Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 9 - Evidence, May 12, 2004
OTTAWA, Wednesday, May 12, 2004
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:04 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 Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: We are continuing our special study on issues concerning mental health and mental illness. Our witnesses today are from the Schizophrenia Society of Canada, the Canadian Mental Health Association; the Mood Disorder Society of Canada and the Anxiety Disorders Association of Canada. Welcome, and thank you for taking the time today to help us bring this important issue one step closer to the public recognition and action that it deserves and requires.
We will start with Mr. Gray.
Mr. John Gray, President-Elect, Schizophrenia Society of Canada: We very much appreciate this opportunity. The Schizophrenia Society of Canada is a national, registered charity founded 25 years ago. We work with 10 provincial societies and over 100 chapters and branches throughout the country to assist individuals and families living with schizophrenia.
Our perspective on the role of non-government organizations, which is our task, in supporting families of individuals living with mental illness and addictions is as follows. The support NGOs provide for families and individuals living with mental illness serves to support the Canadian mental health system. By providing resources such as education materials and support groups to people affected by serious and persistent mental illness, NGOs decrease the demand on governmental interventions such as hospitalization and, unfortunately, incarceration. By working together to build more effective partnerships between NGOs and government, we can work towards containing rising health care costs and provide sensitive, community care.
In addition, NGOs have a unique ability to partner with government and service providers to support families and individuals in ways that are convenient, cost effective and meaningful. Unbounded by provider system obligations that often dictate location, time and format of support groups, for example, NGOs can offer families and individuals support at home, on the Internet, in town halls, community centres and even around the kitchen table.
For example, the Schizophrenia Society of Canada has successfully piloted a national family-to-family education program that will be launched this fall. The program is designed to empower families and to provide valuable information on preventing relapses, effectively communicating with mental health system providers and coping as a family. This flexible 10-module session is taught by volunteers who are most often living with the effects of mental illness on their families.
The biggest barriers to NGOs in terms of providing these services is the lack of resources, which are used for developmental costs and training costs, and also the lack of awareness of some clinicians and providers of their programs. Sometimes there is not effective communication between mental health clinics and NGOs in the area, so that NGOs need the capacity to inform their communities about available programs, to educate service providers and to assist organizations like clinics, police officers and educators to understand the continuum of care that is available for individuals and their families.
The second question was the role of NGOs in advocating for changes in provincial and federal legislation. Advocacy on the part of NGOs in the mental illness sector is particularly important, as ill individuals, especially with serious illnesses such as schizophrenia, may not realize they have an illness themselves and therefore are not in a position to advocate for themselves. Advocacy efforts can range from a local organization advocating for a particular person or family's needs, to provincial advocacy for programs such early intervention in psychosis, which is very important from our perspective, to advocating for changes in mental health legislation that will provide less restrictive services. Finally, advocacy at the national level may focus on a range of national issues, and ones that we have been involved in, for example, are the disability tax credits and issues of support like housing. With advocacy, sometimes direct confrontation is necessary, but it has been our experience as a society that problems are more productively solved through partnership and dialogue.
We recognize that one of the barriers to partnership and dialogue has been the fragmentation of the mental illness sector — that is, a large number of organizations all in the same area. A group of mental health illness groups, including the Schizophrenia Society of Canada, recognized this barrier and joined together to enhance the ability of NGOs to effectively advocate for change and also to communicate with governments and make it easy for governments to discuss these issues with the sector. That organization, you well know, is the Canadian Alliance for Mental Illness and Mental Health. It is positioned to work with government to develop a national action plan for mental health.
The third issue is the role of NGOs in pursuing efforts to improve treatment and services. The best way for NGOs to improve treatments and services is to be part of the solution by educating and supporting the community, in addition to the advocacy issues that I just spoke about. NGOs can improve treatment and services for ill individuals and their families by working with funders and with providers such as pharmacists, physicians and so on. For example, we have recently been working with pharmacists and drug manufacturers in assisting them to produce pamphlets about medications that are easy for families and consumers to read and understand.
The fourth issue is supporting research into mental illness and addictions — an important issue to our society. There are two key ways for NGOs to support research. First, organizations can financially support research initiatives, and we do this nationally. B.C. has a research fund, as does Ontario. This can either be done independently or by partnering with other organizations. For example, the Schizophrenia Society of Canada has an excellent working relationship with the Canadian Institutes for Health Research. We put up $75,000 last year and were matched by CIHR on that. That is a good mechanism for NGO involvement in research.
Second, NGOs can support research by participating in the process. For example, they can be involved in the priority setting of topics that are relevant in research. They can be involved in designing questionnaires, sitting on review panels and disseminating results when the research is concluded.
The fifth issue is raising public awareness and reducing discrimination and stigma. Schizophrenia is, unfortunately, one of the most stigmatized mental illness. People do not understand it and fear it. It is a particularly important issue for us, but it is important to everyone sitting at the this end of the table. There are many ways that an NGO can work to reduce stigma through public awareness. Producing newsletters, Web sites, information brochures and manuals to provide clear and accurate information are all effective ways of communicating clear and accurate information.
For example, the Schizophrenia Society of Canada's Web site receives approximately 400 visits per day. Some publications such as our manual, which is really quite a substantial document, are downloaded approximately 2,000 times per month. It is staggering. This clearly demonstrates that accurate information is reaching numerous people across the country and around the world.
Another example is SSC's youth-oriented education program, entitled ``Reaching Out: The Importance of Early Treatment.'' It consists of a video and teaching materials. It is now in 4,000 schools and mental health clinics across the country.
In British Columbia, this year, the Schizophrenia Society has received $3.25 million for television and radio ads supporting changing public attitudes about schizophrenia.
In summary, NGOs have an important role to play in the key areas noted above. However, NGOs cannot continue to play this role and expand their level of service without the capacity to partner with governments on programs and initiatives or the opportunity to meaningfully participate in the decision-making process.
We encourage your committee to strongly recommend financial support from government, where appropriate, for NGO projects focusing on public awareness and education as well as improving services. We should also like to recommend that government facilitate opportunities for NGOs to sit at the table assisting with government policy committees that are related to legislation, policy or program issues. In that way, we can be meaningfully and directly involved in shaping legislation and programs for the individuals that we represent.
The Deputy Chairman: Thank you very much, Mr. Gray. I am sure we will have many questions when the question period begins.
I will now turn to Ms. Marrett from the Canadian Mental Health Association.
[Translation]
Ms. Penny Marrett, Chief Executive Officer, Canadian Mental Health Association: Thank you very much for this opportunity to talk about mental health.
[English]
Mental health should be of concern to all, not just the mental health community. The Canadian Mental Health Association is pleased that the Standing Senate Committee on Social Affairs, Science and Technology is researching this issue in such depth.
The Canadian Mental Health Association is an active member of Canada's mental health community and accomplishes its mission of promoting the mental health of all in supporting the resilience and recovery of people experiencing mental illness through public policy development, education, advocacy, research and service. With a presence in over 135 communities from coast to coast to coast, the Canadian Mental Health Association captures the wide-ranging issues and concerns affecting the mental health of the people of Canada.
[Translation]
The Canadian Health Association has five recommendations for your committee.
[English]
First, as a founding member of the Canadian Alliance on Mental Illness/Mental Health, the Canadian Mental Health Association is a strong supporter of the call by the alliance for a pan-Canadian strategy on mental illness/ mental health. Without such a strategy, the people of Canada experiencing mental health problems will continue to lack the strategic and coordinated services they so rightly deserve.
Second, as you are aware, the premiers' council has indicated that community mental health is one of the council's top priorities. The Canadian Mental Health Association could not agree more. Its experience in communities across the country has shown the importance of community mental health as a critical component of the mental health continuum. The federal government must demonstrate its willingness to work with the premiers' council to achieve a comprehensive and coordinated community mental health system that crosses all boundaries.
Third, one of the challenges that Canada faces when developing strategies is the need to ensure that various populations are well served. It is critical that the federal government not forget the needs of children and youth, Aboriginals, women and new immigrants when developing a pan-Canadian strategy on mental illness/mental health. These populations are particularly vulnerable, and we must ensure their needs are considered throughout the process.
Fourth, suicide is a particularly tragic occurrence in this country. Canada's suicide rate is high. Over 4,000 people in Canada die by suicide each year. We must address this serious issue. The Canadian Mental Health Association believes that the best solution would be to ensure that there is a comprehensive and coordinated suicide-prevention strategy included in the pan-Canadian strategy on mental illness/mental health.
Last, consumers, families, friends, neighbours, colleagues and employers all alike need somewhere to turn for information, support, education and to become more actively involved. The voluntary sector in mental health provides an excellent avenue for the coming together of communities to address issues of concern. These issues are addressed through public policy development, education, advocacy, research and service. However, the voluntary sector of mental health cannot do its important work without resources. As part of the federal government's commitment to mental health, the government must also demonstrate its commitment to increasing the capacity of the voluntary sector in mental health to enable it to participate in public policy development and to provide the programs and services its constituents so urgently require.
Thank you again for this opportunity. Rest assured that the Canadian Mental Health Association is ready to assist you in your work in whatever way possible.
The Deputy Chairman: Thank you, Ms. Marrett.
Mr. Upshall is our next witness.
Mr. Phil Upshall, President, Mood Disorder Society of Canada: It is a real pleasure to be here with you today. I sit here as the president of the Mood Disorder Society of Canada, MDSC, and as a consumer to bring you a unique perspective in that regard. I want to say how wonderful it is to be able to appear before this august committee. We have provided the committee with a copy of our written presentation.
We had our institute advisory board committee meeting in Quebec City over the weekend. At that meeting, there was a representative who is the head of the mental health group within the World Health Organizations. He was saying that, unfortunately, mental health issues have fallen somewhat from the World Health Organization mandate, but he was specifically looking to countries such as Canada that are at the forefront of at least engaging in the discussion of what must be done. He is quite aware of the activities of the committee and certainly endorses it. He is willing to attend or provide you with whatever information he can from the global perspective. Your reputation is going far beyond the boundaries of Canada, as I am sure you know.
The Canada Health Act has as its primary objective Canadian health care policies to protect, provide and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers. The reality, however, is that in Canada the word ``mental'' and the word ``barriers'' seem to be forgotten frequently by our policy makers. It is something that I hope you will bear in mind as you move forward in your deliberations.
The Mood Disorders Society of Canada is relatively new non-governmental organization. It was formed in 1995 with a view to providing people with depression, bipolar disorders and other mood disorders a voice at the national level; since 2001 it has been registered as a charitable organization.
The opportunity to network among mood disorders provincial associations is something that has been sought for some time. We are happy to provide that platform. The MDSC is developing as a virtual NGO, having primarily contract employees across Canada, and is operating through the World Wide Web. Our Web site is quite active and currently has a number of active forums and chat lines that we are quite happy to see used.
The Mood Disorder Society of Canada partners internationally with the Global Alliance on Mental Illness Advocacy Networks — GAMIAN-Europe — which is a voice primarily developed in Europe for national consumer voices. There are now over 70 national groups represented in that organization. We are proud to see the activities that they have undertaken, mainly in Brussels but also in their home countries.
We are also associated with the Depression and Bipolar Support Alliance in the United States, which is the largest self-help group in the U.S., with 20 million or more contacts per year. Our vice-president is the first non-American president of that organization. We think we are reasonably well connected.
I endorse the comments of the previous speakers this afternoon — however, I am somewhat more direct and a little more pointed in my comments than my diplomatic colleagues.
The reality is that mental health care appears nowhere on anyone's agenda at the federal level in a meaningful way. The Minister of Health, whom I hold in high regard, responded to a question earlier this week that appears in Hansard. I am sure senators have seen this, but I should like to read it into the record, if I may. Mr. Marcel Proulx asked the question:
Mr. Speaker, my question is for the Minister of Health. This week is Mental Health Week in Canada. Mental health indirectly affects everyone, whether it is through a parent, a friend or a colleague, regardless of age, education, revenue or culture.
What is the Government of Canada doing about mental health?
Without missing a beat, the Honourable Pierre Pettigrew responded:
Mr. Speaker, I thank the hon. member for his very important question. Along with all the provinces and territories across Canada, we are trying to find solutions to mental health issues. We have numerous programs in place to support this commitment. The Canadian Institutes of Health Research are currently investing over $30 million in research relating to mental health.
Hon. members can show their support by visiting the National Gallery of Canada, where an exhibit entitled ``Mindscapes'' is featuring works created by artists affected by mental illness. I had the opportunity to see it two days ago. It is very important. We must congratulate our artists.
It is an important art show, and wonderful to visit and something you should see, but it is hardly the stuff of national policy. The $30 million from the CIHR includes neuroscience research. That is not particularly associated with the mental health issues such as schizophrenia, depression, bipolar illness and others that people deal with. The reality is that Health Canada has no major champions from the top or the bottom that are prepared to deal with issues of mental health.
In our written brief, I comment that no Canadian Prime Minister or leading cabinet minister has ever acknowledged the size of the burden of mental illness on the health system in Canada, or on the lives of individual Canadians or their families. There is a list there of things the government has not done. That is not withstanding the fact that the Justice, Human Rights, Public Safety and Emergency Preparedness Committee in the other place pointed out the horrendous conditions that people with mental illnesses suffer in our correctional institutions. It is not hundreds, it is thousands, of people who are entitled to mental health care but are denied it deliberately. There is absolutely no doubt that there is recognition that these people are entitled by virtue of the Canada Health Act and the legislation governing Corrections Canada to have good mental health care whether incarcerated or not. They are denied it, because if it were provided to them it would bankrupt the provincial mental health care systems. What a tragedy for Canada; what a black mark.
The Senate Subcommittee of Veterans Affairs has commented twice about the lack of attention paid to the mental health of our Armed Forces — another true tragedy.
The House of Commons Standing Committee on Health has done absolutely nothing with regard to mental health. The standing committees in both Houses have commented on the lack of adequate mental health services for Aboriginal populations, homeless populations and other significantly marginalized groups in Canada.
It is only recently that a positive response has been made to issues with regard to mental health when Finance Canada undertook its review of the disability tax credit; but that did not occur without a legal requirement to do so.
Unique characteristics relate to our NGOs in Canada that deal with mental illness and mental health issues. With de-institutionalization, the great mantra was that we would close these thousands and thousands of provincial psychiatric hospital beds and move people into a continuum of care that is community-centred. It was a beautiful philosophy, one that I do not think anyone around this table would disagree with. However, the reality is that thousands of hospital beds were closed and the provinces diverted the money, I suspect deliberately, to more well- advocated activities. As a result, we got them all dumped out and NGOs, such as CMHA, MDSC, the Schizophrenia Society and others, have mandates to help deliver those services. At the same time that we were supposed to help, the funding was withdrawn not only from the health care continuum but also from the support of the NGO community. That was hardly a fair or effective way to proceed.
NGOs in the mental health and mental illness community are part of the primary health care delivery system. In looking at community care, you are looking at NGOs, primarily. In looking at primary care for physical illnesses, you are looking primarily to hospitals and hospital-based activities. That is the first distinction.
The other distinctions are set out in my paper, so I will not speak to them here, other than to indicate that the NGOs today need the support of the federal government if they are to complete their mandates and if the federal government takes their mandates seriously.
The recommendations that I have made on behalf of the Mood Disorder Society of Canada are in my brief. I will not read them into the record. I am sure you have had the opportunity to read them. We do support the Canadian Alliance on Mental Illness and Mental Health's brief to this committee last July and all of the recommendations contained therein. We do support the Canada Health Act as it ought to be interpreted, which means available to all Canadians, including people with mental health issues.
It is our hope that you seriously consider our recommendations as they relate to deliberate planks in a national strategy. We do not think that they are overly difficult to attain. From our perspective, an interdepartmental committee at the deputy minister level would be appropriate; a blue-ribbon panel to monitor its activities and to evaluate and do results-based management considerations is doable; and a $50-million funding envelope with research support is doable.
Thank you for the opportunity to appear before the committee. I will be happy to answer questions.
The Deputy Chairman: Thank you, Mr. Upshall.
Mr. McLean, please proceed.
Mr. Peter McLean, Vice-President, Anxiety Disorders Association of Canada: The Anxiety Disorders Association of Canada appreciates the opportunity to share our concerns and recommendations with you.
I will take the liberty of coming at this a bit differently because anxiety disorders are largely misunderstood and, functionally speaking, the Canada Health Act is largely irrelevant to sufferers of anxiety disorders. I think it might help to understand why.
Anxiety disorders happen to be the most prevalent group of mental disorders. About 2.2 per cent of Canadians have a chronic anxiety disorder, and 1.2 per cent have a very severe — that is, disabling — anxiety disorder. Those are significant numbers. Anxiety disorders are the most invisible of all mental disorders. These folks behave themselves. They are cognitively intact, if you will pardon the expression. They are embarrassed, ashamed, and they fake it socially, so who would know? Even trained people have a hard time knowing. Family physicians only identify it 50 per cent of the time.
People who suffer from anxiety disorders are also, by all accounts, the most treatable. There are two evidence-based treatments that are used — that is, a pharmacological treatment and a psychosocial treatment called cognitive behaviour therapy. Hence, we have the least known, least identified and most treatable of the mental disorders in sharp contrast here.
They are also the most overlooked for, I think, a variety of reasons. For example, the mental health managers who run our health authorities across Canada should know these things. They should know what the prevalence rate is; they should know about the frightening economic impact. Most economic studies show approximately $4,000 per person with an anxiety disorder, per year, in terms of direct medical costs, which is slightly larger than productivity costs, should the person be employable.
Most anxiety disorders are untreated. Importantly, untreated anxiety disorders in children provide an incubator effect for downstream or subsequent depression, alcohol abuse and smoking. Therefore, there is some leverage effect here by early intervention.
Hence, one would think that our health managers, and planners and our policy people, at least at the health authority level, would know this. However, they are not driven by market forces. Consequently, mental health treatment is optional in most jurisdictions. Money that should be targeted goes to the health authorities to spend as they see fit. In the push and pull of the drama of physical versus mental, physical usually gets it. In the push and pull of mental health, anxiety disorders are the last to get it. That has been the history.
There is no proportion to the rate of disability or the treatability of disorders, or any other logical investment guide. There appears to be system indifference, if not discrimination. That is the background. That is why the Anxiety Disorders Association of Canada was developed three years ago, and is now a vigorous organization.
Moving over to new directions, we strongly support, in principle, as have many of your other witnesses have today and elsewhere, the recommendation for federal leadership in the development of a national plan for mental health. We are not, however, at all confident that other measures, such as increasing public information, more research, federal monitoring or policy changes in the primary physician level, for example, will make things significantly better for those with anxiety disorders. For example, why increase public awareness if there is a treatment capacity problem, if you cannot do anything about it?
Specifically, we have three broad recommendations that we would like you to consider. One is that we recommend only evidence-based assessment and treatment services in our universal system be paid for on the public purse. It simply makes no sense that, in 2004, people should be able to bill for what they think they would like to do, regardless of outcome, regardless of guidelines by professional organizations that have looked at this from the perspective of an evidence-based treatment. We need to have evidence-based treatments, flat out and exclusively on the public purse.
I shall read a sentence or two from the brief that we submitted: ``The system's tolerance for low-quality standards in knowledge and skill for mental health practitioners in Canada has the effect of prolonging illness, discouraging patients from publicly funded services and allowing practitioners to deliver well-meaning but ineffective treatments at public expense.'' That is the rationale behind moving toward evidence-based treatments.
Another example of the lack of that is the use of paediatric prescriptions for anti-depressants, which is an off-label practice, not evidence-based. It is widely used and has come to your attention recently, I am sure. Fortunately, in some jurisdictions, there are changes. I am delighted that, in British Columbia, for example, where I am from, the Ministry of Children and Family Development is systematically upscaling its clinical workforce in evidence-based treatments, which is most refreshing.
The second recommendation we would like to offer for your consideration is that we would like to see the provision of patient choice, by directly funding non-medical, psychological, psychosocial treatments, if necessary, on a restricted basis, to ensure treatment standards and cost offset. Right now, in Canada, patients do not have a choice of practitioner, unlike the United States. They are forced largely into medical treatment, because that is what the Canada Health Act supports. What this means, in practice, is that an individual pretty much gets a pharmaceutical intervention, because it is primarily dispensed by family physicians, who largely are not trained in psychosocial methods.
This is not entirely a bad thing, because pharmaceutical treatments can be very effective, although they are not always the treatment of choice in anxiety disorders. The problem is that the informed patient has no choice. In the system, they are denied.
I will give you an example. At the University of British Columbia, I work in the anxiety disorders area, specifically, obsessive compulsive disorder. These folks often end up in hospital because they become depressed, reactive to the untreated OCD — 1,500 bed days a year in British Columbia. Many of these people end up on disability in their parents' basement. It has a very early onset, and there is an average length of interval between onset of symptoms and effective care in Canada and the United States of 17 years. This is documented.
It is very difficult to get funding for this. What happens in British Columbia is that if an individual who has the right connections can get sent out of the country for treatment in the United States. Getting that data and presenting it to mental health folks at the government level has not been successful, because most of the health authorities do not care. They do not care because they do not pay for it anyway. It comes out of a central funding source.
We have been trying to repatriate those dollars. If there is one thing that you could do for anxiety disorders, it would be to ensure funding of regional daycare programs for OCD. Office treatment is not enough and hospitalization is rarely necessary. What is necessary is to have a dose-response relationship, which can occur in a daycare program. In any event, that is just offered as an example.
The third recommendation we wish to bring to your attention is that the system itself needs incentives across mental health disorders, not just anxiety disorders — incentives or guidelines for cost-effective management practices.
For example, as someone said in previous days, the hot area of intervention should be, by all accounts, children, because it is easy to influence them in a school-based program and they are a risk factor, if they have anxiety disorders, for subsequent disorders and the like. I do not think education will fund it, but health care could in cooperation with education. There have been some exciting efficacy studies done in Australia and now in Canada that would support this as a form of intervention, both universally and in targeted populations, where teachers and parents identify kids who appear to be at risk.
We need to, I would suggest, on behalf of our organization, allocate financial resources as a function of cost to the system. If, for example, mental health costs X of health care, X proportion of resources should be allocated to mental health. That is not the way it works. Similarly, with CIHR, there should be some relationship between the cost of mental health disorders that are researched and their societal impact. That is not a consideration for that organization.
With respect to the health authorities, in British Columbia, for example, we spend approximately $800 million per year, including — for all mental health — hospital care. Of that, there is virtually no direct program costs for anxiety disorders. We have an anxiety disorder clinic in British Columbia with 1.2 clinicians. That is it for the province. Obviously, it is not meaningful. What I am suggesting is that, if you have $800 million and if you know the prevalence rates for severe and chronic mental illness, and you know the treatment response or some other meaningful measure, why not have some representation, some guideline, that would reasonably co-relate? Right now, there is absolutely nothing for anxiety disorders for all the reasons we have mentioned.
Finally, we would like to advocate the practice of private-public partnerships. In our opinion, that will breed competition, which will breed innovation, and it would go a long way to help communities and provinces develop novel ways of approaching the difficulties that anxiety disorder sufferers face. What is lacking is the will to move away from a monopoly that is ill-served. The monopoly is doing what monopolies do. Prices go up. Services stay pretty much the same, if you are lucky. We would like to suggest some proliferation of three-P arrangements in a funded and supervised manner.
The Deputy Chairman: Thank you Mr. McLean.
Honourable senators, I have a copy of the brief Mr. McLean was referring to; I will make sure that you are provided with a copy after the meeting.
Before I turn to my colleagues, there was something you said, Mr. Upshall, that tweaked my interest when you referred to the Canada Health Act, when you used words ``as it ought to be interpreted.'' My thought at the time was that it would be good for you to further expand what you meant by that. That may be the crux of the matter in dealing with the Canada Health Act. I would appreciate if you could enlarge on that statement.
Mr. Upshall: I would be happy to. The issue for me, for the Mood Disorders Society of Canada and for the Canadian Alliance on Mental Illness and Mental Health, is that the Canada Health Act is paraded around the country by our significant politicians as the crowning glory of Tommy Douglas' efforts and others. It provides — they say — for equal access to all Canadians. As you noted, it talks about mental health and reduction of barriers.
The reality, however, is that with respect to physical health care there is no problem identifying under the Canada Health Act, and the federal government acknowledges that. With regard to mental health services, on the other hand, Health Canada in particular is the proponent of the argument that mental illnesses and services related to them are primarily and solely the responsibility of the provinces. As a result of that suggestion or departmental policy, they have demoted and reduced the status of mental illness within Health Canada to a mental health promotion unit led by a very capable individual, but really far below the ADM or DM level.
The most recent involvement we have had with the issue occurred last December, when a patient — and I am sure you read about this — Laura, a student at Carleton University, had a significant issue with regard to clinical depression. She was entitled to be hospitalized, notwithstanding the fact that she came from Alberta. She was in the hospital receiving treatment when all of a sudden, during the course of her treatment, she was presented with a bill and told that she should get out. This is a very difficult situation.
The Canadian Alliance on Mental Illness and Mental Health undertook some advocacy on the issue because it was such a disgraceful situation, totally unbecoming of any provincial health ministry, let alone the Ministry of Health in Ontario, which is espousing advanced mental health reform initiatives, which I am sure you are aware of, and the Government of Alberta, which constantly suggests that it is a leader in the subject.
The initial reaction by the Alberta Minister of Health was that Alberta was not paying. However, he then said that they would pay but that the individual would have to come back and complete her treatment in Alberta. Finally, he said, after some advocacy efforts were undertaken, the minister agreed to pay for Laura's treatment in Ontario, thereby allowing her to stay in school. That would never have happened with any other health care issue.
A delegation of CAMIMH members met with Minister McLellan's staff and a representative from Health Canada, who was engaged in interpreting and dealing with the Canada Health Act. The response we got was very clear, black and white: ``Take a hike. We will not involve ourselves with any amendments to the Canada Health Act or any attempt to clarify it.'' That was a stunning comment to me, and, really, very disappointing.
We wrote letters to the various ministers of health across the country. Of those who deemed it appropriate to respond — three — the most interesting one came from the province of British Columbia. We were told by the B.C. director: ``Rest assured, we will not at this time or any time in the near future undertake a redefinition of the word `hospital' within the meaning of the Canada Health Act.'' Again, this is another indication that mental health issues are not particularly significant.
You know the background on the provincial psychiatric hospitals and how they were excluded principally and continue to be excluded from the Canada Health Act. However, most of them have been closed, so there is no argument about who pays for those, but there certainly is a the willingness of the provincial and federal authorities to collaborate on the denial of mental health services to Canadians in every province. To my mind, in the 21st century, this is beyond my ability to understand.
That is the background and the context within which I suggest to you that we have a two-tier system in Canada, physical health and mental health. Mental health is not on any tier that I know of, and physical health is. I hope that answers your question.
The Deputy Chairman: Thank you for that. It brings back the word ``stigma'' again. As you say, no other illness would have been treated in that way. Therefore, the Canada Health Act stigmatizes this illness and puts it into a silo that they do not think they are responsible for.
Senator Callbeck: My questions will relate to financial resources. There is no question that we have to spend more money in this area — an area that always tends to get pushed aside.
Mr. Upshall, on page 7 of your written presentation, it says:
CHST and other health care transfers to the province would have a proportion specifically directed to the provision of mental health services within the provinces...
By that, do you mean that the federal government would direct the provinces to spend a certain percent on mental health services?
Mr. Upshall: I could mean that, and I would be happy if they were prepared to do that.
My suggestions is that, of the $2 billion additional dollars that are transferred, 20 per cent, $400 million, or whatever — pick a number — should be tied to the conditions that I sent out. In other words, the provinces should have to spend those funds in the delivery of mental health services, which will be primarily dealt with within the community. The provinces should be specifically prevented from stealing money away from the mental health envelopes that they provide through their own provincial funding resources, and there should be an accountability aspect to it. Yes, I guess that is what I mean.
Senator Callbeck: Ms. Marrett, you talked about the premiers' council and their indication that community mental health is one of its top priorities. How much work have they done in this area? You say in your brief that the federal government must demonstrate its willingness to work with the premiers' council. What role does the premiers' council want the federal government to take? Is the council that far along?
Ms. Marrett: Unfortunately, they are not as far along as you have indicated or that we would hope they. The council has indicated that it is a priority, but so far no strategy has been developed in which the framework for such a priority could be outlined. Part of it may be that some of the provinces are involved with amalgamation and thus are not as ready as they would like to be, as compared to other provinces.
Ultimately, the provinces will have to ensure that access to services at the community mental health level is available across the country. Right now, that is not the case. Some services are available in some provinces but not available to the same extent in other provinces.
The federal government must provide the leadership and facilitate the discussions, to ensure that accessibility to mental health services across the country is equal and accessible.
Senator Callbeck: How many priorities has the premiers' council set out?
Ms. Marrett: They have eight, and this is one of the eight. Clearly, they have heard the message. Their citizens have told them that this is important. One of the challenges, I believe, is that the topic is enormous, and perhaps they do not know where to start. The federal government could begin that discussion through the premiers' council, in order to be able to find a way to address the concerns of Canadians across the country in this area.
Senator Cook: Describe to me the premiers' council in its present form. Does it have a membership? Does it have a membership of the premiers of the provinces? Are there consumers on it? Are there advocates? You said they have six priorities in their mandate. How did they arrive at six, and not at seven or eight, and who helped them formulate that?
Ms. Marrett: The Premiers' Council on Canadian Health Awareness includes the premiers of the provinces and territories. They unveiled their new Web site, www.premiersforhealth.ca in early March. It is within that Web site that they actually talk about community mental health and their other priorities. This is not a formal viewpoint, but it was their way to start to talk to Canadians collectively.
The premiers meet regularly, once or twice a year, to discuss common issues of concern. Health is clearly an issue of concern to the premiers' council. It has been through the establishment of their Web site and their desire to speak more directly in a collective manner to the people of Canada that this information becomes far more accessible.
Senator Cook: My question is still out there: From whom or where do they get their information? It is from groups like you, from consumers? Where does their information come from? Is it from the bottom up or from the top down?
The Deputy Chairman: Do you mean to set priorities?
Senator Cook: Yes. There must be a mandate there. In order to establish priorities, one must have evidence-based information to get them started.
Ms. Marrett: I do not have that information for you, but I could find out.
Senator Cook: Am I offside, here?
Ms. Marrett: I know they have had papers written on a variety of different topics. However, the premiers of the provinces and territories comprise the membership.
Senator Cook: Did the Canadian Alliance on Mental Illness and Mental Health have any input into the council?
Ms. Marrett: Not to my knowledge, no.
The Deputy Chairman: I think this is a relatively new body that Premier Charest was behind. It was originally called the Federation of Premiers, I think. My understanding is that the premiers are getting together, collectively, to form one voice.
Senator Cook: That is fair. I understand can that, but I want to know where their wisdom comes from.
Mr. Upshall: The wisdom comes from the various deputy ministers of the various areas within the provinces. The health wisdom comes from the deputy ministers of health.
Senator Cook: It comes from their bureaucracy?
Mr. Upshall: Yes.
Mr. Gray: I would speculate, having worked in ministries, that that frequently happens. The advice would have been collected from the various mental health services and from the various mental health branches and up through the bureaucracy, usually.
The Deputy Chairman: It is a little hopeful that mental health has been included as one of the six priorities.
Mr. Gray: It is important.
Senator Cordy: Being a priority, we hope it will mean that action will actually happen. There is a difference between putting it on a list and actually taking action.
When I looked at what you said, Mr. Upshall, about the Canada Health Act, I thought of portability. As Canadians, we assume that as we travel from province to province our coverage is portable. You said that, indeed, it is not portable.
Mr. Gray: Mental health services are portable within a hospital. For example, had the individual been in a hospital that was funded and recognized under the Canada Health Act, there would not have been a problem. It is when the person is in a provincial hospital that a problem arises. That is the distinction. These problems arise because the person did not go to a regular hospital but rather to a psychiatric hospital.
Mr. Upshall: I did not know that the Royal Ottawa Hospital was not a regular hospital. We will have to talk about that off stream, because I think you are wrong.
Ms. Marrett: I think Mr. Gray is right. Psychiatric hospitals fall under provincial legislation, whereas general hospitals fall under the Canada Health Act.
Mr. Gray: That is right.
Senator Cordy: However, we are now moving away from extended periods of time in hospitals, moving away from doctor-hospital, to the reality of the health care system. Regardless of whether we are speaking of mental health or physical health, times have changed over the past 20 or 25 years. You have made your point.
Mr. Gray: I am not supporting that; I am saying that it is wrong. I am just explaining it.
Senator Cordy: I know you were not supporting it.
Mr. McLean, as you said, anxiety disorders are the most common and most treatable, but the most invisible and the most overlooked. How difficult is it to gather data on anxiety disorders?
Mr. McLean: Large community studies have been done in the United States and, more recently, in Canada. The one in Canada, for example, does not deal with all the anxiety disorders — for cost reasons. As well, OCD, for example, is excluded from that because it is beyond the capacity of community interviewers to get that information quickly, given the secretiveness of it all. One must rely on other means. There are good international surveys. There is broad agreement as to the prevalence and the severity rates.
Senator Cordy: I was also interested when you spoke about children and the importance of early intervention. In my other life, I was an elementary school teacher. I found, first, that there is a shortage of money in health. In my province of Nova Scotia, there is also a shortage of money for education. There were class sizes in elementary school of over 30. In addition, some children were identified as needing extra help, whereas other children were not identified. For instance, if a child were exhibiting behaviour problems in the classroom, being disruptive, he or she tended to get attention more than the child who was withdrawn and quiet and not a bother to the other students. My experience was that if the child did not have a label, it was very difficult for a teacher to get help for that child. You could talk to someone but it was very, very difficult.
As you have said, if there is not early intervention for children, other problems arise. You talked about the coexistence of smoking, drinking, drug usage, depression and those kinds of things. Certainly no one would disagree with you that early intervention is the way to go. However, the reality is that teachers are not trained for that. As a teacher, I found it very difficult to get early intervention for a child unless the child was aggressive — and then often those children were put on Ritalin.
Mr. McLean: In British Columbia, for example, the Ministry of Children and Family Development, which has responsibility for the mental health of under-19-year-olds, has started a pilot and is planning a universal program in British Columbia schools on exactly that issue. How it works is that a specialist trains, on a professional-development day, a number of teachers. They are using a program called ``Friends.'' In the U.S., they have another one called ``Coping Cat.''
The program is not pathology-based. It helps children understand what certain things, when their body feels funny or they ``feel mental'' as they call it, or how to change thoughts and how to avoid being catastrophic in one's interpretation, how to be pro-social. It is a coping program. It is cost-effective for a teacher or a counsellor or others who come into the school for that purpose to deliver that type of program. Parents and teachers, typically, highly welcome the program.
You are right: If we had to rely upon teachers to set aside individual time for one-to-one consultation, it is very difficult to get a spot on the curriculum. Now, however, as emotional education is becoming more acceptable in school curricula, there are opportunities to go in and do this. That one just happens to be a very effective program that pays high returns.
Senator Cordy: Mr. Gray, you spoke about a program called ``Reaching Out: The Importance of Early Treatment.'' Do you have any results that show how it is working, or is it still too new?
Mr. Gray: Not specifically. We are trying to teach people, pupils and teachers about early signs of psychosis so they can see that there may not be a drug or a behaviour problem, that it is conceivable that there might be a psychosis. Then they can get an early referral to someone who understands and can do something about it.
We do know that the program is very well accepted. Teachers like it; students like it. That program started in British Columbia and it has been around for about three years. It has been very well accepted in the schools. Students say that they have really learned something. We have anecdotal evidence of people saying, ``Perhaps my friend is starting to exhibit some interesting symptoms and should see a counsellor.'' We are doing some good work in that way and making appropriate referrals. In terms of a controlled case study, no, we have not done that.
Senator Cordy: Are students willing or able to self-diagnose? Fitting in socially as a teenager is probably the number-one priority. Are they willing to admit that they may be a little bit different?
Mr. Gray: With some disorders, such as anxiety or depression, they might be willing. For those with schizophrenia, they often do not realize anything is wrong. ``These voices in my head are sort of normal; I am getting them from the television.'' It depends a bit on the disorder.
Senator Cordy: People with schizophrenia often do not believe they are ill, which causes them not to take medication. In looking at advocacy, you have done a wonderful job of explaining how NGOs can be advocates on behalf of the patients. What about advocacy by family members for an individual? I am looking at the issue of privacy.
If an individual does not believe that he or she is ill, that person may not allow their medical information to be given to family members. How can families help out?
Mr. Gray: That certainly can be a problem. Where the person provides permission for the family to talk to the physician or the treatment team, there is no problem because the consent is there. Sometimes the person does not do that. It depends somewhat on the provincial legislation, but, in British Columbia, our privacy laws say that if there is a need for information to be provided — and obviously it must be circumscribed to the purposes — then you can do that.
In a situation where you felt you could not do that, then you have to talk in terms of examples or generalities. You can say, ``Nineteen-year-old males on this medication are experiencing these sorts of symptoms and may do this.'' You are talking about the situation that the family member is in but you are not providing any information about the son or the daughter specifically. You are generalizing but providing enough information for the parent to provide some service.
Certainly if the physician is speaking, let us say, to a family member who supervises medications and reports symptoms, our Freedom of Information and Protection of Privacy Act in British Columbia would allow the physician to do that, even if the young person said, ``No, I do not want that to happen.''
Senator Cordy: So the family can be an integral part of helping the person become integrated back into the community?
Mr. Gray: Yes. It is very important.
Senator Cordy: In Great Britain, we heard last week that they have outreach teams that go into the community. From what they told us, the teams seem to be very successful. They basically follow the person around in the community, so the patient need not go into the hospital, which can be stigmatizing for some. They would meet them in the laundromat or some place like that and they would talk together. Could we do that in Canada?
Mr. Gray: The situation varies across the country, but certainly we have that model. I used to work in Saskatchewan and we had that type of model. I can think of examples in Victoria where that happens. London's program is a good example of an early-psychosis program that goes to extraordinary lengths to keep people out of hospital and helps them avoid the whole trauma of hospitalization. That is certainly not fun for someone who is 17 or 18.
Those programs are there but are not as widely available as we would want. There is nothing in law or in practice that would prohibit those programs from happening here in Canada.
Ms. Marrett: That type of program should comprise part of a community health system. We should have outreach teams who can work with individuals in their communities so that they can live their lives as productively as possible. Certainly that would be part of a community mental health program.
Mr. Upshall: For your information, and I am sure the researchers know this from the material from the mental health implementation task forces in Ontario, there are several acute care treatment teams, ACTT, in and around the Toronto area. Some are associated with the Centre for Addiction and Mental Health and other hospitals. If I recall correctly, one is an independent ACTT team, which is composed of eight or ten members. They have almost a one-for- one or 1.5-for-one relationship. They do not follow them around, but they are available to the individuals in their care 24 hours a day, seven days a week, with beepers and pagers and what have you. They monitor medication and rehabilitation.
One of the issues for the ACTT team is that those who are not associated with the Centre for Addiction and Mental Health or other institutions have difficulty getting admissions into hospitals. The independent, stand-alone act teams do have a difficult time if there is an admission issue.
The Deputy Chairman: As a supplementary to Senator Cordy's question, the issue of human resources has been raised in testimony many times, trying to attract people into the mental health care field. Would each of you comment on how we would approach trying to attract practitioners in this field, in all of the different aspects?
We had some testimony about the amount of time, for instance, doctors are required to spend with a patient suffering from a mental illness as opposed to a patient with a physical illness. Perhaps you could all shed some light on this question of how we would start to build a stronger human resource base. The numbers are growing, and it is getting much more complex. If you have a comment on that, I would appreciate it.
Ms. Marrett: In talking about discrimination and stigma with respect to mental illness, we are not just referring to the patients. We are talking about discrimination and stigma across the whole spectrum. I have met several health care practitioners over the years who have talked to me about the fact that their colleagues are absolutely stunned that they would be in this area, and why, et cetera. Oftentimes, these individuals are some of the most committed individuals I have ever met and they are there for their whole career.
It is very difficult if, from a financial point of view, an individual is not able to support his family or meet his living expenses. It is very difficult if an individual is in a position that is not considered to be ``permanent.'' It might be a contract position. Therefore, if the organization you are working for does not get the contract with government, for example, you no longer have a job. It is extremely difficult.
The other issue is that there are not as many people going into many of these fields because of the amount of time and commitment and burnout. This is it not a nine-to-five job. It is very difficult and very challenging.
If we were able to reduce the stigma for mental health, I think we would be able to attract many more people into the field from the care side. It is certainly not an issue that we can deal with overnight.
Mr. Upshall: I agree completely with what Ms. Marrett has said. The first attempt to resolve the stigma issue is to get the federal government to start modeling good anti-stigma behaviour.
The second is to get the medical schools themselves to recognize that the value of this kind of education is important and to dedicate a substantial amount of additional time to training GPs, given the high incidences of mental illness they see in their practices.
The third issue is to somehow resolve the discussion between the medical community and the psychological community as it relates to payment. There are issues there that must be investigated. We have a two-tier health care system. The EAP providers are able to purchase services, and those who have those benefits available to them get reasonably good, non-mainstream mental health care through their EAP providers, and the payment that is afforded to the people involved in that structure is substantially different.
There are a number of issues, but it is primarily anti-stigma, and leadership is required at all levels.
Mr. McLean: I would like to reiterate that. It is a sad comment. I teach in a medical school. I teach the very people we are talking about. I am very familiar with the curriculum. It is difficult. Not that many choose to go into psychiatry, for a variety of reasons. The 50 per cent that go on beyond family medicine do not go there. I think that could be enhanced. I think it would be the same for specialists and clinical psychologists.
We are facing a big problem, in that the average age of clinical psychologists and psychiatrists is over 50. This is a difficulty. We can see where this is going. Something needs to be done about that, you are absolutely right, from a resource point of view — not just psychologists and psychiatrists, but other folks involved in treatment, counsellors, and so on.
Everyone that is in the diagnosis and treatment business should be asked or required to use evidence-based treatments. I know I am repeating myself, but it is of interest that the Royal College, the regulatory bodies and the universities themselves do not require this. An individual can graduate with a masters degree in counselling psychology, not having taken one single course on diagnosis, on psychopathology, assessment or treatment. We graduate thousands of them, in Canada, every year. You can check on this independently. It is easily available. Check the course curricula. The graduates can then get a position on a mental health team. I am trying to make the case for the resources, which are a problem. We can find ways to try to attract people into that, to look at the incentives and the barriers respectively, but evidence-based requirements would go a long way to helping as well.
Finally, we need to look at new models. I do not think we can do it, but even if we were able to turn the resource spigot or the psychiatry spigot or the psychology spigot on, it would take a long time, as you know, to get these people on stream. We need to look at three-P, as I mentioned before. We need to find new ways of providing treatment, where you have people that are not necessarily at a high level providing all the treatment. You do not need it. For example, you do not need an electrician to change a light bulb. The high-level people can be there for a diagnosis, but there can be a vertically accountable consultation model, like law firms, and that might provide better range.
The current issue is highly restrictive. Only certain people are on it, and not many of them. They are getting old. You can do what you want and get paid for it. Let us be honest. You get paid for contact in this country, for the time spent with someone. You do not get paid for results. That has an effect.
The Deputy Chairman: That is right. Actually, I heard on CBC radio of a doctor — I think the only doctor from Guelph — who was leaving, and it was only because this person could not possibly see the number of patients and earn a living. Thank you very much. That is very valuable. We have heard other testimony, especially the doctors themselves or the people in the field, stigmatized as well, not only the patients.
Senator Léger: I have five questions. I will ask the five questions first, and then you can answer them. Each one will be very short.
First, Mr. Upshall said that mental health appears nowhere. Is mental health separated from society? For example, when discussing housing, are people from mental health organizations representative on the team. When we are studying lack of jobs and transportation, are they there? These days we are studying unemployment insurance. Are you there?
Second, are there consequences of the constant change of ministers in the government? What is done meanwhile? Life goes on, I imagine.
Third, Mr. Gray was saying that the accent was on individuals and families to help. I was quite pleased to read in your report that the stigma factor was put as number five and not as number one. I was sort of happy about that.
Fourth, in the past, there was no medication, or less medication. That is why people were required to go to hospitals. How did we get out of it in the past? I do not think everyone went to the hospital for anxiety troubles and all the new illnesses that we have today.
I have the feeling today that, be it nurses or doctors, science has predominance over human love and human compassion. A person became a nurse because he or she wanted to help. Someone became a teacher because they were passionate to help.
I have a friend in psychiatry, and she chose that field because of her passion to help human nature. It was not from a scientific motivation. I am not saying that it is not needed, however.
My last question is this: How do we get out of the violence we are living today? You will have many patients tomorrow. Are we controlling what we see on television? What is happening presently with violence? There will be consequences, wanted or not. That is all.
The Deputy Chairman: That is a pretty big basket full. Who will start?
Mr. Upshall: I will be brief because other people are more knowledgeable about the details. There are token people sitting at tables dealing with homeless and shelter issues and the other issues that you raised. The question is: Are they having an impact? In my view, the answer is no.
As you know, Minister Bradshaw is very concerned about homeless issues. She is well aware, as is her department, of the size of the mental health component within the homeless group, primarily because of de-institutionalization. The reality is that the proof is in the pudding. There is it not much done in that area.
Are we at the table in other areas? Certainly, we are at the table. Are we heard? From a ``consumer'' perspective, it is de rigeur now to have a consumer member of a committee. There are not many people as fortunate as I who have a big mouth and a willingness to be aggressive. The reaction of many consumer representatives has been to question whether they aught to take the appointments because they are not listened to.
The constant change of ministers is inconsequential because Health Canada does not care anyway, so it does not matter what minister they have.
Is there any policy or government direction in this regard? The answer is no. If there were a government policy that required application and a powerful minister was at Health Canada, and certainly Ministers Pettigrew and McLellan were powerful ministers, it would have an impact. If they were motivated to change Health Canada, which is a huge department, they might have had the chance to do that, had they had longevity and the willingness to confront the issue. Health Canada is a monster bureaucracy. The impact that a minister can have on it is not that great.
I have a comment on your question about medication. Traditionally, people who lived with depression or bipolar illness did not get treatment. They were hidden in the basement. They were killed. Huge numbers of women went through significant changes of their life with enormous personal consequences and consequences to their family and loved ones. Whether those issues were ever resolved, no one knows. However, there are all sorts of family stories in the past generations of what happened. Medication came along at the right time. It has been a lifesaver to many people.
In reality, as you know, those who were not treated were shunned. My family had two friends who had people with severe mental illnesses totally incapable of treatment living with them. The big fear in those families was what would happen to my son or daughter when I go. Those impressions were made on me when I was very young.
I will speak to the science predominating over humanity comment quickly. The Mood Disorder Society of Canada and anyone involved in psychosocial issues recognizes the need in the spectrum to include peer support. Without peer support and community support, healing within the context that we define healing, is impossible. Drugs are important, but certainly, they are not the only answer.
Ms. Marrett: There is a growing recognition of the need to involve representatives from the mental health community in more and more either studies or committees. Mr. Upshall has made an excellent point about whether we are heard, however.
The challenge is that everyone wants to be heard. Our voice is not always as strong at those tables as we would like it to be. Some of that may result from the fact that we do not have the research that has been done to be able to support some of the statements and anecdotal evidence that we have. Some of it may relate to our capacity to be able to be involved.
The Canadian Mental Health Association is asked to be involved in a number of things. We do not have the capacity all the time to become involved. If they are not willing to invite someone else from the mental health community to sit at the table, it becomes that much more difficult because as an organization you do not want to lose an opportunity to have that voice heard.
I have a slightly different opinion than Mr. Upshall. There are some opportunities coming up that somehow the mental health community needs to be able to address. There are capacity issues in order to become more actively involved. Capacity is not just having the people, but it is also being able to have the research that is needed to be done in order to have a meaningful involvement. It is also important to have the financial resources.
You mentioned medication. A book published several years ago — it is entitled Political Asylums, by Ron LaJeunesse, who had a Muttart fellowship. He did research on the issue of mental health in Alberta, and started back in the 1800s. It is a phenomenal book, and one that is easy to read. He talks about what happened in the area of mental health and ``feebleminded'' people in Alberta. In reading the book, one will discover that the changes that have taken place are quite amazing, but also that we are nowhere near where we should be. The book addresses issues such as why people are hospitalized if they do not need to be. It asks where the community supports are, et cetera.
Your question about how do we get out of the violence is very interesting. I am not sure that there is a recognition amongst policy makers all the time about where and how television and other entertainment might influence. I think we are just beginning to learn about that, through some of the research over the last few years. We hope it will soon be seen and understood while policies are being made.
Some people at Health Canada truly believe and want to make a difference. When the Department of Health and Welfare was broken up and became Health Canada, we lost the absolute holistic viewpoint for mental health. All of a sudden that more holistic voice was not at the table in many of the discussions. When Health Canada was talking about health, often it was about physical illnesses and there was no strength.
When it was Health and Welfare Canada, there was a division for mental health in the 1980s and 1990s. Finally, after its disappearance, we have one unit but we are nowhere near where we should be. I have much faith in the unit and what the new manager wants to do, but it has many challenges ahead. If it is truly important, it should be, at minimum, a division.
Mr. McLean: It is hoped that NGOs will be increasingly present at policy level from CIHR to federal to provincial and so on. It simply has not been the case and it needs to be rectified. For anxiety disorders, many of the issues that you spoke of do not apply. This speaks to the diversity of needs across the spectrum of mental health disorders. People with anxiety disorders rarely need hospitalization, housing, transportation. At issue is the complete lack of specialty services.
I think you are right — it is lovely when people enter the helping professions, whether education, mental health or health, on the basis of compassion. Compassion is a gift. I would hope all those in the profession have that gift, but it is an insufficient condition to make significant change. Therefore, science is necessary — and the two are not mutually exclusive. I suggest we would need to marry compassion and science to achieve the most effective interventions. Medication is a godsend to so many people. In anxiety disorders, medication is effective in about 40 per cent of cases, and about two thirds of the people prefer psychosocial treatment to pharmaceutical intervention. That goes back to the topic of consumer choice. In many places, psychosocial treatments are not available and pharmaceutical interventions are key those places. We need both, I would suggest.
The violence issue is intriguing and disturbing at once, I agree. I am not sure that exposure to violence, aside from personal exposure as in the case of developing post-traumatic stress and seeing it on TV, necessarily cranks up one's vulnerability for the usual anxiety disorders, although I suspect that it does not. Stress can aggravate although it may not directly cause anxiety disorders.
If anything else, we truly need a vibrant, competitive system that looks at outcomes and allocates resources accordingly. That would solve most of our problems. If we have a monopoly, if we allow people to do what they want and pay them anyway, if we do not require evidence-based treatments, if we do not train family physicians to recognize the occurrence of these disorders more often — depression, anxiety — then we get what we designed. It is not sufficient, and that is why we are pleased to be here.
Mr. Gray: I have a quick comment because I agree with everything my colleagues have said. One of the real concerns is self-violence — suicide; 4,000 people in this country each year kill themselves. A small number of people with mental illnesses kill other people or are violent, and you are aware of them. For example, we have had a mother with postpartum depression that killed her children. If she had been treated, she would not have done that. I have been involved in cases wherein if the person had been treated, a tragedy would have been averted. Treatment, in terms of what we can offer, is early recognition and early treatment. This is critical, especially in respect of potential suicide cases. Homicide does not happen often, thank goodness, but again, early treatment is the answer. I do not have the broader perspective on television violence, et cetera, and I believe that is difficult. As a community, we could contribute to emphasizing effective early treatment.
Senator Léger: Often those are causes of becoming mentally ill. That is why I spoke to those things. There is much roughness of life around us that can contribute to the causes. I do not have a problem with medication for absolute cases. However, excessive medication can contribute to the causes. We have help now, but often science may go overboard. I want both, not just one, because it will not work.
The Deputy Chairman: The witnesses indicated there was agreement in that.
Senator Cook: I have pages of questions that we will not have time for today. First, Mr. McLean, I believe you mentioned the private-public partnership. Would that be funded from the public purse? Second, Mr. McLean, you talked about human resources. Would you include social workers? Would they be appropriately trained as professionals in this field? I believe there is an emerging role for the nurse-practitioner who could work in the mental health area of primary care, possibly in conjunction with a family physician.
Mr. McLean: I think all of the professional groups have a relevant role to play in mental health. Collaborative models of referral and support are necessary in a well-functioning system because the sources of an individual's particular problem may spill over into the various specialities. It is more likely that a private-public partnership would be more adroit, more flexible and more able to put those groups together to provide the desirable outcomes. I wish the public system could do it, but for anxiety disorders to date, it has not done it. There is nothing encouraging, unless there is significant system reform, to make us believe that it will change.
Senator Cook: Would the partnership be funded from the public purse? The delivery would be private-public, but who would pay?
Mr. McLean: There are opportunities. For example, one of the big difficulties, as you know from the economic round table on mental health presented to you, the Fortune 500 of Canada are looking with aghast at the rise in disability payments. The most common disability is musculoskeletal — such as back pain — which causes people to miss work. There is a whole list of such disabilities. They are all flatlined and have been for decades, except for the second one — mental health. It is on the rise into the double digits at an alarming rate. Currently, 30 per cent to 40 per cent of short-term disability payments are in favour of mental health reasons. Yet, these folks are in the context of insufficient treatment.
I would have thought that the employers, then, would be in a position to contribute co-payments in this system. That is an example of a shared payment plan that I think could be entertained, because right now they are out of the loop. They have no recourse. They just hope that either the public system will do it or their own EAP program, which, by the time it gets to short-term disability, they are typically not involved.
Senator Cook: Given that we are working through the lens of a federal system, attempting to interface into a provincial system, I am searching for a way to interface. Those services are delivered provincially. I am coming to believe more and more every day that an open wallet will not do it. We have an opportunity now to be innovative. We have to look for innovation within the system. I am looking at the recommendations of the Canadian Mental Health Association. I have circled the first and the last. You are saying that this group should move forward on developing and implementing a pan-Canadian national strategy on mental illness/mental health to commit to increasing the capacity of the voluntary sector of the mental health community to participate in public policy development.
I would like insight on how to move this forward, because this is what you are saying to us. If there were time, I would ask you to do them all.
Ms. Marrett: I will ask my colleague, Mr. Upshall, to respond to the first one because he can talk about the strategy in more detail, based on his position with the Canadian Alliance on Mental Illness and Mental Health, if that is okay.
Mr. Upshall: All of us associated with the Canadian Alliance on Mental Illness and Mental Health, and a number of NGOs in addition, support the need for federal leadership to establish a national strategy. The national strategy from our call to action is a relatively simple step-by-step process, involving, first, the need for additional surveillance so that we know exactly what we are dealing with. Much of the numbers that we deal with are anecdotal. We need much more funding dedicated towards research, and we need the involvement of the federal government in developing an awareness program and, generally speaking, taking a leadership role in providing direction and guidance to the provinces.
I would expand that a bit, personally, because I think our current Prime Minister has acknowledged his willingness to consider tied funding. In terms of requiring accountability and getting more bang for the buck, as discussed elsewhere today, is appropriate. The move towards a federal national strategy would be incredibly anti-stigmatizing. It would be a leadership model that would say to the rest of Canada, ``This is something to which we need to pay attention.'' It would say to the rest of the provincial premiers and their health ministers that this is something that we will finally take seriously. That is the overarching idea that there is a national strategy over which we are all supportive and it is discussed more particularly in a number of documents that the research staff has.
Ms. Marrett: We are very supportive of the strategy and the importance of the strategy, particularly that it be coordinated across the country.
Your other question related to how we might be able to increase the capacity of the voluntary sector in the mental health community. About three or four years ago, the federal government announced the voluntary sector initiative. It was a $94.6-million initiative that the government announced to assist the sector and to work with the sector on a number of different issues that were of common concern. A number of excellent things have come out of that.
The mental health community has a unique challenge in being able to provide the policy development work that is being asked of it by governments in different ways, which is one of the reasons for our recommendation. It follows along the federal government's commitment to the voluntary sector. It would also recognize the unique challenges that the mental health community has in its capacity. The Mood Disorder Society of Canada is not a very large organization in general, if you compare it to other organizations within the voluntary sector, as is the Schizophrenia Society of Canada and the Anxiety Disorders Association of Canada. That is one of the biggest challenges that we have from the voluntary sector's perspective, namely, that we do not have the capacity. Finding a way to assist organizations to develop that capacity would enable them to become more active in policy development, which is critical if the government is serious about getting and hearing the various voices on that particular issue that they are dealing with — certainly on the issues related to mental health.
There are a number of other consumer organizations, and their capacity is also very limited to be able to become actively involved in policy development. All of the organizations want to become more actively involved but are absolutely limited by that. It seemed to follow very much along the lines of the government's commitment to the voluntary sector as a whole, particularly through the voluntary sector initiative.
Senator Cook: Given that we are people who live in communities, large or small, in order to move through this complex system of governance — if that is what it is — I am always searching for a way. Is the way, in part or in whole, through the premiers' council? Would that be a linkage? Will it be the new national plan that has been unfolded for public health that came into being primarily as a result of SARS? Could that be a vehicle for change and innovation to help this? What about integration of the NGOs? I have heard from the three of you today, who are all doing worthwhile work. Is that part of a new model, new innovation? Those are my questions.
Mr. McLean: The first step — and we are all very hopeful that this will happen — is that your committee will develop and support a national mental health plan and a set of policy guidelines. There is no silver bullet. It will not go necessarily one way or the other but will go out in many different directions, including the premiers' council, so that it is really clear what the importance of this, in your view, would be. I think that would be a wonderful jump ahead.
Having said that, the organizations that we all represent are volunteer organizations. We get our funding from wherever we can, for example, membership drives, cake sales — in our case, carol ship cruises at Christmas to raise funds. We have to ask ourselves what is practical. Going back to your point, there may be a possibility of you asking or expecting or setting as a target guideline for provincial health organizations to operationalize, through groups such as our own.
I will tell you about one program, briefly. We have a program called LEAF, which our provincial association started. It stands for Living Effectively with Anxiety and Fear. We developed it because of the lack of treatment capacity.
We brought in people on the Weight Watchers model who had previously had a disorder, for example, a panic disorder or agoraphobia, and overcame it. We paired them, trained them and gave them treatment models. We had them go out to their communities across the province and look for church halls or schools, somewhere that did not cost money, and run a bit of advertising, typically a public service announcement. We had them run a consecutive 12-week, once a week in the evening, two-hour program. The trick was that we provided consultation, from a specialist point of view. They could call us if they were having difficulty, if they had a question about diagnosis or about how to proceed with an individual person, and so on. We were absolutely surprised at the outcomes. These are open trials, as opposed to random controlled trials. We are getting people back to work, off disability — it is just astonishing. It is in the community — the people are credible who are already there.
That is a model that we would like to cookie cutter across. We are talking with CMHA provincially to see if there is something that we might do collaboratively. That is the kind of model that I would like to see our province support. The finances are not significant here. It is the will for cooperation between the government, the NGOs and other groups, including private groups that have the ideas and the commitment to making these things work.
Mr. Gray: Could I just make a comment about your question about integration? I think what you are seeing here is an example of that. We have members here — there are now 13 members in the Canadian Alliance on Mental Illness and Mental Health. As individual organizations, schizophrenia, anxiety and so on, we represent particular constituents; but as an integrated body, we belong to the Canadian alliance.
It is a bit like within the physical sphere: We have heart and lung, cancer and various other societies with a concern about a particular disorder or illness. In fact, I do not think they are as well integrated as we are. Certainly, at the federal level we have this well-integrated organization.
In the provinces, it varies. Alberta has a strong one. It is not as well organized in B.C., and I do not know about the others. However, in essence, at this level, we have a fairly effective, integrated group. If you wanted to pick just one person to talk to, you would talk to Mr. Upshall as the chair of our particular alliance.
Ms. Marrett: In response to some of your comments, I would not want to see the committee put all their eggs in one basket by working through the premiers' council. That is one of many different avenues. One of the things we all need to do — and certainly at the Canadian Mental Health Association, we are trying very hard to do — is think out of the box. Think about other organizations or other individuals that you would not normally go to to talk to about the issues related to mental health.
One example is the Canadian Federation of Municipalities. In the end, municipalities bear the brunt of many issues related to mental health. We are initiating conversations with them to talk about where we may see some synergies together in order to be able to effectively address issues of concern that actually are of common concern, although we may not have seen it in that way before. It is ways such as that that we will be able to see a real influence and see some real change.
Senator Cook: I throw out the question, because for 30 years I have been a volunteer on a community-based board, running a social centre that arose when de-institutionalization came about. It has evolved into a cohesive community doing wonderful things. We are not connected to anybody. We are just there. We offer the service and I think we do great advocacy for our consumers. We are not connected to anybody.
Senator Keon: First of all, I wanted to tell you that I am sorry that I could not be here for the entire meeting. Senator Morin and I had to attend another committee and we just could not get here on time.
You raised the question of the private sector. It is very interesting that here in Ottawa there is an institutional experiment with the private sector. You may not be aware of it, but I will tell you about it and hear your comments.
The Royal Ottawa Hospital has gone to the private sector and asked a private corporation to build a new hospital. In other words, they will provide the hotel functions of the Royal Ottawa Hospital and the Royal Ottawa Hospital will provide the program functions. How this will all work out, I do not know, but it certainly is something totally new and different.
I appreciate your reference to the private-sector involvement with something totally different down at the delivery end. I think that will become necessary also, but it is something totally different.
I wanted to hear your comments about how reasonable you think it is for the institutional sector to be going to the private sector to fundamentally have the private sector provide the hotel functions of their programs?
Mr. McLean: I am unfamiliar with the one that you mentioned, but it is not surprising. I think when we bifurcate into entirely private or entirely public, we run the risk of getting the worst of either world. It is appealing to me, as I have seen in other jurisdictions, where you have a partnership, where there is input and there are clear performance expectations and mechanisms for intervention and cooperation all the way through. I think that allows us to have the innovation that can occur in the private sector, and we can share that with public sector.
I was thinking not so much of the building infrastructure per se as the program part, only because it is simply not available. I think it needs to be cooperatively managed, at some level. Otherwise, it puts so many Canadians in a hopeless position — they simply cannot get treatment.
Right now, it is being solved with anxiety disorders in a private way, but an unsatisfactory way, I would suggest, because they are going state-side for treatment. The difficulty is that it can be provided cheaper here, I think, and it does not help to have intensive treatment outside of your jurisdiction and come back and not have local follow-up. It is much like drug or alcohol rehabilitation. A better way of providing regional centres for that in a 3-P model is very worth exploring.
Ms. Marrett: One of the things we always need to do is look at some of the experiences that have taken place. One example is in Ontario with the Victorian Order of Nurses, where the government went into a much more private mode. Many of the services that the VON provided — they lost the contracts with government from a service point of view — are no longer provided in many communities to that extent. I would caution us to ensure that we examined all of that in order to learn from that — should we go down that road? In the end, communities have suffered, and they continue to, because what the private sector is offering is not at all what the VON was offering as a whole. There is nobody else, no other organization that replaces that. I would caution us to look at it. I have heard a little bit about the Royal Ottawa Hospital experience, but I do not know enough about it at this point to comment specifically on that.
Senator Callbeck: Thank you very much. I wanted to follow up on something that Mr. Upshall said in his brief.
There is a recommendation here regarding the development of a national strategy, and you said you would like to see this in our final report. The recommendation is a group of deputy ministers at the federal level, and they would have a committee — I believe you called it a blue panel committee — that would advise them.
Who would be on that? What would be the makeup of that committee? What type of qualifications are you looking for?
Mr. Upshall: You are looking at them right here — the people who have their hands dirty in this field, who know the needs, and who can provide the advocacy that is necessary to infuse the deputy minister with great vigour and enthusiasm for doing a good job.
Senator Callbeck: What about the provinces? Would they have input for this?
Mr. Upshall: Not for the national strategy, but as you roll out a national strategy, it will require the involvement of the provincial ministries of health and other ministries, because obviously you will not have the necessary impact.
To start, the federal government has within its own capacity the ability to establish a strategy, start on surveillance and change methodologies and corrections in the homeless area. There are all sorts of opportunities for the federal government to take leadership through additional funding towards research and involving the provinces as partners in the delivery of the services and tying funding to them.
At the outset, you want to do something that is not antagonistic towards the provincial governments, and none of our recommendations are, but it is a start. We need a start. We have to stop the discussions and move forward on action.
Senator Callbeck: You would not involve the provinces until you start to implement the plan?
Mr. Upshall: I would like to see a commitment by the federal government to move forward within its own area of jurisdiction, followed very quickly by meaningful provincial consultations. I am not saying that the federal government move forward and thumb its nose at the provincial government, but the reality is that the federal government needs to exercise leadership. The national strategy would not be an independent federal model. However, there are many federal-provincial strategies. For example, there is the Australian strategy that you heard about last week that we could model it on.
Senator Callbeck: Has there been a past attempt to develop a national strategy of mental health within Canada?
Mr. Upshall: Not at the national level, to my knowledge. About 40 years ago, commissioner Hall said it is the biggest issue, and I do not think we have made any progress. Provincially, the only province that I know well is Ontario — which has had their mental health implementation task forces. However it has not done anything for the people on the ground. Alberta has undertaken some major structural changes, and to their benefit they have recognized some problems within it and they are trying to change it. However, a lot of the cost savings have been achieved on the backs of people without a voice, and that is the people with mental illnesses.
The Deputy Chairman: On behalf of all of my colleagues, I wish to thank our witnesses. We have had two hours of excellent presentations and questions. Thank you all for attending here.
The committee adjourned.