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

Issue 11 - Evidence of March 19, 2003

OTTAWA, Wednesday, March 19, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:52 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.


The Deputy Chairman: We are continuing today with the study that follows on our study of the health care system in Canada. We have been authorized by the Senate to examine issues concerning mental health and mental illness.

Our witnesses today are Dr. Paul Links, Dr. Alain Lesage and Mr. Tom Lips.

Mr. Tom Lips, Senior Adviser, Mental Health, Healthy Communities Division, Population and Public Health, Health Canada: I am pleased to be here to speak to you today about mental health and mental illness.

This presentation centres on a few key messages. The federal and provincial-territorial roles and responsibilities differ where mental health and mental illness are concerned. Mental health is a broader concept than mental illness or the absence of mental illness.

Because physical health and mental health are interdependent, promoting mental health contributes to physical health and vice versa. We believe that an integrated approach to both physical and mental health is appropriate.

Many determinants influence mental health and mental illness. A developmental or life stage perspective is important in addressing these determinants.

Provincial and territorial governments have primary responsibility for the planning and delivery of health services for the general population. As you know, federal transfer payments contribute to health services delivery. The federal government has a special mandate for health service delivery to certain populations, notably First Nations people on reserve and Inuit. It also undertakes national health promotion efforts.

Both levels of government have been involved in health promotion, research and surveillance, and have collaborated to address some service delivery issues, for example, identifying best practices.

Health Canada's involvement in mental health has consisted of information activities for the public and professionals; of collaboration with provinces and territories to strengthen mental health services; of research funding, project funding and nongovernmental organization grants and contributions; of funding for crisis intervention services, and prevention and promotion programs for First Nations and Inuit; and of broad-based health promotion programs with mental health implications and surveillance. For example, there is strong mental health content in the 1994 National Population Health Survey and the 2002 Canadian community health survey, cycle 1.2.

The terms ``mental health,'' ``mental illness,'' ``mental disorder,'' and ``mental health problem'' are often used interchangeably or inconsistently. In order to have a productive study of mental health and mental illness, it is helpful to review what the terms include and how they are interrelated. There are varying opinions about what each of these terms includes and excludes. Some groups, including many Aboriginal people, prefer to avoid the term ``mental health'' and use other expressions, with other implications, such as ``mental wellness'' or ``emotional health.''

Because the pain and burden of mental illness is so great, most public and policy discussions that are nominally about mental health actually focus on the treatment of mental illness. It may be difficult to retain a positive understanding of mental health as the ultimate goal of all services, programs and policies in this area. Mental illness undermines mental health, but mental health is more than simply the absence of mental illness. It is a fundamental resource of all human beings and an essential component of all health.

There is not a universally accepted definition of mental health. Most definitions stress that mental health is manifested in people's ability to interact with each other and with their environment in effective, constructive and satisfying ways; to develop and use their capacity for thought and feeling throughout the life-course in ways that lead to subjective well-being; and to cope effectively with challenges and stressors. The development and maintenance of mental health is not an issue that is limited to people living with mental illness. It is a crucial issue for all people.

In the presentation, I have given you several federal definitions. One is from ``Mental Health for Canadians: Striking a Balance,'' a 1998 discussion paper. I will not read it, but it is an interactive discussion that highlights the capacity of individuals and groups to interact effectively with their environment. A more colloquial definition is the capacity for each of us to feel, think and act in ways that enhance our ability to enjoy life and deal with the challenges we face.

Poor mental health is characterized by the inability to recognize, understand and cope with stress, emotions and personal needs or boundaries. It involves the learning of maladaptive responses or the failure to learn adaptive responses. It involves subjective distress, anxiety, alienation, depressed mood or dysfunctional behaviour. It is manifested in hopelessness, anxiety, school failure, lack of self-care, excessive risk-taking, lack of productivity, family breakdown, substance abuse, antisocial behaviour and, in the extreme, self-injury, suicide and violence.

In the 1994 National Population Health Survey 17.4 per cent of the population over age 12 reported high levels of distress. Twenty-five per cent of Canadians consider their workplace a major source of stress and anxiety. Suicide is the leading cause of death among Canadian males ages 10 to 49. Those rates are particularly high in the Aboriginal population.

As with mental health, definitions of mental illness are also subject to debate and the boundary issues are still being discussed and probably always will be.

A widely used definition of mental illness or mental disorder is taken from the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition. I have given you a copy of that definition. It is a definition that allows for the possibility of either biological or psychological causes of illness. It excludes normal reactions to stressful situations.

Research indicates that there is a continual and often powerful interaction between physical and mental health. Personal resiliency, optimism, a sense of social support, a sense of autonomy or mastery, a positive self-image and even basic happiness contribute significantly to health promoting behaviours, to resistance to illness, to help seeking, to the perceived severity of symptoms, the speed of recovery and the degree of excess disability from an injury or an illness. An example is the increasingly well-documented link between the incidence and outcome of cardiovascular disease and such factors as depression, anger, stress and copying style.

When mental and physical illness occur together, to which ``co-morbidity'' refers, care needs are more complex and recovery is slower. Many behaviours contributing to illness are closely tied to mental health issues and problems.

Smoking, unhealthy eating, physical inactivity, drug and alcohol abuse, and excessive risk taking may involve not only rational choices and preference, but also a response to psychological pain or maladaptive efforts at psychological self-care. As a group, people with mental illness tend to have poorer physical health, engage in more unhealthy and risky behaviours and have higher rates of premature mortality.

Health policy is moving toward a more integrated approach to health promotion and disease prevention at the population level. A central goal is to address modifiable risk and protective factors so as to maintain and improve both the physical and the mental health of Canadians.

There is a growing body of evidence that physical activity has a moderate but significant beneficial effect on depressive symptoms and may protect against the onset of depression. Healthy eating and healthy weight has implications for self-image and self-esteem. We may expect general benefits in mental health from interventions such as the provincial-territorial healthy living initiative, which targets such factors. This initiative represents an opportunity to coordinate prevention promotion efforts aimed at a series of important health issues.

The determinants of health identified in the population health model used by Health Canada are also the determinants of mental health. These broad categories subsume a large number of risk and protective factors. It is rarely appropriate to assume a direct causal connection from one single determinant to a particular outcome. Mental health and mental illness are multi-dimensional, multi-determined phenomena.

Even in the case of a disease like schizophrenia where biological and genetic factors are crucial, the full range of health determinants remain relevant. Excessive stress or substance abuse may be implicated as a triggering factor of the onset of a mental illness.

It is essential to address not only the adequacy of biological or psychotherapeutic treatment, but also issues of social support, social inclusion, living and working conditions, personal health practices, et cetera.

I have given you a table from an Australian document that lists a range of possible protective factors and the settings in which these factors can be addressed, including individual factors, family factors, school context, life events, community and cultural factors. I will not go through those in detail.

The next table from the same document looks at developmental tasks across the lifespan. An important dimension of mental health is that it is a developmental concept. Mental health milestones, challenges and needs arise and evolve continually throughout life as do opportunities to promote mental health and prevent illness. This is true whether a mental illness is present or not.

Mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health. Promoting mental health at the population level includes providing information, resources and opportunities that help people to establish a positive self-image and a sense of autonomy; to improve their ability to offer and receive mutual support; to understand, express and cope with their emotions; to develop skills for parenting, partnering and problem solving; to recognize and deal with stress and its effects; to recognize the symptoms of mental disorders; to seek informal or formal help, when appropriate; and to overcome prejudices, stigma and discrimination about mental illnesses, as well as other differences.

A key challenge faced by researchers, policy makers and program developers is clarifying and, perhaps, broadening, our conception of what mental health includes and, therefore, what mental health research, interventions and policies might include. A related challenge is determining how mental health promotion can best be situated in relation to general health promotion and in relation to primary care and mental health services.

A third challenge is in the domain of research. How do we identify and reach the point at which the research evidence is strong enough to have a significant impact on decision making, knowing that in this field, few, if any findings, can be regarded as the final word.

Finally, as the population of health highlights, mental health is promoted or undermined by many factors outside of the health jurisdiction. There are countless policy issues competing for priority and resources. How can mental health research findings best be applied to guide policy both within and beyond the conventional health domain?


Dr. Alain Lesage, Past President, Canadian Academy of Psychiatric Epidemiology: Madam Vice-Chair, this afternoon I am also wearing my other hat as Vice-Chair of the Advisory Council of the Neuroscience, Mental Health and Drug Addiction Institute of the Canadian Institutes of Health Research. I am also a psychiatrist and researcher with the Fernand-Séguin Research Centre at the Louis-H. Lafontaine Hospital, which is affiliated with the University of Montreal.

I would just like to say a couple of words about the Canadian Institutes of Health Research, since we will be discussing the causes of mental disorders and mental health determinants. CIHR's vision is in fact very similar to what I will be presenting today.

The Canadian Institutes of Health Research talk about four health research pillars. First of all, basic research, which is applied in the area of mental health and mental disorders; we will be talking about neuroscience later on. Then, there is clinical research, which is research on specific interventions relating to mental disorders and their efficacy; interventions can involve medication, psychotherapy and rehabilitation. We will also look at the third pillar, which is services research. What health policies and programs will allow us to ensure that the right people benefit from the right interventions at the right time. And the fourth pillar is population health research, which relates to the epidemiological perspective and health determinants discussed earlier by my colleague, Mr. Tom Lips.

I would like to table two documents with you today that could be of some assistance. The first is a book resulting from a Franco-Quebec collaborative effort in which I participated, called ``Planification et évaluation des besoins en santé mentale.'' The first few chapters of the book present a mental health/mental disorder framework of reference. My French colleagues are always reminding me that one of the most quoted frameworks of reference was developed in Canada and reflects both the mental disorder and mental health thrusts. The second document is a recent article that appeared in Santé mentale au Québec, one of the main forums of discussion for Francophone mental health workers, and which is entitled ``Données récentes d'étude scandinave: traiter la dépression, une stratégie efficace de prévention du suicide.''

This research was carried out in cooperation with a Scandinavian colleague. The research results showed that the treatment of depression in Scandinavian countries, which had been on the rise, was associated with a drop in the suicide rate. In Sweden, for example, we are talking about a drop of 25 per cent over a ten-year period. That is highly significant in a country like Sweden. What that means is that Sweden will have 400 to 500 fewer deaths by suicide every year.

While taking action to treat depression — which deals with one of the causes of suicide — is important, we mustn't forget other kinds of action that are necessary. For example, using a public health approach, our colleagues in Great Britain are proposing four major areas of intervention aimed at improving health. The first area has to do with changing the etiology of the causes of mental illness — in other words, taking action to alleviate social disadvantage and social inequality which, as you well know, are important population health determinants.

The second area involves changing the causes: in the case of suicide, that means being able to treat depression, which is one of the causes associated with suicide.

The third area is strengthening protection. How can we foster greater resilience in children, and self-esteem in adolescents through mental health promotion interventions, for example.

The fourth area has to do with improving the quality of our services. What can we do to make services more accessible? How can we ensure that interventions that are known to be effective — for example, medication for depression and specific psychotherapy, which are effective — are available to the right people, at the right time and in the right place?

The rest of my presentation will deal with mental disorders.

The focus of the presentation made by my colleague, was mental health. So, I would like to talk about mental disorders. I would like you to think about — you may have read this in the material provided to you in advance — how many people suffer from mental disorders? Try and arrive at a percentage. The answer is that one in five people currently suffer from mental disorders.

When we talk about mental disorders, it is important to mention that the most prevalent of these are anxiety and depressive disorders. According to the most recent population surveys conducted here in Canada, 5 per cent of Canada's population suffers from major depressive disorder.

The third major area is substance abuse and the possibility that more than one of these disorders may be present. What that means is that these disorders are highly prevalent. In contrast, you will also be hearing about major psychiatric disorders, such as schizophrenia, bipolar affective disorder, and in adolescent children, and possibly in adults, autistic disorders. These are clearly major mental disorders. It is estimated that they affect from 1 to 2 per cent of the population.

Common mental disorders such as depression are extremely prevalent, and a recent World Health Organization report shows that depression will eventually be the major cause of incapacity in industrialized countries such as Canada. Already both public and private firms are aware that one of the main causes of disability, for which they are paying insurance premiums, are depression and anxiety disorders. A second observation is that most people who suffer from common mental disorders do not seek help.

For example, less than 30 per cent of those suffering from major depression attempted at least once in the past year to take antidepressant medications. When people are asked in surveys why they do not seek treatment, the answer is always the same. People say that the problem will resolve itself, or that they can get through it on their own.

And yet, as a general rule, they are mistaken. In Canada, studies were carried out over long periods in the Maritimes by Professors Leighton and Murphy. These studies, which were conducted over a span of more than 40 years, demonstrate that anxiety and depressive disorders do in fact last for decades — in other words, that they are not just a temporary health problem. The seriousness of the symptoms does fluctuate, although some symptoms are always present. They may fluctuate based on life events or triggers that occur in certain people.

And yet there are effective treatments for most common mental disorders. Take major depression, for example: the efficacy rate of antidepressant medications and of specific psychological therapies, such as cognitive behaviour therapy or interpersonal therapy, ranges from 60 to 70 per cent.

Let's also look at chronic depression among people who have been suffering from such a condition for almost two decades. A recent study on this was recently published in the New England Journal of Medicine. Those of you who have a medical background will know that that is currently one of the most prestigious medical journals around. This particular study showed that the efficacy level of treatment combining antidepressant medication and cognitive therapy — a psychological therapy — was 73 per cent. This combination was more effective than each of the therapies used separately. Medical students and residents are currently being taught a bio-psycho-social approach to the treatment of mental disorders.

Among Francophones in Quebec, the primary psychiatry manual is the one written by Professors Lalonde and Grunberg, which is subtitled: A Bio-Psycho-Social Approach. This approach applies both to the causes and understanding of factors that influence the course of the illness and treatment.

With respect to causes, let us take the example of depression. Several factors are known to cause depression. There are also genetic factors that give rise to a predisposition to depression in some people and have different manifestations, depending on the individual.

The second group of factors is what are called neurobiological factors. For example, it is known that there can be abnormalities affecting the pathways for certain neurotransmitters, such as serotonin.

A third group of factors is developmental factors. Living with a parent who is depressed puts a person at risk of developing depression, and this goes beyond genetic and family-related factors. It means living with someone who is less available.

As regards developmental factors, unfortunate, but more rarely encountered, events as child abuse, physical or sexual abuse can greatly affect the development of the individual and are risk factors for depression.

There are psychological factors as well. An individual's conception of the world, self-esteem and way of reacting to stress are all things that develop in childhood. These are significant psychological factors for depression and are addressed through cognitive behaviour or interpersonal therapies.

There are also environmental factors or triggers; the best known triggers are obviously a loss, separation, or problem relating to one's employment or interpersonal relations. But along with those triggers are what are called protection factors; social support or positive interpersonal relations are protection factors in depression.

And finally, the clinical factors — in other words, the presence of other problems, such as substance abuse, or of other disorders, like anxiety disorder, are risk factors.

There are clinical factors, as well as other disorders in cases that also involve substance abuse. Anxiety disorders are also risk factors and, more often than not, physical problems are associated with possible depression.

I am highlighting all of these with a view to demonstrating how a bio-psycho-social approach can help us to understand the causes of mental disorders. Treatment must also be based on a bio-psycho-social approach. There has already been some reference to that, and Dr. Links will address this further in his presentation.

For example, for the treatment of schizophrenia, psychiatric residents and physicians are taught that appropriate treatment involves a combination of things. First of all, optimal medication, which refers to the biological aspect of such disorders. Then there is rehabilitation, which combines the psychological and social sides of the equation, in order to restore an individual's ability to function. There are also psychotherapeutic approaches that help the person to make sense; some were developed to help patients with delusions and hallucinations who may not respond to medication.

Without necessarily eliminating such symptoms as hallucinations, cognitive therapies have been shown to have a positive effect on individuals, who are then quite able to live with residual symptoms. Finally, there is the psychoeducational approach, that involves explaining to family members what it is like to live with someone with schizophrenia and how to help him or her cope as best as possible.

Since we are talking about causes, I would like to delve a little further into some of the concepts and ideas here. There is often a tendency to wonder whether the cause is biological or psychological in origin and not to realize that it could be both. Scientific progress and brain imaging are useful in demonstrating that biological events have psychological manifestations, and that psychological approaches have a biological impact.

Schizophrenia is a brain disorder with both genetic and neurobiological features. Using instruments that allow us to visualize brain activity, we are able to see that in people suffering from schizophrenia, activity in areas located in the front of the brain, called the front lobes, is lessened.

These areas regulate mental activity related to problem-solving. We also know that schizophrenics experience memory and concentration disorders, and have difficulty dealing with the problems of everyday life. When individuals with schizophrenia are placed in a machine that measures brain activity — called a functional magnetic resonance imaging device — and are asked to perform specific tasks that require concentration, we can see that this area of their brain is less active than in normal subjects.

We experimented with a psychological intervention intended to improve the attention span and concentration of people with schizophrenia. This intervention is known as cognitive remediation. When we again tested the subjects in whom this intervention had yielded positive results, the functional MRI test showed that frontal lobe activity had increased. That example shows that psychological interventions do have an impact that can be measured in the brain.

I would like to conclude my presentation by making a number of recommendations that flow from the points I have addressed thus far. What can be done to reduce mental disorders? The first action we could take would be to raise awareness among the general population and health services about mental disorders, and to get the message across that such disorders can be effectively treated. A lack of awareness is probably one of the greatest obstacles we are currently facing. Increasing awareness will ensure that more people are able to benefit from therapeutic treatments that we know to be effective and which would make a difference in their lives and those of their families.

The second recommendation is to ensure that effective medicated and psychotherapeutic treatments are available for the most common mental disorders. I'm sure you will be hearing about how difficult it is to access the therapies I have mentioned at other roundtables.

Finally, a third recommendation is aimed at people with major mental disorders. I believe you have already been told about how difficult it is for people with autism to access services. With psychiatric residents, a great deal of emphasis is placed on the bio-psycho-social approach for the treatment of patients with schizophrenia. Unfortunately, we are realizing that a number of the services they are taught to offer their patients are not in fact available, especially rehabilitation in the community and social reintegration services, and even psychological interventions. These are the things that we should be focusing on.


The Deputy Chairman: Thank you for your excellent presentation. Dr. Links, please proceed.

Dr. Paul Links, Arthur Sommer Rothenberg Chair, St. Michael's Hospital: Madam Chair, I am pleased to be before the committee.

My central message is that in the area of mental illness and mental health we have the knowledge and approaches and that with federal leadership significant things can be done. I will use the area of suicide prevention to prove those points. I have that bias because I hold the Arthur Sommer Rothenberg Chair in Suicide Studies at the University of Toronto. I am a psychiatrist who does clinical work and research.

Arthur Sommer Rothenberg was a physician at St. Michael's Hospital. He suffered from bipolar disorder and took his own life at age 35. With courage and leadership his mother and family came forward and spoke about their loss. With great effort, they raised the money to establish this Chair. When it was established, it was the only Chair in North America dedicated to the study of suicide.

I will come back to the issue of suicide because it is so significant in the area of mental illness and mental health. Over 4,000 Canadians per year commit suicide. The figure is four-to-one men to women in suicide deaths. However, in terms of attempts, the figure is the opposite; four women to one man make suicide attempts.

Suicide is a leading cause of death for men from ages 10 to 49, and is a significant problem both in the youth and in the elderly.

It is particularly important to remember that suicide is related to mental illness. It has been shown that nine out of ten people who die by suicide are suffering from mental illness at the time they die.

There is also the issue of people who make attempts on their life. They have a high mortality and are at a very high risk to die from suicide. It is estimated that they may be at a risk 100 times greater than the general population.

My role in the presentation today is to focus more on the clinical aspects of what we are doing and, hopefully, give you the message that there is a lot happening but that there is a lot more that could be done. As a psychiatrist, I want to challenge the stereotype that we sit in our offices with a pipe next to our couch. That is not what we do.

Some of the examples that are promising include the model of assertive community treatment. This is the very active treatment of people with schizophrenia and major bipolar affective disorders. A multidisciplinary team visits the person daily and with the help of a comprehensive treatment approach the team helps the person to maintain his or her self.

It is important to realize that this is the most studied service delivery model in all of medicine. It is a well-established intervention with proven effectiveness. It is proven to keep people in the community and improve their functioning.

There is a movement to develop comprehensive crisis response for people who have mental illness. There are highly developed models throughout the country.

We have a highly trained multidisciplinary team with psychiatric input. We have 24-hour coverage, and have access to hospital services, including a secure in-patient service for people who are highly disturbed. We have crisis phone contacts through another community agency with which we work. We have a number of alternatives to hospitalization, so that if people do not require hospitalization they can be cared for in a safe home in the community. We have a mobile crisis response team. That is a team that actually goes out to people in need.

We work directly with the Toronto police. We have a mental health worker and a police officer that attend to people in crisis right on the street corner. In that way our expertise is brought right in to the street and professionals are able to make effective decisions about what kind of services are needed. The hope, and we are looking at this now, is that people can be directed to the right service, so those with mental illness do not end up in the judicial system and lack the care that they require.

An important part of crisis service is that we provide expert input to people who have made suicide attempts or have demonstrated suicidal behaviour. They are a high-risk group that often die from suicide.

We have evidence that there are promising interventions that can actually prevent the risk of further suicide behaviour. These are usually combined individual and group approaches where we teach people better skills at managing and coping with their difficulties. We can demonstrate that we can prevent subsequent suicidal behaviour. In our setting, we are carrying out a cost-effectiveness study looking at the delivery of this service and how it affects the costs of services.

Another example of where the field is evolving is in the area of family psycho-educational programs. Dr. Lesage talked about the new models of care that are very inclusive. Hopefully, we have moved away from blaming families for mental illness. These family educational approaches are widely adopted in a number of disorders: schizophrenia, effective disorders, childhood autism, and children with chronic physical illness. Our focus is to understand the disorder, the etiology and the prognosis, and often there is very active work on problem-solving skills. Often, groups of family members work together.

An important part of the field progress is the development of effective and safe medication. We have many new anti- psychotics that have a much broader potential to affect the disorder, including the positive and negative symptoms, without causing the disabling movement disorders.

Dr. Lesage talked about the anti-depressant medications and other therapies that are now proven effective. They are safer and easier to prescribe.

There is evidence that medication can affect the risk of suicide. The use of lithium therapy in bipolar disorder is a fine example of a medication that can reduce the risk of suicide. Research indicates that the elevated suicide rate from that disorder can actually approach the general population rate. It can be reduced by seven-fold or eight-fold. If this was a cancer therapy drug and I could report that it reduced mortality by eight times, you would be thrilled by that news

There are these effective therapies. Clozapine, which is a very powerful drug for schizophrenia, has significant side effects, but in the appropriate cases it is a very effective drug. It has been demonstrated to reduce the risk of suicidal behaviour by 26 per cent in a carefully conceived study.

We work with models of shared mental health care where mental health workers and psychiatrists work directly with family physicians to deliver more effective services to those who need service and are not able to access it. Most mental health care services are delivered at the primary care level. Because of the frequency of such things as anxiety and depression and their high coexistence with other medical disorders, it becomes an important place to deliver appropriate care.

The College of Family Physicians of Canada and the Canadian Psychiatric Association have developed a shared mental health care approach. Under the leadership of Dr. Kates, they have developed a statement of this method of care. It has an important impact for the future as it involves collaborative relationships between mental health workers and primary care physicians. It allows them to increase their skills and comfort levels in dealing with mental health problems. It strengthens the links between these services, and obviously develops a close working relationship between these two important areas of service delivery.

As you may know, most developed nations in the world now have suicide prevention strategies. I have listed the countries that have adopted national suicide prevention strategies: Norway, Sweden, New Zealand, Australia, the U.K, Netherlands, Estonia and France. In 1999, the U.S. adopted an action plan for suicide prevention.

I want to leave you with the impression that there is much development in the area of mental health delivery. It is an important time for federal leadership in the area of mental health and, in particular, suicide prevention.

Senator Morin: Is Canada on the list?

Dr. Links: No. The irony is that all of these suicide prevention strategies came out of a group in Alberta that developed the framework for suicide prevention. We have the knowledge and the ability, but have not developed the strategies.

In 1999 Dr. David Satcher wrote:

Only recently have the knowledge and tools become available to approach suicide as a preventable problem with realistic opportunities to save many lives.

Some of the aspects of a national strategy that are available to us are things like health promotion, combating stigma, and preventing access to means. We worked hard, in Toronto, to barrier the Bloor Viaduct. That is a way we can prevent suicide. We can teach people about suicide. In the United States, the plan is that everyone in the nation will have some knowledge of suicide prevention the same way we have knowledge about cardio-respiratory intervention for someone who has a heart attack. We want to improve mental health delivery, including the integration of mental health and substance abuse services. We want to watch media portrayals of suicide and promote research.

Let me close by saying that the federal position on this issue is very important.

Of course, we have a universal health care plan, which is extremely important. We have an excellent surveillance system through Statistics Canada that can be built upon. We have a new research initiative through the Canadian Institutes of Health Research that has recently adopted a focus on new suicide research, which is a very promising initiative.

Canada has led in the issue of access to means, such as the gun legislation. Within the federal domain we have a responsibility for high-risk groups such as native Canadians, the military and prisoners. We need better ways to account for the costing of health care. Reducing the levels of suicide must be one of the ways of accounting for service delivery.

Canada has an active suicide prevention approach. Suicide prevention has a long tradition of working at the community level. The Canadian Association for Suicide Prevention has much leadership in this area. At the ground level, we are set.

We are at a stage where national leadership can have true impact.

The Deputy Chairman: You talk about the national prevention efforts in Norway, Sweden, New Zealand, et cetera. Do you have data to show the success rates of these programs in those countries? You could provide it, or perhaps you could answer that quickly.

D. Links: The Finland program has been the most closely evaluated. The indication is that at the beginning of the program they experienced a 20 per cent reduction in suicide rate; it has now levelled off at a 10 per cent reduction.

They had an external group of evaluators review the entire program. Essentially, they felt that program had been highly successful, with some areas for improvement.

That is the most significantly evaluated program. In the coming years we will hear from other settings, including the U.K. and Australia.

The Deputy Chairman: You said that the study in Finland was done in 1986. Are the studies for the other countries more recent or in that same time frame?

Dr. Links: They are more recent.

The Deputy Chairman: Mr. Lips you referred to a strong mental health content in the 1994 and 2002 surveys. What has Health Canada done with this data? Do we have access to the data? Do all of the organizations and provincial and territorial governments contact Health Canada to disseminate the data?

Mr. Lips: The national surveys are conducted through Statistics Canada in cooperation with Health Canada. The data are made available primarily through Statistics Canada, although we also use them internally.

The cycle 1.2 data, which is the biggest landmark of improvement of mental health information in Canada, is not available yet. I expect that it will be available towards the end of this calendar year.

There are various initiatives to make that available to the academic community and to the different levels of government. Therefore, I expect that it will be widely used, especially the new CCHS data.

Senator Callbeck: Thank you, witnesses.

Dr. Lesage you have said that 20 per cent of Canadians have mental illness and that 5 per cent have major depression. How does that compare to other countries? Do we have statistics to compare from 20 years ago?

Dr. Lesage: The figures compare to most industrialized countries such as the U.S., U.K., France. There is currently an international effort to use exactly the same methods before as there may be differences resulting from the method. There is one survey study that used similar methods in Ontario and the U.S. that seemed to show that there was a lower rate of mental illness in Canada than in the U.S. There may be method differences.

Globally, those studies will find around 20 per cent mental illness in the population. That is a stable figure across most of the industrialized countries. Anxiety disorders, depressive disorders and substance disorders are all about the same.

Studies of this subject are very rare. However, there has been at least one, and it took place in Canada. It is called the ``Sterling County Study.'' Sterling County is a fictitious name, and, therefore cannot be found on a map; the name of the city in which the study was performed was changed in order to protect the confidentially participants in the area.

The indications from that study were that the overall rates of anxio-depressive disorders do not seem to have changed, but there may be changes in the people at risk for those anxiety and depressive disorders. Very few studies have been conducted on this subject. However, we often hear that the disorders have increased. People seem to be more stressed and have more anxiety and depressive problems.

We can be certain that there is a greater awareness concerning these disorders. Canadian studies have shown that in 2000, 30 per cent of the population was prescribed anti-depressants for depression. Ten years ago that figure was 15 per cent.

The Deputy Chairman: Could the increase be due to a greater awareness of the problem? Fifteen or 20 years ago, people did not seek help because of the stigma related to depression. Now they are inclined to seek help as the stigma starts to fall away?


Dr. Lesage: It is in fact possible that change is occurring and that we are seeing the stigma associated with mental disorders start to fall away. Such a change would be particularly positive for people suffering from serious mental disorders and their families, but also for the most prevalent mental disorders, which affect people around us on a daily basis. If that were to occur, it would be extremely positive. However, it would be even better for that trend to continue, so that people who wish to can receive treatment with therapies that can help them and meet their specific needs.


Senator Callbeck: Dr. Links, you mentioned the national strategy for suicide prevention. Is it too early to tell whether that strategy has been effective?

Dr. Links: The Finland national strategy indicates that they were able to achieve lower rates of suicide. There is no such strategy in Canada.

Senator Callbeck: Mr. Lips, you talked about mental health promotion and mental illness prevention. Have we put more resources into that area in the last few years or have the resources been decreased?

Mr. Lips: There has not been a great increase in resources for mental health promotion and mental illness prevention. There are some broad health promotion initiatives that have received significantly more resources in the last few years that do have mental health implications.

Some of the early childhood development work programs such as the Aboriginal Head Start Program and the drug strategy program have strong mental health implications. However, there has not been a substantial increase in funding concerning mental health or mental illness.

Senator Callbeck: Do you do an evaluation of the strategies that you have put in place after five years?

Mr. Lips: There is an emphasis on evaluating the major strategies. It is a complicated task, but there is a commitment to accountability. Those major strategies receive evaluations over a number of years.

I would like to see is evaluation that addresses the mental health component of some of those strategies.

Senator Cordy: In Nova Scotia a recent amalgamation brought the Nova Scotia Hospital, which helps people who are suffering from mental illness, into one of the regional health boards. The amalgamation caused people to fear for the funding for the Nova Scotia Hospital. The fear is that funding may be reallocated from hospitals dealing with mental illness to general hospitals. It seems as though general hospitals receive funding more easily than the hospitals that treat people with mental illness. There seems to be a greater concern for the patient who has a heart attack rather than a patient who is suffering from depression.

Dr. Links we have spoken about the accountability of health care and the need for targeted funding. Will you be looking at targeted funding for health care initiatives?

Dr. Links: A particular accountability marker could be the reduction in suicide rates. Certainly, nations that have undertaken a mental illness or suicide prevention health strategy have set specific suicide target rates as an indicator of effectiveness.

Senator Cordy: What about amalgamation? Do you think that will have an effect on funding?

Dr. Links: I am troubled by the thought that there is no need for early intervention in psychiatric disorders. Dr. Lesage has talked about the issue of depression, and there is quite a bit of evidence that the sooner you intervene in the illness, the better the outcome.

There is tremendous interest in the field of schizophrenia and studies show that early intervention can prevent the chronicity of that illness. We are looking at the prodrome of that illness in order to catch it as quickly as possible. If it is felt there is no urgency involved in these disorders, that would be quite wrong.

Senator Cordy: Dr. Lesage you said that most people do not seek help if they have a stress-related illness. Why is that?

What training are doctors given to detect the early states of these illnesses? In particular, what training do family doctors receive for detecting anxiety or stress-related disorders in patients who may not even realize that they are suffering from a stress-related disorder, but are just trying to get through each day?


Dr. Lesage: I mentioned earlier that the main reason people give for not seeking help is that they believe the problem will go away or that they can resolve it on their own.

Now in terms of consultation between an affected patient and his family doctor, that he will see in any case — indeed, we must not forget that most Canadians see their family doctor every year. It is estimated that 80 per cent of Canadians consult their family doctor for a variety of reasons. The family physician is the health professional most often seen by Canadians. These physicians do recognize a lot of people as suffering from mental problems. People experiencing anxiety and depression tend to consult their family doctor more often than not. However, these problems are not always identified by the family doctor, and such individuals may not be willing for the recognition to occur. These anxiety and depression problems generally manifest themselves through physical problems that give them something else to focus on.

I mentioned earlier that here in Canada, the number of people suffering from major depression rose from 15 per cent to 30 per cent over the last decade. These individuals are now being treated with antidepressants. The basic treatment is provided by family physicians — not specialists, but family physicians. So, there is certainly greater awareness among family physicians of this kind of health problem.

In terms of current training, family medicine programs are now a little longer. There is greater emphasis on such issues in some family medicine programs in Canada and in mental health programs. Family physicians are able to treat individuals with common mental disorders. And that will make a difference in the coming years. We are seeing steady progress in that regard. It is a long process, but it already underway.

What could help that process is what Dr. Links was referring to earlier — in other words, shared mental health care, although that would mean increasing access to the specialized care that can be provided by a psychiatrist, as opposed to a family physician.

In medicine, we learn by doing things. If you are treating a patient with depression or anxiety problems and you are having problems providing effective treatment, you will immediately want to consult a colleague, who may say: ``Try this.'' The family physician tries what is being suggested, and when it works, he incorporates that into his practice. That process only takes a few minutes. However, the reality is quite different. If you are a family physician and you attempt — and this is far too often the case here in Canada — to get in touch with a specialist or a psychiatrist, but it takes you six months to be able to speak to him, you will simply stop trying. We have a major problem in the area of continuing education and continuing care. There is a lot to be said for improving the quality of care on an ongoing basis.


Senator Fairbairn: The Head Start program has been mentioned today. The other day as I was leafing through a government publication I came upon the Head Start program. The publication set out anecdotal information to illustrate the benefits it provides for Aboriginal youth.

One story struck me. It was the story of a little boy who was not responding and with great reluctance his mother was persuaded to take him to a special needs area. The child did not, and would not speak.

A teacher conducted the first test on the child. She walked behind the child and clapped her hands. There was no response from the little boy. It became evident that the child could not hear.

I recently had a conversation with Nancy Karatek-Lindell. I was shocked when she told me that 70 per cent of children in Nunavut are suffering from some degree of deafness. The suicide rate in this area is also very high. I raise those issues for your comments.

I am interested in education, learning and literacy. Literacy is a concern for approximately 40 per cent of adult Canadians; they are unable to read, write, or perform numeracy skills well enough to carry out routine tasks that we take for granted. That is a horrible statistic, and one that is often disputed. The fact of the matter is that it is fairly well based.

We ought to be able to deal with these two areas. To what degree do you find illiteracy affects mental illness?

Mr. Lips: Dr. Lesage talked about the biopsychosocial approach to these issues. The two examples that you have given us illustrate how critical a multi-dimensional approach to mental health issues is.

From the perspective of mental health promotion, the ability to communicate and to be accepted by your peers, to have a confidant, to be successful in the things that you do and to be part of a community are very important. If you cannot hear, that needs to be addressed or there will be mental health implications.

Regarding literacy, there may be mental health reasons that contribute to illiteracy. As well, there are mental health impacts to being illiterate. Not being able to participate on an equal basis with other members of your community and not being able to join in e-mail conversations that most young people are be involved in can be isolating. It may produce feelings of shame.

Those are issue that I see as being relevant to mental health and, certainly, to mental health promotion.


Dr. Lesage: You are absolutely right to make a connection between problems with reading and writing and the presence of psychological distress or even mental disorders. A colleague of mine, Dr. Richard Boyer, set out to try and understand to what extent people taking adult classes to learn how to read and write — in other words, people who had been through the school system but had been unable to learn — showed signs of psychological distress, and possibly more significant anxiety and depression disorders than in the general population. So, you are absolutely right to make that connection. I will not try and give an explanation as to why that is the case. However, the connection is there and it can be seen in a variety of ways.

To come back to the story about the young deaf boy who was seen within the school system — what I would call the community level — I think there is a lesson to be drawn from this with respect to services. It is very important for primary care services not to operate in silos — in other words, not to compartmentalize services under different headings such as education, psychology, behaviour disorders, psychiatry, and so on. If we can be there and there can be recognition using the bio-psycho-social approach, then all the right questions can be asked and the people interacting with these children, whoever they may be, will have that awareness — rather than saying: ``He was referred to me, so he must have this kind of problem'' and not considering what other kinds of problems may be involved. That requires more significant recognition of the biological, psychological and social aspects of these health issues.

We also see this at centres in Quebec that deal with problem youths. Because of the issue of suicide among young people and the potential association with mental problems, one can see why a system that was dominated by the psychoeducational approach was forced to recognize and require a medical presence in order that — if depression or bipolar disorder seem to be involved — the potentially biological causes of the problems experienced by these young people could be examined. Their challenge is to make that part and parcel of the psychoeducational and social approach used with these young people, and which are essential interventions if we want to help these youths.


Senator Fairbairn: I would like to draw a line between literacy difficulties and the other field of learning disabilities.

To what degree have you found people who in every other way are fine, but have special kinds of learning disabilities that require special treatment or strategies?

Tragedies may result if the necessary assessments are not performed in the schools or the family doctor.

Dr. Links: I am an adult clinician and the results of unrecognized assessment is what I deal with. The child you mentioned might have grown up unaware of his learning disorder and become antisocial. He might have been ostracized by his peers and, perhaps, gotten in trouble with the law and in adulthood presented psychiatric problems that could have been, perhaps, corrected with early medical intervention.


Dr. Lesage: This is not only a problem in cases involving children. It is a more general problem, in terms of providing the expertise in the right place and at the right time, and always avoiding creating ghettos. With children who have learning difficulties, we want to avoid segregating them because of a specific problem, which would mean they would be unable to benefit from the social integration that occurs in a classroom setting. At the same time, we are a little torn, because if the child is sent to a special place, he will be treated by the finest experts, receive the latest treatment and benefit from the most sophisticated educational approach, which will give him a greater chance of success. This is the constant dilemma we face. We want to be able to provide front-line medical or health services, and bring the expertise there, so that every child with a problem can be identified and benefit from the specific approach that can help him in his own environment, and we want this kind of treatment to be available to all children, wherever they may be.

This is not a perfect solution in every case. Sometimes it is preferable to seek outside treatment for a certain period of time, despite the fact there may be a cost attached to this kind of segregation, again in the hope that you will give the child every opportunity to deal with his or her specific problem, although in other cases it may be better to leave the child in regular classes using an approach that will allow him or her to continue as part of that regular class. A lot of tests have been done, and yet there is still the general problem of determining whether by providing highly specialized services and taking people out of their environment, we are creating an issue of segregation and ghettoization, or whether it is better to provide those services in people's own environment and ensure that in that environment, they are able to access the best possible expertise. That is the difficulty.


Senator Fairbairn: It is a question of awareness, understanding and knowing where you can go to get help in making those kinds of choices and decisions.


Senator Morin: I would like to talk about the prevention of mental illness and the scientific basis for prevention. We know just how hard it is to demonstrate the effectiveness of preventive measures. For example, we believed intuitively for many years that anti-oxidants, such as Vitamin E, are an excellent means of preventing heart disease. However, a study has shown that is completely untrue. We have many examples of interventions that we believed to be effective. For example, diets rich in fibre for the prevention of colon cancer, which we intuitively believed to be effective. However, they have been shown not to have that effect.

I would like to know whether the same parallel can be drawn with mental illness. Are we aware of any specific measures that have been shown to be effective in preventing mental illness? If so, then the answer is to actively carry out public education and awareness. For example, in Canada, preventing heart disease meant reducing smoking. That is a Canadian success story. There is no country in the world where federal action has been taken and succeeded in reducing smoking. That has an impact on heart disease. The same thing has occurred with respect to diet: measures were taken with respect to product labelling. These are examples of actions taken by the federal government that have a scientifically proven impact on physical diseases.

I am drawing a parallel here to mental illness. Are there any specific measures that have been scientifically proven to be effective? To me, the term ``health promotion'' is quite vague. All kinds of resources are swallowed up in the name of this kind of promotion. I think such resources could be more effectively used for research.


Dr. Links, I am struck by the fact that we do not have a national program of suicide prevention. I understand that suicide prevention is what we would call ``secondary prevention.''

Do you think we should have a national suicide prevention program? If you do, do you believe it should be an official initiative?

Dr. Links: I will talk about the issue of prevention from the suicide perspective. It is true that we need to know more, but I think we know enough to proceed.

There are primary prevention initiatives in the area of suicide prevention that are quite robust in terms of their proof. One of the most promising initiatives deals with access to means, such as gun legislation.

There is an interesting initiative in the U.K. where the packaging of acetaminophen was restricted. The quantity of pills one can get with each package of Tylenol is restricted. The drug is called something different in the U.K. This public health initiative has shown that the number of deaths from overdosing can be reduced.

There have been other examples where reducing the access to means can have an impact. Restricting coal gases in the U.K. led to a reduction in the suicide rate. It may well be that the changes to the exhaust from car fumes will have an impact on suicide. Clearly, there are primary prevention initiatives.

Another one that seems to be in that realm is media intervention. We know that if suicide is reported in a highly sensational way and if each and every suicide is reported, you can increase the risk of suicide. A nice example from my local community is that in the 1970s all suicides on the TTC were reported. At that time they sought advice and decided that they would not report suicides that occurred on the subway. A significant reduction in the rate came from that simple intervention.

There are things that we can do on the primary prevention level. Some of those clearly require a federal initiative.

There is then secondary prevention: early identification of people at risk. One of the classic studies in the suicide prevention area took place on a small island in Europe. All the family physicians on Gotland were trained in the recognition of and intervention for depression. There was a drop in the suicide rate subsequent to this intervention.

There are many questions about that research. It raises as many questions as it answers. However, there is evidence that if you teach gatekeepers to more readily identify depression and intervene, there can be an impact.

On the tertiary side, where I do my research, we take people at high risk that have recurrent suicide behaviour. We can now develop interventions that can prevent them from repeating that behaviour and suicide.

There is a need for timely federal leadership in this area. The U.S. is a good example. We know enough to put in place a preventive strategy that could have an impact on reducing the rates. The Canadian leadership formulated these kinds of strategies that could be put in place. We have the knowledge. Unfortunately, Canada has a higher suicide rate than the United States. We could be shamed into taking action.

In the area of suicide prevention the time is right. We need national leadership on it.

Senator Morin: Should Health Canada or a professional organization initiate the program? Do you have any specific that you might share with us?

Dr. Links: There must be federal government leadership. The most successful national strategies have had federal government leadership.

Obviously, it must be translated to each and every community because the community initiatives need to be different according to their situations. Native issues are much different from the issues in Toronto, where I am. We need federal leadership. Most national strategies have set targets and work toward a specific goal that can be measured and to which people can be accountable. Some of these issues would very much come from a federal initiative.

Research comes from federal funds. There are a number of high-risk groups, as I mentioned, for which the federal government could have leadership in developing strategies. There are issues about access to means where the federal government could show leadership.

In the area of health promotion, we must remember that the stigma is an important factor in this area. People, particularly men, do not go for help. The health promotions leadership in the area of stigma would be very significant.

There is clearly a role for the federal government. I think we are well set for this because we have much expertise at the ground level.


Dr. Lesage: As regards cardiovascular disease, lung cancer and a reduction in smoking, we do know that tobacco is not the only cause of cardiovascular disease. Nor is it the only cause of lung cancer.

For example, in the case of cardiovascular disease, we know that some people are more vulnerable than others; there are genetic, developmental, work- and diet-related factors, and so on, that can have an effect; indeed, even depression can have an impact. It has been identified as a risk factor. Those are the causes.

We are not necessarily seeking the real cause, but in terms of prevention, we are trying to act on those causes on which we can have some effect in order to bring about a change. With mental disorders, our level of knowledge is different depending on the disorder, but there are a number of things that can be done and that can make a difference. They include promotion and prevention. We have evidence to that effect.

Let me just give you one example involving promotion. You mentioned the Head Start program; in Montreal schools, it is known as the ``Programme un, deux, trois.'' These programs have demonstrated their positive impact on underprivileged children; they have succeeded in increasing the numbers of young people who read adequately, as well as the numbers of young people who stay in school and present fewer behavioural problems. Behaviour problems can suggest the presence of anxiety and depression and suicidal tendencies, both in young people and adults. These programs have proven themselves to be effective.

If we were to apply them generally, what would that imply? We know less about their impact on the general population, but we do have evidence of the effectiveness of such programs. Indeed, that is why our U.S. colleagues use these programs in schools located in underprivileged areas.

I want to come back to the example of the treatment and prevention of suicide. I believe there has been a fairly solid demonstration that these kinds of measures work. I would refer you to the document I tabled with respect to what has been done in some Scandinavian countries: there it was shown that by increasing the treatment of depression, it is possible to bring down the suicide rate. By doing this, we are acting on one of the causes, but not all of them. So, if we do take this kind of action, it can have an effect.

Finally, in terms of public health, when we do take action for prevention purposes, we are always concerned; we worry that by increasing one kind of intervention, there may be negative effects that we have not foreseen. In that connection, I would remind you of how traumatic it was for the medical profession and the population to learn that hormonal supplements given to pre-menopausal women to prevent the undesirable effects of menopause could be linked to an increased incidence of cancer and cardiovascular disease.

That gave us food for thought, and allowed us to realize that while expanding the treatment of depression, we should not lose sight of the possibility of perverse effects over the long term.

As regards the treatment of depression, however, the situation is different because depression is widespread and is therefore associated with a greater number of incapacities or disabilities in the population. The treatment of depression may possibly prevent suicide, but its main effect is to reduce the incapacity of those affected, which helps them to perform their proper role of parent, spouse, or worker. It reduces their suffering.


Mr. Lips: For many people prevention and promotion are more challenging and difficult to grasp because they are dealing with long timelines. We are talking about real life situations where it is impossible to control all the variables. We probably will never have the degree of evidence for a psycho-social intervention that we can have for a medication. The latter can have a randomized clinical trail to establish which medication works well and what the side effects are.

When you are dealing with, for example, a classroom intervention, every class is different; every human being is different; every generation is different; and every teacher is different. You cannot have this absolute control over the circumstances of whatever it is you are testing.

The level of evidence for many psycho-social interventions is comparable to the level of evidence that we have for many physical interventions. I know that it may seem that mental health promotion is a vague, feel-good kind of concept. It is also my business to push it so I cannot speak impartially. However, my feeling is that mental health promotion requires are things that are good on a number of counts and that do not necessarily require a huge encyclopaedia of research evidence to support them.

We know that interventions with single mothers that provide home visits to help them to learn about parenting and promote attachment with their infants have measurable positive outcomes in mental health, physical health and general well-being. However, we do have a way to go in establishing primary prevention of illnesses such as schizophrenia.

We cannot say that we have a method of primary prevention for schizophrenia or bipolar disorder. Perhaps some of the things involved in mental health promotion would help to prevent these disorders but I certainly could not prove that with the evidence that we have today. It is important to look at each situation in a holistic way to know what we can prevent and what are the positive impacts that we could achieve.

In the case of schizophrenia, perhaps we are not at a stage where we could have a primary prevention method that is evidence-based but there is a great deal of evidence to show that early intervention can improve the outcome.

The case for mental health promotion is based on observation of what is associated with what. We know that certain parenting styles are associated with better outcomes in children in families on a number of counts. It makes sense that we modify those parenting styles in favour of the style that seems to have the best outcome.

We know that there are events in life that are associated with risk of poor outcomes of various kinds. For example, entering or changing schools, losing a job, getting married, getting divorced and retiring are all examples of such events. We see that in the population there is a range of outcomes. Some people manage those transitions extremely well and others do not manage well. We can study why they do not and we can look for interventions that will address those reasons.

There is a vast body of literature that supports these kinds of interventions. There is a point at which we must look at both the high-tech and low-tech interventions in mental health. We do not need a high-tech intervention to discover whether a little boy in the school system is deaf. If parents are not providing safe environments for their children, it is not surprising that there would be poor mental health outcomes, maybe not schizophrenia but maybe suicide or antisocial behaviour. We cannot predict which way some of these risk factors will take us.

Mental health promotion is not really that far behind physical health promotion in the sense that we know many things that are not good for people. Some of the challenges are to identify exactly how to modify those factors, just as we know that smoking is bad for the health of your lungs and heart as well as your general health. We are sure of that and yet we are still learning how to further reduce the rates of smoking. It seems that we have to re-learn that with every generation because each generation of young people is different. Now, we see some of them taking up smoking again.

It is the same with mental health. We know that certain patterns of behaviour and experiences are harmful to mental health. We need to learn how to modify those experiences. We have a good start on a number of those things. As Dr. Links mentioned we know about restricting access to means for suicide, which is a promising strategy in a number of cases. From my perspective, that is still a late intervention because if someone is ready to kill him or herself you are restricting the means. It is important to restrict the means but I would also like to discover an intervention whereby he or she would not even reach the point of wanting to commit suicide. Mental health promotion is a serious and important endeavour with a growing evidence base.

Senator Keon: I would like all of you to address the question of access to care. You have all alluded to the need for leadership and the specifics associated with leadership in suicide prevention. However, I think mental illness, unlike some of the other big disease entities, such as cardio-vascular disease and cancer, has a huge problem in respect of access to care. Some of this is probably associated with the existing stigma associated with the disease and much of it is related to manpower and manpower distribution.

Some of you alluded to the fact that it can take many months before a patient with a problem can get in to see the right expert. We would like to be helpful in our recommendations to the government. In that respect, what could be done at the federal level to make a significant impact on this horrific problem of access to care in the area of mental illness and mental disease?

Dr. Links: I agree that one of the greatest challenges is the issue of access to care. I believe that it would also be useful to look at the manpower issue. I do not know if the manpower issue falls at the federal or provincial level. The provinces need to address it as best they can.

In the area of psychiatry, the manpower issues are highly acute, particularly in areas of child and adolescent services and services for the elderly. A large part of it is having adequate manpower and providing the training to develop people in those areas.

Some of the models about which we talked today do offer some hope. There is evidence that collaborative care can improve the recognition and treatment of depression. We must move forward on creating the primary care initiatives that can meet this need.

As we have heard from Dr. Lesage stigma is a huge problem. As you know, people do not come forward for treatment of mental illness, substance abuse and suicide because of the stigma associated with them. It is a complex problem. Part of tackling stigma is to provide the knowledge and evidence that things can be done to correct the problem.

The federal government could lead in the area of research. We know that proper knowledge and research can reduce stigma. We are seeing that already. That is an area for federal leadership.

We need very broad initiatives. I have the experts here on the primary prevention level.

Certainly in the area of delivering services, we are trying to look at very broad initiatives, which include many self- help initiatives, so that the families and the community can become a very important part of assisting in the person's recovery and maintaining them in the community.

In Ontario, we are investigating that approach for people who have severe personal illness. They offer opportunity in conjunction with other kinds of service models to help people cope with mental illness.


Dr. Lesage: I have two suggestions to make in response to your question. The first one that I have already referred to involves raising Canadians' awareness of mental disorders. It is important that they know that it is possible to receive effective treatment for mental disorders. If we are able to change people's perceptions over the long term, and get them to accept that mental health problems should be treated the same way as physical health problems, then we will have made a giant step forward, because these attitudes are very prevalent. That is something that would reach every community and affect this country's social fabric. At that point, access would no longer be a policy or planning issue for a few experts, but something that all Canadians would think about in terms of how to seek and receive help in resolving mental health problems — whether they were fathers with a family, employers, CEOs, union leaders, et cetera. It would be something people would be very aware of. At every level, everyone would be doing something to try and expand access. There is a lot to be said for increasing Canadians' awareness.

My second comment is about services and increasing access to services. In Canada, it is through research and knowledge transfer that we can identify best practices that will allow us to enhance access to mental health care in communities, cities, and towns. We will have to find appropriate models, that may well be different in Eastern and Western Canada. They may also be different depending on whether they are aimed at a large or small urban centre. We have to identify incentives and service organizations, so that social service workers and clinicians take a greater interest in mental health problems, and are more available to identify and treat patients with these problems.

We have to reflect on this in the context of current models — and this is something I am suggesting — such as the ones now being used to enhance access to better care for conditions such as diabetes or hypertension. Anxiety and depression disorders last over a long period of time. Treatment cannot be limited to one point in time. It covers an extensive period and affects not only the patient but his environment; the patient has to be encouraged to follow the appropriate treatment. That requires approaches that are more similar to those used for treating chronic physical conditions, as opposed to acute conditions. We need to do more research or encourage people to use models that are already in place in Canada and that could be more widely used and accessible in other regions of the country.


Mr. Lips: It is very important to approach these issues in a way that honours the federal provincial-territorial division of responsibilities. There are ways that Health Canada has already demonstrated work of this kind.

In the area of research, there are models such as the Health Transition Fund and the new Primary Health Care Transition Fund. The Health Transition Fund had some 20 or 25 projects relating to mental health service delivery. The provinces recognize that this is a pressing and important area.

There are research questions relating to service delivery and access to care. That is one example of an area where the federal government made a substantial contribution to this issue. I expect something similar to emerge from the Primary Care Fund.

The increase in research funding has been substantial and a fair amount of those funds have been directed toward mental-health related issues. CIHR identified $30 million of mental-health-related research in 2002-2003.

Another issue of interest is telehealth. This technology is being used more widely in delivery of health services, especially to rural and remote areas. It holds much promise. It also is an area where the federal government has made substantial contributions.

Dr. Lesage mentioned self-help. The federal government at various points has contributed to self-help through training and developing resources to encourage the fostering of self-help for people with various problems, including mental health problems.

Stigma was mentioned. Again, there are requests for applications from CIHR with respect to research relating to stigma. That is an area where some leadership is being exercised. In a modest way, our unit has tried to advance the shared-care agenda.

We have also been in dialogue with the provinces around many of these issues. I think there is a role, but it is also important to address these issues, while honouring the provincial and territorial primary responsibility for health care delivery.

Senator Keon: It would seem to me that if we could ever get primary care organized the way we would like to see it in Canada, you would then have a structural framework or net for people to enter into the system.

Currently, there really is no system for entry of these patients. They have to find their own entry points. I believe many of them are embarrassed to look and ask. You are the expert on this subject.

Could you speculate on the usefulness of well-organized primary care programs across the country that would have this dimension of access for mental illness?

Mr. Lips: I agree that mental health is and should be an essential part of primary health care and that improving primary health care should include improving access to mental health care. I think some of the models that have been advanced for 24/7 access to primary health care and the efforts to promote multidisciplinary delivery of primary health care are things that will contribute to improved access to mental health care.

I think it is widely acknowledged in the provincial systems that there are big challenges, in terms of creating easy access to mental health care and connecting up the pieces of the system to better serve people with serious mental illness that have multiple needs. It is an ongoing struggle, and I would certainly hope that the federal, provincial and territorial contributions around primary health care would focus in a significant way on mental health care.

Dr. Links: Maybe I can respond to that by giving an example of people we work with and are trying to study.

On a clinical basis, we deal with men who are both suicidal and violent. They are people who are very difficult to deal with and tend to be extruded from our health care system. Many of these men have both mental health problems and substance abuse problems and often have a family doctor that they will self-identify. However, they do not go to the doctor for mental health problems instead they come to an emergency room. They tell us that they tend not to do anything about their mental health problems until they become so acute that the Toronto police pick them up. It becomes a negative experience, because they are bound to the stretcher and medicated, that they are determined after they leave that they will never say anything about their mental health problems again and so the cycle recreates itself.

I tell that story, because there are huge challenges in this issue; however, those challenges go back to some of the things we talked about, like education, stigma and better training. Even in a city like Toronto that is well-resourced there are silos where people do not get proper services.


Dr. Lesage: I just want to emphasize what you said about the fact that it is through primary care and basic health and social services that we will succeed in addressing the huge problems faced by people with common mental disorders.

Dr. Links referred to the fact that it is important for individuals with persistent serious mental problems or disorders to have access to specialized services. But for people with common mental disorders, that are very widespread, the World Health Organization and most industrialized countries would say that treatment has to be provided through front-line services, because otherwise, it simply will not happen.

If you figure that for every 100,000 people, using the figures just quoted, some 20,000 experience mental health problems, that is 20 per cent.

For that same population, we currently have an average of 100 family physicians, approximately 70 psychologists, and 10 psychiatrists. If we want to treat these 20,000 people suffering from mental health problems using only the specialized services of 10 psychiatrists, that simply won't work.

If we are talking about a psychiatrist at least taking the time to meet with a patient once every two weeks or once every month over a period of a year to help that patient resolve his particular problem, and if he is to spend half an hour to an hour with that patient each time, well, I do not believe any psychiatrist is able to handle more that 300 or 400 patients per year.

So, how can these 10 psychiatrists help these 20,000 people, in theory? As I see it, it simply cannot be done, unless we increase specialized services. However, there again, that would not be advisable, because as we discussed, appropriate treatment can be provided by family physicians, in the case of medication, or by psychologists, in the case of psychotherapy, or even through cooperation among these service providers for basic services.

I am giving you these figures simply to demonstrate that a real effort must be made to find models that will allow for cooperation on the front line between family physicians, that patients trust, psychologists, and specialized services.

For family physicians, that means having access, at the right time, to the necessary expertise when more complicated cases arise and when physicians have questions and need additional advice, in order that these patients can receive help as close as possible to their living environment from people they trust, like their family doctor.


Senator Cook: Thank you, Dr. Keon, for pursuing my line of questioning.

I come from the province of Newfoundland, where mental health services are in very short supply. However, we cope. I would like to hear your thoughts on the role of nurse-practitioner in mental health care.

I also want to ask about people with mental illness who live in what I call the ``sub-culture'': the homeless, people in boarding houses, and others on the fringe of society. The only resources they have are the NGOs and the people who run social programs.

The promotion never gets to the frontline people who are trying to care for those people. They often suffer from poor nutrition and live in inadequate situations in boarding homes, or they are homeless. They are not capable of caring for any of their creature comforts. They are using food banks. What can we do to give those people a bit of meaning to their lives?

Mr. Lips: Not all homeless people have mental illness, but a significant proportion of homeless people do. Being homeless is not good for your mental health. There is a cycle that goes back and forth. Included in this problem are substance abuse issues.

This is a challenge that goes beyond the scope of one department to address. Clearly, an educational intervention will not solve the problems of people living on the street. There may be some role for education, but a multi- dimensional effort is needed from all levels of government to ensure that people meet a basic standard of living, safety and nutrition.

I do not have a simple answer. Housing, for example, is not a jurisdiction of my department, but I recognize housing as a basic need.

People who are homeless and mentally ill have medical needs for treatment, for access to services, for nutrition, for improved shelter and safety, and for fair and just treatment by the various authorities that they deal with. This is a large and complex problem. I hope that our department will be able to contribute within its jurisdiction to resolve that problem.

The federal government does have a homelessness initiative. That is an excellent step in addressing this problem, but I am sure there is more that needs to be done.

Senator Cook: I intended to say that this is not education for the consumer, it is for the volunteer and front line workers who do not have the expertise that they need to take care of those people who flow through the department.

Mr. Lips: The department has been involved in helping various groups, developing resources for professionals and volunteers, and dealing with different populations. That is an area that would be worth pursuing in terms of giving some of the front line people the tools they need to deal with mental health problems and to support people who have mental health problems.

Senator Cook: In regard to the holistic approach to the area of mental health, would you advocate mental health as an integrated component of community health? Do you envision a multi-disciplinary team with all the different facets that would contribute to the holistic approach?

Mr. Lips: I do not want to advocate for any particular model of service delivery. That is not my area of expertise. However, I will echo the European commissions' comment that there is no health without mental health. Whatever health service delivery is happening must be cognizant of mental health issues and reflect mental health needs.

Dr. Links: From the clinical perspective homelessness is a complex issue and only partly related to mental illness. The assertive community treatment model can target severely mentally ill people who are also homeless. There have had successful outcomes in terms of maintaining them in the community, in housing, and even in certain situations, in work-related outcomes. There are promising models that are intensive and costly, but compared to hospitalization and institutional care they seem to be beneficial.


Dr. Lesage: I would just like to add that with this assertive community treatment model, a large portion of the staff is nursing staff. You referred to the role of nurses and nurse practitioners. I think you should invite them to discuss their role. As a physician, it is a little odd for me to be talking about the important role that nurses fulfill within our health care system, and specifically in relation to mental health. They could come and tell you themselves just how they see their role and the contribution they could make to primary health care in Canada. I suggest that you invite them to appear.

Most of the staff caring for individuals with mental health problems in Canada in the hospital setting are nursing staff. They are also increasingly deployed to community health service centres. Earlier, we talked about the assertive community treatment program which involves providing care and treatment to individuals who are difficult to reach, such as the homeless; there nursing staff play a very prominent role. Nursing staff are active on the frontline. There is a lot to be said for enhancing their role so that we are able to create a model of care for depression and anxiety problems. In Quebec, we have started to establish groups of family physicians, and we are suggesting in Quebec that this model be used to improve general access to primary care and treatment. These groups of family physicians will have access to or be associated with at least one nurse practitioner. In my view, that's completely inadequate; we really need at least one, for every group of five to ten physicians, to deal exclusively with mental health issues. Also, the holistic vision which is a component of nurse training is certainly an asset in the practice of primary care and would be especially helpful in increasing access and awareness and ensuring more appropriate treatment of mental health problems in the primary care setting.


The Chairman: I wish to thank our witnesses for their excellent testimony. Thank you most sincerely on behalf of the committee.

The committee adjourned.