternatives to hospitalization more widely available.

When seniors can no longer be maintained in their own homes or with family caregivers, long term care facilities are often a next step.  As Dr. Drance has indicated, however, the need of residents for what she terms “care homes” differs from past years:

…I have seen the population of elders within complex care environments [care homes]…change dramatically over the past 15 years.  As more elders stay in their own homes or live in supportive alternatives such as “Assisted Living” environments, the people we are caring for in our care home environments come to us for the following…reasons:

·         Cognitive impairment/Dementia …

·         Severe complex physical illnesses with mobility challenges

·         End of life care

·         Mixtures of all of the above[284]

 

Her views were echoed by Annette Osted, Executive Director of the College of Registered Psychiatric Nurses of Manitoba, who testified that:

The changes in population in personal care homes must be met with changes to what services are delivered and how. Thirty years ago the population of personal care homes were the physically frail and elderly. Today 75 per cent to 85 per cent of the population of personal care homes are persons with cognitive disorders or mental health disorders.[285]

The consequences of this change have not been adequately addressed. There has been an insufficient increase in staffing levels,[286]not enough support for upgrading caregiver skill levels,[287] and too little enhancement of on-site mental health and support services to meet the increased intensity and modification of care requirements that has been the result of this shift.  The end result may be overmedication,[288] the use of chemical restraint,[289] provision of only the most basic or custodial needs[290] — or in short, “warehousing” of our society’s most vulnerable senior citizens.

There are alternatives.  Mental health services can be devolved from acute care to long- term care facilities.  Support services can be adapted to reflect the shift from physically to mentally frail clients.  Committee members who have had a family member living in a long-term care facility described their own experiences with enclosed garden areas employed as an alternative to restraints for persons living with dementia.  Attached to long-term care facilities, such areas enable clients to wander freely but safely. 

Menna MacIssac, Director of Programs and Operations for the Nova Scotia Alzheimer Society, confirmed that best practices for construction of long-term care facilities have already been established. She pointed to these as “…an opportunity to change the physical and pharmacological environment in which people with dementia are currently living.”[291]

Therefore, the Committee recommends:

 

 

29

That efforts be made to shift seniors with a mental illness from acute care to long-term care facilities, or other appropriate housing, where it is clinically appropriate to do so, by making alternatives to hospitalization more widely available. 

That staffing competencies in long term care facilities be reviewed and adjusted, through the introduction of appropriate training programs, to ensure that the devolution of responsibility for patients living with a mental illness from acute care facilities to long-term care facilities is done in a way that ensures that clinically appropriate mental health services are available to residents on-site.

 


7.3.2.2 Managing the Transition

Text Box: While it cannot be predicted when people will make the shift from own home, to caregiver home, to hospital, to long-term care facility, what can be affirmed, sadly, is that the transition between these locations will not be seamless.  While it cannot be predicted when people will make the shift from own home, to caregiver home, to hospital, to long-term care facility, what can be affirmed, sadly, is that the transition between these locations will not be seamless.  Too often it will be inefficient and inconvenient, at worst it may be unsafe.  Dr. Drance described the current situation as follows:

There are many services out there, but right now for a frail senior or their loved one to figure out who to call, where to call, that navigator role is a key one. Family physicians need to be able to navigate the system as well. We have not done a good job of gathering all these services together and helping people access them relatively straightforwardly. It is an incredibly complex system.[292]

There are a number of potential solutions to this problem.  First, resources can be invested to help seniors and their family caregivers better navigate the existing system through the use, for example, of professional system navigators.  Second, there can be greater centralization of transitional services in traditional locations, i.e., where service providers are currently based (pending implementation of the reforms recommended above).  Third, services can be shifted to centralized locations, such as long-term care facilities, where many seniors live.

The Committee believes that the last option would provide the most benefit.  However, we suggest that it be taken one step further.  In addition to centralizing services in locations where many seniors live, we are of the view that different “homes” for seniors should be put in close proximity to one another, perhaps even under one roof.  Menna MacIssac described one such alternative:

There are facilities now, and we have one here in Capital [Capital Health — Halifax, Nova Scotia] called Northwood, which have an array of services and housing options under the same facility so that as people's needs change — and I am not talking about necessarily dementia, but about a person who has care needs — they can progress through different options. That should be looked to as well.[293]

This model has the advantage of addressing simultaneously problems associated with mobility and with making the transition from one housing setting to another.  It also would accommodate situations in which aged couples with different care needs can continue to live in the different settings most appropriate to their needs but still be in close proximity to one another.

Therefore the Committee recommends:

 

 

30

That a range of institutionally based services for seniors living with a mental illness be integrated (e.g., supportive housing units and long-term care facilities) by locating them adjacent to each other, to make the transition(s) between different institutional settings efficient and safe.

That every effort be made to facilitate aged couples being able to continue to live together, or in close proximity to one another, regardless of the level of services and supports that they each may require.

 

7.4       THE DOUBLE-WHAMMY OF MENTAL ILLNESS AND AGING
 

Text Box: I would like us to look at is strategies for eliminating the stigma of the double-whammy of…mental illness and aging. Both are very powerful stigmas, and together they influence the care that people seek and receive.
—Robena Sirett
The Committee heard that mental health and support services for seniors are falling short of meeting real needs.  The question is why?  Having reviewed all of the evidence, we concluded that Robena Sirett, Manager of Older Persons Adult Mental Health Services for the Vancouver Coastal Health Association, was right when she stated that:

A second…area that I would like us to look at is strategies for eliminating the stigma of the double-whammy of…mental illness and aging. Both are very powerful stigmas, and together they influence the care that people seek and receive.[294]

Stigma can be subtle, as in the tendency to consider young adults as the norm for all age groups,[295] thereby justifying the exclusion of seniors from mental health guidelines[296] and negating the need for specialized treatment programs.  It can also be more overt, as in the tendency to locate mental health and support services in locations that are inaccessible to those with physical or mental incapacities.

Stigma finds expression in the sense of fatalism that too often infects society’s attitude toward seniors.  Their symptoms of distress are often dismissed as attributable to “just getting old” or “indulging in a last pleasure.”   Too often seniors are considered a burden, a drain on scarce resources better invested in younger people with greater potential.

Stigma is also reflected in the conditions in which many older adults living with mental illness are expected to exist, where hope of recovery is abandoned to overmedication, restraint, and provision of only the most basic custodial needs.  The “warehousing” of many, many seniors, as cheaply as possible, is perhaps the ugliest expression of an attitude that does not acknowledge the worth of older people living with mental illness.

As described elsewhere in this report, one of the primary mandates of the proposed Canadian Mental Health Commission will be to launch an aggressive ten-year anti-stigma campaign.  A critical objective of that campaign must be to change public attitudes toward seniors who are living with mental illness.

7.5       CONCLUSION

A number of the Committee’s members are themselves older adults.  It is our hope that by drawing attention to the shortcomings in the mental health system that affect seniors, and providing recommendations for change and improvement, our own futures, and those of our children and grandchildren, will be more secure.  In moving forward, we draw inspiration from seniors themselves who, to quote Charmaine Spencer, have pointed out that:

…in their lifetime they have seen other matters that were previously stigmatized, hidden and never talked about, such as cancer, divorce, pregnancy, and developmental disabilities, become normalized through information, education, and social change. They ask why that is not possible here too.[297]

The Committee hopes that the work of the Canadian Mental Health Commission will help to make that “normalization” possible as well.


[147]   As indicated in Chapter 3, the Committee has not been able to devote as much attention to substance use issues as it intended when it embarked on its study of “mental health, mental illness and addiction.” The Committee recognizes that in previous decades, services for the two types of disorder were administered separately; they developed divergent treatment philosophies, used different terminology and constituted different “cultures” that were often in conflict. However, the limitations of this report with respect to substance use issues means that the Committee has been unable to examine fully the similarities and differences in approach in the mental health and substance use fields. Although some examples are drawn from the substance use sector, the main thrust of this chapter is the transformation of the organization and delivery of mental health services and supports. It would clearly not be appropriate for the Committee to assume that conclusions it has reached after carefully considering the mental health evidence necessarily apply with respect to substance use issues. Some may apply, but the Committee has attempted to avoid any unwarranted assumptions in this regard.

[148]   Health Evidence Network, World Health Organization. (August 2003) What are the arguments for community-based mental health care? p. 4.

[149]   Goldner, E. (2002)  Mental health. Health Transition Fund Synthesis Series, Health Canada, p. 8.

[150]   Government of Newfoundland and Labrador. (September 2001) Valuing mental health: A framework to support the development of a provincial mental health policy for Newfoundland and Labrador.

[151]   Government of Newfoundland and Labrador. (2005) Working together for mental health: A provincial policy framework for mental health & addictions services in Newfoundland and Labrador.

[152]   Quebec, Ministère de la santé et des services sociaux. (2005) Plan d’action en santé mentale 2005-2010 — La force des liens.

[153]   Government of Ontario. (1999) Making it happen: Operational framework for the delivery of mental health services and supports.

[154]   Government of Ontario. (December 2002) The time is now: Themes and recommendations for mental health reform in Ontario. Final Report of the Provincial Forum of Mental Health Implementation Task Force Chairs.

[155]   Government of Alberta. (April 2004) Advancing the mental health agenda: A provincial mental health plan for Alberta.

[156]   Every Door is the Right Door: A British Columbia Planning Framework to Address Problematic Substance Use and Addiction. BC Ministry of Health, 2004.

[157]   Community Mental Health Evaluation Initiative (CMHEI). (October 2004) Making a difference: Ontario’s community mental health evaluation initiative, p. 43.

[158]   Health Evidence Network, World Health Organization. (August 2003) What are the arguments for community-based mental health care? p. 5.

[159]   Ibid., p. 15.

[160]   Ontario Federation of Community Mental Health and Addiction Programs. (2003) Outcomes and effectiveness: The success of community mental health and addiction programs, pp. 8-9.

[161]   Ontario Federation of Community Mental Health and Addiction Programs. (2004) The benefits of funding addiction and mental health services, pp. 7-8.

[162]   Ontario Ministry of Health. 2003/4 ACT data outcome monitoring report.

[163]   Examples drawn from: Ontario Federation of Community Mental Health and Addiction Programs. (2003) Outcomes and effectiveness: The success of community mental health and addiction programs, pp. 9 and 12.

[164]    Ibid., p. 9.

[165]   See Chapters 13 and 14 for an extensive discussion of issues relating to the mental health and well-being of people of Aboriginal origin in Canada.

[166]   These reports build on: Government of Ontario. (1999) Making it happen: Operational framework for the delivery of mental health services and supports.

[167]   Quebec, Ministère de la santé et des services sociaux. (2005) Plan d’action en santé mentale 2005-2010 — La force des liens, p. 72.

[168]   1 June 2006, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[169]   1 June 2006, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[170]   Ascentum Incorporated. (2005) Final report on the online consultation by the Standing Senate Committee on Social Affairs, Science and Technology, pp. 28-29.

[171]    9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[172]    9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[173]   15 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[174]   Ontario Federation of Community Mental Health and Addiction Programs. (2003) Outcomes and effectiveness: The success of community mental health and addiction programs, p. 13.

[175]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[176]   CIHI. (30 November 2005) Inpatient hospitalizations and average length of stay: Trends in Canada, 2003—2004 and 2004—2005, p. 10.

[177]   Ibid., p. 12.

[178]   9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.  

[179]   Wiktorowicz, M. (2005). Restructuring mental health policy in Ontario: Deconstructing the evolving welfare state. Canadian Public Administration, Vol. 48, No. 3, p. 392.

[180]   16 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[181]   20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[182]   21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[183]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 2 — Mental health, mental illness and addiction: Mental health policies and programs in selected countries, p. 8,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report2/repintnov04vol2-e.pdf.

[184]   Ibid., pp. 7-8.

[185]   Pepler, E. (October 2005) An evaluation of service delivery and financial data within Alberta for the purpose of evaluating ‘ring-fence’ protection of mental health funding, p. 17.

[186]   See Chapter 16, “National Mental Health Initiatives,” for a full discussion of the creation and composition of the Canadian Mental Health Commission.

[187]   20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[188]   2 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/17eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[189]   9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[190]   Canadian Mental Health Association. (April 2005) Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology.

[191]   15 February 2005,

[192]   16 June 2005,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[193]   6 June 2005,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/18evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[194]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[195]   15 February 2005,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[196]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[197]   2 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/17evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[198]   Lehman, A., Goldman, H., Dixon, L., and Churchill, R. (June 2004) Evidence-based mental health treatments and services: Examples to inform public policy.  Milbank Memorial Fund, p. 14.

[199]   Nick Kates. (17 February 2005) Testimony before the Standing Senate Committee on Social Affairs, Science and Technology, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.  The Canadian Collaborative Mental Health Initiative (CCMHI) is a consortium of 12 national organizations representing community services, consumer, family and self-help groups, dieticians, family physicians, nurses, occupational therapists, pharmacists, psychologists, psychiatrists and social workers funded by the Primary Health Care Transition Fund.  The CCMHI is completing a series of 12 reports on collaborative mental health care in Canada and abroad; before its funding terminates in March 2006, CCMHI will publish toolkits designed to help patients and their families, health care professionals, and policy makers to understand the issues involved in, and work with, collaborative mental health care.  

[200]   17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[201]   17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[202]   17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[203]   Gagné, M. (June 2005) What is collaborative mental health care? An introduction to the collaborative mental health care framework. Report prepared for the Canadian Collaborative Mental Health Initiative, Mississauga, Ontario, p. 4. www.ccmhi.ca.

[204]   Ibid., p. 3.

[205]   Standing Senate Committee on Social Affairs, Science and Technology. (October 2002) The Health of Canadians — The federal role. Final report. Vol. 6: Recommendations for Reform.

[206]   Canadian Institute for Health Information. (Nov. 2001) Canada’s Health Care Providers, p. 39.

[207]   The Canadian Academy of Geriatric Psychiatry and Canadian Coalition for Seniors Mental Health. (June 2003) Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 8.

[208]   Canadian Psychiatric Association. (March 2006) Wait Time Benchmarks for Patients With Serious Psychiatric Illnesses.

[209]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[210]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 2 — Mental health, mental illness and addiction: Mental health policies and programs in selected countries, Chapter 1, p. 14. http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report2/repintnov04vol2-e.pdf.

[211]   Bosco, C. (September 2005) Health human resources in collaborative mental health care. Report prepared for the Canadian Collaborative Mental Health Initiative, Mississauga, Ontario, p. 7.

[212]   Toronto-Peel Mental Health Implementation Task Force. (December, 2002) The Time Has Come: Make It Happen. A mental health action plan for Toronto and Peel, p. xv.

[213]   15 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[214]   For a more detailed explanation, see Employment Insurance (EI) Compassionate Care Benefits,  http://www.hrsdc.gc.ca/asp/gateway.asp?hr=en/ei/types/compassionate_care.shtml&hs=tyt#Who.

[215]   In her November 2004 Report, the Auditor General indicated that the accumulated surplus in the EI account had risen to $46 billion.  See: Office of the Auditor General of Canada. (November 2004) Report, Chapter 8.   http://www.oag-bvg.gc.ca/domino/reports.nsf/html/20041108ce.html#ch8hd3b.

[216]   Reference re Employment Insurance Act (Can.), ss. 22 and 23, 2005 SCC 56. http://www.lexum.umontreal.ca/csc-scc/en/rec/html/2005scc056.wpd.html.

[217]   11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evf-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[218]   Doris Ray, 6 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/18eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[219]   Menna MacIssac, 10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[220]   Christine Davis, 20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[221]   Penny MacCourt, 8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[222]   20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[223]   Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 5, Section 5.1.2, p. 86.

[224]   Ibid., pp. 86-87.

[225]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[226]   9 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/21eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[227]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[228]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[229]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[230]   21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[231]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[232]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[233]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[234]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[235]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[236]   20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[237]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[238]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[239]   Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 8, Section 8.2.6, p. 163.

[240]   9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[241]   For a full discussion of stigma and discrimination see also Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 3.

[242]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[243]   16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[244]   10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[245]   16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[246]   10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[247]   10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[248]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[249]   Global Business Roundtable on Addiction and Mental Health.  (September 2005)  Special Report to the Premiers of Canada:  Guidelines for Working Parents to Promote and Protect the Mental Health of Their Children, p. 2.  Available at: www.mentalhealthroundtable.ca.

[250]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[251]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[252]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[253]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[254]   6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[255]    6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[256]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[257]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[258]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[259]   15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[260]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[261]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[262]   21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[263]    Both the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases, published by the World Health Organization, classify autism as a mental disorder.  However, some experts offer an alternate viewpoint. See, for example, Professor Greg O’Brien’s testimony before the UK Parliament, available on-line at http://www.publications.parliament.uk/pa/jt200405/jtselect/jtment/79/4102708.htm], and that of Drs. Betty Jo Freeman and Dr. Ritvo (12 Employee Benefits Cases 1221, 19 A.L.R. 5th 1017, 910, F.2d 534 (9th Cir.)),  available online at http://www.geocities.com/fishstep/Kunin.html.

[264]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[265]   Statistics Canada. The Daily, Demographic statistics. (28 September 2005) http://www.statcan.ca/Daily/English/050928/d050928a.htm.

[266]   By 2016, it is estimated that seniors will represent over 16% of the population, up from 13% today.  Penny MacCourt.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 4.  By 2026, it is estimated that one in five Canadians will be aged 65 and over, up from one in eight in 2001.  Statistics Canada.  (2002)  Canada’s Aging Population:  A report prepared by Health Canada in collaboration with the Interdepartmental Committee on Aging and Seniors Issues, p. 1.

[267]   Ibid.

[268]   Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 5, Section 5.1.3, p. 88.

[269]   Drance, E.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 2.

[270]   Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 5, Section 5.1.3, p. 88.

[271]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[272]   Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 5, Section 5.1.3, p. 88.

[273]    8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[274]   Malach, F. 8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[275]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[276]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[277]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[278]   MacCourt, P.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 6.

[279]   Fine, R.  (June 2005)  Brief to the Standing Senate Committee on Social Affairs, Science and Technology, Addendum No. 1, p. 1.

[280]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[281]   MacCourt, P.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 4.

[282]   Henderson, K.  (October 2002)  The Dichotomies of Caregiving:  Mental Health Challenges of Informal Caregivers.  In Writings in Gerontology:  Mental Health and Aging  (National Advisory Council on Aging), No. 18, p. 44.

[283]   Drance, E.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 1.

[284]   Ibid., p. 2.

[285]   31 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[286]   31 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[287]   Drance, E.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, pp. 2-3.

[288]   MacIssac, M. 10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[289]   Osted, A. 31 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[290]   Drance, E.  (June 2005)  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 3.

[291]    10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[292]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[293]   10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evd-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[294]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[295]   Spencer, C. 8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[296]   MacCourt, P. 8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[297]   8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.


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