Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 16 - Evidence for May 29, 2003
OTTAWA, Thursday, May 29, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:06 a.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Welcome. Today we will continue our study of mental health and mental illness. Our witnesses this morning are Dr. David Marsh, Dr. Donald Addington, Mr. Robert McIlwraith and Ms. Margaret Synyshyn.
Dr. Marsh, please proceed.
Dr. David Marsh, Clinical Director, Addiction Medicine, Centre for Addiction and Mental Health, University of Toronto: Thank you for inviting me; it is a pleasure to meet with you. I would also like to thank my collaborators and colleagues at the Centre for Addiction and Mental Health, CAMH, whose data I will refer to at various times throughout my presentation. I would like to mention a publication from Health Canada that came out in the last year that is a best practices guide for concurrent disorders. Mr. Brian Rush is one of the principle authors of that report. It is available on the Health Canada Web site and is an in-depth look at concurrent disorders.
I will try to touch on key points that I think are important to give you a framework to think about in respect of concurrent disorders — the combination of substance use disorders and other mental health concerns.
It is important to distinguish between substance use, abuse and dependence. Psychoactive substance use is very common. Abuse is less common and dependence affects only a minority of people who use psychoactive substances. The level of severity of consequences is higher for those with abuse and even higher for those with dependence.
The third slide shows some data from the Ontario Monitor, 2001. Being from Newfoundland, I know that data from Ontario does not reflect everyone across the country. Unfortunately, we do not have a good national monitoring system, so I must rely on Ontario data to give you a sense of the prevalence for substance use affecting Canadians. The last good Canadian epidemiological survey was done in 1994. I look forward to some renewed effort at national monitoring coming out of the new national drug strategy that was announced this week — or perhaps as a recommendation from this committee.
You will notice amongst Ontarians that lifetime use of alcohol affects practically everyone — 93 per cent. A small number of adults in Ontario have never consumed alcohol. About one-half of Ontarians have consumed 100 or more cigarettes at some point in their lives, which would constitute lifetime consumption of tobacco. More than one-third have used cannabis at some time in their lives. Cannabis consumption is occurring in a large minority of adults in Ontario.
The proportion of people who have used those substances in the past year or in the last month is much smaller. That will reinforce the point that those who are affected with frequent regular use leading to adverse social consequences is a small minority of all those who use substances.
The Ontario Monitor does not capture a large enough number of people to have statistically significant data on drugs such as cocaine or heroin, which are used by a smaller minority. That would be another important element, if a national monitoring system were put in place, that it capture enough members of Canadian society to give us good data on drugs that are used by smaller minorities of people.
Substance abuse as opposed to use has a clear diagnostic definition in the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM-IV4. It reflects a maladaptive pattern of use, which means that someone takes a psychoactive substance in a way that adversely affects his or her behaviour. If someone takes morphine for pain and they function better with it, then that would not constitute part of the criteria for abuse or dependence. If someone has a maladaptive pattern of use that causes adverse psychological or social consequences such as failure to fulfil major obligations at work or at home, or continued use despite harm, but they do not meet criteria for dependence, they may meet criteria for abuse.
This is important because people who do not meet criteria for dependence often do not see themselves as candidates for treatment. Yet, brief interventions or education can have significant positive impact on these kinds of people. For instance, someone who drinks five or more drinks on a regular basis is at a higher risk for having unsafe sex and acquiring diseases; at a higher risk for committing domestic violence or for having motor vehicle accidents. A 15- minute intervention by a family physician taking a good alcohol-use history and expressing concern about the consequences could dramatically decrease their alcohol consumption and decrease the consequences. These people who meet the criteria for abuse constitute a larger portion of society than those who have dependence.
The proportion of people who have used a substance and meet criteria for dependence is small and it varies by substance. For example, only about 5 per cent of current cannabis users — or less than 1 per cent of the general population — meet the criteria for dependence on cannabis. I have given you the criteria for dependence in the handout. They basically constitute: more than six months of repeated attempts to cut down, compulsive use despite harm, and significant adverse psychological and social consequences. They can, but necessarily include physical dependence with symptoms such as withdrawal or tolerance.
The consequences of dependence vary also with the substance and the social situation. In general, the consequences of being dependent on a substance are greater if the use of that substance is less socially acceptable. For instance, amongst people who are regular daily users of an illegal substance such as heroin, there are very severe adverse consequences — both for those individuals and for society. Dr. Benedict Fischer, a scientist at our centre in 1999, published a study in addiction research. The exact reference is in the material that I provided.
He recruited 114 regular heroin users in Toronto and administered a questionnaire to them to determine the consequences of their heroin use. He found that the overwhelming majority — over 80 per cent — were male; that more than one-half of them were in temporary housing; that just over one-half of them had been employed at some time in past year, although only one-third had income from a job in past month. You can see high levels of unemployment and unstable housing.
The majority were on some kind of social benefits, but they had more income from illegal activities in the last month than they did from government sources or employment. He also asked them about their known prevalence of diseases that are transmitted by injecting drugs such as hepatitis B, hepatitis C and HIV. He did not do testing then, but we are now in the middle of a larger study that does involve testing to confirm the prevalence. The figures in the handout would reflect a lower estimate of the prevalence of these diseases. Given the acquisition of diseases and the high levels of homelessness and unemployment, you can see the impact on society as well as on the individuals when someone is dependent on a drug such as heroin.
I want to emphasize a point about heterogeneity — about the range of problems when you talk about concurrent disorders and substance abuse. With respect to the range of drugs and combinations of drugs that people use, in the 2001-02 fiscal year, we saw about 20,000 clients at the Centre for Addiction and Mental Health. Just over 7,500 — or 37 per cent — of these people were treated in the addiction programs. Of those people treated in the addiction programs, about 50 per cent identified alcohol as the primary substance that brought them to treatment; 20 per cent identified cocaine; 10 per cent identified cannabis — that may surprise you because many people mistakenly think that cannabis is harmless but there is definitely a minority of cannabis users who develop significant complications; 7 per cent came primarily for smoking cessation; and about 5 per cent with problems with opiates.
The vast majority of in-patients and out-patients identified problems with multiple substances. I have provided the data on the range of substances that people identified. Amongst those who received in-patient treatment, although only 50 per cent came primarily for treatment of alcohol dependence, 80 per cent identified alcohol as a problem; 24 per cent identified cannabis as a problem — higher than those who identified tobacco; 50 per cent of the in-patients and 29 per cent of the out-patients identified cocaine as one of the problems that led them to seek treatment.
This heterogeneity — this mixed bag of substances — that leads to a mixed range of consequences and the need for a range of treatment interventions that match the individual's social skills, social situation and consequences of substance use.
I also want to highlight for you some evidence that we have around the prevalence of disorders. The Centre for Addiction and Mental Health, CAMH, was formed five years ago. One of the rationales for merging our organizations was to deal more effectively with concurrent disorders. In 2001-02, we piloted a new instrument called the "resident assessment instrument for mental health," RAI-MH. This is being proposed as something that the Canadian Institute for Health Information, CIHI, will collect for all in-patients in psychiatric facilities in the country. I do not think that decision has been made yet. It would be useful to have some kind of standard assessment that is applied to all in- patient psychiatric facilities in the country so that we could collect data on things such as the prevalence of different kinds of complications of mental health and different diagnoses from different facilities across the country.
One of the pieces of data that actually surprised many of the staff at the centre was the high prevalence of addictive problems amongst people who are admitted to the mental health programs for treatment of their mental health disorders. Many of the staff had expected that figure to be around 30 per cent to 40 per cent, which would be in keeping with much of the published literature. In fact, this instrument indicated that for 70 per cent of the people admitted to most of the mental health programs at our centre, addictive problems were one of the top three that they were experiencing at the time of their admission.
I want to talk a bit about our response to concurrent disorders. Many physicians and health care providers are pessimistic about the effectiveness of treatment for substance use. In surveys of family physicians, one of the main reasons they identify for not asking about substance use in their patients is that they feel there is nothing effective they can offer. That is not true. Treatment for substance use disorders is very effective. In 2000, Dr. Tom McLelland, Dr. David Lewis and colleagues published a paper in the Journal of the American Medical Association in which they compared the effectiveness of treating substance use disorders with treating other chronic relapsing conditions such as diabetes, asthma and hypertension. The figures are comparable, with about 60 per cent of people having treatment success at one year for substance use disorders. I have also included some data from our evaluation of our methadone maintenance program.
Senator Morin: What is "MMT treatment" in slide 3?
Dr. Marsh: MMT is methadone maintenance treatment. It is the most effective treatment we have for heroin or opiate dependence.
The next slide shows you some data from our own methadone maintenance treatment evaluation where we conducted a six-year retrospective evaluation of our program during a period when availability of methadone maintenance was rapidly expanding in Toronto and Ontario. Dr. Bruna Brands and I are also co-authors of another best practices manual that was released in November by Health Canada with a literature review dealing specifically with the topic of methadone maintenance.
The data from our program shows that within the first six months of admission to a methadone maintenance program, about 40 per cent of the patients were able to achieve sustained abstinence from opiates. There was no significant change in their use of cocaine or benzodiazepines early in treatment. However, for those patients who were retained for four and one-half years or longer, about 85 per cent of them were drug free from cocaine and benzodiazepines.
If those people who are dependant and regularly using heroin having high levels of homelessness and unemployment and acquiring HIV and hepatitis, that Dr. Fischer studied in his profile of Toronto heroin users, can be engaged in treatment and kept in treatment for a period of time, they make very dramatic gains in decreasing drug use. I am not showing the data in getting back into the workforce and decreasing the risk of acquiring diseases and acquiring stable housing.
Unfortunately, we are not able to engage all drug users in treatment. For some, treatment is either unacceptable or ineffective. We need to have a range of responses, including what are often called "harm reduction initiatives." I have included one slide showing you data from the Swiss heroin trial. This data comes from a paper in the Lancet published last year by Dr. Juergen Rehm and colleagues. Dr. Rehm has recently come to Toronto as the chair of addiction policy.
You can see that in a group of people who were dependent on injection heroin and failed other treatments, prescribing heroin to them that they inject in an environment under supervision of medical professionals led to a fall in unstable housing from 43 per cent to 21 per cent. Homelessness practically disappeared: It went from 18 per cent to 1 per cent. Unemployment fell as did daily use of cocaine, and use of street heroin fell dramatically.
Even though they continued to inject heroin every day, they were doing it with medicinal heroin that was free of impurities in a known dose. They were doing it under the supervision of health care providers and engaged in counselling. The consequences of that heroin use dramatically decreased.
The Chairman: Would such a study be legal in Canada? That is to say, is there a legal reason that would prevent a similar study being done in Canada? Would the law say that you cannot give people heroin?
Dr. Marsh: Within the context of a clinical trial, were it to be approved by Health Canada following the clinical trials application process, it would be legal in Canada. I am involved in a group that is pursuing exactly that project for Canada.
The Chairman: You are pursuing it in the sense that it is not underway. You are pursuing the application? Is the study actually underway?
Dr. Marsh: We are in the process of gaining various regulatory approvals.
In summary, substance use is very common — especially if we look at alcohol, tobacco and cannabis. There is an important distinction to be made between use, abuse and dependence. The distinction hangs mostly on the consequences of use with those who are dependent having the most severe consequences. There is also heterogeneity around which drugs are used as well as the consequences in which concurrent disorders can occur.
Treatment can be effective. We need multiple approaches to treatment. We need a range of treatment options as well as other options such as syringe exchange, safe injection facilities, and heroin trials that do not necessarily lead to decreased drug use but can address the consequences of drug use.
Dr. Donald Addington, Professor and Head, Department of Psychiatry, University of Calgary: I would like to commend the committee for addressing this very important issue. Of all the areas in health, if you have major impacts on mental health services, you will end up with the greatest return on investment for the general health of the populations. I have been asked to focus on the major adult disorders: depression, schizophrenia and anxiety disorders. My recommendations are around some patient issues, systems issues, clinical service delivery recommendations and some research recommendations. They are fairly generic but apply particularly to the adult disorders. I am speaking as a health care professional and clinical researcher with administrative, academic and health service delivery responsibilities. I am sure that patients and consumers can speak for themselves as well.
However, from a patient perspective, addressing a couple of major issues would make a big difference — and they are related to access to timely and appropriate care. These kinds of things can be achieved through a patient charter with access to mental health care and primary care. On the whole, this is not available; you can get care from physicians, but not from other professionals in primary care.
There are significant issues for access to specialists, specialized services and acute care. The recommendations can be in the form of a charter or, more bureaucratically, in terms of defined wait lists and thing like that.
There is an issue around access to comprehensive evidence-based care. You have just heard much detail on effective treatments for addictions. This applies across treatments for all mental disorders. Very often, there is not access to evidence-based care. That is a major problem. That can be addressed by defining the services available under the Canada Health Act that should be available to different groups and categories.
I have some specific recommendations. A good start is that there are hearings at a national level on mental health. That is an important achievement. It would be very possible to set national mental health goals. Those obviously have to be negotiated between provincial and federal governments. That is embedded in all of these issues. It is not my business to get into the details of that. For a practical example, goals might be set around reducing suicide both at the societal level and for those who are actually in contact with mental health services.
We really need a policy framework to guide the implementation of mental health services. That does not exist. It may need to exist at an individual provincial level, but that needs to be done.
Then there are issues related to funding. With respect to funding for mental health, a concern is that it really has not kept up generally with funding for health services. A particular way of addressing that is to focus on population-based funding approaches, so that you define the funding that would be available to a set population and then deliver the services in the most appropriate place for that population.
The final systems issue is really an accountability framework that addresses two things: one is performance measurement and as well as some sort of oversight agency to ensure that those performance targets are met. Again, that is primarily at the provincial level, but there have been discussions and recommendations about a national one as well.
The important thing from a systems perspective is those mechanisms should occur and, specifically, they should be addressing mental health. The Canadian Institutes of Health Information, CIHI, have a working group looking at performance measurement in mental health. However, more work is needed in that area.
In the area of service issues, it is important to remember that adult mental health issues occur in late adolescence and early adult life; and then, very often, the major ones tend to persist over time. Whereas we tend to think about health as more of an issue for the older population, mental health is still a major issue for the generally healthy population. That affects the kind of services and funding that needs to be provided because funding formulas are often weighted toward the older population.
The specific recommendations around services are that the services should be based on the disorders treated and population served — adult services, children services and seniors' services. We know a great deal about the prevalence and the impact of disorders; we are just hearing details about addictions; other areas are very well known. We can calculate the number of cases and the kinds of services that need to be provided for that population. Through such a "needs-based" approach, we can provide services appropriately.
We need another recommendation as national support for clinical practice guideline development dissemination and implementation. Those are the practical guidelines for clinicians on how to deal with particular cases. We also need treatment teams with defined service goals and objectives for different groups of individuals — certainly the severe and persistently mentally ill — as well as support teams for primary care. The specialized mental health services cannot deal with the large burden of mental disorders that are dealt with in primary care, but they can enhance the care to that population through shared care programs and services.
We need improved information systems that provide support across the continuum of care so you can support the ongoing care in lower, less intensive and expensive levels of care. We need improved collaboration between social and health care providers. When patients with severe mental illnesses are discharged from hospital and they have no place to stay, that is a big problem. In the current environment, it is difficult to get the regulatory agencies, authorities and accountabilities for those services working together.
Finally, around research issues, I have a couple of specific recommendations. Federal health research budgets should be allocated on the basis of burden of disease for society. This is not currently the case in Canada; it is, in fact, the case in the United States. The National Institute of Mental Health and the addictions research institutes receive funding based on the burden of disease in the community. Mental health research is significantly underfunded and can have a big impact.
We need an increased number and quality of university-based research centres associated with care delivery organizations. For example, we have seen great advances in the collaboration in heart health services, where there is an intensive relationship between research and health services delivery. That close relationship does not tend to exist in the mental health services in the same way.
The Chairman: Thank you. You have raised many questions, but we will hear the other presenters first.
Mr. Robert McIlwraith, Professor and Director, Rural and Northern Psychology Programme, University of Manitoba: Thank you for the invitation to speak about mental health. The primary focus of my remarks today will be on the issue of access to mental health services.
I want to address three points. First, access to cognitive behavioural therapies, which, for many mental disorders, are as effective as medications, less costly and preferred by patients in many cases. Second, I want to talk about access to psychological services in the public health care system; and third, I want to talk about access to mental health care services by recruitment of mental health professionals to rural and northern areas of Canada.
With respect to access to service is that people want therapy, not just drugs, when they have mental health problems. I agree that medications have an important role to play in the treatment of mental disorders, particularly in acute or emergency care of severe mental disorders. However, it is also true that many — if not the majority of patients — when asked what kinds of help they would like with their mental health problems, say they would like to talk about their problems with some qualified person who could help them solve their own problems themselves.
There are people who do not want this type of help. They prefer, for their own good reasons, to just have a prescription. That is fine; they should have that choice. However, many people who are also taking medication still have things they would like to talk out and solve with professional help. Many individuals, when given a choice, say that they would prefer to have psychotherapy rather than be treated with medications. This is particularly the case in studies where the details of the different treatments and their efficacy and side effects have been explained to people beforehand.
This is particularly the case with depression and anxiety disorders, which are very common and where ample research shows that cognitive behavioural therapy, CBT, and other science-based psychotherapies have approximately equal efficacy to drugs, often without nasty side effects and, in many cases, with less of a relapse problem later.
The first point is that patients should have the choice of a non-pharmacological treatment if they want it, or combined treatment if they want it. With the increasing cost of prescription medications, cognitive behavioural therapy may even be more cost-effective than pharmacotherapy in the long run.
In the past decade, a combination of aggressive marketing by pharmaceutical companies and some cutbacks in funding for health care services is in danger of creating a system where treatment for mental disorders is equated only with medication; where everything other than medication is seen as social support and no longer the responsibility of the public health care system but rather a job for the volunteer sector. Families and support groups fulfil important roles, but they do not claim to be providing psychotherapy. The mental health system — squeezed as it is — seems to be abandoning the idea that treatment includes therapy. Persons with mental health problems, however, have not abandoned that idea.
My first recommendation is that the mental health care system should re-emphasize psychotherapy as treatment, not just drugs. There are extensive data to show that cognitive behavioural therapy is as effective as medications in many cases and can be more so in the long run for many mental disorders. Furthermore, it is often the patient's preference. It is also the case that people living in rural and remote areas have much more problem accessing psychotherapies, hence they are more likely to be treated with medications than people in urban centres.
Since I am a psychologist, I am aware that professionals from a number of backgrounds are trained to provide CBT, but because my background is psychology in the training of psychologists, I will talk briefly about access to psychological services in the public health care system.
There has been much spirited discussion about the dangers of Canada falling into a two-tier health care system. Such a system already exists, unfortunately, in quite an extreme form in the case of access to psychological services. Psychologists' services are not covered under medicare, as insured services, in any province. If people have the money or private insurance coverage, they have access to high quality psychological services, often within days or weeks. If they are dependent upon the public health care system, however, they will encounter long waits for the available psychological services in hospital out-patient departments or services based in schools, if they can even find them embedded in those institutions.
Psychologists are certainly out there in the community in professional office buildings or in practices located at the local mall, just like family physicians. However, the family doctor's services are insured while the private psychologist charges a fee. Despite this difference, however, psychologists in private practice are in high demand. The gap between fee-for-service incomes and salaries for psychologists in the public sector is leading more and more psychologists to forsake the public system, which will further limit access based on the ability to pay.
Excessive reliance on a pharmacological model of treatment within public health care institutions also leads to some psychologists leaving the public system. As a result, it is important to re-emphasize that the choice of psychologists to increasingly practise in the private sector rather than in the public sector is not a choice that is made in isolation. Psychologists in public practice have historically been inadequately paid, especially given the number of years of postgraduate training required to become licensed. In view of the fact psychology services are not insured under any provincial health plan, the availability of psychologists in the public system is constrained by the availability of salaried positions within the public institutions, which are frequently strapped for funding.
My second recommendation is that a variety of alternative mechanisms for funding psychological services should be explored in this country so that all Canadians — not only those who are better off — have access to the services of psychologists, if they need them. Certainly, the experience of private insurers in the United States has shown that inclusion of psychological services in health insurance schemes there has typically more than paid for itself due to the offsetting decrease in other health care costs for mental health and physical health problems, including hospitalizations and disability.
The third point I want to mention is in regard to mental health services in rural and remote areas. Delivery of health care services is always a matter of economies of scale. Canada, because of its geography, poses some significant challenges. We have a relatively small population spread across a very large territory. By Statistics Canada's definition, almost three quarters of Canadians live in urban areas, or within commuting distance of urban areas. While we frequently hear urban Canadians complain about their access to health care services, the real problem is for that one- quarter of Canadians who live in the other 90 per cent of the country, which are considered rural or remote communities by Statistics Canada's definition. Furthermore, 65 per cent of Canada's Aboriginal persons live in rural or remote areas, by Statistics Canada's definition. All of the economies of scale work against efficient delivery of mental health services in rural and northern communities.
Access to mental health services — as with all health care services in rural and remote communities — is a matter of recruitment and retention of health care professionals in these locations. Rural areas are significantly under-served by mental health professionals compared with urban areas. In Canada's urban areas, there is one psychologist for roughly every 2,000 people; in rural and remote areas, there is one psychologist for approximately every 10,000 people. I am sure the same sort of rural urban disparity applies for all other mental health professions as well.
I want to describe a program we have established in the Faculty of Medicine at the University of Manitoba to address the shortage of psychologist practicing outside of Winnipeg. Prior to this program, there were virtually no doctoral level clinical psychologists practising full time outside of Metropolitan Winnipeg. The rest of the province, up to the border with Nunavut and Hudson's Bay, had either under-qualified persons or occasional fly- in services from psychologists.
In 1996, with funding from the Manitoba health department, we established a rural and northern community-based training program for psychologists. There are now full time doctoral level registered psychologists in Thompson, The Pas, Flin Flon, Dauphin and the Interlake. They provide services to outpatients in the community, and also to small mental health in-patient units that have been opened in general hospitals in these communities. They also consult with community groups on prevention programs and public education.
We provide them with backup to help them do their jobs because they have to be generalists. In the North, you will see one or two of every kind of possible case that you would see larger volumes of, in the south. In addition, we send interns to spend six months or 12 months in rural areas under their supervision. This is so these trainees can have a taste of a rural practice for six months or a year with a clinical supervisor right there, and see what life and practice in a rural community is like. We expose them to the challenges and rewards of rural practice.
Some people find it is not for them and they head straight back to the city. Others find that they quite enjoy it and like to practise there. In the past seven years, we have trained ten interns and four post-doctoral fellows and have hired five of them for positions in Thompson, The Pas and Dauphin.
We recognize there will always be turnover in rural and northern communities. People typically last two to three years before moving on, although we have had one staff psychologist with us for seven years. People will move on. We decided we would evaluate our success based on how long the position remains vacant after someone leaves — not how long someone stays. In most cases, when someone has left the North, we have been able to replace them the next day or the next month with another trainee from our programs. We are able to keep bringing in trainees and replacing their supervisors later on.
My last recommendation has to do with the use of telehealth in remote areas. Telehealth is interactive television video through the Internet. We use this to support our psychologists up north and to provide extra training and supervision and collegial contact to our trainees when they are up north. We use it to provide them with access to specialist consultation when they run into complex cases. I believe strongly that while telehealth is a wonderful support to the professionals working in remote communities, it should not and cannot substitute for them. In all areas of health, perhaps especially in mental health care, the personal contact between the professional and the patient is essential. Talking via TV to a psychologist in Toronto or Atlanta is not the same as face-to-face psychotherapy. Some might counter that telehealth service is better than no service at all. I do not accept the premise that the alternative has to be no service at all. Our experience in the past seven years has shown that it is quite possible to deliver high-quality health care service by fully qualified psychologists to people in rural and northern communities.
The danger is that if you provide service only by telehealth, it reinforces the impression that the mental health problem dwells in that individual client or patient if the professional at other end of the TV link sees nothing of the context in which that person lives or the context they will be returning to following treatment.
Psychologists who live in rural and northern communities also have the opportunity to become involved in prevention, community development and education. I remind them that they are role models and I send them to every high school career day in every town in the North so that some student in a northern town might start thinking that they want to be a psychologist some day.
My final recommendation, therefore, is to use this telehealth technology as a support to our colleagues in rural and remote communities — not as a substitute for them. I fear that provincial governments might embrace telehealth excessively and see it as the solution to this difficult recruitment problem of finding professionals for the North, but I think that would be going too far.
Ms. Margaret Synyshyn, President, Registered Psychiatric Nurses of Canada: On behalf of the Registered Psychiatric Nurses of Canada, RPNC, I would like to thank the Senate committee for the opportunity to speak to issues that we feel are of the greatest importance to all Canadians. The RPNC has forwarded a written submission to the committee regarding mental illness and mental health. I will not read that submission, but I will try to emphasize some things that the RPNC feels are necessary for a comprehensive approach to mental health and mental illness in Canada.
Registered psychiatric nurses have been providing professional mental health services to Canadians for more than 75 years. We are a regulated profession and we have regulatory bodies and accredited educational programs in the four western provinces of Canada. Registered Psychiatric Nurses, RPNs, are not an entity in Eastern Canada. I have provided you with supporting documents regarding our code of ethics, our standards of practice, components and competencies, as well as provincial legislation.
The RPNC strongly supports the recent call by the Canadian Alliance on Mental Illness and Mental Health, CAMIMH, for a national plan for mental health. The federal government needs to set a strong tone and standards for mental health service delivery in Canada or mental health services will continue to be the "orphan child" of the health care system — a system that continues to focus on high-end technologies, out-dated medical models and systems of remuneration. This system frequently has little appreciation for the connection between mind and body and how this relates to overall health.
The focus in the past has always been on the treatment of illness after the fact. Although commendable and, of course, of the utmost importance, both the literature and recent research have begun to look at different models of how we conceptualize health, which focus on the before-the-fact concept. We know that many physical illnesses are preventable or more easily treated if identified early. This is also true in the area of mental health and mental illness.
Early intervention is a principle that applies to all areas of mental illness and across all ages. Early intervention applies in the case of at-risk populations, such as those individuals who may be at risk for developing psychotic disorders or those who have suffered trauma due to life events or individuals who do not have strong coping skills due to a number of circumstances in their early lives.
Research and early intervention is undisputable and points to better outcomes for individuals who are able to access a range of services from a range of service providers in settings close to where people live and work. It is most effective — from both a human perspective and a financial perspective — for individuals and families to access services before their symptoms interfere with the quality of their family life, their social life, educational preparation or employment.
In our submission, we have spoken to the need for embedding mental health services as a component in a primary health care model for service delivery. Principles of this model include: Essentiality — ensuring that mental health services are included as a universal standard of delivery; community participation — helping persons with mental illness build personal capacity so that they can participate meaningfully in decisions that affect them; intersectoral collaboration — having all services necessary for a reasonable quality of life available, not supporting the traditional stovepipe models that serve to fragment and compartmentalize services; access — providing home care to those with mental illness so that they can remain in their homes and ensuring that those who have employment can afford the medication that is prescribed to them without having to make a choice about quitting their jobs or going on social assistance so that their medication costs can be covered; and, finally empowerment — ensuring that everyone has a voice and that the respect that is a right is demonstrated throughout society.
The RPNC believes in the concept of naturally occurring supports for persons with mental illness. Families, colleagues and friends continue to be the ongoing support when all the professionals have gone home for the day. We believe that a commitment by government at all levels for financial support to groups that advocate self-help and empowerment to individuals with mental illness will go a long way in combating stigmatization and creating awareness about mental illness.
We believe that there is urgency in putting words into actions. We know that one out of every five people are likely to experience some type of mental disorder in their lifetime. According to CIHI, in 1995-96 hospitals devoted 5.5 million bed-days to people affected by mental disorders — twice the number of hospital days devoted to people with all forms of cancer.
The current literature speaks to the high incidence of co-occurring disorders — addiction and mental illness. Mental health issues and mental illness can no longer be treated as someone else's issues. These are everyone's issue and the time for a national response is now.
The Registered Psychiatric Nurses of Canada thank you for this opportunity and thank you for your time and attention.
The Chairman: Why are you registered in only four provinces? What is wrong with the East?
Ms. Synyshyn: It has to do with the development of nursing in Canada. In the West, they tended to follow the British model, which had not only generally prepared nurses but also psychiatric nurses and nurses prepared in midwifery.
The Chairman: Do you mean at nursing schools?
Ms. Synyshyn: Yes. We are a separate body of knowledge and we have separate educational systems.
Senator Morin: We Easterners must realize that this is not a specialization; they train as psychiatric nurses.
The Chairman: As opposed to being registered nurses plus?
Ms. Synyshyn: That is correct. We are registered psychiatric nurses.
Senator Morin: You might stress this point. We are not familiar with it.
Ms. Synyshyn: You would not be, although at one point in Nova Scotia there were registered psychiatric nurses and a registration body. I have not been around that long, so I am not sure what happened there. However, there are registered psychiatric nurses in Britain. We do a lot of exchanges of registered psychiatric nurses among Commonwealth countries. There are RPNs in New Zealand, Australia and Bermuda, and we have reciprocity to some degree.
The Chairman: There are nurses in the East who are fulfilling the same function as your members in the West, but they are not trained in the same way?
Ms. Synyshyn: I do not know about that. I know that within Western Canada, registered psychiatric nurses provide a wide range of mental health services — much of it in the communities. I do not know how well they are incorporated into mental health service delivery in Eastern Canada. I know that within hospital settings RNs work in acute treatment units. However, but in terms of community I think that many RNs who might be working in the area of mental health are masters prepared. Many of them get into the field after they have worked in the mental health field for quite a while. However, in Western Canada our people are prepared at entry level.
The Chairman: We will have to find out how the eastern program works.
A number of witnesses over the last couple of months have talked about the need for a national mental health plan. I liked the words Dr. Addington used. He called it a national action plan. I want to emphasize the word "action." You then talked about getting the federal government and the provinces to do something — which is a plan for "inaction."
None of you may have an answer right now to my questions. However, I would like to have your views on these two questions. First, what are the major components of such a plan? Forget about the intergovernmental process, we will handle that. My second question also deals with something two or three of you raised: You suggested that there ought to be a number of things covered under medicare that are not now covered under medicare. You did not put it that way, but that is what you implied.
To have any practical hope in the world of selling that, one needs to be able to carefully ring-fence what is inside the tent and what is outside the tent. Let me give you a concrete example of what I mean. In our previous health report — contrary to what some of the media said — we did not support universal home care. The home care we talked about was post-acute home care. The only way you could get into the program was by being discharged from a hospital. It is service-based funding, so the guidelines were clear. It was not a sinkhole that was going to go off somewhere. More important, it saved money because you would move people out of an expensive bed into a less expensive bed.
We could really use your help on this issue. You and your colleagues in the business may wish to comment generally on this question. How do you tightly ring-fence what is to be included inside the "medicare covered" tent if you were to expand it beyond hospital and doctor services? Unless you can persuade ministers of finance — federally and provincially — that the ring-fence is really there, you have not a hope, because they will see it as a sinkhole.
That is a simple question to open it up. I would love to hear your comments.
Dr. Addington: One way of doing that is to define clearly your target populations in terms of their disorders and their disabilities. At the moment, that is how people get into different components of the health care system. If you are acutely ill, totally disorganized, at risk to other people or yourself, then those are criteria for acute-care hospitalization. You could treat that for one or two weeks and then follow through with home care.
There are some people who are suitable for acute-care treatment who can be treated before hospitalization. That group can be clearly defined. The numbers can be described and the services delivered.
Early intervention is another area that was mentioned. As an example, we used to count schizophrenia in terms of its prevalence — that is, the number of new cases per year, by hospitalizations. We can now deliver services whereby less than half end up coming into hospital at presentation. They can be seen and identified in the community.
We know fairly clearly how many new cases per 100,000 population to expect. We can set up early psychosis- identification services that reduce the length of time between when people get sick and when they are seen. At the moment, it is an average of one to two years in the major mental disorders.
Senator Morin: Are these early detection services not already covered by medicare? The chair's question dealt with areas that are not covered by medicare but should be.
Dr. Addington: The issue is you can conceive at the moment that those services can be covered. However, mostly the services do not exist. The ones that are very clearly not covered were mentioned. They include individual psychological treatments. However, they are sometimes available within the health system, but the quantity is incredibly limited.
Dr. Marsh: In response to your question about a national action plan and the issue of how we distinguish between what should be funded and what should not be funded from public monies, the first key component is good data on which to make decisions. We have some types of data, such as prevalence, incidence for new cases of major mental illnesses. We do not have reliable data even on prevalence of substance use disorders in Canada. We certainly do not have good data on outcomes from different treatments using well-accepted outcome measures such as disability- adjusted life years or some other measures.
If someone were to make a case that, for example, the services of an individual psychologist or a registered psychiatric nurse should be funded from public funds, then there should be data to demonstrate that those services would be more cost-effective than what is currently offered by public funds. For that matter, what is currently paid for out of public funds should be analyzed under that lens.
The Chairman: I totally agree with you. However, here is the problem: The collection of that data is a multi-year process. Meanwhile — and I will exaggerate to make a point — nothing happens. The question we need to think through is: What are we doing in parallel? We cannot do it in the optimal research way, whereby we first get the data then make the decisions and put them in place. We must start doing something now. The question is: How do we move in parallel?
Dr. Marsh: My comment is that throwing money at a problem without good accountability mechanisms is not likely to be effective.
Mr. McIlwraith: I agree with that. I think we are all supporters of data and comfortable with basing service decisions on data, particularly if you have data that indicate that certain interventions reduce the number of hospital admissions or reduce the chronicity lifelong.
There is not a complete absence of data. There have been a number of studies done in other jurisdictions, which this committee has likely reviewed. Many of us could present you with articles showing things like medical cost offset of various treatments and benefits of early intervention in terms of cost savings. Of course, it is hard to put a price on the degree of disability from mental health disorders.
In the case of the sinkhole question, I am not necessarily advocating, in the case of psychologists, that they be put on a fee-for-service basis similar to physicians. There are a number of funding models. The Canadian Psychological Association has looked at this a number of times. They have looked as psychologists in primary care practices and capitation kinds of systems. There are lots of different ways.
My point is that it is hard to go to Thompson and hang up a shingle because you do not have a billing number. People coming to see you either must have cash or there has to be an existing salaried position in Thompson before you go there. There are a lot of different models to define the populations and activities in a fairly accountable way.
Ms. Synyshyn: I work in the area of child and adolescent mental health. I work in a facility that has a hospital-based service, bed-based. We have a large community component that we actually initiated in 1994. We used to have 25 beds.
The Chairman: In what community?
Ms. Synyshyn: Manitoba.
In 1994, we had a 25-bed hospital setting for adolescents. Those beds were full. That year, we got the opportunity to provide some community-based service that was not physician-based. It was a multidisciplinary team that worked in the community. Since 1994, we have closed eight of those beds and we anticipate more closures. The fact of the matter is those beds are not being used. Once you do put services in the community, a multidisciplinary service where people can seek service prior to getting so bad that they end up in emergency room, your need for costly bed-based services decreases. That is a fact. I have lived it. I know what happens.
The fact of the matter is that you have to push those services a lot of times kicking and screaming into the community. That is where they need to be delivered. It needs to be a multidisciplinary perspective. Not everyone needs the same kind of service.
Dr. Addington: Many services are currently provided in the community and those services are for defined patient populations with identifiable needs that can be measured and assessed. There is much good data indicating that these are effective programs and we do not need to wait for more research to be able to deliver on a practical and coherent mental health plan. In fact, it is already being done in the United Kingdom and in Australia. There are good recommendations out of the Surgeon General's office but they do not really have an organized health system.
Senator Morin: Dr. Marsh, I fully agree with your need for an accountability performance measurements information system. There is a gap there that is probably more important than for other diseases and other specialties.
I would like to have your opinion on the bill regarding the decriminalization of marijuana that is before the House right now. With regard to the national drug strategy, I read the press release from the CMA that it was underfunded by 50 per cent but that generally it was satisfactory. What is your opinion on the decriminalization of marijuana bill and the national drug strategy presented by the Minister of Health?
Dr. Marsh: It is fortuitous that I am here this week.
The Chairman: You may think it is unfortunate.
Dr. Marsh: The Centre for Addiction and Mental Health does have an official centre position on the issue of cannabis regulation. The centre's position is in favour of decriminalization, with the clear statement that changes in cannabis control policy should be in the context of an overall health strategy and that changes should be made gradually and monitored carefully. From the organization's perspective, we support the bill. We are also glad to see the national drug strategy.
In terms of how the funding is allocated and the amount of funding within the national drug strategy, I have not seen in public releases the detailed distribution of the $245 million. We are assuming that it is new dollars, as opposed to currently allocated dollars. We certainly welcome any significant increase.
The positive part of the new national drug strategy is that it puts in place a system of monitoring and biennial reports to Parliament so that there will be repeated opportunities to evaluate the effect of changes and for the Canadian public to speak in favour of ongoing support for these changes.
Senator Morin: If in the future you should, Dr. Marsh, have suggestions, changes or additions to the plan, we would appreciate hearing them. I know it is possibly too early for you to have made a good study of it, but we would be very interested. For us, the plan is already there. We cannot reinvent the wheel every time, but we would welcome your views pertaining to any additions or corrections to the plan.
Senator Robertson: In our previous study, whenever we had a group before us we heard much about the lack of people in the health professions. I have not heard anything about that issue from the witnesses this morning. It sounds to me as if Manitoba is doing reasonably well in some areas.
We have heard about some of the gaping holes that exist in the delivery of mental health. Could you tell me about the availability of mental health workers — from psychiatrists to psychologists to nurses and everyone else who is involved? What is the ratio that you would like to have for your population? How much has to be done in bringing the number up?
That ties in with another question. We have been advised that there is such a lack of mental health services in Canada for residents in long-term care facilities that we are accused of warehousing, and that 80 per cent to 90 per cent have mental disorders of one form or another. We are very obviously not doing very much for those people.
Perhaps we can consider the medical ethics or the lack thereof. If you look at the warehousing of senior citizens without consideration to caring for them properly, what is our responsibility? We are failing. If this is true, is it because we do not have enough resources? Is it because the profession does not care and chooses not to work in these facilities? I would like your comments on these matters, please.
Dr. Addington: I specifically did not mention the issue of numbers and training because of the focus of the questions we were asked. However, you are correct. This is a major issue across all of the mental health professions. I am more familiar with psychiatry, because that is my profession and I am responsible for training and developing a local workforce plan.
With regard to the attendants for long-term care facilities for senior people, we have a few people locally who do that. They work most effectively with teams of individuals. Psychiatry is very much focused on working with teams. There is a role for the individual expertise of particular professional groups.
We provide a few people who provide consultations. We do need more training positions nationally. There is a position paper from the Canadian Psychiatric Association that specifically addresses that point.
Senator Robertson: How many more?
Dr. Addington: We are looking at a doubling of the number of psychiatrists.
Senator Robertson: Is this true in psychology as well?
Mr. McIlwraith: I think so. I would like to make a correction if I gave the mistaken impression that we are heavily staffed in Manitoba. Perhaps I could say we are doing good but we are not doing well.
The Winnipeg Regional Health Authority has about 30 EFT psychologists. That is it. Although we have had the opportunity to do some interesting things, we are probably at half the national average for urban areas in terms of the number of psychologists in practise in the City of Winnipeg. The national average is substantially better than that.
As far as seniors are concerned, there is a significant gap in training programs. There are not many people coming out of psychology graduate programs who are trained to work with seniors in mental health or physical health rehabilitation areas.
Senator Robertson: Why is that so? Is that because it is not glamorous?
The Chairman: There will be a lot of us in the next little while. We would like some of you to be around.
Mr. McIlwraith: You would think that smart people would be able to project that and we would be training more of them.
We are adding positions. We currently have advertisements out for psychologists to work both in communities and institutions with seniors. There must be more people working before you can bring people in and train them in those settings. I do not have a good answer for that.
Senator Robertson: Could you say that again?
Mr. McIlwraith: More people need to be working in the community and with seniors in order to provide the training for the next generation of trainees coming along. I do not have a good explanation for why that area has been ignored.
Ms. Synyshyn: There is a split between mind and body. I do not know that the mental health component of anything that goes on is considered. Often it seems to be split off from physical concerns and that kind of thing.
Perhaps we are getting to the point where we will be able to talk about those things from a more holistic approach. We can thank our Aboriginal community for starting to point out some of these things. Perhaps we can look to other cultures to start talking about the idea that there are all different aspects of things that go on with us — not only physical things.
Psychogeriatrics, by the way, is a growth industry. If anyone wants to go into it, think about it.
From my perspective — and I am not a physician or a psychologist — but frequently, there seems to be a split between service delivery and academia. I am sure anyone with a professional background will understand that often universities or education institutions prepare people in a certain way. Yet, in the field, there is not a good fit between the academic world and service delivery issues. You are not always responding to the need. It is not a terrible thing, but I think some of that goes on. People are not necessarily prepared to go into certain areas, or it is not seen as particularly glamorous as in the case of geriatrics.
There is also a great need in neuro-developmental medicine, working with kids who have autism and different things. A lot of it is starting to appear on the radar, but there are large areas of under-serviced populations within mental health. Mental health itself is under-serviced, but many of these things have an impact on that.
Senator Morin: You referred to the number of psychologists being low in Manitoba, Mr. McIlwraith. What is the situation throughout Canada?
Mr. McIlwraith: The Canadian Psychological Association has done a report. I can certainly send you a report using Statistics Canada definitions of rural and urban communities. I quoted some figures on that. With respect to national distribution, I know that the largest proportion of psychologists per capita is in the Province of Quebec. That is the richest province in terms of psychological service availability.
As you move into the smaller provinces and into the North, the ratio is much smaller on a per capita basis. I do not have those figures from memory, but I could send the committee a copy of that report.
Senator Morin: Do we need more, generally? For example, we need to double the number of psychiatrists. We know that. Do we need to double the number of psychologists in the country?
Mr. McIlwraith: The question has to be this: If you need more, what do you need them for? We have to identify what the tasks are. I have certainly said that there are a number of areas. Certainly, we do need more science-based psychotherapies in mental health. We need more access.
The point is, again, that there are more psychologists in a province than people in the public system can access. There is a barrier to their getting that service. Therefore, even though we are producing more psychologies, we are losing them out the other door into private practice because of the problems I mentioned.
Senator Fairbairn: Your presentations here today justify the decision of this committee to pull the mental health issue away from our major report. In itself it is huge and, obviously, undervalued.
We had some great witnesses yesterday. We heard a significant amount about stigma. When I look at what you have said today and the general inability within the health care community to focus on this. In our technological day and age, it is not rocket science to know that everyone is under tremendous and increasing pressure and stress. That obviously has to come out somewhere. It would be in the mental and emotional stability of a great chunk of our population.
Yet, from everything we are hearing, this is the part of health care that just has to fight every inch of the way to be recognized, promoted and accepted.
Historically, how much of this is stigma within the medical profession itself or within the scope of, for instance, young people that you would hope would be wishing to come in in greater numbers?
Ms. Synyshyn: All you have to do is look at the history of mental illness. People who were mentally ill years ago were kept in institutions outside the cities, put away. You did not want to see it.
You have to look at the development. There is a parallel, in some ways, with the professionals who have worked in that setting. Not only do our clients and patients feel stigmatized, in fact, but also many people who work in the area of mental health are kind of feeling behind the eight ball to begin with.
Mental illness is not a sexy topic of conversation. It is much better to talk about cancer and other things. It is a very emotional subject. It is difficult for people to talk about and acknowledge, because it is frightening. That is part of it. Historically, it has been treated as being "out there."
There may be some hope to be had as well. CMHA, CAMIMH and many other advocacy groups are finally bringing it to the fore. If it were not for the advocacy groups, we still would not hear as much about it as we should.
Mr. McIlwraith: Stigma may be part of it. Another problem is competition within the health care system, since there are so many things competing for health care dollars. Mental health services have typically not fared well in that competition. Part of it is that maybe these are sort of low-tech services. They do not have much fancy equipment.
Senator Fairbairn: The mind is a piece of fancy equipment.
Mr. McIlwraith: We do not have big scanners or complicated equipment.
The Chairman: You do not have the kind of thing that Senator Keon has at the Ottawa hospital.
Mr. McIlwraith: We have pencils and paper, and we talk to people. There are not things you can donate and put a plaque on. The health care system seems to put a lot more emphasis on high-tech equipment and invasive procedures.
We are talking about conditions that often begin in late adolescence or early adulthood. Many of the decisions about health care are made by more vocal, older adults who have conditions that require surgery and invasive, heroic measures.
In the rest of the health care system, we see that governments would often rather buy dialysis machines for every neighbourhood clinic than spend any money on public health care prevention to prevent diabetes that leads people down the road to needing dialysis and all these other complicated invasive things.
Mental health suffers in the competition for resources with the other health care areas because we do not have much flashy equipment or invasive, life-saving procedures that might be required in your 50s and 60s.
Dr. Marsh: Stigma is a real issue for people with mental health. It is even more of an issue for people with substance use disorders, especially if they are dependent on illegal drugs. It is difficult to shift the enormous inertia within the health care system. As a society, we are afraid of death and we spend an inordinate amount of our health care dollars on the last few days of people's lives with very expensive, technically involved interventions that do not contribute a significant amount to quality of life. Whereas effective treatments for mental illness applied in late adolescence or early adulthood could lead to a long life of quality and productive contribution to society.
In respect of attracting professionals, we also should not underestimate the degree to which professional schools are still essentially like apprenticeships. One of the strongest factors in determining which sub-specialty medical students choose is which faculty members they admire most during early training years. As long as there is not a body of well recognized and respected leading academics who work with older adults, or in psychiatry or in treating addiction, it is difficult to attract new graduates into those areas.
Senator Fairbairn: Anybody in this room would agree that all you have to do is go home at night and the phone calls start coming in asking to support this, that or another cause. I was astounded by the comment that there is virtually no non-governmental funding for research in mental disorders. This eliminates an important level of research support for developing researchers.
Why is no one prepared to step forward and take on an issue that is probably starting to formulate by the time a child gets to grade one? I would think this is not only a heroic and noble, but also a tremendous investment to make in our population and its future.
Dr. Addington: I agree with you. The practical reality is that in regard to national level mental health funding, the Canadian Psychiatric Research Foundation recently did a tour across Canada trying to raise funds. However, that has been the only organization to do so. I work with them, have reviewed for them and have a lot of respect for them. They do not give much money out. Students know that, too. They support a few junior investigators each year.
It is completely different for the Kidney Foundation, the Heart and Stroke Foundation, or organizations for cystic fibrosis or children's health research. Those groups raise millions of dollars. That does not exist for us.
The competition for federal funds is intense and difficult. When you are starting up, you need some more local funds. It is sort of like a league system, really. Smaller grants are given to have research on more focused questions and simpler methodologies. This is a societal issue.
There is a general lack of knowledge of the benefit and need for research in these disorders. People are pessimistic about that, but the reality is that the research is being done, and it does show great benefits. The Canadian Institutes of Health Research are now broadening the kinds of research that they will support. It tended to be biomedical in the past; now it is basic, clinical and health services research, which looks at how effective they are. Then there is the social or population-based research that looks at whole populations, policy and so forth.
Senator Morin: What prevents the Canadian Mental Health Association from doing that?
As you said, it is not easy. You have to go door to door and organize events and find volunteers. However, there are so many volunteer organizations. This is a typical Canadian success story. In other countries, you do not have these health organizations raising money for research, as they do in Canada. You do not have that in the U.S.
What prevents the Canadian Mental Health Association from doing that? I realize it is not easy. If someone from the Canadian Mental Health Association rang at my door, I would give money. However, they do not come.
Dr. Addington: You need to ask the support organizations those questions.
The Chairman: We will certainly do that when they appear.
Ms. Synyshyn: I wanted to say, "Write a cheque before you leave."
Senator Fairbairn: Clearly, at a time when so many things in health care are exciting, rocketing all over the media and around the world, this area needs one much more communication effort in a targeted way.
I do believe that if people in their homes and in their communities understood better, they would fork out the money. Mental health should not be explained in hushed tones. There is not a community in Canada that does not have people with mental health issues living within it. We always hear about Australia and New Zealand. Why do we not hear information about Canada? We are supposed to have a social conscience.
Senator Keon: Ms. Synyshyn, I congratulate you on the accomplishment of your program. There is something very interesting there. Do you have any idea of the cost effectiveness of the institutionalizing program, and more importantly, of the integrated multidisciplinary program that allowed you to do this? Did you experience cost containment or did your costs escalate as you moved into the community?
Ms. Synyshyn: Our costs decreased. We actually moved money from the hospital-based services into the community- based services. A community-based service is always cheaper to run than a 24-7 operation. We have been able to save enough money so that when we started out in 1994 with eight community-based clinicians we have, now in 2003, 18 of them. We have closed hospital-based, very costly services and doubled our ability to provide community-based services. That is using it as a human resource; we support our human resources that way.
We have received increased funding for our community-based services because of the efficacy of them in terms of where the service is provided. We have been able to prove that the kids who normally would have ended up in those beds have been able to stay in the community because we started at a younger age, identified them earlier. We have intervened in a more aggressive fashion. We have maintained kids out in the community as opposed to bringing them into a costly 24-7 operation.
Senator Keon: Could you supply us with some hard information on that?
Ms. Synyshyn: I certainly will do that. I must make the point that that is my day job. I will be sure to give that information to the committee.
Senator Robertson: As a supplementary comment, in my province of New Brunswick, a big problem in getting the mental health workers attached to our extramural hospital is the lack of trained people. We do that as much as possible.
The Chairman: That is why you asked the human resource question.
Senator Robertson: That is right.
Senator Keon: Dr. McIlwraith, you made a very interesting comment about telehealth that I have never heard made before. I have quite a lot of experience with telehealth myself. The hypothesis of our programs was that you could exploit telehealth to use less skilled health professionals to deliver the service satisfactorily.
You seem to make the point that this should probably not be done in mental health and that you should have the expert living body beside the patient. This is different from our experience in this area.
Dr. McIlwraith: In part, mental health is different from physical health. Someone can have a look at an X-ray sent to a tertiary care centre by telehealth. That does not usually require the same relationship with the patient that a mental health assessment, let alone mental health therapy, requires.
We all love technology and we tend to see it as the solution to everything. However, technology is the solution to some things and not to others. Mental health is different from physical health. I made the additional point that having professionals living in the community has other helpful benefits in terms of their involvement in other areas of their profession in the community such as planning, health research and health promotion — more than simply treating a symptom in the symptomatic patient.
The other point that I would like to make about the telehealth is that the medium changes the nature of the interaction. In some areas, it does not matter much while in other areas it would matter quite a lot. It is true that you cannot have a full range of specialists in every northern community but having access to those specialists helps the generalists to not burn out. If you are a generalist, front-line psychologist, psychiatrist or physician, you have to know a little about many things. One of the most important things to know is when to consult with someone with greater specialized knowledge. Being able to spread the benefits of having those specialists in tertiary centres and making them available to support the person in a rural community is the tremendous value of telehealth. I would not want to be misunderstood as not being in favour of telehealth.
However, I am concerned when I hear suggestions that we should move radically to provide all services through telehealth and not bother with the messy expensive business of recruiting and retaining professionals in rural communities. We need to support them by consultation to specialists because otherwise they would not have that benefit at all. I do not see telehealth as a substitute for the personal contact. Mental health care is simply different. It is an extreme of that.
Dr. Marsh: If you are interested in the issue of telehealth, I would encourage you to try to get some input from the Psychiatric Outreach Program of University of Toronto, which is based at our centre. I am not personally involved with the program, but my understanding is that on some evaluations they have shown that treatment over the Internet can be as effective as person-to-person treatment.
However, I do not think it is a black and white issue — I agree that, where possible, having a professional live in the community would give them different kinds of input and influence. I do not think you should have the impression that remote treatment is impossible for mental health.
Senator Morin: Perhaps instead of a real person at the other end you could have a computer.
Dr. Marsh: I would like to ask a question to Dr. Addington about a different topic.
Senator Keon: To answer Senator Morin's question, in tele-home care, the technology is simply that the patient sits in front of the television set. They do not have anyone with them and it works very well. I suppose it is different in mental health applications than in physical applications such as teaching someone how to bathe their foot or something.
Dr.. Marsh, you said something very encouraging during your presentation about the outcomes. This is truly encouraging information. I do not think most people are aware of this; I am not aware and yet I am a medical doctor.
I want to push you further. One thing that seems to compound the problem in looking at drug use and abuse, for example, is that young people are institutionalized in the criminal system rather than in the health system. Do you have any data comparing the outcomes of people who have been criminalized as opposed to those who have not?
You all know how difficult it is for someone with a criminal record to get into university — it is impossible. The doors of life are closed to these young people. I would like to hear from you or perhaps from Dr. Addington, or any other witness, if there is comparative data on this.
The Chairman: May I add a question to that? Does anyone have data that compares the relative cost of treatment with the cost of incarceration? It must be cheaper to deal with the problem at a younger, earlier age from a preventive standpoint than to pay the price to maintain an individual in a juvenile detention centre or ultimately in a jail. If you have data, I would like to have that.
Dr. Marsh: Thank you for your comment on our outcome data. I feel very confident in pushing us more toward databased decisions because of the effective outcomes and strong cost-benefit of treatment for addiction.
The impact of incarceration is a negative prognostic factor in individuals who have substance use disorders. It is difficult to do a comparative study of two people who are otherwise identical except for the incarceration. The issue of incarceration brings me back to the earlier question about the cannabis reform bill. One of the benefits of decriminalization of cannabis is that we would no longer be subjecting mainly young men in their late teens and early 20s with a lifelong criminal record for possession of a small amount of cannabis.
I talked about the centre's position on cannabis reform earlier. My personal opinion was changed by Senator Nolin's report. I would think that there are other benefits to moving more radically toward legalization of cannabis and removing the criminal involvement in production and distribution of cannabis. Decriminalizing possession would not change the fact that the people who grow large amounts and sell it would continue to be criminals. It would remove the government's ability to influence consumption through pricing and taxation, which has been effective for tobacco.
In comparing the costs of incarceration against treatment, for the cost of incarceration of someone for a heroin possession offence for one year, you could treat five people with methadone maintenance. We know that methadone maintenance is more likely to decrease the heroin consumption than incarceration will. Additionally, the Solicitor General announced that part of the national drug strategy was to move toward making methadone maintenance more available for people who are incarcerated in Canada. The Canadian Medical Association Journal published a paper last year that looked at mortality and morbidity among people in the federal corrections setting. The single biggest contributor to premature death of people in federal corrections is accidental overdose due to drug use.
Senator Léger: Dr. Marsh, I loved your made it easier to understand the issues of mental health and the related problems of housing, employment, social benefits and illegal activities. Do all of those departments ask you for information?
The diagram showing the reduction and percentages in Switzerland is unbelievable. I hope those who are studying housing do go into things, because it is powerful.
Dr. Marsh: We sometimes have opportunities to make presentations to different governmental and other bodies — some of which are looking at issues around homelessness.
Senator Léger: Dr. McIlwraith, you talked about rural and remote areas and how you have the supervisor there and you send the trainee. If I understood correctly, once the trainee has finished, you have another trainee the next day.
Is there a danger that in these areas they feel they are sort of "guinea pigs" all the time? That word is strong, but I have seen that in another field, not health, where they come and train the people and then off they go back to Montreal, once they are well educated.
Dr. McIlwraith: I hope that is not the case. These are clinical psychology interns who are at the last stage before receiving their Ph.D.s, so they are fairly skilled to begin with. Certainly, they are also providing service in the teaching hospitals in the city and so on. As we all know, teaching hospitals are run by interns and residents, so many of the people who provide you with care in teaching hospitals in the cities are interns or residents.
Previously, the situation in many of these communities was that if they had any psychology service at all, it was from people who had less training than a psychology intern. However, we clearly try to give the message that we are not seeing students as the solution to the human resource problem in rural areas.
The students are there to learn and to gain experience. The supervisor is still responsible for their cases and the students are there to sample rural practice. Some of them will like it and we hope to hire some of them as we have vacancies. Others will not like it and will go away, having had an interesting six-months' experience in a rural area and maybe learned something new.
I have not had any feedback from the regions indicating that they find it offensive to have trainees. In fact, they are very eager. If we ever have to skip a year without sending a trainee to a particular region, they will ask us, "Are we not getting an intern this year?" They see it as a doubling of service to have the staff person plus an intern.
Senator Léger: I think it can be dangerous in the sense that the people themselves may feel as if they are second- class.
What do you do if speech is not the method of help? Do you have a method to help those people who need mental help but do not express it through words? I thought telehealth was a guide, not an answer.
Ms. Synyshyn: One of the psychiatrists I work with has quite broad experience working with individuals who are more comfortable speaking through the computer than face-to-face. She does a fair amount of work with individuals who are fairly isolated, but are more than happy to engage in a discussion. They form their relationship through the computer. She does this with a number of people who are very reluctant either to come out of their homes or just do not want to engage in a face-to-face. There are different ways you can use the technology, but you have to be very careful about it as well.
Senator Léger: Do they talk?
Ms. Synyshyn: They talk by type.
Senator Léger: Supposing they do not talk? That might be another line.
The last thing I would like to say that while there is the high specialty in the West, even if we do not have the organization for registered psychiatric nurses in the East, we could surely have someone come to talk about how we are in this area, including Quebec.
The Chairman: In that sense, it will be useful for us to understand the nature of the training nurses receive in the East who do the work you do in the West. I know you cannot give us that, but I know that the woman who represents the Canadian Association of Nurses is here. That was really said for her benefit.
Dr. Marsh, you had a question for Dr. Addington — and to show you how we never play by any rules, that is fine, go ahead.
Dr. Marsh: Dr. Addington mentioned population-based funding as a recommendation in his presentation. I was curious how he would deal with the problem of population-based funding for centres such as ours, which offer treatment of a specialized nature to people referred from across the province and, in fact, across the country and around the world. We would not be able to offer those services if we were funded based on the problems arising out of a defined catchment area, such as the number of people in the western half of Toronto.
The Chairman: Dr. Addington can answer for himself, and Senator Morin wants to make a comment. However, that is not what I heard Dr. Addington say.
I understood him to say that the allocation of funds from — for example, CIHR — to the various areas of health where it allocates funds ought to be based on the relative incidence in the population of a particular disease, not — to use Ms. Synyshyn's word — the "sexiness" of the particular disease.
I will let Senator Morin make his comment, and then I am curious to know what he really did say.
Senator Morin: I am interested in Dr. Marsh's comment because I tried obtaining data on the support for research in the fields of addiction in Canada from the Centre for Addiction and Mental Health. We can get it in the U.S. and U.K, but it is apparently impossible to get in Canada.
Perhaps the first thing, Dr. Marsh, is to have an actual figure for the research that is being done in your field, and then we can increase it — but it is absolutely impossible to obtain.
Dr. Marsh: I hope I have not confused the issue, I was speaking about population-based funding for treatment as opposed to the burden of illness-based funding for research, where I would agree with his recommendation.
Dr. Addington: I did make two separate recommendations; one was about research funding and one was about mental health services funding. Population-based funding can be applied at any level of system organization. You could say at a provincial level it will be X dollars per person per year. Obviously, some of that will go to community- based services; some might go to regional specialized services that support the whole province. The basic concept, though, is that the funding is available to mental health at a discrete and specific level, and you get away from some of the competition within the acute care services.
Within the current health system, it tends to favour the acute care sector. There is a piece of mental health in there, but it does not address the broad and optimal way of delivering health services. If you can provide a community service and prevent them coming in, that is preferable.
Senator Keon: I think this is an excellent idea because you can combine epidemiology with your health care programs. Furthermore, the adjustments are quite simple to make for national and international referrals into a population-based funded health institution. With the systems the way they are now, the numbers just fall out at the end of each month, and various governments can respond to them. Indeed, with the interprovincial schedules, you get reimbursed from the other provinces anyway. For out-of-country, there is usually another solution.
The Chairman: I thank all of you for coming. We greatly appreciate your taking the time to be with us.
Senators, I have one quick item. I need a motion to allow me to move $300 from our transportation budget to goods done.
Senator Fairbairn: I so move.
The Chairman: The second item is that next week, after our Wednesday session, I need about 15 minutes in camera. Please keep that in mind.
The committee adjourned.