Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 5 - Evidence -  Wednesday, March 31, 2004

OTTAWA, Wednesday, March 31, 2004

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 4:13 p.m. to study 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.


The Chairman: Honourable senators, I want to apologize to our witnesses for being late. There was a Royal Assent with the Governor General. We felt that we needed to be there to provide a corporal's guard, or whatever.

Before we start, this is Senator Roche's last committee meeting, after being with us for a long time, and through all our trials and tribulations in producing our original health care report. I know he would like to say several things before we start the hearing.

Senator Roche: I want to express my appreciation to the Chair, the Vice-Chair and all the members of the Standing Senate Committee on Social Affairs, Science and Technology for the many courtesies extended to me. Membership on this important committee has been extremely important to me. The health care study done by the committee has made an invaluable contribution to public understanding of complex issues and has, I hope, acted as a catalyst for the development and advancement of policies to strengthen Canada's health care system.

Before joining the committee, health care had not been one of the primary focal points of my life. I am still far from expert. However, I have learned a great deal through the processes of the committee, and for that I am deeply grateful.

This is one of the great committees of the Senate, well led by Senators Kirby and LeBreton. I am proud to have been a member. I am grateful also to Howard Chodos and Odette Madore, two perceptive researchers, and to Daniel Charbonneau, the clerk, and to others with whom I have been associated.

Mr. Chairman, I wish the committee well, particularly as you continue the important mental health care study.

The Chairman: Thank you very much, Senator Roche. I will say to the witnesses and the other people in the room — many of whom have been around the health care file a lot longer than the rest of us — that I am sure you found it amazing that we were able to reach a unanimous decision on all of the recommendations we have made on what is an otherwise extremely controversial subject, on which it is usually impossible to get two people to agree. It happened through all the people on the committee, particularly people such as Senator Roche. He is an independent member of the committee, was a member of the House of Commons for many years, and came to the Senate as an independent member. Our unanimity has been through the willingness of everyone to listen to other people's points of view, to be willing to debate issues and, ultimately, to reach consensus solutions that were not arrived at by trading off but by saying we have to take positions that are in the best interests of the Canadian public.

On behalf of us all, we will miss you, Senator Roche. It has been fun having you around. Thank you for holding our feet to the fire on several issues. We might very well have not ended up where we did had you not pushed so strongly for certain points of view — points of view that we all came to completely understand. I thank you very much for that.

I have been instructed by my colleague Senator Cook from Newfoundland that there is a reception for Senator Keon's replacement upstairs in the foyer that starts at 6:30 p.m. We will end sharp at seven o'clock because, as Senator Cook pointed out, an Upper Canadian like Senator Keon is finally being replaced by a Newfoundlander. The new head of the Ottawa Heart Institute is from Newfoundland. I say this as someone whose parents are Newfoundlanders: You do not keep a Newfoundlander waiting for a drink. I have been threatened that I must end promptly at seven o'clock. We will try to run on time today.

We have two panels, both of which include people who deal with the provision of mental health services. On the first panel, from the Canadian Medical Association, we have Dr. Sunil Patel and Dr. Gail Beck. We also have Dr. Paul Garfinkel, who is both Chair of the Mental Health Working Group of the Ontario Hospital Association and also the CEO of CAMH, the Centre for Addiction and Mental Health in Toronto, and Dr. Blake Woodside, Chairman of the Board of the Canadian Psychiatric Association.

Welcome to you all. Dr. Patel, you may begin.

Dr. Sunil Patel, President, Canadian Medical Association: Thank you. Honourable senators, I thank you for the opportunity to speak to you on the critical need to address mental health and mental illness in Canada. As the chair identified, I am joined today by my colleague, Dr. Gail Beck, who needs no introduction. She has served this community as well as the communities of Hamilton and Montreal for the last 20 years in the field of child psychiatry. She is very knowledgeable on issues being discussed today.

I want to talk briefly about the dimensions of the issues, the instruments available to government to address them, and the CMA's specific thoughts and recommendations on moving forward.

As the members of this committee know, the economic toll exacted by mental health disorders, including stress and distress, topped $14 billion in 1998. The human cost, however, extends far beyond dollars and cents.

Estimates show that about one in five Canadians — close to six million people — will be affected by mental illness at some point in their lives. This number climbs still higher if one includes the serious problem of addiction to illicit drugs, alcohol, and even prescription drugs and tobacco. Yet, our society and health care system remains woefully inadequate in promoting mental health and in delivering care and treatment where and when needed. These systemic shortcomings have been exacerbated by the twin barriers of stigma and discrimination.

These barriers have a detrimental effect on recovery from mental illness and addictions by hindering access to services, treatment and acceptance in the community. This is especially unfortunate because the effective treatment exists for most mental illnesses and addictions.

Poor mental health affects all aspects a person's life and requires a collaborative approach. Family physicians, psychiatrists, psychologists, social workers, nurses, and other counsellors can be involved in one patient's mental health care. While family physicians can deal with a number of mental illnesses, most are not trained in the complicated medical management of severe mental illness. Many family physicians' offices are also not sufficiently resourced to deal with family counselling or related issues such as housing, education and occupational problems often associated with mental illness. As a family physician myself, I should be assured that when a patient's mental health care requires additional expertise, the appropriate resources are available for my patients and their families.

Physicians are striving to ensure that care is provided by the appropriate caregiver at the appropriate time. For example, the Shared Mental Health Care Initiative of the College of Family Physicians of Canada and the Canadian Psychiatric Association is designed to lead to better outcomes for patients. I know the committee will hear more about this initiative from the Canadian Psychiatric Association. I mentioned it now simply as a reminder that progress is being made and even more can be gained with the establishment of a national strategy to address mental illness and mental health.

Canada is the only G8 nation without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children's mental health services and dire health human resource shortages. A case in point is that there are no child psychiatrists in the northern territories, where such care is so desperately needed.

The fragmented state of mental health services in Canada did not develop overnight and it would be overly simplistic to say problems can be solved immediately. However, it is important to understand there are means available to the federal government to better meet its obligations with respect to surveillance, prevention of mental illness, and promotion of mental health.

The way forward has been clearly described by the Canadian Alliance for Mental Illness and Mental Health, and the October 2002 National Summit on Mental Health and Mental Illness, hosted by the CMA and the Canadian psychological and psychiatric associations. This gathering helped define the form that a national strategy should take.

Participants recommended a focus on national mental health goals — a policy framework that includes research, surveillance, education, mental health promotion, health human resources, adequate and sustained funding, and an accountability mechanism. In addition to a national strategy, the CMA believes it is also important to recognize the deleterious effect of the exclusion of a hospital or institution primarily for the mentally disordered from the application of the Canada Health Act.

Simply put, how are we to overcome stigma and discrimination if we validate these sentiments in our federal legislation? The CMA firmly believes the development of a national strategy and action plan on mental health and mental illness is the single most important step that can be taken on this issue.

The plan also requires support — wheels, if you will — to overcome the inertia that has foiled attempts thus far. Those wheels come in the form of five specific actions that are listed at the back of the presentation before you. However, to summarize, they would include amending the Canada Health Act to include psychiatric hospitals; adjusting the Canada Health transfer to provide for these additional insured services; re-establishing an adequately resourced federal organizational unit focused on mental illness and mental health and addictions; the review of federal health policies and programs to ensure the mental illness is on par, in terms of benefits, with other chronic diseases and disabilities; and finally, an effective national public awareness strategy to reduce the stigma associated with mental illness and addictions in Canadian society.

While my remarks have focused on the broad status of mental health initiatives in Canada, the mental health status of Canadian health care providers is also of concern to the CMA.

In recent years, evidence has shown that physician stress and dissatisfaction is rising and morale is low. The CMA's 2003 physician resource questionnaire found that 45.7 per cent of physicians are in an advanced state of burnout. Physicians — particularly women physicians — appear to be at a higher risk of suicide than the general population.

The CMA has been involved in a number of activities to address this situation, including last year's launch of the Centre for Physician Health and Well-being. That centre functions as a clearinghouse and coordinating body to support research and provide trusted information to physicians, physicians in training and their families. A first activity of the centre was to provide, through partnership with the CIHR's Institute of Neurosciences, Mental Health and Addiction, $100,000 in physician health research funding.

This funding is currently supporting two research projects. One will develop a guide of common indicators for Canadian physician health programs. This will generate a national profile of the physicians who use the programs, the services provided and their outcomes. The second will study the psychodynamics and physicians' work to allow for a better understanding of the dynamics of problems such as stress, burnout, addiction and violence in the workplace.

These efforts must be bolstered. Other health providers are also impacted by mental illness and need support. The health care provider community needs help in terms of the reduction of stigma, access to resources, and supportive environments.

I know some of what I have said today will have been familiar to members of the committee, given the impressive list of round tables, witness testimony, and submissions that you have reviewed already as part of your study on mental health. I only hope my comments will be of help in your important efforts, and lead to real progress in addressing the largely unmet mental health and mental illness needs in Canada.

I would direct you once again to the presentation we made to you and the document that has our five recommendations for action. Thank you.

Dr. Paul Garfinkel, Chair, Mental Health Working Group, Ontario Hospital Association: Thank you, Mr. Chairman, for the opportunity to have the OHA comment on issues related to mental health and mental illness.

I would like to begin by reinforcing the urgent need for action. As you have just heard, 20 per cent of Canadians will experience a mental illness or substance abuse problem at some point in their lives — 3 per cent a serious, persistent form of mental illness. Mental illness accounts for between 13 per cent and 14 per cent of disability worldwide, and the share of disability is increasing.

The most important statistic I can give you about mental illness is that more than two-thirds of people who need care get absolutely no care at all. For children, the elderly and immigrants, the figures are worse than that. Despite these numbers, mental health care is largely absent from health care reform initiatives.

Government investment in mental health care services is desperately needed. In Ontario last year, just over 4 per cent of the health care budget was spent on mental health — the same percent of the health budget in 1984. Only 1 per cent of Ontario's health care funding serves community-based mental health care services.

We believe it is extremely important to bring mental health into the mainstream. People with mental illnesses should be treated as any other people with suffering and pain. The Canada Health Act has excluded people who are in mental hospitals, reflecting the stigma of the times in which it was drafted. We feel there should be building on the work already under way through the First Ministers' Accord: Mental health and addictions should be included in a national home care program; we need to address the needs of people with mental illness for access to prescription drug use; and we need to include mental illness and substance abuse within primary care reform initiatives.

We see five priorities for action. The first is an investment in community-based mental health care services. There are many reasons for this — they are listed in my handout to you — including humane and economic ones. This community-based care has to include peer support, and family and consumer advocacy initiatives. We must listen to the knowledge and experience of those who have experienced these illnesses.

Critical investments are required for early intervention to improve access. As I said, over two-thirds of the patients who need care receive absolutely none. Some do not realize they are ill. Some are frightened off by the stigma. At times, the primary physician does not recognize the illness, and other times, the resources are not available. Early intervention is critical for outcome.

Housing, income and employment support are very important to the outcome to these disorders. We also need to improve access to remote care. For example, video conferencing is extremely effective. Studies of video conferencing show that the outcomes can be as good as direct office visits.

We also have a special problem reflecting people with both substance abuse and mental illness. About 40 per cent of people with substance abuse problems have this kind of concurrent disorder. Few people in this country are trained to deal with these shared problems.

Our second priority relates to integration and continuity of care. Currently, the system is fragmented, with huge gaps in service. We have long waits for treatment. At the facility that I work in, someone with an obsessive-compulsive disorder, autism or a developmental handicap with a mental illness can wait for months for assessment. In many regions of the country, however, key services are just not available.

We lack standardization of core services in mental health, and people have difficulty accessing services or moving from one part of the system to the next. We believe that models for integration should be flexible and tailored to the needs of the local community. The models have to be client-centred and end the divide between physical and mental health. They need to enhance collaboration to meet the needs of people with a variety of problems, including those who have both a mental illness and a substance abuse problem. A great deal of attention has to be provided to the issue of information, sharing of information and use of information technology in this sector.

Our third priority is the national strategy. As you have just heard, Canada lags behind other countries. In Australia in 1992, a national strategy was adopted. The United States, in 1999, made a commitment to improve mental health for all the people in their country.

In our view, the national strategy should have a number of components. The first issue is public education, health promotion and anti-stigma work. This is education for the general public using role models and other means of education: education in school and of health professionals who often share in perpetuating the stigma. The second issue is research. The third is information and data collection. The fourth is a human resources strategy, as you have heard, and the final is a national policy framework that defines the roles of various governments and ministries.

Our fourth priority is to set national standards. In this respect, we are talking about building capacity in the system through education: education of nurses, psychologists, social workers, occupational therapists, and of family physicians who do need more training in order to take on some of the difficult problems our patients present with.

Similarly, research and development becomes a very important part of the national strategy. We have learned more about the brain in last 10 years than we learned in the previous 100. We have also learned about interpersonal and inter-societal functioning. We have much better research methodology. However, we have challenges relating to how new knowledge is implemented and how this affects day-to-day practice through the country.

We do believe that federal funding should be targeted to research and development dealing with treatment innovations, developing benchmarks to aid and strengthen accountability, and in developing information systems in assisting with data collection.

Finally, our fifth priority is federal funding for Aboriginal services. As you know, the mental health and addiction services needs for the Aboriginal population continue to increase. The suicide rate amongst Aboriginals in Canada is five times that of the rest of the country. Programs and services for Aboriginal people are disjointed, uncoordinated or nonexistent. At the hospital where I work, we have five people serving a very significant population in downtown Toronto, probably 50,000 to 70,000 people. There is an urgent need for culturally appropriate mental health and addiction services for this community. Federal funding is critical to provide community support such as housing, education and employment, which is so fundamental to treatment and recovery. We need to provide appropriate community mental health supports to assist Aboriginal communities to develop services to address their own needs.

In conclusion, the lack of progress in the mental health and addictions world is a reflection of stigma. It would not be tolerated for other illnesses of similar severity or prevalence. The federal government can play a key role and ensure mental health and addictions are included in a reformed health care system. There should be a lead taken to develop a national strategy on mental health and addictions. Set national standards in education and research, investment in community-based services, and support efforts to create a more integrated and seamless system of care.

Dr. Blake Woodside, Chairman of the Board, Canadian Psychiatric Association: Mr. Chairman and members of the committee, in addition to being chairman of the board of Canadian Psychiatric Association, I am a clinician and researcher. I run the in-patient anorexia program at the Toronto General Hospital in Toronto. I grapple with these issues on a day-to-day basis.

I will be very brief with the first part of my presentation, because much of it is similar to what has already been said, and I will move reasonably promptly to our recommendations about how we can build on the work that has been done to this point and try to be as specific as possible.

The Canadian Psychiatric Association represents 3,000 psychiatrists across the country. It is a voluntary association. We have been around for about 55 years. We are interested in facilitating the development of the best possible forms of mental health care in the country for the benefit of the citizens of the country.

Partnerships are very important to us. There is a long tradition in psychiatry of working in teams or groups. We have known for decades that we cannot do it all, so our partnerships with groups such as the Canadian Alliance for Mental Illness and Mental Health are extremely important for us.

Psychiatrists have a large number of roles to play — perhaps larger than some of you realize. In addition to the clinical practice, psychiatrists are very involved in teaching, research and administration — in some cases increasingly involved in administration. These multiple roles lead to increasing challenges for psychiatrists on day-to-day basis.

One of the most difficult challenges that psychiatrists face is what Dr. Pamela Forsythe, from New Brunswick, has called the ``snakes and ladders'' of mental health care. For example, you are a graduate student from Alberta doing your masters degree in Ottawa. You roll a three, and you develop bipolar disease; that is a ``snake.'' Then you roll a four, and you are admitted to the Royal Ottawa Hospital, one of the leading institutions for treatment of bipolar disease in the country; that is a ladder. Then you roll a two and go along for a couple of months. Then three months have passed and Alberta will no longer pay for your treatment. The ROH discharges you. That is a six, and you go down another snake.

Is there any part of health care in this country where something like that would happen? Would we tolerate that occurring with any other illness in this country? Why is it happening now with people with bipolar disease? A particular problem that psychiatrists face is trying to manage frankly bizarre and Byzantine rules about the provision of what should be a very basic provision of health care services.

In respect of their treatment goals, psychiatrists want to reduce disability, dysfunction and death. It is important to recognize that death through suicide claims the lives about 4,000 people in Canada per year — that is every year; it is a really big problem. We are not just talking about the ``worried well.'' We are talking about people with severe and persistent mental illness, a substantial number of who die from their illnesses every year.

Dr. Garfinkel and Dr. Patel have reviewed the spectrum of need that is present for people with mental illnesses. I will briefly recap, because it helps formulate how you try to attack this problem and reform the mental health system.

People have different needs across the lifespan; children have different needs than seniors and middle aged adults. Different communities have different needs. Aboriginal communities and rural and remote committees have different needs. Women have different needs than men. Cultural groups have specific needs. Individuals in federal prisons have a particular collection of needs that are not addressed at the present time.

There is also the continuum of severities. Psychiatrists are sufficiently short in number in this country that we mainly see very ill people; we do not have the time to see the worried well. We are too busy for that. People do not understand that.

That forensic population is a real problem that you need to think about carefully. The resources required to deal with people in federal prisons will just be enormous. That is something that nobody wants to talk about, currently.

You know about the scope of the need. You know about the rates of disability related to mental health. You know that treatment makes a difference. You know that most people do not get treatment. You know that mental health is more than physicians giving out pills to people who are sick. It includes housing, social support, vocational rehabilitation — all of that stuff. You know that one of the biggest problems in the provision of mental health is the systematic discrimination that is applied to individuals with mental disorders in our society.

We often use the word ``stigma.'' In my opinion it is discrimination. That woman from Alberta was discriminated against on the basis of her medical diagnosis. This is one of the last areas in our society where it is acceptable to discriminate against people on the basis of their medical condition. That simply has to change.

I use the word ``discrimination'' rather than ``stigma'' because stigma is about shame. There is not much you can do about being ashamed except get over it. Discrimination is something we can take action about. We have taken action about many issues in our society in the past couple of decades and this in one we need to address now.

Everyone in this room agrees that it is time to act. We have spent 40 years drifting from the move to asylums to community-based treatment. It is time to make changes in the mental health care system and make it a major priority for policy-makers in this country.

In the year 2020, depression will comprise half of the disability in the industrialized world is not all that far off. You have heard that we are the only major industrialized country that does not have a national plan for mental health. In our view, that is a profound problem for us as Canadians.

The first step in our view has been the call for a national plan for mental health put out by the Canadian Alliance of Mental Illness and Mental Health. I believe that you have a copy of that. This was derived by a national group with stakeholders from all over the country. We managed to come to a consensus, which was an amazing feat, just as your committee managed to come to a consensus. As you know, the four action areas in the call for national action plan are a public information arm, a research arm, a national data arm and a policy framework to facilitate a system that is responsive to needs.

Where does psychiatry fit into this? We know that you want me to talk about psychiatry's specific role in mental health reform. There are three areas where psychiatry has work to do and where we need some help from you as well. The first is awareness. The second is access. The third is accountability. Let me talk about each of those in turn.

With respect to awareness, the first element is attitude. That is, combating discrimination and stigma. There is a certain amount of institutionalized discrimination inside the profession. We acknowledge that and it is our job to take care of that. We need help from federal leaders to combat societal discrimination and stigma. The second element is knowledge generation and the research capacity in this country. I mentioned before that I am a researcher and clinician. I am a mid-career researcher; I am 47 years old. Ninety per cent of my research money — and I hold several million dollars' worth of grants — comes from outside this country. I cannot get funding from inside this country to conduct my research. I am a successful researcher. I can get money from the United States or private foundations, but I cannot get money from Canada.

The Canadian Institutes for Health Research, CIHR, is making good strides. They are making a good start to try to address this problem. We need to do so much more to properly fund mental health research in this country. We must transfer the information that is derived from research both to the general public and to the profession. We need a mechanism to ensure that that is done in a sustainable fashion.

The second area is access. The most important thing about access is to remove barriers. As we try to transform the mental health system into a more community-based system, we need to ensure that we do not recreate the asylum. People with mental disorders need to feel that they have multiple entry points into the system. They do not want to go through one set of doors, as they had to do 50 years ago. We need to ensure that the barriers are removed from funding for medications to treat these mental illnesses.

We need minimum, acceptable, national standards for care. I treat the most severe individuals with anorexia nervosa. These people are down to 50 per cent or lower of chart average weight — for example, a person who is 5 foot 4 inches tall and weighs about 60 pounds. These people wait four to six months for treatment. I am a sole service provider. There is no other program. If that were your daughter, how would you feel about that? We need some standards for what is acceptable.

We need a national psychiatric and mental health education strategy so that we can train psychiatrists and other mental health care workers in a flexible fashion so that they can respond to changing needs in our society.

Finally, we need a human resources strategy not only for psychiatry but also for all of mental health. Psychiatry is a shrinking specialty; by 2020 there will be about two-thirds as many of us as there are now if something does not change.

In my view, it is unacceptable and immoral to continue to solve our manpower problems by, for example, recruiting three of the last five psychiatrists from Uganda to an under-serviced part of Ontario. It is not acceptable in a wealthy country such as ours to steal physicians from other countries. We must have a solution that is made-in-Canada and sustainable for the long term. I will elaborate on that shortly.

In respect of access, we need to support innovations to improve access to specialize care to the under-serviced groups mentioned earlier. I would like to tell you about the shared care initiative, an important initiative focused on helping psychiatrists and family doctors work together. It is a good thing. It probably improves outcomes. It also makes the physicians — and patients — much happier. It is not a panacea. There is a shortage of family doctors as well. Trying to transfer the load from psychiatry to general practice is probably not feasible because there are just not enough family doctors to take up the slack. It is an important initiative. That is something on which we must continue to focus.

However, it will not solve the human resource problem. Collaborating with other mental health practitioners will not solve it either. There are shortages across the system in all disciplines.

The third area is accountability. As you have heard, we are talking dollars and cents here. If we are suggesting that resources need to be applied to this problem, there must be accountability mechanisms in place. That is very important. The first element of accountability is good surveillance of mental health. That means more than just the length of stay in hospital. The Statistics Canada mental health survey that was published in the fall was an excellent start. That was the first population based survey of mental illnesses ever done in this country. Can you imagine if 2003 were the year of the first survey of heart disease or cancer in this country? That would be appalling. We need a better surveillance system.

We need surveillance of clinical practice and information provided both to the profession and to the public about what constitutes appropriate and effective treatments for mental disorders so that people will not buy pigs in a poke and they know what is safe and they know what is not.

Finally, it is our responsibility as a profession to ensure that we are competent, that we are not only well trained but we also maintain our competence over time.

What will it take? The first thing it will take is that we continue to urge the adoption of a detailed national action plan that includes all the stakeholders and jurisdictions. This national action plan needs to have an evaluation framework so that we know that what we are planning to do is having some useful outcomes. The development of this plan in and of itself will not change anything, but it would set the national tone. It would get people on side and secure commitments.

We will need to invest some money in this system. We will also need to reallocate some of the existing resources. We will not be able to do it solely by reallocating existing resources, which are stretched to the maximum now.

There are some things for which the federal government can and should take responsibility. The first is leadership. That is, leadership and policy development, integrating and integration and framing the action plans and some funding. In addition, the federal government has a role for helping out with public education, a role for this cross- jurisdictional data collection, a role in monitoring and regulating safety of treatments, a role in building and developing research capacity in this country, a role in setting standards for best practices, and a very important role to ensure that mental health components are added to the public health mandate that the government has recently established. At present, that is absent. That is a critical piece that the federal government must take on.

Finally, again, the federal government must take the lead, in our view, in developing a national, cross-jurisdictional, independent, long-term, sustainable human resource plan for mental health practitioners. All of these components are needed. This cannot be done jurisdiction by jurisdiction or we will be in the same mess we are now.

We think the development of an interim integrative body accountable, perhaps, to the Minister of Health to oversee this process might be useful. It has proven to be difficult to make any progress using existing mechanisms over the last two or three decades. We think some sort of independent body would be useful to help deal with some entrenched jealousies and competition in this area.

I should like to present our recommended first steps. First, there should be a policy announcement that mental health is a national health priority in this country and that there is intent to move forward to develop a national action plan. Second, we suggest that the development of this independent, integrative body would be useful. Third, we suggest the public health agency include elements of mental health as part of its mandate. Finally, we recommend that Health Canada develop the capacity to assist in the development of this national plan that would include Health Canada recruiting on a contract basis individuals who are actually in clinical practice and involved in the delivery of mental health services.

In conclusion, we should not overlook the progress that has been made. This is not a totally awful situation. In 1998, when the Canadian Alliance on Mental Illness and Mental Health, CAMIMH, was formed, mental health was nowhere on the radar screen; now it is firmly on the radar screen.

We must now to take the wonderful ideas that your committee and others have developed and start to put them into action.

The Chairman: I wish to thank all of you for your comments, in particular, for the focus on some things the federal government can do.

I wish to ask you a question that you may want to think about and then maybe get back to us.

As I listened to all of you talk about the nature of your delivery system, there was a discussion about more being done in the home, a discussion about community home services, a discussion about Dr. Woodside's collaborative model, and so on. I am struck by the fact that mental health services do not fit into the very rigid structure of the Canada Health Act. I know they are not now included in the Canada Health Act.

However, should we be looking at effectively trying to modify, somehow, the existing system to bring in all of the delivery systems that relate to mental health, or should we be saying, ``Let us treat mental health and mental illness as its own piece of legislation separate from the Canada Health Act, funded by a different mechanism.''

I worry about attempting to sweep it into the very rigid model of the Canada Health Act, which everyone regards as a panacea. In many ways it is a terrific piece of legislation, but it also has some rigid boundaries. I do not know how we could deliver under the Canada Health Act, services and the means to which they are actually delivered today in the mental health area.

When I raised this informally with some psychiatrist friends of mine they were appalled at the notion that we might actually suggest that mental health should not automatically be part of the formal health system. They find that a disquieting thought — I suppose it is okay to give psychiatrists disquieting thoughts. However, it seems to me that we really need some input from you on that. I cannot see a way in which the existing health system could be broadened enough to deliver all the services that you deliver without sweeping in everything else. We cannot have universal home care. The country cannot afford it and there are all kinds of problems with potential boondoggles that we talked about in our last report.

I do not know if any of you want to comment on that, but I would like to hear your thoughts. We are beginning with a blank piece of paper and asking, ``How would we approach this if we were starting from scratch?'' I have not spoken to my colleagues, but I would not begin with the Canada Health Act if I were starting from scratch — at least with regard to mental health. Would anyone care to comment on that simple question?

Dr. Garfinkel: That is a disquieting notion. The history of our field is that very well meaning people have wanted to separate it from health, take it on and that is how we ended up with the big asylums, neglect and often abuse.

On its own, the mental health community has never fared well. It is also an artificial distinction. We should not differentiate. Depression is a huge issue in heart disease. You cannot separate these subjects in a meaningful way for the person. You do it in an arbitrary way.

I also think that we could deliver care much more efficiently in community and home settings if we had the right accountabilities and got away from the large mental hospital models.

Dr. Woodside: Our association would have some reluctance to endorse segregating mental health from everything else.

When I was a resident, I had a supervisor who trained in upper New York State in a town of 10,000, which comprised only psychiatric patients and the people looking after them — about 6,000 patients and 4,000 workers. That is how mental health was segregated in the 1950s. People were shipped off to upper New York State and no one ever saw them or any of the health care practitioners again.

The majority of people with mental health issues present to a family doctor. If you create a segregated mental health system, how will that interface with the primary health-care system, given that the majority of first contact is with family doctors? That, in and of itself, is a sufficient argument to suggest that, while attractive in some ways, a segregated mental health system probably would not serve those with mental illness very well.

Dr. Gail Beck, Acting Associate Secretary General, Canadian Medical Association: Honourable senators, in addition to working at the CMA, I am also the director of the youth in-patient psychiatry ward at the Royal Ottawa Hospital. While the multidisciplinary approach is long-standing in psychiatry, it is certainly not the only area of medicine to have multidisciplinary approaches. Like my colleagues, I am reluctant to once again introduce some discrimination by saying that mental health is something different from the rest of health care.

Furthermore, for many patients who have a mental illness, one of the things that is extremely reassuring to them is that it is an illness. Very often they are not treated as if they are ill; they are treated as if they are bad. If you take their care out of the mainstream of health care and put it somewhere else, that will only reinforce something that they tend to think anyway.

Dr. Patel: Before I came up here, I made a list of the patients I saw. The first patient was a lady who had seen a psychiatrist, was diagnosed to have depression and decided to go off her medications, saying, ``I was just going to walk on the lake and disappear.'' Fortunately, she came to see me and I had a session with her. Another was a family dealing with cancer and death. To make a long story short, I saw about six or seven patients with mental illness, and problems relating to their other health problems, as a family physician.

Family physicians are the first point of contact. On average, I would say — I never thought of it in those terms before — that one in four patients has some degree of other problems complicating his or her existing health problems. Alcoholism is one example; a couple came in that same day. I cannot believe that I saw seven patients with different problems. I need to deal with them on a day-to-day basis. That is an average day's practice.

I do not know whether separating mental illness and giving it a special status, would necessarily help.

Senator LeBreton: Dr. Patel and Dr. Garfinkel both talked about Canada being the only G8 nation without a national strategy. Dr. Garfinkel talked about commitments made in Australia in 1992 — 12 years ago — and in the United States. You did say that we have made some start in this country.

Is there any way — so we do not reinvent the wheel — that elements of the Australian program or the program in the United States could be imported into Canada and put at the forefront of the national agenda without going through all the studies and input? Have your associations had any meetings with those countries to short-circuit what we want to do here?

Dr. Garfinkel: Yes. However, we lack the impetus from a federal body saying, ``Take charge.'' For example, Canada had a national drug strategy in the late 1980s and it expired. We were one of the few countries without a drug strategy until very recently. Through a lot of push and a lot of central impetus, we have come back with a four-point drug strategy that is spectacular. We could easily do that, modelled on our drug strategy, modelled on Australia. I think Dr. Woodside's comment about an integrated body needing some support, particularly for the work on fighting stigma and public education, does need some resourcing.

Dr. Patel: We have not had any formal study of the different models in the countries that we mentioned, except to say that we are lagging behind other nations in providing that degree of care. I trained in the U.K, where there was a much more comprehensive, collaborative model of delivery in the community with resources such as mental health workers and others. We have a resource problem. I cannot refer my patients for specialist intervention or diagnosis or assistance, in carrying out my responsibility as a family physician. That is the crux of the matter. We need not only that model, but also we need additional resources.

Senator LeBreton: I suppose when you refer your patients, sometimes they go on yet another long waiting list because, as Dr. Woodside said, their numbers are diminishing.

Dr. Woodside, when you said that there are no research dollars, I was really taken aback. You can get research dollars if you go to the United States. I find that appalling.

Dr. Woodside: I have some from Canada, but the majority of my research funding is from other countries or private foundations that are located outside of Canada.

Senator LeBreton: That is unbelievable. Therefore, is that not then contributing to your diminishing numbers — when you say in 10 years it will be two-thirds?

Dr. Woodside: We have been solving our human resource problems for many years across many specialties by importing physicians from other countries. International medical graduates have made a huge contribution to Canadian medicine. There is no question about that. It is not that the people are bad; they are wonderful people, highly qualified, very good physicians. However, is it ethical for us to indefinitely solve our manpower problems by taking physicians from other countries, or is it time that we stood up to the plate and decided to train our own in appropriate numbers — to maintain appropriate numbers of physicians and specialties across the country?

I would like to make a comment relating to you first questioning. The information is available about other countries' policies. It is in the public domain. We need federal government leadership to say this is a priority; we must come up with a plan. Of course, we will take elements of other countries' plans into consideration — the information is all there. We need the leadership.

Senator Fairbairn: These documents are rather depressing to read. How can you persuade young people who are interested in medicine to go into this field? Leaving aside the resources question, one of the things that struck me in listening to you was when you said there was virtually nothing in northern Canada. Is that because it is an uncomfortable climate? Is that because of the difficulty in communication with an Aboriginal population?

For government to take leadership — and I think government should — how can you create an atmosphere that will persuade young people coming into medicine that this is what they want to do?

Dr. Beck: In the same way as there is a stigma about mental illness and mental health, we know there is a stigma relating to seeking help for themselves is something that physicians also have. By the same token, there is, for a number of people in medical school and who are physicians, a stigma about psychiatrists. I regularly hear jokes that I am not a real doctor. That is not related to what I do in practice; it is related to the fact that there is a stigma and discrimination about the kind of illnesses that I treat.

Dr. Patel: Furthermore, it is not just the Northwest Territories that has a problem. New Brunswick has the same problem — lack of child psychiatrists. As Dr. Beck said, the same stigma probably could go through to other sectors, such as family medicine. It is now at an historic low, and yet family physicians are singularly placed to treat the majority of patients in an early manner because they have the long, enduring relationships that are essential to treating mental illness on an ongoing basis. I have been fortunate, because I stayed in one community for 30 years. I have enjoyed that, and I think that is what we have to encourage.

Dr. Garfinkel: I do not find this depressing at all. I have been a psychiatrist in Ontario for 32 years. You would not have had a conversation like this or a panel like this even a decade ago. The effects of CAMIMH that Dr. Woodside talked about, the effects of having role models like Michael Wilson speak out, and the idea that corporate Canada is interested in the workplace effects are all very recent.

Most important, psychiatry is a therapeutic field. When I graduated from medical school, there was not a lot of specific treatment available. Today, it is very strong in its therapeutics, in its ability to treat people actively. We make a huge difference in people's lives. Dr. Beck is correct in stating that there is a stigma that is reflected in our health care community as much as in our broad community. Any education efforts that we undertake have to address the health care community, as well as any other opinion-leading group.

With regard to the congregation in cities, we have a maldistribution, and this is very marked in many specialities in medicine. It is very true in psychiatry; it is very hard to be the only psychiatrist in Whitehorse. It is very difficult in terms of social relationships and a whole variety of issues.

The hospital where I work has a fly-in service to 17 communities in Ontario, and we do videoconferencing in 70 communities. It may not be perfect, but it is a way of dealing with some of the rural mal-distribution.

Dr. Woodside: There are models to help deal with this problem. Unfortunately — and I know I am probably repeating myself endlessly — it has been convenient for the last 30 years is to recruit from abroad people on return of service contracts who agree to go to remote and rural areas for five or ten years until they get a general licence, and then they move to the city. That is a short-term, band-aid solution. There are other ways to make a practice attractive in remote and rural areas. They cost some money. The will just has not been there to work on them much over the last 20 or 30 years.

Dr. Beck: A few years ago, I served on the expert panel on health human resources in Ontario. At the time, we learned that half of the students in the five medical schools in Ontario, no matter where the schools where located, were from Metro Toronto. We said, ``No wonder that is where they want to practise.''

Therefore, we know that people tend to practise in the kind of community that they come from and to return to their communities. Therefore, we need to go to communities where we need physicians of any kind and recruit not only physicians but also those health care workers in those communities. Some people in Canada are involved in that kind of work. Dr. Peter Walker, the Dean of the University of Ottawa's medical school, talks about what he calls ``mining northern Ontario for physicians.'' Part of the thinking behind the location of a medical school in northern Ontario that was that if you had a medical school from northern Ontario and more students from northern Ontario, there was a greater likelihood that people would want to practise in northern Ontario.

We must look to the communities for the resources that we need and the young people that we need. The University of Manitoba also has a specific recruitment program for Aboriginal communities and has a cohort of Aboriginal medical students. There is an initiative underway in the Yukon Territory — which of course does not have its own medical school — to find young people from the Yukon to train in the hope that they will return to the Yukon.

Senator Cordy: Dr. Woodside, you spoke about what psychiatry needs to fulfil its roles. One of things was attitudes and how we combat stigma within society. You spoke about it, first of all, within the public realm and also within the health care sector. You said that sector is starting to deal with it.

From a federal government perspective, how do we deal with that? How do we change public attitudes?

Dr. Woodside: The first thing is to make mental health a public priority, so a declaration by the federal government that a national action plan for mental health was being developed would be a huge step in the right direction. Out of that would fall a wide variety of public educational activities that would help combat this discrimination and stigma. Validating the severity of mental illness by starting to collect adequate data, adequately funding mental health research and investing in mental health education. All of those things would help society at large begin to decide that these are valid concerns — these are real illnesses and serious problems, and cannot be ignored or swept under the carpet. That is probably the major role that the federal government can take.

Senator Cordy: People themselves whose have mental illness, or think they may have a mental illness, have a difficult time to make that first step, which is admitting it. The first person they usually speak to is a family physician. Family physicians, as a number of you have already said, are not receiving the training that they need. In the current system, which is the doctor-hospital system — in which we do reasonably well other than very long waiting times — what would a family doctor, who is paid by the number of patients that he or she sees, do when a patient comes complaining of a headache or some other general system? Human nature being what it is and as this is the doctor's career and livelihood, would he or she take an hour to sit down with the patient and ask what might be the underlying cause?

We have two problems. The first is the lack of training. The second is that within our current system, where doctors are paid based on the number of patients, they may necessarily take the time to look. How do we deal with those issues?

Dr. Patel: You have identified the problem that exists in primary care, especially family physicians. I would not say they have not received training. They have received training, but they need ongoing continuing medical education to keep up to current practice patterns, and they need that supporting hand from psychiatrists like Dr. Woodside and Dr. Garfinkel to be available on an as-needed basis for ongoing consultation.

As far as time, I think each physician finds his or her own way on how to deal with it. Right from the beginning of my practice, I set aside one hour at the end of my day to deal with all those kinds of problems. If I had a patient that needed my time, I would then make the time and spend one hour, if necessary. In fact, as I mentioned recently, I saw seven or eight patients, and because of my ongoing relationship with them, I could compress my supportive psychotherapy and direction for treatment into a 20-minute segment.

Efficiencies can arise as you become more adept. Of course, when they need that counselling, I send them to my mental health worker. Guess what, the waiting time there is three weeks or six weeks. I say to them, ``If you cannot see them, come back to my office.'' You are right that it may not be the norm, perhaps, but that is the encouragement that we need to provide.

Provincial associations are dealing with that in terms of moving away from this fee-for-service conundrum towards recognize quality of care, but it is just beginning.

Dr. Garfinkel: I support that in the sense that the fee schedules really under-value psychiatric care. In Ontario, if you are a family doctor and you spend the hour that Dr. Patel is describing, the return is about $100. If you have a nurse that you are paying, and maybe a receptionist, and you are paying rent, you are taking home not too much money for that hour.

With regard to your other question about the national role, there is very good literature on this in terms of anti- stigma in Britain. In Britain, they went through a five-year program, centrally directed, involving the British Psychiatric Association and the federal government. They had a very significant effect on public attitudes. We have models that we could pursue if there was a will.

The Chairman: Is it not a hugely inefficient use of a doctor's time to provide the hour of psychotherapy rather than immediately referring that person to someone like a clinical psychologist, social worker or whatever? You cannot do that because you would be referring them to someone whose services are not covered under medicare, but that is a funding type question.

In our previous report, we argued for having professionals delegate down if there was a qualified person who could do it, and we supported nurse practitioners doing a lot of things that GPs do. Does that same principle not apply in this case? My family practitioner spends 50 per cent of her time effectively as a clinical psychologist, which first, reduces half the value of the time of a GP when we are short of GPs, and second, she is trained to do all kinds of other things that do not get done. Am I missing something here? Is that logical?

Dr. Patel: Senator, I think the problem is just a lack of resources and lack of people. In my clinic, which is slightly rural, if I want to send a patient to a mental health worker, I cannot get an appointment for three or four weeks.

We have, through the primary care transition fund, a nurse practitioner is being foisted upon us without consultation. I tried to refer a patient the same day. I was told that I had to wait three weeks see the nurse practitioner. Excuse me? I am dealing with 35 or 40 patients.

We are forced to deal with those problems. They cannot wait.

Dr. Woodside: At times, it makes perfect sense. At other times, if it will take the other person three or four hours to understand the individual's difficulties, then you are probably not saving any money. Sometimes the family doctor is in the perfect position to spend the 20 or 30 minutes to deal with the problem and resolve it, rather than having to tell the person to hold that feeling for a week or two while we get him or her to see the social worker who will then take a complete history and a few week later, resolve the problem.

There is obviously a place for more teamwork and more shared caring where work is handed around in a more rational way.

Senator Cook: I am trying to process much information on a subject of which I have scant knowledge.

How can the federal government get involved in human resource planning in the mental health addictions sector without encroaching on provincial jurisdiction?

Dr. Woodside: We think that the federal government needs to take the lead in calling for the development of a national plan for mental health in this country, which would include a human resource component. The feds would have to round up the provinces and say, ``Look, this needs to be a national initiative as we have national plans for cancer, AIDS, diabetes and heart disease.''

The federal government cannot take the jurisdiction away from the provinces, but it can take the moral high ground and say that this is something that has to be done and these are reasons that make it clear that it has to be done. The federal government could tell provincial leaders that they have a moral imperative to join in this good work and then try to set up something that is cross-jurisdictional with an actual national plan. The federal government can take the lead in saying that very publicly that it really must happen for these reasons and that the provinces are not doing their job if they are not joining in the effort.

Senator Cook: On the last page of your brief, you make suggests about what can be done now and refer to a public health agency that could include elements of mental health. We all know that in the throne speech there was the creation of a public health agency. Is there an opportunity here for us in the creation of this agency?

I ask this question in light of the budget in my province yesterday. The budget had a deficit of $600-odd-million deficit. I will tell you the good news with my daughter's words. She said, ``Mom, I cannot believe it. He gave $1 million to community health for mental health services, but the irony was, he hired a head nurse.'' How long is it since we have heard the phrase, ``head nurse?'' I am probably trying to play God here and add up two and two to get five.

The first ministers meet this summer. Is there maybe an emerging opportunity where the minds might be on the same wavelength? Could we find an opportunity here to push forward what we are seeing?

I live in a small province. I realize that we virtually know all of each other. When it comes to the social aspect, I do not sense the stigma that I hear about in other parts of Canada. The NGOs do very well with social programs, housing and a number of things to take care of the coping skills that are needed after primary care is finished with mental illness. Is there an opportunity here?

We talked about the Canada Health Act. Most provinces have a mental health act. That is a real barrier to care for people. There are restrictions on the police force alone in my province when they pick up someone. There are barriers there that we need to address from a legislative point of view.

Dr. Beck: There are actually two opportunities at this point to address the mental health issues in Canada. There is, as you say, the new public health agency. As well there is the work of the Health Council of Canada, which has not yet begun.

There is an opportunity in these two new endeavours to initiate an entirely new attitude and vision of mental health in the context of other issues. It was my impression that part of the mandate of the Health Council of Canada is to consider overall the issue of health human resources. It seems to me that health human resources for mental health care might well be a part of that.

Dr. Garfinkel: It is very timely for the public health agency. We know a lot about health promotion and the effective use of resources. Health promotion is very valuable in terms of dollars spent and the results. We have a good body of knowledge in drug use, tobacco use, and alcohol use and what treatment is effective and what is not.

There are many opportunities on the mental health side. I will give you an example of one that we are currently pursuing. We know that in youngsters self-esteem is fairly similar in both boys and girls. At adolescence, the girls' self- esteem plummets. This very well could have something to did with depression and eating disorders that develop eight and 10 years later. There are many efforts now being made to try to prevent that fall in self-esteem and prevent illness later. That is just one example, but there is a huge opportunity here to use dollars very wisely for the health of Canada.

Senator Cook: There are two streams of what can be done now and the long-range planning that must begin now with an eight to ten- year window. It covers the recruitment of personnel to all the other systems that are there. Do you have any comments on how we can begin the other stream?

Dr. Garfinkel: I agree with Dr. Woodside about the immediate first steps. He has outlined them in his paper very nicely.

For the longer term, tying in with the health council and with the public health agency makes good sense. The payoff there is down the road.

Senator Cook: It is up to us to get in on the ground floor with the creation of those new agencies.

Dr. Garfinkel: Yes.

Senator Keon: I would like to discuss the mental health strategy in the national action plan. I suspect that if we do not address this, we will be labelled as being irresponsible, so we may as well learn what we can from you.

I have been sitting on the Ontario committee attempting to plan the public health system for Ontario. It is become obvious to me in these meetings that this will be dependent on the primary care infrastructure. I gather from you that you are all convinced that if there ever were a successful mental health strategy and national action plan, it will be dependent on a primary care infrastructure. We have yet to create it, but we must.

Dr. Patel, in your brief that you mention one of the five wheels. The first one is amending the Canada Health Act to include psychiatric hospitals. I want the full panel to comment on this, but I would ask you first. I do not profess to know any more about mental health than anyone else on this committee even though I am an M.D.

It seems to me that you have some very useful tools in the management of mental health, with psychopharmacology, and so forth, and this fosters a close working association with the primary care infrastructure. Why would you want to make hospitals the focal point of a statement? It seems that you need something much bigger and broader. Would you comment on that, Dr. Patel? Perhaps the other witnesses will comment after.

Dr. Patel: We focused on the Canada Health Act and the hospitals so that, as in the case that Dr. Woodside elucidated, we can treat mental illness on the same footing as all other illnesses, including cardiac care. The act has ignored that aspect of the continuum of care. That brings us to the primary care, which is a continuum of total care from primary contact all the way to specialty. The CMA does not recognize it as a division of primary versus specialty care. We think there is a continuum of care from birth to end-of-life issues. We need to make it patient-focused. If we then provide the necessary services, we can address the problem. To segregate it in any arbitrary way does not make sense.

Opening up the Canada Health Act has come into discussion recently. Politically, it is probably not palatable. The Prime Minister says that he is loathe to open up the act. However there could be regulatory changes to address the inequities of the treatment of mental health and mental illness patients, but give them the same credibility and recognition. Take, for example, disability tax credit forms; why are they being discriminated against? Dr. Beck is on one of those councils looking at the fact that we should address that for patients who have mental illness. The fact that when I give a sick note to a patient of mine, if there is a mental illness, there is a kickback or a push back from the employer to get more evidence, more certification. However, if I say they have a fractured femur, there is no problem. They can be disabled for a long time. There are many issues that come to mind. Certainly, the Canada Health Act could be changed to include patients on the same footing as other illnesses. I hope Dr. Garfinkel can add to that.

Dr. Garfinkel: I certainly agree that primary care reform has to be the basis for how we would advance the mental health system. I also agree that the powerful new treatments in psychopharmacology have changed our field. When you look at our entire treatment continuum, it is much beyond the hospital. I am here representing a hospital, but we are looking at a system of care that must be formed.

I think changing the Canada Health Act would be hugely powerful from a symbolic point of view. It would be saying that we are correcting a wrong. We did not understand mental illnesses years ago and now we realize that they are like any other form of human pain and suffering. That would be dramatic.

Senator Keon: Dr. Garfinkel, may I lead you down the garden path a little further? If there were a recommendation to change the Canada Health Act, would you recommend an inclusion of a mental health strategy rather than including psychiatric hospitals?

Dr. Garfinkel: That is a good point. I must give that more thought. On first thought, that is a very good idea.

Dr. Woodside: Senator, your points about integrating mental health reform with primary health care reform are key. Part of the way our association sees the matter is that they can proceed apace. That is where our shared caring initiative is coming from. It is trying to help drive some of the process of change in the primary care system while we try to drive some of the change in the process of the mental health system as well. They do go hand in hand.

I would be alarmed if you were suggesting, senator, that we should defer efforts to reform. The mental health system until there was some nation-wide agreement about the reform of the primary health care system. We would all be long gone by that point.

Senator Keon: However, when we draw the boxes we could draw that, regardless of how much dust it gathers. May I ask you the same question, Dr. Woodside?

Dr. Woodside: The specific issue about mental hospitals could be addressed by a simple regulation. Reopening the Canada Health Act is a slam-dunk. That could be done tomorrow. That does not require a lot. The minister only has to change the regulation; it is very simple. Reopening the Canada Health Act to alter some of the wording related to mental health would be a dramatic, symbolic act.

However, there are other ways for the government to take dramatic, symbolic acts without opening the Canada Health Act if that is a barrier. For example, as I said before, the government could say that they are committed to developing a national plan for mental health because it is a serious illness. That would be a similar dramatic symbolic act. This specific issue just requires a regulatory change. The regulation was written the way it was because of a misunderstanding about the nature of mental health care 20 years ago; that is all it is.

Senator Keon: You think that is one small step worth taking in isolation?

Dr. Woodside: Absolutely.

Senator Keon: Dr. Beck, would you care to comment?

Dr. Beck: When you mentioned it in terms of the focus, I did not see it really as a focus. Again, it goes back to the case that Dr. Woodside spoke about. In the same way that all other health care meets five conditions of the Canada Health Act, mental health should also meet those five criteria.

The Chairman: Dr. Woodside, to clarify for you, it was not a mistake when they excluded mental institutions in the Canada Health Act. The original hospital act had existed since 1957. It was excluded in 1957 because the federal government argued at the time that, because they perceived mental illness to be a perpetual, on-going situation, they were contributing to long-term care through the Canada Assistance Plan. All they did when they did the Canada Health Act was carry that over.

Senator Morin: That is exactly my point. I do not know what we mean by opening up the Canada Health Act. Provincial psychiatric hospitals are excluded from the Canada Health Act because they are considered as chronic, long- term care hospitals. They are excluded in the same way as long-term care hospitals in other areas such neurological disease or long-term care for quadriplegics.

If we want to include provincial psychiatric hospitals, the other long-term hospitals in the country will want to be included, too. I do not blame them. Psychiatric units in general hospitals are included. That is where the great majority of psychiatric patients are treated.

I do not know what we mean by opening up the Canada Health Act. That is the question the chair asked. If mental illness is considered differently, and then we are including home care and other parts of it in the Canada Health Act, then this would not apply to other illnesses. Mental illness is considered exactly the same way as the other conditions. They are treated no differently. We do not open up the Canada Health Act for symbolic reasons — that is, merely to show that mental health is important. This is not the first time that we have heard this. The CMA has been asking to open up the Canada Health Act ever since I have been in the Senate. There is no special virtue, unless we want to treat mental illnesses differently from the other conditions.

My last point, Dr. Woodside, is this: What about applying to the CIHR for funds?

Dr. Woodside: Senator Morin, I do apply to CIHR for funds. Several of the projects that I am involved with are very large and too large for CIHR to fund. They do not have the money to support the application. One is a $10 million project with 11 sites. I am not the lead; I am one of the 11 sites. The project is too large for them to fund. They do not have the budget to fund a project of that magnitude for mental health.

Mental hospitals have changed over the last 30 years. I am sure Dr. Garfinkel is eager to comment on that.

In 1957, sure, mental hospitals were primarily providing custodial care. That is a small part of what mental hospitals do now. They are actively involved in providing acute psychiatric care as well. The duration of the treatment is sometimes longer than that in a general hospital, but to class all psychiatric treatment provided in psychiatric hospitals as custodial care no longer reflects the reality of those hospitals' function.

Senator Morin: The answer to that is not to change the act, it is to change the classification of the hospitals. There are a number of things. The Heart Institute in Ottawa is under a special classification. If you think that the provincial psychiatric hospitals should consider such a thing, all you have to do is change the classification, not open up the act.

Dr. Beck: I think that the speakers felt that changing the status of the psychiatric hospitals does not require opening up the Canada Health Act. All this requires is a regulatory change. However, it unnerves me somewhat, senator, when you say it is not worth opening up the Canada Health Act for a symbolic gesture. If, by opening up the Canada Health Act, we could remove a tremendous amount of the discrimination around psychiatric illnesses in this country, I would say go for it.

Senator Morin: Opening it in what way?

Dr. Beck: In terms of making certain that mental illness in this country is treated the same way as other illnesses.

Senator Morin: That is not under the Canada Health Act; that is just the transfer of federal funds to provinces under certain conditions. It is nothing more than that.

Dr. Patel: The example we raised was of the Alberta resident not getting the appropriate care she needed. That is a portability of in-patient psychiatric care that is currently not addressed in the Canada Health Act. That is why we focused on that. There is no other reason — just to make sure that Canadians get the same service nationally.

The Chairman: I thank all of you for coming. It has been a terrific time. I know that we are also dealing with a number of you individually on other mental health issues as we go along. Thank you for coming.

I would ask the next panel to come forward. I thank our next witnesses for coming. Senators, we have three witnesses — Ms. Nancy Panagabko, Mr. John Service, and Mr. Stephen Arbuckle. Welcome all of you.

We will begin with Ms. Panagabko. I know you have been here so you have watched the process as we have gone along.

Ms. Nancy Panagabko, President, Canadian Federation of Mental Health Nurses: Honourable senators, I am president-elect of the Canadian Federation of Mental Health Nurses, which is an affiliate of the Canadian Nurses Association. Beside me is Ms. Annette Osted, who is representing the Registered Psychiatric Nurses of Canada, and we will be available to answer your questions.

On behalf of all Canadian nurses, we are here to address our concerns with the care available to Canadians with mental illness. In the recent budget, the federal government has committed significant resources to public health. In early February, the Prime Minister reconfirmed the intent of the federal government to work with the provincial and territorial governments to reform and sustain Canada's health system. However, as mental health and psychiatric nurses, we are concerned that mental health and well-being continues to be the ``orphan child,'' without family, support and recognition.

We see many different types of mental health cases. According to Statistics Canada, 3,863 people take their lives each year. Canadian-born males are four times more likely than females to commit suicide. Suicide is primarily a youth phenomenon, with the elderly following close behind. With respect to stress, a recent Ipsos-Reid survey indicates that the top two contributors to absenteeism and/or health costs in the workplace are depression-anxiety-other mental health disorders, about 66 per cent, and stress, about 60 per cent. This places a controllable burden not only on Canadian businesses and the economy, but also adds direct costs to the health care system. Can it be addressed? Yes. Will it be addressed? It is partially, through employee assistance and other wellness initiatives; however, we do not know if the system will be there for them and for how long.

Another illness is schizophrenia. A person diagnosed with paranoid schizophrenia can handle most day-to-day challenges with the appropriate medications and supports. If that person is homeless and/or if they lack consistent access to health professionals, there are significant challenges to the management of the illness.

At what point will it become politically appropriate to deal in a concrete and coordinated fashion with mental health issues? Senators, you have had a chance to read our submission. We look forward to answering your questions. Canadian mental health workers and psychiatric nurses are looking to the committee to play a leadership role in ensuring action on mental health issues.


Mr. John Service, Executive Director, Canadian Psychological Association: Mr. Chairman, I am very pleased to have this opportunity to meet with the committee to discuss Canada's health care system and how mental health fits into this system. The Canadian Psychological Association presented a brief to the committee in 2003. At the same time, we submitted several other documents.


I would like to look at political leadership, mental health across the continuum of care, intersetorial disorganization, stigma as a systemic discrimination — which seems to be a theme, does it not? — and, interdisciplinary collaboration.

Provincial and territorial governments are responsible for listing and de-listing health services. It is the history of provincial and territorial governments over the past several decades to de-list mental health services, both in actuality, in terms of them not being provided — such as hospitals in Toronto eliminating departments of psychology completely — and by not allowing them to grow as they should, based on population health data. That is a relative kind of de- listing that has been occurring for decades.

The Canadian Psychological Association, CPA, strongly supports a national action plan. How can we get about the business of correcting something unless we have a plan? How can we have discussions with different levels of government unless we have a plan, and how can we evaluate progress without a plan? We must have a plan. The CPA is a member of CAMIMH — the Canadian Alliance on Mental Illness and Mental Health — and so we strongly support CAMIMH's proposed action plan.

What would be helpful would be for Health Canada to work closely with CAMIMH, to provide some funds, and flesh out a comprehensive plan that looks at stigma, service delivery, social conditions, and social interventions such as housing, research and recruitment.

In respect of recruitment, you have heard from the previous panel the terrible difficulty in attracting psychiatrists and family practitioners into the field. Psychology does not have that problem. There are about 400 applicants today for graduate programs such as the Dalhousie and Queens Ph.D. programs, and they are accepting four or five people. We have many people who would be interested in working in this field, but they cannot get into the system.

In regard to practitioners and providing service, in the City of Ottawa, for example, there are as many practitioners as anywhere else in the country per population. They are extremely busy, because people who can afford the psychological services service within two to three weeks and they are very happy. They are paying $100 to $150 an hour. They have to be discriminating consumers, and they are getting benefit.

There are significant structural problems within the system that can be addressed. We would think that this action plan could address much of that, but there will be no change without dollars. Everybody has said that so far. I know governments hate to hear it, but dollars will bring change. If there is a significant contribution to the federal- provincial-territorial transfers, it is possible to move this forward in an exciting way. Your comments and questions to the other panellists in respect of how that might be done and whether it is preferable to have, as the honourable senator said, a separate plan. Those are important issues, and I have had some experience with that.

Mental health is across the continuum of care. That has been said before. Psychology is the science of the biological, cognitive, affective, social, cultural and environmental determinants of behaviour. That framework — how we think, feel and behave in our social and physical environments — is applied to the continuum of care. It is impossible to see how we can do a good job by carving behaviour out of wellness. Wellness is a big chunk of that. It is about behaviour — the things we choose to do or not, the things we eat or do not eat. Behaviour is a big issue — so it is in injury and illness prevention and so it is in family practice and primary care. Studies show that up to 60 per cent of the patients who walk through a family practice door has a psychological or psychiatric illness, or that it is an important contributor. Behaviour is also important in rehabilitation and relapse prevention, in chronic disease and long-term disability management, and in palliation.

If we conceive of mental health, mental illness and addictions as part of and central to the operations of the entire health system, we then make an extremely important structural change that brings mental illness into prime time as opposed to it being ghettoized over here with just the ``crazy people'' that nobody has to really deal with or the ``worried well'' for whom we have no time to deal with.

You have heard about stigma and discrimination. I cannot enforce that enough. I heard a young congressman from Rhode Island by the name of Kennedy talk about this. He was very interesting. He conceptualized the discrimination against people with mental illnesses in the United States as the same kind of discrimination experienced by Black people and by women in the 1950s and 1960s. He said it is the same system, and that we can correct it in the same way. He says you solve that systemic discrimination by doing what we know works in discrimination, which includes things like significant financial investments to turn the system and for affirmative action.

In our case, affirmative action will mean a disproportionate investment in mental health, mental illness and addiction services over the short and medium-term to bring a reasonable balance. It will not happen otherwise. It is the same problem that the Social Sciences Humanities Research Council, SSHRC, has. SSHRC has to expand. They cannot do it without having some kind of asymmetrical investment. We also need to have public education and mental health and mental illness and addictions must be included as prime time players across the whole spectrum of health, as are cancer and other chronic illnesses.

I worked as a clinician for 15 years in Nova Scotia. I worked with children, adolescents and families. I was the last post on the way out of town heading towards Halifax and the regional hospital or the Children's Hospital or the reform school. If you did not make it with me, you were in serious trouble, or you went back to the community. After I had been there about five years, I would see people who had been on a waiting list for two years. Therefore, a seven- year-old would be nine by the time he got to see me. We had a huge initiative to ensure that hip replacements and cardiovascular problems were taken care of, but it took two years for kids to get help.

Thinking back to that experience, there is another problem, and that is the silo problem. The European Union can allow you to get into all those countries with one passport and travel across all those borders without much of a problem. A child comes to see me after waiting two years. He or she has been taken in to the criminal justice system, gone through the school system, maybe seen the minister, probably been over to social welfare by the time I see him or her. They have been through all these systems, re-intaked, involved, separate files, and there is no transfer of information. They are fed up with telling their story. The European Union can do this with all of those kinds of complications, and we cannot allow people to transfer among those systems that we control without all of this headache, redundancy, cost and inefficiency. It is just a thought, but I think we can do something there as well.

Finally, interdisciplinary collaboration is absolutely essential as is interdisciplinary education in professional schools and doctoral programs, and in primary health care reform. There are several terrific programs for several million dollars that have nice constellations of anywhere from five to ten different professions. This kind of innovation will be extremely important. We know how to work together. Psychologists have been working with cardiologists, respirologists, nurses, and physios and vice versa for decades. It is the system. If we can jig the system to allow that to happen on an as-needed basis, based on population health demands and what the patients need, we can really do a nice job, but it will take some work and some money.

Health Canada needs a department or a division of mental health. How can we have Health Canada without a division of mental health? It does not make any sense. Such a department could drive this agenda to no small measure. A mental health division could inform all of the other stuff that Health Canada has to do, like surveillance and cancer and the laboratory for disease control.

Finally, mental health has to be a partner in the new and burgeoning, developing public health agency. Social scientists and behavioural scientists comprise about 9 per cent of the employees at the Center for Disease Control, CDC, in the United States. That is a little known fact. That is a big percentage that is intimately integrated into every facet of their activity. We have a letter that we will forward on to you from CDC, describing this. This is essential.

Senator LeBreton: What percentage did you say?

Mr. Service: Nine per cent of their staff is social and behavioural scientists. We need a presence in the new public health system.

Mr. Stephen Arbuckle, Member, Health Interest Group, Canadian Association of Social Workers: Honourable senators, the Canadian Association of Social Workers is pleased to have this opportunity to provide the committee with its thoughts on this vital topic.

The social work perspective on mental health delivery, needs and services has been developed from diverse practice experiences that include not only social work involvement as health care professionals, but also social workers' experience in youth and adult corrections, victim services, child welfare, private practice counselling, employee assistance programs, housing programs, community development and policy development. Using these experiences, social work has considered the impact of mental health problems and mental illness on individuals' families and communities and has formulated priorities and recommendations in response.

Observation, assessment and consultation informs us that solutions to the problems existing within the current mental health service delivery system must begin with acknowledging the need to have a holistic approach that will reach within and outside the current system. The required changes must occur at the levels of policy development, community's capacity building and service delivery. All changes must reflect social justice principles in order to correct an imbalance of priorities that have resulted in mental illness services receiving minimal attention in comparison to physical health services. This lack of attention has been most acutely felt as institutional in-patient services have been appropriately decreased without any comparable increase on services that support people in their families or in the community-based programs.

The Canadian Association of Social Workers has a few recommendations for the committee's consideration.

First, a comprehensive national action plan must recognizes the need for unique solutions at all levels of government, and reflect the diverse population regional differences, urban-rural differences and cultural differences.

Second, universal access to preventive, primary and tertiary mental health services needs to be established as a principle.

Third, poverty, as a key underlying issue for many mental health problems, must be seriously addressed by emphasis on ensuring a standard of living that truly promotes mental health.

Fourth, social policy development that affects mental health services should be guided by the Canadian Association of Social Workers social policy principles of dignity and respect, equality, equity, comprehensiveness, quality services and constitutional integrity.

Our fifth recommendation is that because psychological, social and biological determinants of health are complex and interconnected, policies that govern interconnected services such as financial assistance, transportation for the disadvantaged populations and housing should be adjusted to assist clients requiring mental health services to access available services, seek appropriate employment and live in housing that provides a mentally healthy environment.

Sixth, persons with mental illness should be recognized as being part of a family system. Therefore, the relevance of families, significant others or other personal networks must be included in treatment considerations. Health agencies should be required to provide services to families of people with mental illness and be funded in a manner that supports such services.

Seventh, financial support needs to be available to caregivers who provide in-home care and support to relatives who suffer from persistent illness.

Eighth, financial support needs to continue to increase to those not-for-profit agencies that provide mental health support services and prevention services.

Ninth, provincial and federal funding should be provided to further develop technology that supports consultation, assessment and treatment services in rural and remote regions of the country where specialized services are particularly lacking.

Tenth, interdisciplinary training opportunities should be expanded to prepare health care professionals to work in the field of mental health. Colleges and universities that train health care professionals should ensure that the curriculum includes a comprehensive segment on mental health and mental illness.

Finally, workplace health initiatives should increase their focus on mental health issues as employees struggle to cope with the increased workload, insecurity related to downsizing and other workplace stressors.

In conclusion, the Canadian Association of Social Workers hopes that this committee will develop a plan that will provide a comprehensive national mental health strategy that will address the needs of individuals, their families, and the community.

The Chairman: Mr. Service, could I ask you to think about the following problem. I was struck by your comment on the number of people who pay between $100 and $150 an hour for counselling. I put that against Mr. Arbuckle's comment for all of the things that he would he like to see funded.

We have an interesting dilemma. Obviously, there is a clear limit to the amount of government resources that are available for health care and other services. Second, a significant amount of private funding from individuals or corporations through EAP programs or whatever that is now funnelled into the counselling end of mental health by psychiatrists, social workers and whoever. Providing the services is not the issue. The point is that there is a significant of money coming in.

The extent to which you go immediately to some form of an universal publicly funded program, you substantially increase public funding while saving money for upper and middle income people who are now spending money out of their own pockets to pay for the services. I hate to take money out of the system with the notion that it would come out of the system only to be put back in through public funds.

How do we keep that substantial amount of money that is now being paid for counselling services by individuals out of their own pocket coming into the system while at the same time meeting the egalitarian objectivities of the Canada health plan?

I do not know the answer. However, I would hate to see a chunk of money taken out of the system because individuals would no longer have to pay for it. Then, all of that money plus the money to cover people who cannot afford it has to come out of public funding. There must be a way in which one can keep people paying who now pay.

I ask you to think about that. It strikes me as an issue with which one would want to deal otherwise we are increasing the cost of the public sector to do all the things that Dr. Arbuckle talked about. In addition, we would need to replace all the money now coming into the system.

I would like you to reflect on how we might do that from a practical standpoint.

Senator LeBreton: Ms. Panagabko, regarding psychiatric, and specially trained nurses, I am presuming it does take some specific special training to be a nurse in this field. What extra training is required? What facilities are there for that training?

Like all other areas, I am sure there is a tremendous shortage. I would want to get a picture of what the status is of this very important group of people in this field. What is the reality check that we are facing in terms of the nursing profession in this field?

Ms. Panagabko: Ms. Osted will speak to that as well because the RNs and registered psychiatric nurses are trained differently. I will tell you about registered nurses. Most of us come out of various programs.

I came out of a three-year hospital based diploma where I had six months' particular training in psychiatry. As you go along can you start making choices about where you want to focus your practicum experience.

Registered nurses come out with a general knowledge. At the time of graduation, they could hit the ground running in any of the specialties with the expectation that as time goes by, they will gain increasing knowledge in whatever they choose to go into. I went into registered nursing because I wanted a variety and figured I would move around. However, when I hit mental health psychiatry I just loved it and stayed with that and have done that for the last 30 years.

I will let my colleague here talk about that with RPNs, but the shortage in nursing is very similar for nurses as what Dr. Service was saying about psychology. There are lots people who want to go into nursing and many nurses who want to go into the area of psych-mental health but there are long wait lists. In B.C. to get into any kind of university or college programs now it is at least a two-year wait so they choose to go elsewhere. There are not enough seats within the education system to take them into nursing.

Ms. Annette Osted, Board Member, Registered Psychiatric Nurses of Canada: Some of you may have heard our president, Marg Synyshyn, last May talking about registered psychiatric nurses and mental health. She specializes in children and adolescent mental health, so she may have taken that approach. Registered psychiatric nurses are regulated in Western Canada. Nancy Panagabko is from Victoria, British Columbia; I am from Winnipeg, Manitoba. We are the western contingent here.

We are regulated in Western Canada to operate as a separate profession under separate legislation with separate education programs. The education programs are either three-year diploma programs or four-year baccalaureate programs, as we have. About 25 per cent of our members are men and two-thirds of us work full-time, which is slightly different data than for registered nurses or licensed practical nurses. We are the largest single group of professionals providing mental health services in Western Canada.

Because 25 per cent are men, who usually have less interrupted work lives; and two thirds of us work full time — again, less interrupted work lives — we expect earlier retirement dates. There is a serious shortage now. We expect that, within the next 10 years, that will get worse. That has been validated by the recent CIHR report on registered psychiatric nurses.

Ms. Panagabko: To add to that, within the RN population, the same things follow in terms of the shortage. It is partly around the age. The average age for nurses is about 47 years now. We are all moving into retirement.

If we could move fast to get seats available in the schools and the universities, we would not be in the shape we are in now. This has been a move over the last 10 years or so. It used to be that 10,000 nurses graduated annually in Canada; now it is 3,000. That has been the case for several years so.

The Chairman: Run that by me again? I knew the figure had decreased.

Ms. Panagabko: It was 10,000 when I graduated, so 1974 to 1980. It is at 3,000 people. It is no wonder we have a shortage.

The Chairman: That number blew me away.

Ms. Osted: As Ms. Panagabko said, for registered nurses, mental health is one of their many specialties; for registered psychiatric nurses, it is our primary area of practice. Again, we have the same situation as the registered nurses do. In Manitoba, with which I am most familiar, we have 60 seats now — both in Brandon and in Winnipeg — for 250 applicants. We cannot get them in; therefore, we cannot get them out. We cannot produce them.

Senator LeBreton: It seems obvious that if we move the whole mental health issue more into the forefront and more treatment, down the road we will have again more demand for nurses.

Ms. Osted: One of the important things to remember, for our group, 50 per cent of registered psychiatric nurses who work in community-based services, do not work in hospital-based services. That is an important factor. We are especially prominent as the single mental health resource in rural and remote areas. Working with psychiatrists in consultation very often by telephone or when they do their six-week or every three-month visits. I want to emphasize that we are not just talking about hospital services.

Senator LeBreton: I suppose the optimum would be to have increased numbers in both areas — that is, in the hospitals and in the community.

Ms. Osted: The shortages are in both places.

Senator LeBreton: Mr. Service, I thought you made a great presentation. Of course, it always comes down to political leadership. I was struck by your comment about services being de-listed by provincial governments because of budgetary concerns. Who makes the decisions and on what basis? Is it budgetary? When things are de-listed do they ever get re-listed?

Mr. Service: No, it is not often that things get re-listed. Mostly, they are de-listed.

The most dramatic example would be the teaching hospitals in Toronto, where they shut down the psychology departments at St. Mike's, the Toronto General, but they hired some back, at Sunnybrook, and at Scarborough. They were all teaching hospitals; it was all budgetary. Your report eloquently defined the different ways that hospitals are funded. It was global budgeting. It was left up to CEOs and off it went.

People of low and middle income who need those services and those facilities are out of luck. They are to be provided in the community, but they are not provided in the community.

When I say, ``de-listing,'' I mean it in quotation marks. It is not a decision taken that no more psychological or mental health services will be provided, it is a functional de-listing by not providing the services because money is going into biomedical health or because hospitals are shutting down because of budgetary reasons or the dollars that are supposed to move to community-based services do not go there.

When we shut down the psychiatric hospitals, there was supposed to be a bonanza of money going to the communities but it did not reach the communities. That is another way that access becomes compromised. That is what I meant.

Senator Pépin: Nursing takes you everywhere. I must admit that when I watched you and listened to you, I am so proud. I thought that nursing is really picking up. I must congratulate you on your leadership because we would have big problems if we did not have nurses. The work you are doing now in mental health is fantastic. However, when you were speaking about the closure of the nursing schools, they did the same thing in the Province of Quebec, from where I come. To realize that we now lack nurses is terrible.

Senator LeBreton asked many of my questions. However, you spoke about the importance of recognizing mental health and incorporating it with all the other sick persons, as did the other panel. Many years ago we de- institutionalized the mental health institutions that we had. Now, we find many of those patients are on the streets. We are told that a large part of the homeless are mental health patients.

Your proposal is very important. We all want to do the right thing in that direction, but how do you think we can recuperate those patients and find them? If there were some important changes, we could find less of those patients on the streets. How can we correct that situation now?

Mr. Arbuckle: I also work at the Royal Ottawa Hospital. There are some very good things happening in terms of working with people who have been ``de-institutionalized.'' The problem is that not enough money and services have gone into serving this hard-to-serve population.

There are some examples of good things happening in Ottawa such as psychiatric outreach teams, the new crisis intervention services and the community treatment teams, which are located in the communities — usually attached to a hospital or a community health service. A number of services are quite effective.

We still see people falling through the cracks in different ways. There are some very hard to reach people out there. We need to have more outreach and community-based services with a continuum from hospital to all the different levels of service, including the treatment services.

We need housing resources and financial resources. It is very hard to house someone in a supportive living situation when they are left with $112 to buy cigarettes. They do not want to stay; that is all they have. There are a number of intertwining issues that must be considered in finding a solution.

Ms Panagabko: To some degree, it speaks to the integrated health team. Mr. Service alluded to it a little earlier. There is a lot of work to do. We have limited resources. We have limited people to do it, and we need to be thinking far more broadly.

Even if there were enough resources, we still would not be able to deal with the problem if we do not have a bit of a paradigm shift in terms of understanding the illness. This is an illness that spans a person's lifetime. It is not just from hospital to community; it is from being a child to being an adult and having the ability to enter the system at whatever point they need to. The crisis lines are involved. The police are involved as are social workers, psychologists and others.

I am against the medical model. Doctors are one entry point. They should not be the only entry point. People need to be able to come in wherever they are and get the service they require.

We are setting up a system on Vancouver Island that tries to follow that approach. Most people do not have a GP these days. There is such a limited resource. Saying we will set up a system utilizing a doctor as the gatekeeper does not make much sense to me. We are trying to have a system that tries to ensure that no matter where you enter, you receive the level of resource that you need. Not everyone needs a psychologist at $150 an hour. The psychiatrists are precious resources. Let us ensure that the people who need to get there, do get there. If you need someone to talk to provide emotional support, it makes sense that calling the crisis line is an entry point for you.

Ms. Osted: There are some really good examples. I have found it very frustrating that treasury boards plan mental health services. Who has the least political clout? Who has the most stigma? Who will speak up the least? It is people with mental illnesses. They will not speak up. They are afraid. They do not want people to know that they have a mental illness. Their families are worried; they are afraid to speak up.

Who goes first? What gets cut first?

In Manitoba a mental health hospital — psychiatric hospital or mental health centre, which it was called at the end — closed down and the funds remained in that community. That city of 60,000 people has the best continuum of mental health services and the best integration of those services that I have seen anywhere. They are known for it. It can happen.

However, in respect of addressing the homeless and what we are doing with persons who have a mental illness in the criminal justice system, we have de-institutionalized them from the mental hospitals and re-institutionalized them into the criminal system. We have to take a systemic approach to this. I reinforce the call for an action plan.

We must look at the fact that what worked in this small city in Manitoba was the ``hump money'' to help the transition from one system to the other. Yes, it will cost more, but if we are committed to this, we will do it. It requires a strong political commitment.


Senator Pépin: Discrimination is no doubt the most difficult thing.

Ms. Osted: Absolutely.

Senator Pépin: People often pass judgment without realizing it. We need to change attitudes and we need to change our education process. When people meet an individual who is suffering or who has suffered from a mental illness, they must not think that this person is different from the others.

Ms. Osted: Quite right.

Senator Pépin: My question deals with discrimination. If someone is running as a candidate for a political party and is asked whether or not he or she has ever suffered from mental illness, is that discrimination?

Ms. Osted: Yes.


Ms. Osted: That is why CAMIMH, our organization and several others objected to the questionnaire that posed those questions.

Senator Fairbairn: I would like to direct my question to Mr. Arbuckle. You mentioned the Royal Ottawa Hospital. My husband worked as the director of public affairs there for a number of years in the 1990s so I became fairly close to some of the good things and some of the frustrations that exist — not just there, but in any institution like it.

I would like to ask you the social worker's perspective on two things. To what degree is the family itself one of the difficulties influencing whether a person who has these problems will come forward and seek help? How difficult is it for families to either recognize or get themselves to the point that they understand that they have a person in their family who has a mental illness and is not simply bad-tempered or cranky?

Second, are any of you able to identify patients who come to you with a variety of problems and who might also have difficulty with literacy?

Mr. Arbuckle: Many families are in denial that there is a problem. The stigma of coming to a mental health facility or being referred to a psychiatrist to get help is sometimes stopping people from moving forward. Sometimes people put up with what they call ``bad behaviour'' perhaps in their home when someone is going through a first break with schizophrenia. They do not seek the kind of help that they need.

Some of that has lessened in recent years. There is a little less stigma. One of our programs is called the schizophrenia program. Fourteen years ago, there was a great uproar when we decided to name it that because people would not want to be identified with that serious diagnosis. It is a non-issue right now, but in some ways it does help to break down the stigma.

Our hospital provides a significant amount of support to families. However, there are feelings throughout the country, I believe, that maybe families are not included in the treatment component. They are left out. It is only the patient who may be seen. The family is very much part of helping and they are quite often the support system. That may be where the person is going after they will be discharged, or they will want to continue to have a relationship with their family. It is important to involve them in the treatment.

You mentioned literacy. When somebody first comes into the system and is assessed, that kind of thing is usually picked up if there is a problem. I can only speak for the Royal Ottawa Hospital. We actually have an adult literacy program within the hospital that is accessed for out-patients and in-patients that is funded by various sources. That is certainly something that we look at. I do not know on a national level whether this is something that is assessed. Perhaps someone else would have more input into that, I do not know.

Mr. Service: For us, literacy would be a major barrier to re-entry to the job market or to means of using the social system to get oneself back on track. It is a very serious issue in the mental health population, particularly those who have been out of work for a while and probably dropped out of school early and so forth. Enhancing literacy skills is a way of re-entering the system and keeping well, so that is very important.

Families are critical. Family therapy is one vehicle, but supporting people, as my colleague said, is one of the ways of staying healthy. We know from research that healthy families will tend to keep people from being as depressed or as anxious, or getting depressed or anxious and the like. There are many studies on health outcomes, status and functional families, so families are absolutely critical.

Third, in terms of stigma, our profession finds that the stigma is reducing. Stigma is reducing significantly in certain populations. It is the populations who can access and use the service who do not have a problem because their neighbour, their friend, brother or cousin have accessed services and had a good experience. That is how you break down stigma. In our business that is also one of the best referrals. It is not from another professional, it is from somebody saying, ``I went to see Mr. Service and he did not a bad job so you might want to try him out.'' That is how you get most of your referrals and that is how you break down stigma.

The folks who you are describing do not have access to services. Many middle- and lower-income Canadians do not get services and it is highly difficult for them to identify with that process. They do not have other people in their social systems who have had experiences; in fact they have probably had negative experiences. In a way stigma is resolving itself for one group of Canadians but it is not resolving itself for another.

Another way that stigma could really be nailed on the head is if we beefed up the services available to kids in primary and secondary schools. I remember being in New Glasgow, my daughter or my son would be in school and some kid would come up to them and say, ``I saw your dad the other day.'' and Jessie or Aaron would go, ``You're not supposed to say that. I didn't know that.'' And while they would be embarrassed their friend would not be embarrassed. They would think it was fine and off they would go. Providing that experience at that level you break down that kind of stuff because that child goes home and talks to his parents about it and it is okay.

Senator Fairbairn: That would also mean a greater access too in the school system to assessing learning disabilities.

Mr. Service: Absolutely. Two of the places where people are captured for long periods of time are work and school. If we could provide better services at work and school we would do a tremendous preventive, resiliency, maintenance and curative job that we are not able to do now.

Ms. Panagabko: We need to differentiate somewhat between people with chronic, serious and persistent mental illness and the other folks. I agree totally with what you are saying around depressions, anxieties, and so on.

Illiteracy is not generally an issue in the psychotic population; oftentimes these people have reached university when they first become ill. Families around those issues often report their frustration with trying to access services for their loved one because no one will listen to mom or dad. If it is an 18-year-old and it is his first psychotic break we will say he is an adult, he can make his own decisions, and he is caught up in being afraid that he is crazy. He is trying to avoid treatment and the stigma and his parents are dragging him around. The health professional will say, ``Well, he is an adult, he can make his own decisions,'' and we end up waiting another two years until he is so sick that they end up being certified under the Mental Health Act and dragged in against his will. It is a difference between psychotic and non-psychotic.

Ms. Osted: The earlier and more aggressive the intervention, usually the better the success.

Ms. Panagabko: In respect of stigma, again, the psychotic population — which is not the largest group — tends to be the most sensational when things go bad. These are the folks that police shoot or they murder people in their homes and all that kind of stuff. When you talk with people such as police officers, they end up getting some of the worst discrimination of all because they are dealing with people when they are their most ill and most out of control and bringing them into hospital or whatever the case may be. My background is emergency mental health, by the way. I have had police officers telling me how they will sit in an emergency room with a person who is ill, watching the doctors and nurses continually put the patient's file down to the bottom of the pile again and again and again, because they do not know what to do and they try to wait until their shift is over so someone else will have to worry about it.

Ms. Osted: In Manitoba, there are psychiatric nurses on duty 24 hours a day in every emergency department of every general hospital. That is working out very well.

Senator Keon: I was very interested to hear that 50 per cent of Canadian mental health nurses are working outside the institutional sector in the community sector.

Ms. Osted: That is in Western Canada. Do you want me to elaborate on this?

Senator Keon: Yes, I do.

Ms. Osted: That figure includes crisis stabilization units, which are outside hospitals and are not on the medical model. The psychiatrist is not on-site. They may be on call and will be on call usually. Mobile crisis units have registered psychiatric nurses who go out when there are calls from people who are in distress. For community mental health worker positions or community psychiatric nursing positions — different titles, different jurisdictions — the geographic location will usually determine the role they will play. In the rural area, for example, they will be the consistent mental health resource. They will work with the family physician, with the psychiatrist, usually by distance, and with the public health nurse, with the schools, the churches, and service clubs, what have you.

In the city of Winnipeg — which, of course, is the largest city in Manitoba — the role is different because there are many more services that are not always as well integrated as in the rural areas. Usually their role is more concentrated on persons with a long-term mental illness. They are trying to help those persons be reintegrated into the community.

Those are some of the types of roles that are in the community. Yes, 50 per cent of our members are there.

Ms. Panagabko: That is typical across Canada. That is not just in Manitoba.

Ms. Osted: I do not know Eastern Canada that well.

Senator Keon: With the previous panel, I was trying to grapple with this whole business of mental health strategy, or how this whole universe will some day unfold.

In British Columbia and in Quebec, the public health system, I believe, will evolve to the point where it will be heavily dependent on the CLSCs in Quebec and similar community clinics in British Columbia, where they only use part of the services of the people who staff those particular areas. In other words, they may only need one-tenth of a public health nurse, so they buy that from somebody who is working in a community clinic.

Have you had any experience with that kind of thing? I am leading you down that road because I am trying to pursue the possibility of organized primary care to the point where some of these issues can be dealt with.

Ms. Osted: We see primary care as including only physicians, psychiatrists and family physicians, whereas primary health care is a broader approach with social workers and psychologists.

Senator Keon: I will stop you there because I do not see it that way. I see primary care ultimately as community clinics staffed with health professionals, including a public health capability. The question is whether you can put a mental health capability in there.

Ms. Osted: Absolutely.

Ms. Panagabko: Coming from British Columbia, I am aware of clinics that have tried to do this and found it difficult because of the stigma. It is so discombobulating for the other patients presenting to the clinic to have the paranoid schizophrenic in the same waiting room, so that they object to it.

However, we are looking at having parallel clinics, so that the person with mental illness can be headed toward integration, but we cannot get to integration until we have done much more work around public awareness and so forth.

Mr. Service: Currently, there are several in clinical psychology. One is the parallel clinic model in which physicians and psychologists and other practitioners all work in a location and they co-refer.

Another is the co-located model, where the physiologist, psychologist and physician are working in with a group of others and they refer back and forth. Those work well, but the revenue streams are quite different. Then there are new emerging models where the clinic is actually then contracting with private practitioner psychologists, for example, for a piece of their time, or a hospital and a community clinic will buy half the time each. That happens in more rural areas.

Those kinds of models are starting to develop. Those are very exciting. For us, these funding systems must be flexible and different from urban to rural to remote, and they have to get the right people to the right patient at the right time. There are many possibilities.

With respect to what I said earlier about psychology charging $100 to $150 an hour and then factoring that into a primary health care system, these are private business people. They are paying real estate and staff, and they are running a business. There is that cost. When you factor that cost into marrying the public and private system, you are talking about a system where the overhead is paid for versus another system that has to generate income to pay for itself.

To get back to your original question, trying to marry those two is one of the issue that must be addressed.

Mr. Arbuckle: I can think of a couple of examples in Ottawa where we are working in partnership, for example, with the Sandy Hill Community Health Centre. We second some services half a day a week or half a day a month to have a psychiatrist provide some consultation in regard to some of the more difficult cases.

We also have other health professionals, including a nurse-practitioner who is seconded to Sandy Hill because they are dealing with a population in which a number of people are homeless and a number have serious mental illness. They do integrate the mental health services into the health centre atmosphere.

There are other wonderful examples of the inner-city health project, where many agencies and hospitals are providing seconded services. It may be on an on-call basis, social work or psychiatric nurses but also physical health services because it is for a population that is tertiary and, in some cases, palliative.

There are examples where you are purchasing a little bit of service. You do not need a full person to do the job, but you need a bit of somebody and you can get that from one of the other agencies. There are ways of working in terms of partnership through that kind of model.

Senator Cordy: I used to be an elementary school teacher. I found two frustrations that most of the teachers on the staff shared when dealing with children who had needs. The first was the waiting time. In some cases, you spoke to administration in the school and then in many cases, you would have to talk to parents, particularly in the early grades, to let them know that there was a problem. Then you would refer them to the school psychologist, which would take many months. At my age, you do not want to wait three to six months, but it is not the end of the world. When one is five or six years old, many things can happen in three or six months.

The child would finally get his or her appointment with the school psychologist, who is dealing with 10 schools in the system and gets to each school maybe one day a week or every two weeks. The school psychologist would meet with and test the child and then make a referral to the child guidance centre or the IWK, which would require another period of waiting. That was one huge frustration — and that was when the parents were compliant and agreed that this should be happening.

The second issue was the families. Particularly in families with young children, you saw parents and siblings who were really hurting. The siblings were often feeling discrimination from other students in the school because they had the weird brother or sister in the school.

How do you deal with those things? How do you speed things up within the school system? Is that possible?

Mr. Service: I think it is possible. There are a number of different ways of doing it. First there is the old question of resources. Why is there one school psychologist for 10 schools? What happened to the public health nurses in the schools? I have the scars to prove it. I remember them well. You remember them well, too, maybe.

Why have we decentralized and taken those support systems out of the environment that these kids are in more than any other environment except perhaps home? That does not make sense.

In New Glasgow, we tried to move the mental health services from the hospital into the schools. I was on the children's team at the Aberdeen. We were going to disband that and provide all of our mental health services out of the schools and try to get some psychology and nursing support into the school system to deal with it there. That was a great idea, but it died because we had a change in government.

We need a national action plan that can look at not only providing more mental health services in the health system but also providing those services across systems in an effective way. Personally, I spent a lot of time in the school. I also spent a lot of time at this Pictou County Children's Aid Society and I would have to follow this kid around. I was also attached to the court. Why was I doing all that and providing files in the different areas and running around when we could centralize it? Children's services could be centralized and rationalized by locale as opposed to by silo. That could go a huge way.

I am getting older, so I have a real investment in geriatric services. If you ask me where is the bang for the buck, it is not there; it is in kids. If we loaded that system up, that would be fine with me. That is where it should go. Then it could be provided to the schools, the criminal justice system, kids' courts, Children's Aid, the hospital and public health. That is the way to go.

Senator Cordy: We had some witnesses who appeared before us who were actually using the mental health system as patients. One of the things they found frustrating was retelling their story over and over again.

Mr. Service: Furious.

Senator Cordy: Is the information shared? How many times must an individual be assessed and tell their story? Would an electronic health record help that?

Mr. Service: Absolutely. I found that because I was the last guy on the train before the IWK, the Nova Scotia hospital in Shelburne. They had been through a whole bunch of folks and people were angry by the time they got to me. They were fed up with telling their story repeatedly. It is a painful and complicated story to tell. Furthermore, if I saw the kid in the school I had to re-intake them for the school system or Children's Aid. I personally then had to do all these different interviews to satisfy those systems.

That is why the European Common Market idea is a wonderful idea. Why can we not have a common community market for mental health service so that you could travel around get your services and your electronic record follows you?

There is another problem, though. The hospital, the school and the Children's Aid Society all feel as if they have legal responsibility. We have to free them from taking responsibility solely for those services that they deliver on their premises. The providers have to have some way of providing services without that kind of malpractice complication that can occur. That is the other problem that can be resolved by governments and very quickly, I think. That is a horrible thing for someone who must retell the tale. You know that.

Senator Cordy: We are not just dealing with silos, we are dealing with the health, education and community service system and never the twain shall meet.

Ms. Panagabko: Even within one silo, a teaching hospital, I have talked with clients who have told their story up to 20 times because they have to tell all the students, including their supervisor, and on and on it goes. It gets to the point where it is dangerous.

I will give you an example that I heard from a mountie on Vancouver Island a while back. He phoned and was so upset that he was beside himself and could hardly speak. He had been called by the crisis line saying that a woman was going to kill herself and refused to contract with them and hung up the phone. They were able to trace the call. She lived out in some remote community. The police officer went dashing out there. The place was dark. There was no one home from what he could see. He thought, she could have either gone to the hospital or she had taken her pills and was lying in the bush somewhere. His first course of action was to phone the hospital to see if she had shown up or not. The emergency room staff informed him that they could not share that information with him. It interfered with his ability to do his job. I have had similar experiences.

As well as figuring it out within our silos, we need to have a way to cross them. For example, having one record for that person. How do you get it from social services to education to health? I do not know the answer to that. There must be degrees of what you can and cannot share. If we do not work this out, however, we will have big problems down the line.

Senator Morin: I would like to put a different note on this retelling of stories. This has been going on with the committee over and over again.

Mr. Service, as a psychologist, if a patient comes to you he is referred. He has a note. Will you not question him on his case history? You have different questions the patient answers with different nuances. I was a practising physician. I never took the history. I will not question you, but I was a cardiologist.

I am amazed that, as a psychologist, you would not want to hear the patient's history over again. I do not know about nurses but I am sure that, as psychologists, you would want to question him again. That will be the twenty-third time he tells his history. If he sees another health professional who wants to make a diagnosis, he will question him again. That is part of the story.

Mr. Service: No. I disagree. There is a significant amount of basic information that you will tell me as a patient or your patients will tell you that is the same. That will not change.

What I will want to talk about is your problem. What is it that you feel is the reason you are coming to see me? That, I will go through a lot.

Senator Morin: That is the twenty-third time he is telling his story.

Mr. Service: No. That is very different. That is absolutely relevant to the discussion that patient wants to have with me because that is the problem we will work on. I do not want to have to talk about your educational history, your GP, or verify what is in the GP record, all that kind of stuff.

Senator Morin: All the patient is telling you is the history, it is not the time that he will be at school.

Mr. Service: My responsibility under my regulatory body is to get that information to verify, just as you said. I do not want to have to do that. In our hospital in the Aberdeen, we use volunteers. We have a volunteer program. There were people with behavioural science degrees. You train them and they went out to get that information for them. They did some classroom information gathering and so on. Yes, we trusted that information. That, I think, is a very responsible way to go ahead.

Senator Cook: This afternoon we heard from both panels talking about the need for the creation of a national action plan. How do you see integrating that into provincial jurisdictions for implementation?

Ms. Osted: In both Alberta and Manitoba there are provincial alliances for mental illness and mental health that are also committed to advocating and lobbying for having provincial action plans that will be consistent with the federal action plan. We know that CAMIMH will be successful. We can see that happening. We need the leadership at both levels, but we need it at the federal level first. People who are homeless and have mental illnesses travel between provinces so it must be national so that there is some consistent philosophy of approach to the issue. We will not wait for federal leadership before we do our thing at the provincial level. However, it would be very helpful to have it at the national level.

Senator Cook: That is my dilemma. In my province, I see the continuum of care happening at a provincial level. If we have a national plan, how do we integrate it? Is this another way of getting funds and professionals and whatever into the system?

Ms. Panagabko: There are all kinds of excellent programs out there, but they are small, little programs. There may be a cluster of programs in your province that are good. However, there are also clusters of programs that are not good. Leadership is required.

First, a paradigm shift needs to occur around the use of resources. Leadership would make a huge difference around the stigma, and so on, if it is seen as something that is important.

I would also like to see national mental health act that is not different from province to province. Right now, within each province, it is interpreted in different ways in and of itself. If we had a national act, and some guidelines around how to interpret it, we would get somewhere with that. That would make a huge difference to the lives of a lot people with mental illness.

Senator Cook: When Minister Bennett was in Newfoundland, she had a round table with all the interested and responsible stakeholders. About 30 people around that table told their story. Before she was half-way around the room, you could see the duplication of services, of programs in that small area. Right away, I could see where you could save on human resources and financial and volunteer resources.

I agree that there are many little pockets of services out there doing things well, there may be duplication, and other things are not being done. I was just looking for your thoughts on integration.

Ms. Panagabko: There are many parallel programs. With some national leadership, perhaps we could get past that so that we are using the broader health care team in a more effective way.

Ms. Osted: As well as the financial resources.

Ms. Panagabko: That is right.

Senator Cook: Thank you very much. Newfoundlanders tell stories and I have a good-news one for you. When my daughter was 17, she became severely anorexic as a result of her dad's death. It was a nutritionist and a psychologist who walked with her on her three-year journey. There was an integrated approach. The good news is that today she is a psychologist and a mother of two little boys.

The Chairman: Thank you very much for coming here. We really appreciate the time you have been with us.

The committee adjourned.

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