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

Issue 14 - Evidence for May 6, 2003 - Afternoon

MONTREAL, Tuesday, May 6, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met at 1:36 p.m, this day, in the Monet room at the Crowne Plaza Montreal Centre, the Chair, the Honourable Michael Kirby, presiding.

Senator Michael Kirby (Chairman) in the Chair.


The Chairman: We will try to make up time, although as you will discover, my colleagues ask a number of very good questions, so I will ask you to be really brief in your opening comments. I think you will find that you will be able to elaborate in your responses to the questions, because previously, the question period went on for a considerable time.

Senators, we have a panel of six people. I will introduce you to them as they make their opening statements. What we found works best is for each of them to make an opening statement and then we will ask questions of the panel, rather than directing questions to one of them specifically.

Our first presenter will be Dr. Mimi Israël, Head of the Department of Psychiatry and also Associate Professor, McGill University. Thank you for coming.

Dr. Mimi Israël, Head, Department of Psychiatry; Associate Professor, McGill University: I would like to discuss the challenges involved in organizing a mental health care delivery system based on the principle of continuity of care, or a circular flow model, in contrast to our current system, which corresponds more closely to the silo model.

The current system of mental health care delivery is poorly organized, inconsistent and inefficient. The result is decreased accessibility to appropriate care, with the expected potentially preventable consequences, such as, in the worst-case scenario, suicide, or, more commonly, chronicity, loss of productivity, alcohol and drug abuse, familial distress and marital breakup.

Although we strive to give the appropriate care at the right time by the right people, and in the right amount, we witness three alternative scenarios occurring at an alarming frequency; no care, poor care, and too much care.

The existing model is sustained by a lack of continuity between primary and specialized services. Currently, the proportion of care that is assumed by primary care services varies dramatically and is not based on systematized, coherent principles or assumptions. In the mental health field, basic definitions as to what constitutes first-line or primary care and what is meant by specialized care have not been established. Definitions such as ``non-complex,'' ``uncomplicated'' or ``typical'' are not particularly useful, nor is the definition of primary care as care delivered by a general practitioner.

In reality, the boundaries between what is done in each sector of care is not so much determined by the nature of the presenting problem as it is by varying levels of comfort and willingness to diagnose and treat mental illness in the primary care sector.

Lack of training and expertise, anxiety on the part of professionals who have not specialized in mental health, stigmatization, stereotyping and unacceptable prejudice against those who suffer from mental illness also contribute to the inconsistent response received by those who present asking for help with emotional distress. The result is ultra- rapid referral to psychiatry, thereby taxing scarce resources and decreasing accessibility to all; over-, under-, or mistreatment; and the shift of care to alternative resources such as therapists, healers and naturopaths, where there is no control over the quality or the pertinence of the treatments offered.

Mental health professionals also contribute to the rift between first-line and specialized care. For instance, psychiatrists, in contrast to other medical specialists, assume much more responsibility for front-line work. As a group, we tend to be protective of those who suffer from the full range of mental health problems. We often choose to treat them ourselves rather than throw them out into the hostile world to face stigma and rejection.

A potential solution would be to create a circular flow model for mental health care delivery, a system whereby primary and specialized services would collaborate to provide a continuum of care and where the flow of information and expertise between sectors would be optimized. Although there are probably many ways in which such a system could be established, I would like to support the notion of developing centres of excellence for the study and treatment of mental health problems.

The mental health institutes that would be created would be responsible for delivering specialized and ultra- specialized mental health care to an assigned proportion of the population and would assume a leadership position in organizing a network of primary care, community-based and housing services to serve that population's mental health needs.

Mental health institutes would also assume the responsibility for ensuring that best-practice care is being delivered throughout its network, through the development of new knowledge and research and the transfer of new knowledge through teaching and training.

Furthermore, mental health institutes would be mandated to develop empirically tested models of shared care, thus promoting collaboration between families, physicians and psychiatrists, and raising the level of expertise of the front line.

Models that involve the systematic integration of mental health care workers into primary care services would also have to be explored. In addition, strategies to motivate front-line professionals, so that they become invested collaborators, would have to be developed. The desired outcome would be a front line equipped to address or treat the majority of mental health problems within a system that favours seamless transitions between primary and specialized care.

Finally, the centralization of service organization and delivery through mental health institutes would facilitate the transfer of knowledge and expertise beyond regional boundaries and the long-term planning of mental health services at a higher level.

Dr. James Farquhar, Psychiatrist, Douglas Hospital: I have prepared a written presentation entitled, ``Mental Health Services Delivery: What Can We Learn from the United States?'' It might be of interest. I will just go through it quickly.

In the United States, mental health services to mentally ill persons, which are provided free by the state, are better organized, more efficiently run and more open to financial scrutiny than in Canada. Mostly, this reflects the fact that the Americans are 10 years ahead of us in deinstitutionalization.

The Chairman: Since we will read the text in some detail later, you may want to just hit the highlights.

Dr. Farquhar: I would like to point out that in Quebec, the government has reduced mental health funding by 13 per cent over the 7 years from 1994 to 2001. Yet almost nobody knows this and it may come as a surprise to most people around the table. I imagine that similar erosions have happened in the other provinces. We are talking about being $130 million in the hole compared to nine years ago — at least that, and perhaps more. Within general hospitals — I am talking about funding for mental health services — there is a micro funding problem. Those hospitals in Quebec have a $700 million deficit right now and it is common to see budget managers pick away at money for psychiatric nurses and other staff, saying, ``You have fewer psychiatry beds now because of deinstitutionalization, so you need fewer staff.'' That is crazy, because all the research shows that you need about the same number of staff just to keep the patients out of hospital.

In the United States, they handle budgets differently. All states have a mental health commissioner, a top civil servant in charge of all mental health services and of the funding. Also, every state has a mental health budget that is discussed every year in the state legislature and published in the media, so everybody knows what it is year by year, which is very different from here, where you almost have to use an access-to-information process to find out.

I would like to recommend that the federal government promote these concepts by asking the provinces to make their mental health budgets public each year as a condition of the annual transfers for health services. Also, the federal government might go so far as to insist that provinces have a mental health commissioner in order to receive those billions of dollars.

Ottawa might set aside money for training, because manpower training is your jurisdiction. Mental health commissioners might spend a year getting a diploma and on-the-job training in the United States, initially, and later on, in provinces that are excellent in that domain.

I want to talk about the structure of mental health services and go over some headlines about what the United States has that we do not. The biggest thing is case management. We do have some case management, but there are many hospitals that do not, even in large cities, and it is a big problem. It means that the doctor has to be a case manager and handle every little thing, which creates the illusion that we need many psychiatrists, who are highly paid compared to case managers, about three or four times as much.

Among other American concepts that it would be important for Canada to adopt — to some extent, we already have — are Assertive Community Treatment, also called ``ACT'' or ``PACT,'' and intensive case management, which is sometimes called ``PACT lite.'' I know other speakers have talked about PACT today, or will. You can use Assertive Community Treatment to help mentally retarded people with mental illness, mentally ill persons with drug and alcohol problems, and homeless persons with severe mental illness.

Another concept is ``Outpatient Commitment,'' something that people perhaps do not like to talk about, but it has been the subject of some debate in Ontario in the last few years. How do you get people who are mentally ill to take their medication if they do not want to? One way is by court order. The American experience indicates that you need Assertive Community Treatment teams to make these court orders work.

I am not taking about psychiatrists, but rather all the people who have to be on the teams with psychiatrists. The United States realizes that there are not enough nurses, just as in Canada, and it is unlikely that there will be enough for quite a few years. Therefore, they hire a lot of young people to work as case managers who have just a bachelor's degree in psychology or something like that, but no professional diploma. These people receive about 50 hours of courses on the nuts and bolts of mental illness, medications, alcohol and drug abuse, and so on, and have to pass written exams, so there is a quality assurance component in their training. That is something that we might adopt here.

There are some American concepts concerning better group homes — meaning more staff — that we might do well to adopt. I have submitted a paper I wrote eight years ago on that subject.

In closing, the federal government could assist mental health reform by doing these things, by creating a good Web site about these new, better practices and by financing the development of the 50-hour mental health course that I mentioned, through the use of educational videos or Web sites across Canada. This would provide quality assurance for the knowledge base of new mental health workers, with or without professional diplomas. This job is too big for just one province and I do not think it has been done in the U.S.

Ottawa could develop a model law for civil Outpatient Commitment, to be shared with provincial legislatures, which has been done in the U.S.

Finally, when Ottawa gives money to the provinces for homeless people, you might ask them to target homeless people who are mentally ill and, especially, to increase mental health support staff at the Salvation Amy residences and the missions. We would achieve so much good for our money.

The Chairman: Thank you for your specific recommendations, and we will come back to those. Thank you also for the detailed list of references that you gave on best practices in mental health service delivery. The committee will be looking at those.

Our third speaker is Dr. Pierre Lalonde, the Director of the Clinic for Young Adults at Louis LaFontaine Hospital.


Doctor Pierre Lalonde, Director, Clinique Jeunes Adultes de l'Hôpital Louis-H. Lafontaine: Thank you for inviting me. We have handed out two documents. The first is called Boundaries of the 1st, 2nd and 3rd Lines of Mental Health Services, which I recently wrote with Dr. Alain Lesage; the second is not quite as recent and it deals with the role of psychiatrists in the rehabilitation of schizophrenics. I will comment on them briefly and refer to them.

I think that schizophrenia is a very complex area to be involved in. For a long time I thought that psychiatrists should deal with that area. I still believe that should be the case. We will never be able to meet the demand. If I take as our starting point schizophrenia, a severe mental illness, three lines of service need to be established, as Dr. Israël was saying, to work with these patients and to deal with many other problems.

The first topic I wanted to raise was, in fact, these Boundaries of the 1st, 2nd and 3rd Lines and how we can intervene at several levels. In your document you have, among other things, a chart that shows — and I think this is a first in the literature — the various factors in the 1st, 2nd and 3rd lines of intervention.

Problems dealing with daily life can be dealt with in the 1st and 2nd lines; the 3rd line is used only when it becomes quite complex or when research is required. The third line is truly focused on research, and the other lines contribute to the 3rd line.

The level of service also changes: the higher the specialty, the broader the area. Interveners on the 1st line are general practitioners. One of the problems in Montreal is the number of general practitioners who want to do psychiatry. In some areas of Quebec, there are fewer psychiatrists and more general practitioners. A balance is necessary and psychiatrists are learning to be consultants.

The areas of care vary, and within a community, one is dealing with the 1st line. You can see different examples of care in the chart. At the 3rd line you have research, and the development of new techniques which eventually are transmitted to the 1st lines.

A few years ago, at the Clinique Jeunes Adultes, we worked extensively on a care model: social skills training that would enable schizophrenics to take the bus, to manage their budgets, and to withdraw money from the bank. It may come as a surprise to you, but these patients do not know how to do these things.

We developed training programs for these skills. These programs have been used throughout Quebec. Psychiatrists are not necessarily required to eliminate these problems, but psychiatric teams have to be established in order to develop these programs.

I would like to mention a research project at Louis-H. that we are working on with my colleague, Emmanuel Stip, that deals with types of accommodation. We are calling it the smart apartment. I will explain it to you in a few words.

For people with physical impairments, customized apartments have been developed, that include, for example, sloped sidewalks and wider doorframes so that they can enter. When people suffering from psychiatric problems leave the hospital, they are often told to go to a particular place and to adapt. The fact that these people have severe cognitive problems that prevent them from taking responsibility for their own care, because of the symptoms, is not taken into account.

A smart apartment takes into account the cognitive deficits of these people and finds remedies to them. For example, the stove may turn off automatically after two minutes, thus avoiding the risk of a fire.

Emmanuel Stip applied for a grant from the CFI, the Canada Foundation for Innovation, to work on this project. This is the first time in the world that accommodations specifically designed for these patients are being looked at.

Teaching also falls under the 3rd line, and this involves providing information. The 2nd line can also be used for teaching. One thing that has to be learned is how to share.

I think that the 1st line can teach us something about how to intervene and information can be shared in this way.

Research, as I already pointed out, is a necessary part of the 3rd line, that the other lines can also participate in.

I would also like to briefly speak about the document about the role of psychiatrists in the rehabilitation of schizophrenics. This is, in fact, a very complex illness. The psychiatrist or the psychiatric team has to intervene in several ways, including assessment.

The symptoms are very hard to assess, not only the positive symptoms, such as hallucinations and delirium, but also the negative symptoms, such as apathy, and lack of conversation.

At times these people appear to be lazy, when they are actually experiencing ``hypofrontality'' symptoms, because their frontal lobes are not functioning adequately. There is this whole area of evaluating needs, how to function on a daily basis, how to adapt solutions and these must be identified by psychiatric teams who are familiar with the brains of these types of patients, rather than simply relying on good will.

Dr. Farquhar spoke of this; there are many people full of good will who would like to take responsibility for this, but there is a certain amount of information that must be acquired before one can intervene in the cases of complex illnesses.

Mr. Jean-Jacques Leclerc, Director, Rehabilitation Services and Community Living, Hôpital Louis-H. Lafontaine: I will try to summarize 30 years of experience in rehabilitation in five minutes. I will talk about it quite briefly by giving you an overview of some issues.

The mandate of short-term or psychiatric hospitals is to treat people suffering from a mental illness in order to stabilize them and then reintegrate them to the greatest extent possible in their environments or in transitional accommodations, with the support that they need.

Research shows that one out of five people will suffer from a mental illness over their lifetime. Seven to eight per cent will use various services and currently 12 per cent do not get the help that they have a right to; 2.4 per cent will experience a serious mental illness.

And yet, in 2003, people are afraid of these illnesses and a good part of the population is very reluctant to have people with these mental illnesses in their area. For example, last fall, in 2002, when an accommodation facility for 17 people was opened in the usual fashion in a Montreal neighbourhood, more than 1,100 petitioners expressed their disagreement.

The grounds these people used were aggressiveness toward children, and toward seniors. They said that they would need the police near the schools because the children would be passing by the facility. They claimed that these were people who assaulted seniors, who had problems with addiction and alcoholism and would insult passersby.

Last, a very important point for that community was that the buildings around the centre would go down in value.

This is unacceptable in the year 2003. Educating the public, our municipal, provincial, and federal representatives, will be a major challenge.

I hope that educating young people, in schools, about mental illnesses and their effects will lead to a decrease in prejudices towards mental illness.

This afternoon I would suggest five points to reflect on, regarding the integration of people with mental illnesses: housing, accommodation resources, work, research, and families and relatives.

The lack of housing in big cities makes seniors, couples with children, people on social assistance, and especially people suffering from mental illnesses an easy target for denying access to housing.

Because there is a lack of investment on the part of the private sector in affordable housing, and because of its low profitability, these people tend to end up in mediocre, and at times unsavoury housing. The development of social housing needs to be supported. This housing has to be accessible to people suffering from mental illnesses and support has to be provided by people living in the community, for those who have been integrated into social housing.

We need financial incentives so that private companies build affordable housing, we need more partnerships with municipalities who are responsible for social housing, we need cooperative housing and financial support for the purchase of bungalows for two or three people suffering from mental illness, who can be the owners. This will require a change in social assistance programs.

There is a lack of housing, of accessible apartments, but there are bungalows. However, these people do not have access to programs that allow them to become owners.

It is absolutely necessary that anyone suffering from a mental illness who cannot be reintegrated into housing have access to good accommodations that is adapted to various needs, and that is being supported by the private sector and public and not-for-profit organizations.

This type of cooperation is essential and it must be done in a spirit of partnership and in the interest of the mentally ill. These three networks must provide all people with access to services that meet their needs to the greatest extent possible, that provide a physical environment and customized support adapted to their needs.

These needs are different. There has been a tendency to provide standard accommodation and to have people adapt to that accommodation, and this is inappropriate. We need buildings for people in groups, families, or on their own, but we also need buildings that are adapted to different categories of people, such as young psychiatric patients like children and teenagers. The type of accommodation required for young adults, adults and seniors suffering from mental illnesses are all different.

We are also dealing with different categories of problems: psychiatry/intellectual disability, psychiatry/addictions, psychiatry/behavioural disorders and psychiatry/legal issues. All of these categories require different programs.

Investing in human resources, in support, in quality control as well as in buildings, is imperative.

For many people, work is an important factor in their social worth. Very little is being done for those who have a job and who are experiencing problems due to their mental illness and who need, among other things, long-term sick leave.

We need to invest in employers, unions and insurance companies so that a joint effort can be made to help support these people and help them keep their jobs so that they are not laid off, as often happens, and so they do not end up in various government or social programs.

This costs millions of dollars in lack of productivity, in the impact on relatives and on the health system. Supporting these people in their workplace is an excellent investment in the future.

Without work, many people are living under the poverty line and they cannot obtain decent housing, decent clothing, enough food, or entertainment or education.

Some make up for this through theft or prostitution — that is the reality today — or in some cases they take a more positive approach, such as mutual assistance or partnerships. We need to support and develop programs that encourage these people to take responsibility for themselves, to help them become independent; we need to stop keeping them under the State's control.

It is important to encourage people to return to work, while being aware of the pressure these people will face when they are required to work at a fast pace and to be productive. It is also important to ensure that mental health does not become grounds for not hiring someone; however, this is what happens.

We need to look to the future. We need to focus on investing in research and in various types of medical, pharmaceutical, epidemiological, and social action.

Greater sharing of our findings, whether they be Canadian or international, will increase our chances of helping many Canadians. Each of us is responsible.

Furthermore, we must offer support to families who are dealing with people suffering from mental illnesses on a daily basis. Often, people who are alone or older end up giving up and abandoning people who are ill over time.

We need to provide access to respite services and special caregivers to help provide a better balance for these families.

My conclusion is this: Myth or reality? I believe in the potential of every human being who, with greater access to rehabilitation, may one day have a better quality of life.


The Chairman: Just to finish your story, what happened when 11,000 people demonstrated against the apartment; did you open the apartment or not?


Mr. Leclerc: Yes, we have in fact opened the accommodation facility. It took a sustained effort with the police, with community organizations, at the political level and with the City of Montreal, and with many community organizations, and the facility is opened. It is working at full capacity. Yes, it is working very well.

Dr. Renée Roy, Assistant Clinical Professor, Department of Psychiatry, Faculty of Medicine, Université de Montréal: I am involved in two main areas in my professional life. One area that requires more time than the other, is my work in legal psychiatry at the Institut Pinel, but that is not the area I want to talk to you about today. I understand that many of you will be visiting Pinel tomorrow. You will learn about all the wonderful things that are happening in that hospital.

I am going to speak about the second area of my work. I am the director of the training program for psychiatry residents. Psychiatry residents are doctors who are doing five years of training to become psychiatrists.

You may already know that there are 16 faculties of medicine in Canada, and therefore 16 people who, like myself, are in charge of training psychiatry residents. The biggest faculty of medicine, and in fact the biggest psychiatric residence program, is in Toronto. They train 100 residents at a time.

We have about 60 residents in psychiatry at the Université de Montréal; we therefore come second on the list of those 16 universities. We are followed closely by UBC.

There are four faculties of medicine in Quebec, five in Ontario, and there are few others throughout Canada, including two in Alberta.

That gives you an idea of what I am working with. I coordinate the training activities for these residents. I must ensure that all the requirements set out by institutions responsible for resident training in Canada are met. These institutions are the Royal College of Physicians and Surgeons of Canada and the Collège des médecins du Québec.

In the course of my work I have had the opportunity of meeting many professors who are very involved in resident training. I have also had the opportunity of speaking with colleagues and I have realized that resident training problems are similar throughout Canada.

There is an organization for directors of programs in Canada, called COPE. We meet twice a year. I am the outgoing chairperson and we have had formal and informal discussions on the future of psychiatric education in Canada. We have realized that we all face the same hurdles.

Since I am generally optimistic, I would like to talk to you about positive things. I will then talk about the more difficult obstacles and will suggest some solutions.

Since my own training as a psychiatry resident, from 1981 to 1985, there have been various, new health care delivery models. In the past, a psychiatrist worked in a hospital — to simplify matters — or alone in his private practice.

Things have obviously changed a great deal. Very few newcomers want to work independently. Every year, I meet with the graduate residents on a regular basis and for the past three or four years, I have seen maybe one who wants to pursue a career entirely in private practice.

The field has also become much more sophisticated. I often tell my residents that I am happy to have passed my exams when I did because I am not sure that I could pass them now.

There have been many developments thanks to evidence-based medicine. Huge improvements have also been made on the research side in terms for program assessment. Dr. Lesage no doubt spoke to you at length about that when you met him.

Several psychotherapy approaches have proven to be very effective. We have better treatments for our patients, the shift to ambulatory care, indeed all sorts of things you have no doubt been hearing about over the past few weeks.

An interesting phenomenon is emerging, namely that there is increasing consistency between the various psychiatry training programs in Canada, which, of course, are all overseen by the Royal College. In the past, there was much more discrepancy in approaches and focus.

It is interesting to note that the various facets of the system are now much more intertwined. On the one hand, you have the two colleges, the Collège des médecins du Québec and the Royal College. The Royal College has a body called the Specialists Committee that deals with resident training. Those people used to operate in an ivory tower, but now we have easier access to them. They work with the Canadian Psychiatric Association as well as with COPE to determine which areas to focus on for the future in psychiatry, including over specialization.

Those are the positive things. There are also negative things, obstacles to overcome. The future is bright because there is an increasing number of medical students in every medical faculty in Canada.

I do not know whether you remember, but a few years ago, the number had dropped significantly. It is now gradually increasing and the University of Montreal will reach its peak as of this year, 2003.

In the past, the medical classes had between 200 and 205 students. They dropped to approximately 120 students and now they will increase to over 220 students. That means more staff will be required to give these students their practical training.

Unfortunately, the professors are getting older and running out of steam. Their caseloads — there is a shortage of doctors right now — is such that we have overworked professors who have less and less time to train the residents. Training is becoming increasingly complicated.

Everyone knows that many professors teach on a volunteer basis. They hardly get any money — in fact they lose money — because the time they could spend at the clinic would be much more lucrative and effective than the time they spend explaining things to all sorts of medical students and residents in psychiatry.

There are also problems because of the reduced emphasis put on psychiatry in the medical courses. We had to fight very hard over the past few weeks because a task force had decided to reduce the training in psychiatry from eight weeks to six weeks for the entire duration of medical studies.

We finally won our battle and the number was brought back to eight weeks. Psychiatry is not the only field affected; gynaecology has also had its problems. They also won their battle and the students now get eight weeks of training in that as well.

There is not enough focus put on psychiatry in the family medicine program. The people handle the training but also the training of general practitioners. In our view, there is not enough focus put on mental health and yet in the offices of family doctors, there are huge numbers of patients who suffer from severe or less severe mental illnesses.

We have heard our American colleagues say they are having a great deal of trouble recruiting students for the psychiatry training programs. The programs are not full, there are vacant positions. That is generally not the case in Canada. Usually when those things happen in the United States, 10 years later the same thing happens in Canada.

There are also problems recruiting professors. When students finish, they prefer to work in a field where they will earn more money rather than become professors. Recruitment is difficult because of all sorts of administrative and political obstacles.

There are fewer and fewer models for psychiatrists who want to practice general psychiatry. Over the past few years, the trend has been to recruit overspecialized people as professors. Those practicing basic general psychiatry are essential for proper training in psychiatry and they are becoming increasingly unavailable. That is a major problem.

What are the solutions? In our view, there are two. The first is to continue to work on improving the content of the training so that it meets our needs today and in the future. We can go into more detail later on, if you wish. The second dimension would be to ensure that there is time, money and recruitment of professors to reach all our lofty goals for the future of psychiatry and to ensure that service delivery is improved. We need qualified people for that and they must be available to work with the recruits.


The Chairman: Our final speaker is Dr. Jean Wilkins, Professor of Pediatrics in the Department of Pediatrics at the Université de Montréal.


Dr. Jean Wilkins, Full Professor and Pediatrician, Department of Pediatrics, Faculty of Medicine, University of Montreal: As you said, I am a trained pediatrician and I have a specialization that is not recognized in adolescent medicine. This afternoon I would like to talk about adolescent medicine from a pediatric perspective.

Adolescent medicine is a relatively new medical concept that originated mainly in the United States. It exists in Canada, but it is not very entrenched in the well-structured programs of hospitals and universities in Canada's various provinces.

Our program at the Université de Montréal has been in existence since 1974. The issue of providing health care to teenagers has changed a great deal in the past 30 years. That has forced all of the stakeholders to be much more flexible if they want to have an impact on our dealings with adolescents.

I will briefly list the various problems: first there were all the problems related to drug addictions, drug usage among adolescents, and all the issues surrounding adolescent sexuality. There were also the problems of teen pregnancy, abortions, access to contraceptives, the contraceptive follow-up that kept the practitioners busy, at least in Quebec.

A very violent period in our society ensued after the number of attempted suicides and successful suicides among teens soared. There was an outcry virtually everywhere in the western world towards the beginning of the 1980s.

At the same time, there were all sorts of separations and parents divorcing, which led to problems for the teenagers as well as adjustment difficulties, and our clinics were full of teenagers with those problems until such time as they were understood. Nowadays, we hardly see any of those problems in our clinics.

In the past 20 years, most of the teen cases being treated have been eating disorders, mental anorexia and bulimia.

Let me give you an example. We have a 25-bed unit in the pediatric ward for children between the ages of 12 and 18. Twelve to seventeen of those beds are constantly occupied by teenage girls with eating disorders, and occasionally a young boy.

At the same time as these eating disorders appeared over the past 20 years — we are less organized for those patients — the so-called ``somatoforms,'' who are adolescents with somatization problems, appeared.

When I started in teen medicine, our concern was to make care available to adolescents by reducing the obstacles to them. I admit I am speaking very much off the cuff this afternoon because I was very short of time for various reasons. I wanted to briefly go over what barriers I see to adolescents when it comes to access and acceptance into the health care structure.

One point that immediately comes to mind is the notion of sectors. Psychiatric care is defined by the sectors, depending on where you live, you must consult someone in your area. No one remembers whether that is a law or not, but everyone knows it is applied fairly strictly.

This is a major hindrance to teens. Getting a teenager to seek medical attention is a long process and may involve his entourage, his family or his friends. Once an adolescent recognizes he has a problem and seeks help, the first question he is asked is his postal code. He then clams up right away. All the effort to get the teen to the clinic is wasted.

It is important to have an entry point, a single wicket, as they say in politics. The adolescent must have easy access to services and must not be discouraged right from the outset because a condition can worsen very quickly with that type of treatment. It has a negative impact.

It is important to clarify this notion of sectors. A lot of work must be done to make the health providers for teens more accessible and to eliminate those obstacles.

Another thing that troubles me somewhat is that adolescents are often given treatments that can upset them. When they go into a health centre, when they manage to get in, they are told: we will start with the assessment.

When a teenager takes steps to get treatment and he or she is made to understand that an assessment is different from the care required, an adolescent patient is somewhat wary. The answers given to the questions asked by the assessor may not be quite correct and the diagnosis may be inaccurate or incomplete.

Of course a period of observation is required. When an adolescent takes the first step, it is because he wants to get treatment. We expect an assessment and treatment. The patient does not make that distinction. He does not go to the clinic to be assessed, but to be treated.

One must be careful. Another obstacle I see regularly is what I would call the problem of incompetent stakeholders. I listed the various problems that have surfaced over the past 30 years. I can understand that it might be difficult to be an expert on everything, and it is perhaps even impossible to be an expert at all in this field.

The health care system is structured in such a way that the front-line workers must be skilled at everything. They cannot be competent in every field. It is extremely important to vastly improve their training. Of course there must immediately be more specialized services to deal with more complicated problems.

I think it is important to encourage the creation and reinforcement of centres of excellence, with the obligation to welcome patients — I was speaking about sectors earlier on — and to ease the transition from adolescence to adulthood.

If you know anything about adolescents, you know that they are very complicated. You want them to turn 18 as quickly as possible so that you can tell them they will be transferred to adult care.

There must be a structure to allow that transition. The adolescent medicine programs in pediatric hospitals are suffering from budget cuts just like all the others. When they have budget problems, they reduce the age. It will go from 19 to 18 and from 18 to 17, so the teenager will suffer the consequences.

The transition between adolescence and adulthood must be rethought. It is up to the centres of excellence to convert tertiary pathologies into primary pathologies by having greater expertise. By developing that expertise through clinical practice, observation and research, they are responsible for teaching and ensuring that those pathologies can be treated in the front-line centres.

There have been great success stories in treating teen sexuality problems. We should be able to see the same success with eating disorders.

The skill level of workers is important because in practice, there is always a sequence of events beyond their control. There is a first meeting somewhere. No one knows exactly what the illness is, but people feel obliged to do something, so medication is prescribed and the patient is referred to someone else.

I find myself more and more in a tertiary centre with patients who have been seen once or a maximum of twice at one clinic and who are already under medication. I wonder whether that is worthwhile.

Doctors should review their way of dealing with teenagers. They should not want to control them with medication.

I would say these are the negative effects of a primary intervention, if it does not succeed and if medication is prescribed too quickly. Inappropriate medication could cause greater problems and deterioration in the patient.

Adolescent medicine and adolescent psychiatry, even if they are not my fields, should be included in our health care system. There is an urgent need for help.

As for the role of the various stakeholders, I have the honour of chairing a committee of the Collège des médecins du Québec, that reviewed the model for sharing the activities among the various health care professionals. Much progress has been made in Quebec. The act and professional code were amended in June of last year. A report was tabled on the medical profession and the roles of the doctor in the health care system. The document exists, it is on the Web site of the Collège des médecins. An excellent analysis was done of what was called advanced practice and the sharing of responsibilities among the various stakeholders in the health sector.


The Chairman: I would like to ask Dr. Farquhar a two-part question. Why do you think it is that the U.S. has been more creative, more progressive, in dealing with metal health patients than we have? I ask the question because in our previous health care study, we concluded there was not a lot that we could learn from the U.S. system. After your comments, and having skimmed your paper, I am led me to the conclusion that maybe there is in mental health, and I am curious as to why that is the case.

Second — and you may want to think about this and send us a note — if you were asked to give a list of three to six places in Canada with best practices in mental health delivery, what would it include? As I say, you may want to think about that and let us know, and you may also want to do it off the record. I quite understand that, but would you mind responding at least to the first one?

Dr. Farquhar: Thanks for asking. I have visited two places in the United States where I had occasion to look at what they were doing and that is where I saw case management working very well. For example, I met one psychiatrist who was working half time in an Assertive Community Treatment team, and I asked, ``What do you do with the other half of the time?'' He said, ``Well, I have about 350 patients.'' I was astounded because the most I ever had working full time was 180. He said it was because of case management. That is why I mentioned it, because it is nothing new, but it is not applied.

If you ask why the United States are ahead of us, I think it is because they have been squeezed more and squeezed faster, for at least two reasons. One is mostly economic. They have been squeezed by the competition between the public and private sector, which I do not necessarily think is a good thing, and they have also been squeezed by legal constraints.

I went to Springfield, Massachusetts, where there was a lawsuit about 20 years ago that ended up obliging the mental health system to offer the least restrictive alternative in terms of housing to all patients, including severely retarded, regressed or aggressive patients.

I saw some people there who would be in the back wards of the Douglas Hospital. They were in the community, although the home they were in — they had their own rooms — looked like a back ward, and it cost about the same as a hospital.

I believe there have been some articles on the economic imperatives. Also, it is worth noting that across the United States, service to severely mentally ill people, which in Canada, I am told, consumes about 80 per cent of the provincial mental health budgets, is the responsibility of the public sector, whether the municipal or the state level, so it is very much the same as here. In addition, of course, there are private psychiatric hospitals that treat both severe and moderate mental illness.

The Chairman: Any comments on the best practices question?

Dr. Farquhar: I wish I knew. I am not that well travelled. I would have to say that in Toronto, at Saint Michael's Hospital, there is a psychiatrist whom I admire very much, Dr. Donald Wasylenki, who I think is in charge of outcome research and has been in charge of the deinstitutionalization effort in Ontario for the last 10 years or more. He has used research and innovation combined to achieve remarkable results, so they have many Assertive Community Treatment teams. That is not to say that that is so wonderful itself, but there are many other things that I admire.

Senator Keon: I will start with you, Dr. Israël, and go to Dr. Farquhar, and I want the panel to comment on what I would like to ferret out from you.

You referred to a problem that exists not only mental health, but in many areas of health, non-continuity of care. I am wondering what you think the root cause of that is. In the other health disciplines, my observations over the years would be that the hospital sector, although it only takes about a third of the system funding, is overwhelmingly powerful. They get a tremendous amount of attention compared to community services and other services. It seems there are ways to overcome that — for example, through regionalization, in which the various services are treated equally. I suppose the best example of that is in Edmonton, although quite frankly, a close look at their structure is a little worrisome too, because again, virtually all the resources are institutionally centred.

I would like you to talk about how we might overcome this as it relates to mental health. Then I will get Dr. Farquhar to talk a little more about a commissioner. In fact, we advocated a health commissioner and it would be interesting to know how this would fit with a commission for public health.

Dr. Israël: You started by asking me what I think is the reason for a lack of continuity in care, and for me the problem is a lack of communication. It is not so much how much power you give to each institution or organization, but whether they see themselves as working together toward common goals and creating a sense of purpose and mission.

In my presentation, obviously I could not give details on how some of these things could be implemented. However, as a specialist, I feel that right now, we are spending too much of our time doing a certain type of work that could be assumed by other people and not enough reaching out to help those on the front line. It would mean having time available to answer phone calls, to teach, and to sensitize others, our fellow doctors and our fellow workers. I do not mean the public. The public is a big challenge in itself.

I share some of Dr. Roy's interest in and commitment to teaching. I want to tell you a little story. Last year, I was teaching medical students. I do that every year, teaching psychopharmacology. And I was in the middle of discussing antidepressants, how to choose one, and a student raised his hand and asked, ``How come you are giving us so much detail? Do we really need this?'' We are also being threatened with a cut in the amount of time we have contact with people who are supposed to be responsible for the major part of mental health care.

We have to establish lines of communication and give people support. We have to teach people. That might help to narrow the gap between what is out there and what is in the institutions. It is changing the perception of the institution, from a place where you send people off to be locked up or to get rid of the unpleasantness, to a place that will reach out and help you to deal with your day-to-day practice.

Senator Keon: Can you speculate on what kind of organization would do that?

Dr. Israël: I talked about a mental health institute as a place whose purpose is to take care of people with severe mental illness, but also to teach and to study. For instance, our hospital, which specializes in psychiatric care and was once an asylum, has gone through the deinstitutionalization process and is surrounded by community organizations and primary care clinics with which we have no time to set up links. We have to create a network and we have to have a mandate to do so, which means we have to have time to do it instead of using scarce resources to take care of work that could be done elsewhere.

Senator Keon: Thank you very much. Dr. Farquhar, pursuing the same theme, you came out with some very interesting ideas, including a commissioner for mental health, making budgets public, addressing alternate health workers in a meaningful way, which Dr. Israël just referred to also, dealing with homelessness, and so forth.

When we were holding hearings on health care in general, before we began the special study on mental health, we were hearing these comments over and over again. However, what has to be addressed is what kind of structural framework could we put in place that would allow these things to happen? Before you answer, I want to tell you that I have long believed that we need the equivalent of a Surgeon General in Canada and our report said we need a commissioner. I think the SARS outbreak really brought this one home again.

How do you think a commission for mental health would fit within an overall commission and commissioner?

Dr. Farquhar: That is a good question. I love the idea of a commissioner for mental health, and for health also. Some people might argue that the deputy minister of health serves the same function, although I do not think that is true.

I have not thought that far. Mostly, I have been thinking in terms of a commissioner for mental health. Just having a person in that position and making everything public would make it very difficult to cut the mental health budgets, which are so vulnerable. When something like SARS comes up, a ministry of health might say, ``Well, we will just take some money from mental health because nobody will notice.'' Indeed, we have documented that at least 2,000 mental patients have become homeless in Quebec in the last five years. That is documented by a survey done by the government itself, and at the same time, something like 3,000 beds for mental health have been cut in the province. It is right there in black and white.

I am trying to say that whether at the provincial level or a regional level, like in the Montreal area, having a commissioner and perhaps helpers or links, or other similar structures, would protect budgets at the local level also. I am aware that in the Montreal area, for example, people want to get moving with some programs along the lines of what I was describing from the United States, but some say, ``Oh well, there is no money for that this year because of this other thing that is happening in the Montreal area.''

I do not have much more to say about that. However, I wanted to mention that I personally would like to see the computerized patient record happen as quickly as possible. In my work, I find that I spend a few hours a week just writing letters to other doctors, saying ``Here is the medication this person is taking,'' because the patient is not sufficiently well organized to know that himself.

If somebody has a psychiatric consultation and there could be some mechanism whereby the person can authorize another doctor or health professional to see the text of that, it might reduce a lot of waste in the system.

We have a few patients whom I follow who will go to a hospital emergency room from time to time, claim to be somebody else and say that they are on certain medications, which they are not. To me, it is more than an abuse; it is a danger to their lives. I hope I have addressed what you asked me to.

Senator Keon: Dr. Lalonde, would you try to build on what the other two speakers have said and speculate on what kind of organization could bring together the existing resources and, of course, provide the new resources that Dr. Roy was talking about? What kind of organization could bring together the resources that we have, plug the holes and create continuity?


Dr. Lalonde: I find it rather difficult to answer because I am more used to health care organization than to larger organizations. I would say more or less what Dr. Israël said. One of the main factors is communication among various interveners and mutual respect among them.

As specialists, I do not think that we should stand up like people who know everything and who will show others how to proceed. This must go both ways. Everyone is a bit jealous of his turf.

In our Quebec system, which is the one I know best, there are all kinds of organizations defending their turf, their types of interventions, and they are not very inclined to communicate with the others.

How can we bring these people to communicate among themselves? This must be done on both sides. Skills must be put to good use. Of course, psychiatrists have done all kinds of things, including tasks that could be delegated, but as there is no one else to do them, they have to do them. There is a shortage of psychiatrists. I would not want to have too many psychiatrists, but there is a severe shortage of other interveners.

Earlier, I mentioned the 1st and 2nd lines and the people on the teams with which I work. I would be able to treat more youths in the initial stages of schizophrenia if I had a larger team for rehabilitation. Rehabilitation takes more time than evaluation, instruction and the prescription of drugs. This kind of collaboration needs to be set up.

Let me conclude on this point: attitudes must change before collaboration can come about, because it is relatively easy to deal with concepts. It is more difficult to learn to change our attitudes.


Senator Keon: Dr. Leclerc, you were emphasizing the tremendous waste that occurs in the system because people do not go back to work, because we are not investing in trying to get people back to work and do not have the facility to get them back to work. Again, it seems to me that this is because of a lack of overall organization, and some of these things should be addressed early on. You should have resources at your disposal whereby perhaps government could even pay somebody to work in an organization just so they are working. There are philanthropic organizations in America that do that.

Would you comment on what you think the bigger system could do?


Mr. Leclerc: I do not think that it is solely up to the State to help persons go back to work. I think that this should be done collectively. Earlier, I said that the first reaction of employers, when dealing with employees with mental health problems was to say: let us get rid of him.

Nonetheless, these people have useful expertise more often than not, and we are depriving our community of that wealth.

Unions, which should normally come to the defence of employees, often have a very hard time with the mentally ill. I think that in order to avoid waste, we should endeavour to support these organizations by informing them and raising their awareness with regard to mental illness.

There is another aspect: if the insurance companies, which invest vast sums of money, would take a preventive approach rather than an approach based on employment termination, I think that community funds could be put to better use in order to help persons with mental health problems.

We should not think that everyone is able to hold down a job or that everyone is able to go back to work; we must be realistic. If we do not intervene early on, it costs a fortune to all concerned. There is a drastic impact, more often than not they are reduced to dependency, which is quite the opposite of what we seek.

We must ensure that our people resume their role in society. And what does resuming one's role in society mean? First, it means a place of work, and a job description, and so forth. One should not depend on a welfare check to pay the bills at the end of the month.

I think that the State does have a role to play in this, but the population and the private sector also have a role to play in all these things.


Senator Keon: I agree. Thank you.

Now, Dr. Roy, you are addressing the tremendously important issue of the manpower shortage. I was an educator for a long time, and in retrospect, I think I did it wrongly because I did not look at people around me. I was too focused on training the perfect heart surgeon. I think what is needed in specialty training is not only the training of the specialist, but also training that specialist to interface with the whole army of health professionals out there. What kind of system would allow you to approach that?

Dr. Roy: Well, I suppose it is a matter of survival. We cannot train our residents in psychiatry to work on their own. They have to work as a part of an interdisciplinary team. We are not talking anymore about multidisciplinary teams, but interdisciplinary, where everybody is an expert on something. We could also put forward models of psychiatrists who work comfortably with teams, but also are able to manage a patient through members of the team, meaning that one team member would be the primary care staff person for that patient. That could be very useful.

What else could we do? There is also shared care. I presume you have heard about that in previous meetings. We do not teach this enough because we do not have that many teachers who are practising shared care. For instance, at the Université de Montréal we have 225 professors, and only one or two would be comfortable teaching shared care. Shared care requires good family doctors trained in working on the other side of that shared care. These days, it is very complicated. I do not know if it is the same in other places as in Montreal — Toronto must have the same problem — where people cannot find a family doctor.

Someone who called a clinic in Montreal yesterday was told, ``We are not taking new cases any more.'' If you want to have shared care, you need somebody on the other side of things.

Senator Keon: It is a big problem everywhere. Thank you very much.


Senator Morin: Let me put a single question to the entire group, on the very important matter just raised by Senator Keon, namely the issue of primary care, which seems important to me.

What struck me in what you said is that this is really the only specialized field where specialists spend so much time in following up their patients. In all other specialties, there is a consultation, the patient is referred to his primary care physician, and that is all. I think that this might not be the most efficient way to use resources.

I know that this issue was already raised, but I would like to know what your group thinks about this matter. Incidentally, Doctor Roy, if you were at Laval, you would have been made a research associate long ago. I do not understand this, given all the responsibilities you have for residency training in psychiatry, as the Canadian president. I think I should write a letter to your dean, because this is not normal!

Seriously — of course I mean this as a joke — is there a problem with the skills of family doctors, are family doctors uninterested in psychiatric matters? Are they apprehensive about that kind of patient?

I think that there is a problem. And I would like to investigate this. If psychiatrists could be relieved of a large part of the follow-up work on their patients — and I do not mean in psychoanalysis, I understand that psychoanalysis is a different issue — psychiatrists would be free to do other things to improve conditions.

I would also like to deal with the way primary care is given. For instance, it was interesting to note that Dr. Lalonde, in his brief, made no reference to the current new model for primary care that was recommended in our report, as well as in the Romanow report and the Clair report — it was recommended everywhere — that is, the new multidisciplinary teams for primary care, which are now being set up here in Quebec, in Ontario, in British Columbia and nearly everywhere, and in which all governments have made substantial investments.

It is interesting to note that your primary care includes all kinds of things: there are CLSCs, private clinics and community resources. But we do not hear much about these new multidisciplinary teams which, in my opinion, are at the very basis of health care reform in Canada.

Could not psychiatry and the treatment of mental patients be included in this care, for the follow-up as well as rehabilitation and so forth? Is this necessary for Primary Assertive Community Treatment, or PACT? Could this work not be done by primary care teams such as the ones currently being set up with much difficulty, as you know, across the land, and which are facing all kinds of resistance?

And, moreover, if community care could be included in this for mental patients, it would be another step forward.

Dr. Lalonde: In fact, I did not mention the primary care teams, because in Quebec, to some extent, they are replaced by what we call CLSCs. But I do not know exactly what you mean by primary care teams.

Senator Morin: They are currently being set up. There are about 20 of them.

Dr. Lalonde: In Quebec, we have what are called groups of family doctors, family medicine groups, and I know that an investigation was carried out in Montreal. It did not cover all of Quebec, but there was an investigation in Montreal, asking general practitioners whether family physician groups had any importance for them.

About 5 per cent of them said that they were very important. Thus, in fact, there is either lack of knowledge, a lack of interest, or a lack of open-mindedness among the doctors with regard to this.

Perhaps the physicians working in Montreal — research was done on the age of these physicians — are older and do not want to change their current practice. Perhaps younger doctors will have to go through a renewal process in order to open up to multidisciplinary work, as Dr. Roy said.

Let me come back to what Dr. Wilkins said. Primary care work opens the doors to many more people, but training is also needed.

Primary care work cannot be done at random. It takes a certain amount of training, of education, as well as the ability to intervene while knowing when one must refer to a higher level to meet the needs of patients.

At the Louis-H. Lafontaine Hospital where we work, we have an equivalent to what Dr. Farquhar called PACTs, or ACTs; we call them SIMs: suivi intensif dans le milieu (intensive follow-up in the community). For nearly two years, I have been working together with people who do intensive follow-up work in the community.

I have two comments about this matter. Most of the SIM teams, work with 10 to 12 patients. This can be convenient when they make 2, 3 or 4 visits a week. Often, they are deterred by the fact that no more than 12 patients can be admitted, but nonetheless, they only make one visit every two weeks.

We should be looking at the number of visits rather than at the number of patients. Secondly, training is also involved; these people have plenty of good will, but they intervene according to the level of their training. You can rest assured that when dealing with schizophrenic patients like the ones I treat, it takes something more than just good will.


Dr. Roy: To go back to your first question, I think that there is reluctance from the psychiatrists' point of view and also from the general practitioners' point of view. For these reasons, we do much more first-line work than we should.

There is a tradition in our system whereby we work mainly through the relationships we have built with the patients over the years, so it is difficult in our line of work to see someone for the first time for a few minutes. In one pattern of practice, a psychiatrist meets with the patients two or three times and then they go back to the primary caregiver. Then at the other end of the spectrum, you have somebody who can take only one new case every two or three months because his caseload is too heavy.

We need to think about levels of care. At one end, you have a quick consultation, you have patients that stay on your caseload forever, and you have patients whom you would see, let's say, every six months and the rest of the time the family doctor will see them on a regular basis and call you once in a while to say that someone is getting worse. ``What should we do?''

There is a tradition among some psychiatrists of working mainly with the same patients and the same caseload all the time, because that is how they were taught to do things. Also, they feel that the special relationship they have with their patients is something that they need to build on, and it is quite easy for them, when they see their patients getting sick again, to figure out what to do very quickly, because they have seen the patient acutely ill four or five times before. That is one important reason.

On the other hand, for the family doctors, there are certainly problems related to their training. There is also a major obstacle related to funding, how they are paid by the health care system. You can deal much faster with a patient with a physical illness than one with a mental health problem. You would have to spend perhaps half an hour or an hour on the same patient.


Senator Morin: I understand your explanations as well as those of Dr. Lalonde. But having specialists give primary care is certainly not a good way to use resources. I understand all the reasons, either they are not qualified, or they are not willing, because they lose money, and so on and so forth.

Nonetheless, we should at least try to have primary care given by primary care physicians so that 3rd line care is administered by 3rd line physicians. But this does not seem to meet with your approval, you seem to prefer the status quo.

Dr. Roy: Oh no, we are not defending the status quo. Obviously, we need different levels of care and we need to work together. And it is a very interesting challenge to work on the 3rd line, and when I work at Pinel, I should say that I am working on the 4th line: the people who come to consult me are psychiatrists. Of course, when people come to see me as a last resort, they have very complicated questions. In such cases, I figure that four or five others have already had problems with the patient now sitting before me.

I have to investigate much more deeply. I think that we will have to adapt the system so as to do this work as efficiently as possible.

Mr. Leclerc: For the past three years, the Louis-H. Lafontaine hospital has endeavoured to transfer patients to general practitioners in the community. I was looking for 350 persons who would be ready to be cared for by a general practitioner. It was impossible to find them, although I consulted universities, private clinics and CLSCs.

In terms of front-line services to accommodate patients — in Quebec it is the CLSC — there is absolutely no accessibility here. It is clear that patients are not eligible for CLSC services. This is a second problem.

Third, in Montreal, there are plans to develop clusters of family doctors. Last week, it was confirmed that there will only be three of these, and in the east there will be none at all.


Dr. Farquhar: If I may speak, Senator Morin, I agree with your thinking that we can get more for our money, and the way to do that is by case management.

You would not tell somebody who has trained as a hospital administrator to go and clean the bathrooms for 10 years. That would be crazy. It is the same with utilization of doctors and psychiatrists. We do not need an M.D. or a psychiatrist to do psychotherapy for a depressed person. If you have a B.A. in psychology, some on-the-job training and some other types of quality assurance, and you are in a team supervised by a doctor, one doctor will seem to produce an enormous amount of work. Just as we are seeing in the United States an explosion in this category of worker called the ``case manager,'' who is not necessarily highly trained at the beginning.

If, in Quebec, we suddenly got back that $130 million for mental health, how would we spend it? I would suggest spending it mostly for new case managers, and some on new secretaries, because there are a lot of psychiatrists who, after a consultation, write as if they were in the 19th century.

The Chairman: Are you serious?

Dr. Farquhar: I am afraid so.

The Chairman: On top of that, nobody can read the writing.

Dr. Farquhar: That is right, so then a secretary might retype the report.

I am on a committee at my hospital looking at that and we found that we do not have enough capacity for dictation and transcription, which is why people do not use it and write as if they were in the 1850s. Thanks for listening.

The Chairman: I have to tell you that the members of this committee are learning interesting facts about the mental health system that border on the kinds of things we use to read in ``Ripley's Believe It or Not.''

Dr. Israël: Dr. Farquhar is using the term ``case manager,'' but I would like to return to the idea I presented about the mental health workers. Going back to what Senator Morin was saying, is the principle of creating interdisciplinary teams within the first line, so that the family physicians do not have to learn to be psychiatrists, but are assisted by people who have the training to deal with mental health problems on the front line. You have to make a distinction between the severe and the persistent problems, which are a small percentage that require specialized services. Maybe one day in the distant future, when the front-line people feel more comfortable with our patients, they can take them when they are stable. However, what about the large proportion of patients who present with acute transient problems, with depressions that can be treated in a few months? Think of coupling a G.P. with a mental health worker who can also do an evaluation and provide the therapy, or the G.P. just prescribing the medication. I think this would be a good way of using our health care dollars.

Dr. Kates from McMaster University published a paper last year in the Canadian journal in which he demonstrated that introducing counsellors into primary care did help patients do better. They did better not just in terms of health problems that were identified as such, but in terms of other problems that impact on the physical health of our citizens and which are not being addressed because people pursue the medical model and prefer to ignore the other dimension.

The Chairman: Dr. Israël, when you say a ``counsellor,'' what do you mean? A psychologist, social worker or whatever?

Dr. Israël: It could even be someone with a technical degree. For instance, in Quebec we have ``techniciens en travail social.'' They study for three years after high school.

The Chairman: At a CEGEP, typically?

Dr. Israël: Yes. There has to be some kind of supervised clinical experience, and so on.

Senator Cordy: Thank you to all of you for taking the time today, because I know you are all busy, just from the things that you have stated.

Staying with Senator Morin's line of questioning, Dr. Israël, you talked about the ``silos,'' and on our very first day of hearings we heard from a lady who has bipolar disorder about the number of times that she had to retell her story. Every time she saw somebody new, she had to retell the story. She talked about the difficulties that that created for her with her illness, just having to keep reliving it. We talked earlier about lack of communication. We have talked about electronic patient records, which would help in passing along information, and about case management, primary health care teams and counsellors, which we just mentioned.

What we have now is fee for service. Doctors get paid because they see the patients. These things do not really fit into that model because, as Dr. Roy said earlier, you can spend at least an hour talking with people, particularly the first time, just to get their story and find how best to meet their needs.

Is there a first step, or do we all of these things that we have talked about this afternoon at the same time? Where do we start?

Dr. Israël: We have been talking a lot in Quebec about ``les réseaux de services intégrés.'' These are networks that integrate several organizations and services around the patient. Within that network, there has to be a person named as the primary case manager or the patient's primary therapist.

You mentioned a lady who had to keep telling her story because she did not have someone assigned to her as her advocate, who would coordinate her treatment, who would reach out to other organizations. I think this is a way to start. People with severe and persistent disorders have a right to have such a person assigned to them. It may well be that our institutions that specialize in mental health services can be responsible for providing that care, but there has to be communication among the organizations and from one system to another.

I wanted to tell a little story about last year. Our régie régionale threatened to close down the Salvation Army mental health shelter. This is an 80-bed institution that was viewed as too much like an asylum. They had asked for more money because the Salvation Army is a non-profit organization that works through donations, and given that all the anglophone donors fled our province way back when, they were running short. They were asking for money because they were providing a service and they were threatened with closure. We all got together as a network to advocate that it remain open. The government was still refusing to give the money, but then we asked for time to try to help them get organized. They agreed to give money for one year on the condition that I, because it is part of my sector, our hospital, would get involved in making them accountable to the system in some way.

We put a committee together and we had people from local clinics and several community organizations coming forward to talk to these people, who were astounded by the support they got. This has encouraged communication to the point that they are going to develop a board including community people, because the Salvation Army wants to be part of our community and of a system that coordinates the delivery of mental health care.

Now when they call us, we know who they are. When we call them, they know who we are. We need joint projects where can learn to work together.

Dr. Farquhar: Where do we start? Something is happening in some places and not in others, and that is the application of enlightened business principles that have been around for the last 10 years. That includes setting goals and priorities, using quality assurance, and some other principles that go along with those things, and it is happening at our hospital. I am very happy about that, but it is not happening everywhere, and I am not sure that it is happening at the ministry level. They tried, but they do not have enough money.

Senator Cordy: Just a quick question, Dr. Leclerc. You talked about needs in housing, in work, in family. I am quite interested in family, because if you look at the patients who do well, they are generally those who have strong support from their families. However, very often, the families do not feel that they are getting support from the system or from the community in dealing with a family member who is mentally ill. How do you help families? Earlier this morning, we talked about families getting a break from caring for an individual, which might make them more inclined to keep that individual at home.

Even families that do not necessarily have the child living with them but try to work within the system are rebuked, almost.


Mr. Leclerc: I was saying earlier that in terms of families — this problem does of course exist also for adults residing with their parents or relatives — it is important that these families be able to take the time occasionally to recharge their batteries, get a change of scene and go out. The only way they can do this is to provide tailor-made services geared to providing caregivers with a break. There are some in existence already, but very few. Very few tailor-made care services for mentally-ill patients exist. Money needs to be made available to support the family fabric and to promote communication between professionals and families. Often, and it must be said, mentally-ill patients are looked after but their families are forgotten.

It is important to maintain harmony between families, professionals and the users of services, in order that patients may continue to live in their natural environment.

However, more often than not, families find themselves totally devoid of support and often give up. People who find themselves in a difficult situation, and constantly facing major problems, give up in the end. The initial reaction is to hospitalize the patient. These patients are often hospitalized, and in many cases for long periods.

This type of situation is extremely harmful for people in terms of social rehabilitation. Therefore, it is very important to provide money for specialized mental health care organizations, be they geared to young people or to adults.


Senator Cordy: I know this started in Nova Scotia a number of years ago with seniors who were living with their children and it was called almost a ``daycare'' for seniors. The same type of program would seem to be something that could work.


Senator Pépin: Doctor Wilkins, you said earlier that you now deal with teenagers suffering from eating disorders, such as bulimia or anorexia.

It is also possible that these patients have other undiagnosed illnesses. For example, they may be suffering from specific heart diseases or other types of ailments. One seems to hear a lot more about autism or schizophrenia than anorexia or bulimia.

If these patients are not given proper treatment, do you think that it is possible that they might end up attempting to commit suicide? I read somewhere that the hospitalization rates for young women, aged between 15 and 24 years old, suffering from these types of ailments, has significantly increased. Has the fact that more young adult women suffer from these disorders always been known or was it something that has only recently been discovered? Indeed, are more women currently suffering from these types of disorders?

Dr. Wilkins: Eating disorders are significantly more common in the west. People involved in teenage medicine have always been inundated with patients with eating disorders, especially restrictive mental anorexia and nervous bulimia.

I do not include obesity. Scientifically speaking, the jury is out on this issue, but in my personal opinion, there is no link. However, this is quite debatable.

We deal with teenagers with eating disorders. This type of illness continues, on average, for approximately four years, from the time the first symptoms occur until menstruation returns, for example. Restrictive mental anorexia will last about four years.

I would just like to mention in passing here that not all approaches work well for eating-disorder patients. You have to be very careful in using American models for patients such as these. I am not really in favour of what has been said on this issue. However, that is all I will say on that for the moment.

The older eating disorder patients get, the more likely you are to find, in addition to the anorexia, other types of ailments. This is what we call comorbidity. Patients might suffer from mood problems, depression, personality disorders, or more serious psychological illnesses.

Sometimes, patients have an element of all these problems and it can take some time to sort that person out. Normally, patients do recover. The majority of teenage medicine physicians estimate that approximately 70 per cent of their patients solve their problems during their teenage years. However, 30 per cent of patients will develop some form of chronic disease.

These patients are treated at the Douglas Hospital in Montreal under the very effective agreement that we have with this hospital. Obviously, this hospital deals with patients who probably have more complex disorders than the ones that we tend to deal with in our facility.

We have to turn to hospitals because there is no other choice. If there were alternative facilities, we might be able to avoid having to hospitalize these patients in hospital facilities, which cost between $800 and $900 a day.

We send patients to hospitals because that is what we have available to us. We need alternative facilities providing more comprehensive, wide-ranging and tailor-made programs. However, we are facing an ever-increasing number of patients and resources have failed to keep pace with this increase. The same situation is occurring almost everywhere in the world, not just here in Quebec.

Senator Morin: To follow on from Senator Pépin's question, has this actually increased?

Dr. Wilkins: Yes, we have seen an increase. And as you mentioned it is difficult to send these patients back to primary care because they are complex cases and their conditions are time-consuming. People in primary care tell us that they do not have the know-how and that they do not have the necessary skills to deal with these patients.

Senator Morin: How many specialists like you are there in Quebec?

Dr. Wilkins: There are very few specialists in teenage medicine. In fact, I was the very first specialist in this area.

Senator Morin: Would you put it at four or five?

Dr. Wilkins: Let us say about ten of us.

Senator Morin: Therefore you are not in a position to treat everyone with nervous anorexia in Quebec. Who treats these people, therefore?

Dr. Wilkins: Indeed. These patients are sent to us from all over the country. We have a small cluster of specialists in Quebec city. In Montreal, we are quite lucky because we have several clusters of physicians. However, this is a problem throughout the province and indeed throughout the country.

Requests are coming in from all over the world, including the United States, because treatment for mental anorexia in the United States costs a fortune. Recently, a parent published a book about his daughter entitled: One Million and a Half After. She eventually passed away after several years of treatment.

Indeed, treatment for eating disorders is very expensive. We are lucky here in Canada and in the Province of Quebec. However, in my opinion, we need to undertake a reorganization of the way we provide care. We need to provide training. There is a role for all stakeholders. Ordinary people can do a lot with these sick little girls, if they have some training on what to do, and then they can turn to us if things get really bad.

We have set out hospitalization criteria in teenage medicine. For example, a heartbeat below fifty is a grave problem. In cases of restrictive anorexia, the cause of death is usually a heart attack.

Yesterday, I visited a little girl in Victoriaville who had been unable to get hospital treatment in Victoriaville. I intend to bring her to our facility for a few weeks and then to send her back to Victoriaville.

There are procedures like these ones that work quite well. However, we find it very difficult to send these patients back to CLSCs or to other facilities.

Senator Pépin: That was my next question, in fact. You said that you have a good partnership with the Douglas Hospital, but what happens to other patients and other teenagers? Apparently, once these patients reach 18 years of age they are no longer admitted to this hospital because they are considered adults.

Mr. Wilkins: It is we here in Montreal who see the most patients. For myself, if I see a young 16- or 17-year-old girl, and my intuition tells me that treatment will be long and complicated, then I get in touch with the Douglas to organize a transfer as soon as she reaches the age of 17.

That is how they received a young seventeen-and-a-half-year- old girl not long ago. We arrange the transfers because we see them coming. We can predict when they will be necessary, and we make arrangements.

Senator Pépin: What happens with other cases, cases that are neither anorexia nor bulimia?

Mr. Leclerc: Clients referred to us from youth centres are more often than not either just 18 or just about to turn 18. They come to us at the last minute.

With some resources, access to in-house treatment can take a year, a year and a half or two years. That is the first problem. The second problem is that the link between the child psychiatry system and the adult psychiatry system is not always made.

Third, if someone is receiving in-house child psychiatry treatment, the system keeps its accommodation budget and something has to be found immediately when the child becomes an adult.

These are all complex problems. At present, we are discussing them with the Montreal Health and Social Services Board.

Dr. Roy: I would add that there are care models where people are under care from birth to death. In addition, there is a Canadian task force now considering the future of psychiatric education here in Canada.

We also wonder whether we should not focus on a trans-generational model, or on what is known as a sophisticated generalist. The sophisticated generalist could provide child psychiatry services where highly specialized care is not required, and, for example, provide geriatric psychiatric services as well.

This is the sort of system that the smaller centres and the regions have. Psychiatric personnel provide care for everyone, in all age groups. The same barriers we find in larger centres do not exist. In the larger centres, there are specialized units for adults, teenagers and children.

Senator Pépin: We hear that funding for psychiatry is being cut. Who is making those cuts? Are officials making those cuts? I cannot believe that doctors would make these decisions.

Dr. Fraquhar: No, these decisions are being made not by doctors, but by officials. Officials are fine as individuals, but as a group, they are responsible for the cuts as I am and others are.

Senator Pépin: I quite agree.


Senator Robertson: I have been trying to listen carefully, but it is a little confusing, shall we say. Dr. Israël, I missed your presentation, as I was a little late getting here.

You touched upon something that I found interesting. You told your little story about the Salvation Army, and I do not know the details of the Quebec system, but I believe, for instance, that you represent three hospitals here?

Dr. Israël: Four hospitals.

Senator Robertson: Four hospitals here. Each one receives its funding direct from the provincial government?

Dr. Israël: We have a regional board in Montreal.

Senator Robertson: Yes.

Dr. Israël: An intermediary between the minister and the different institutions.

Senator Robertson: And does that regional board, that umbrella organization, more or less, deal with the funding for the primary and secondary care institutions in the city? Everything?

Dr. Israël: Everything.

Senator Robertson: Even with that, there were people in the hospitals that should not have been there, as I believe Dr. Farquhar suggested. I think I heard you say something like that.

Dr. Farquhar: They would not have to be there if there were other resources at their disposal.

Senator Robertson: What you are saying is that the trend, as we all know, is to put the services, especially the primary and secondary services, in the home, the workplace or the school — somewhere in the community. Get them out of the hospital, which can be the most expensive place to treat patients.

Perhaps we will have to look at insisting on the development of these issues in our new delivery system. It has been done in some areas and is working very well. I am surprised, because I thought you would have all those community support systems available to you here in Montreal. If you cannot get along, if you cannot get information, or you are having difficulty in transferring patients, are you all doing the same thing in each hospital or what is happening in the community? What is the pressure to develop your community support systems so that all these patients do not have to lie around in the hospital? Money is scarce, and taxpayers are becoming more alerted to the value of their tax dollars, so we cannot afford to be wasteful.

Have any of you been involved with that umbrella group in trying to push for the development of local services?

Dr. Israël: I would say it is weekly for some of us. In fact, we work together on committees to try to heighten the awareness of our régie régionale of the problems that we have to deal with and how services have to be coordinated.

When we talk about the city, Louis-Hippolyte LaFontaine Hospital is at the other end of the island from the Douglas Hospital, so it makes sense to put services in more than one community. The problem, which Dr. Farquhar alluded to in his presentation, is that a lot of patients were released from hospitals but the funds did not follow them. The community resources were not developed in a systematized way, but rather arose helter-skelter in response to the needs of people who were basically on the streets, causing problems that landed them in Dr. Roy's hospital, for instance, which is the legal psychiatric institution.

There has not been a concerted plan to develop the resources to meet the needs of these people who were once very dependent on institutions and who do not know how to live on their own, as Mr. Leclerc very clearly spelled out for us. That is why we have situations where a shelter that has been actually taking care of some of our sickest patients is suddenly threatened with closure, because nobody knew how important it was to our system, and how much it deserved to be supported.

Senator Robertson: You are working at a distinct disadvantage, I should think, in some of these areas.

I just wanted to ask you, is there another industrialized country that has systems that you wish you had, or do you feel that the systems in Canada are the best that you can find internationally? It would be helpful to the committee to know if there are models that you particularly admire.


Dr. Wilkins: I believe that we have a very good health system which makes health care accessible to everyone. However, some existing structures should be reviewed. Those reviews are perhaps not as quick or as frequent as we would like.

I worked in the United States for a while, and I do not envy their system at all. We have an excellent system in this country. I might import some aspects of health care systems in European countries which I believe work well. However, I am still very satisfied with the system we have here. We need to reconfigure it and restructure it, however. Today, we have a funding problem. There are also very complex situations that cannot be dealt with easily.

In Canada, we have an excellent health care system of which we should be proud. But we do need to revamp it and dust it off a bit. That is my view.

Mr. Leclerc: I would like to come back to your first question. We have put a lot of work into assessing practices at the Douglas Hospital, the Lafontaine Hospital, the Pinel institute, and at the Robert-Giffard Hospital in Quebec City.

Let us take Lafontaine as an example., since that is the centre I know best. We have gone from 6,300 people to 545, or 550. The number is still dropping. However, we have established an out-patient network. Insofar as we can, ensuring that patients can live and be cared for in their usual environment is better. For cases where this cannot be done, we have established an over-developed network in partnership with private organizations, community organizations, and even with hospital expertise transferred to the outside.

We hear a great deal of negative criticism about our health care system, though I think Quebec's is very good. There are areas where it should be improved, however. A few moments ago, Dr. Israël was talking about the link with the community. There is a huge gap between the funding invested in community care and the funding invested in health care institutions.

This will undoubtedly improve in the future. With health care access developed at the front-line level, and with greater cohesion among family practitioners, psychiatrists and teams of health care professionals, the system will become even more effective.

I have had the opportunity to work with a number of other countries, and I think that psychiatry and rehabilitation practices in Canada are the envy of many other countries.

Dr. Lalonde: I would just like to say a few words on care for schizophrenics. Fifteen years ago, Quebec opened the very first clinical facility offering a full range of care for early schizophrenia. The care was available in English, but not in French.

Since then, we have developed remarkable excellence and expertise. The future of young people with early signs of schizophrenia who had access to the clinic has been very different from what it would have been if they had not had access to the clinic.

We have quality of care. The problem is accessibility. You were just saying that, Dr. Morin. We cannot treat all young schizophrenics in Quebec. So we have to export, to diffuse the expertise and we are still wondering how that approach will be applied in other fields.

We could undoubtedly increase the care provided at the clinic, at Lafontaine Hospital, by boosting rehabilitation resources — not the number of psychiatrists but rather the number of staff dealing with social rehabilitation. We would also need more people to deal with patient transfers and to establish ties with the community.


Dr. Farquhar: Although I do not admire its general health system, I do admire the U.S.'s mental health system, which for the most part is free to the user, for various reasons.

I should say that I have a Web site about Assertive Community Treatment in English and French. The French portion has been visited by dozens of people from Europe, and they give me feedback, saying, ``Give us more information.'' They are from France, Switzerland, Belgium, other French-speaking countries, and they do not have that system. They do have something like it in Italy and England, but it is not as widespread or systematic.

I just want to stress again the quality assurance component. In some places in the United States there is a lot of Assertive Community Treatment, that is, the home visiting approach in teams. Those teams are accredited every two years, or something like that. The funding comes from various sources and is more complex than here, so they have to pass tests and jump through hoops to get that funding.

The Chairman: Last comment, Dr. Roy.


Dr. Roy: I also cannot think of a reference country that has an ideal model, but I do think we should be optimistic, as Dr. Wilkins said, because we are going in the right direction. There are still significant financial barriers, however.

There are also other barriers, with which we were less familiar some years ago. In its wisdom, the Royal College has done a great deal of work on the new roles of specialist physicians in the new millennium.

Nobody ever used to talk about the role of manager. People who had management tasks in medicine learned on the job. They did not have MBAs and had never done any training in administration. They would come in with very good intentions, then either make dreadful mistakes and fail, or succeed because they had charisma and other wonderful qualities.

But if we want people to have real value for money, we have to be able to show accountability, to prove that what we have done is efficient. This means that we have to be able to assess the services we deliver. At present, we are moving towards an increasingly efficient system.


The Chairman: May I thank all of you for coming. I realize that we took more of your time than we meant to, but it was a very good discussion. Senators, we are adjourned for 12 minutes till exactly 4:00 p.m. and then we will hear from our last panel.

The committee suspended.

Upon resuming.

The Chairman: Thank you for coming. All are from the Douglas Hospital. I noticed that a number of you were here when we were questioning the other witnesses. I would like to have a very brief opening statement from you in the order that you have collectively decided and then we will turn to questions.

Mr. Jacques Hendlisz, Director General, Douglas Hospital: Thank you for having us. We rarely get an opportunity to speak about issues which truly trouble us in not only our everyday working lives, but also in how we are trying to influence and change the system for the better.

As an administrator, I will refrain from talking about clinical issues, but there are four points that I wanted to bring up. The first has to do with the organization of health care, at least in Quebec, and I am sure in many other provinces, and what I think is an inappropriate paradigm for the understanding of mental health and mental illness and the financing consequences that result.

Ministries of health and social services were blended a number of years ago, and mental health has always remained a domain of the social services. Given that we live in a world where genetics and the genome are the order of the day, I feel that the paradigm for understanding mental health and mental illness issues, and the funding results thereof, is totally inappropriate.

Second, there should be a role for psychiatric hospitals as opposed to departments of psychiatry in general hospitals. Psychiatric hospitals should be clinical teaching and research institutes where advancements in learning can be made, which is very difficult to do in a large general hospital with a department of psychiatry, as it tends to get squeezed both in the funding and in the hierarchy. Psychiatric hospitals should have a specific role in which they are a reservoir of expertise on various mental illnesses. The reflex right now is to say, ``Well, send them to the hospitals if they are ill.'' That is also an inappropriate paradigm.

The third point is that there must be reorganization so that the first-line services can be properly integrated with second- and third-line services, since we have deinstitutionalized clients. Clients are treated more and more in the community and that is very important.

Having said that, it does not mean that everyone who works in the communities should be non-hospital based. The decision as to who treats what should be knowledge based, but many things can be treated outside of a hospital. We must reorganize those first-line services to achieve this appropriate integration of needed services, so that patients flow back and forth, which right now does not happen.

Fourthly is that in my opinion, the stigma of mental illness or mental breakdown, whatever we want to call it, is probably the greatest barrier to seeking and receiving care. I am sure everyone in this room is aware of somebody who has a child or parent who suddenly has a psychotic episode, and there is absolutely no natural reflex to make an appointment with the general practitioner. The first thing we do is look for a psychiatrist, and that has to do a lot with the stigma.

Nor do people who have suffered a mental illness — and I am not talking about things like schizophrenia, where it is a difficult road back, but more about mental breakdown — go back to work and say, ``Hey, I am glad to come back as a chief financial officer now.'' We do not talk that way, and yet people are capable.

It is a major barrier, and if we really want to address the issue of people seeking care, we have to address the issue of stigma.

The Chairman: Thank you. Next we have Robyne Kershaw-Bellemare, the Director of Nursing Services. I should tell you before you begin, just for fun, that Senator Pépin was a long-time nurse in Montreal, and indeed my wife was trained as a nurse at the Montreal General, so you have a lot of sympathy as you make your opening comments.

Ms. Robyne Kershaw-Bellemare, Director of Nursing Services, Douglas Hospital: I am always one for sympathy, especially when it is directed at me. Thank you very much for inviting me. I would like to give some context to my remarks. I have only been at the Douglas Hospital for three years this July. I have 30 years of experience in health care in various sectors, including general medical-surgical and community, as well as hospitals in the anglophone and the francophone sectors in Montreal. Therefore, I am looking at things from a little broader perspective.

I am Director of Nursing and Co-Director of Clinical Services with Dr. Israël. In light of my eclectic background, I think that my personal opinions are quite representative of what my colleagues in the health care sector are feeling, especially with regard to psychiatry.

I would like to step away from the clinical perspective because I know you dealt with it prior to our arrival and will be dealing with it again. I would like to talk about some systems issues, because I feel that the problem is not just one of insufficient resources. I think we are not using the resources we have as well as we could.

Good mental health sits at the heart of self-esteem, self-efficacy and self-fulfilment. As such, it is a generator of one's inherent potential to contribute to society. If one applies a wellness paradigm to mental health, one notes that at the extreme end of the continuum are a range of mental illnesses that occur across all age groups, all cultural groups, all societal groups, and from which none of us is completely sure of being protected.

Mental illness is closely associated with other, concurrent phenomena. The stigma that Mr. Hendlisz just referred to is first and foremost, but one could also mention substance abuse issues, homelessness and the general social isolation that people with mental illnesses and their families have to contend with on a daily basis.

People with mental illnesses are too often victims of violent crimes and their families struggle with the social and financial issues related to coping with the illness. Both are confronted with difficulties in access to timely, pertinent and continuous services — services that are delivered as close as possible to where the individuals and their families live, to the place that they call home.

I believe that Senator Robertson mentioned previously that hospitals are very expensive places in which to treat patients. Indeed they are. They are not only expensive, they are places where we foster ``patienthood'' and not personhood, and people with mental illnesses are people before they are patients.

I read your introductory document that was sent to us and I concur with the importance of the proposed national action plan. Given the wide representation on this panel, I would like to talk about some issues more specific to nursing practice and development.

In echo of the Romanow and Clair commissions, as well as the recent Quebec Hospital Association position on health care, I consider that the three major difficulties with which we are confronted have to do with accessibility, human resources and stable, long-term funding.

What about accessibility? As I said, to my mind, it is predominantly a function of how we use what we have today. The only things you can do about tomorrow are plan for it and invest in it. Obviously, we need to improve accessibility to a variety of front-line and specialized mental health services. We know from the literature and our own practice that early intervention, crisis and suicide intervention, first-line mental health services for children and adolescents, mental health initiatives for the elderly, both at home and in establishments, initiatives to put people back into the permanent workforce and stable housing are elements that require our immediate attention. Forensic services in this province are quite unable to meet either the needs of that particular clientele, or provide services for people with combined psychiatric and intellectual deficits.

I would recommend a nationwide initiative to allow clinicians to demonstrate innovative projects, which would enable us to compare key service issues.

I will step away from the clinical area. I do not need to reiterate to anyone here that improved accessibility means well-integrated continuums of service. It means better links between front-line mental health services and the specialized services such as the 53 different programs that we offer at the hospital. It implies more funding for home care, ambulatory and Assertive Community Treatment type programs, as well as residential services.

Today, and tomorrow morning at 8:00, it depends on the optimal use of the services and the individual professionals already in place. We need to ensure improved internal system performance and to revisit the domains of professional competency to allow for more latitude in professional practice for non-physician professionals. We have a shortage of physicians. We have a great demand. We have other professionals who are not used to their full capacity.

For example, the nurse practitioner role in Quebec is virtually nonexistent. And our recent Law 90, which is attempting to set up a structure that will allow us to deal with that, is a very hesitant first step towards allowing all professionals to enjoy greater professional latitude in their practice.

Consider for a moment the impact on the delays that we are hearing about of the 62,000 nurses in this province who could conceivably diagnose — to an extent — treat, admit and discharge people in nurse/physician partnerships. Consider the impact on someone you know who is waiting for services.

I do not have any problems with that. My brother is schizophrenic. I can think of all kinds of more important things that he could be doing with his life than trying to keep track of his various appointments and contacts if he could deal directly with a nurse case-manager.

Consider also the importance of primary care models — I think Dr. Israël was talking about that when I came in — and the different types of case management practices. Despite strong evidence that both of these initiatives are contributing to the quality of patient care, they are not widespread in mental health, especially in our area.

Will it take financial incentives to ensure that we take what is known in the literature and transpose it locally, here in the Montreal and Greater Montreal area? If that is the case, then so be it.

To me, improved accessibility also means that patients are partners. We need in this province and in this country a stronger ``patients as partners'' approach to mental health care. We lag behind on that approach in Quebec. Families may not be the experts on psychiatric illnesses, but they are definitely the experts on what their loved ones need and what their role can or cannot be.

One other critical issue about access, which I am sure my colleagues will bring up, has to do with access to information and electronic patient records. Please, we need that as soon as possible.

The second key point has to do with human resources — developing, recruiting and retaining qualified professionals, both as clinicians and clinician managers. I was very happy to hear one of our physician colleagues demonstrate an interest in that role. This is key to the sustenance of patients and their families in any discipline, but especially so in psychiatry.

For example, there is a large body of research in nursing administration that demonstrates that professional roles, that is, allowing nurses to operate autonomously, ample provision for professional development in the workplace, and the appropriate and timely support of superiors is critical to retaining qualified practitioners.

The Chairman: Can I ask you to condense your comments? I want to make sure that there is time to hear from everybody and ask some questions.

Ms. Kershaw-Bellemare: Certainly. We need to give our practitioners more training on-site, more autonomous roles and more participation in the issues with which we are grappling in health care.

Our staff are getting older. We have to think about that today. The average age of our personnel is 46 and a half, and between now and 2012, we will need to replace 40 per cent.

Some solutions that I would like to put forward have to do with reorganization projects that identify what clinical issues need to addressed by clinicians, specifically, in certain cases, nurses, and what can be addressed by non-clinical people to liberate professionals to do patient care. We think of wide, expansive control, but our managers are trying to manage too many services and too many people and they are not succeeding.

We need interdisciplinary educational programs that are closely integrated into practice settings, and this means better links with our universities. This means sharing our limited resources. Good teaching takes good people, and time. We need to build the structure that will allow good clinicians in the workforce to become good role models, good mentors and good teachers.

The last thing that I would like to talk about briefly is stable, long-term funding. I can only plead with you to agree that we need to fund continuums of care in large practice roles and integrate people into permanent jobs, permanent residential settings and programs that support teaching and research linked to clinical practice. Thank you.

The Chairman: Thank you.

Ms. Myra Piat, Researcher, Douglas Hospital: Honourable Chairman Kirby and honourable senators, I am pleased to be here today to discuss the delivery of mental health services. I am a researcher in the ultra-specialized services division at the Douglas Hospital, and I am sure you know our hospital is McGill University-based and a member of the World Health Organization. I am also an Assistant Professor in the Department of Psychiatry and Social Work at McGill University.

Before embarking upon my career as a researcher, I worked for over 15 years in social services, both in the community and public sectors. Over the past 10 years, my area of specialization has been deinstitutionalization, housing, employment and the negative reaction of communities to group homes or housing, better known as the NIMBY phenomenon.

In my presentation today, and I will try to limit it to five minutes, I will focus on three distinct issues related to the delivery of services to persons with mental health problems. I would like to briefly discuss, firstly, the linkage of service delivery to evaluation; secondly, the role of multidisciplinary teams in developing evaluations; and thirdly, the importance of housing in the delivery of mental health services.

My first preoccupation relates to the need to link the delivery of mental health services to evaluation. Very often, mental health service delivery and the work of multidisciplinary teams are kept separate from the task of evaluating services. For example, it is not uncommon for us to evaluate on a case-by-case basis as situations arise. Often, evaluation is an ``add-on'' or, at other times, ``imposed.'' Multidisciplinary teams may view evaluation as more work that results in few concrete benefits. Consequently, evaluation is not always an integral part of service delivery. However, I believe that in order to improve the quality of existing services, as well as develop new and improved services, concrete links must be developed between service delivery and evaluation.

Everyone will agree that there is a need to evaluate services on an ongoing basis. How we do it, whom to involve and how we make it useful and pertinent are the challenges we face. I firmly believe that the various stakeholders involved in both providing and receiving services should be given the opportunity to evaluate them. This includes mental health professionals, caregivers, families, community organizations and consumers.

Consumers have increasingly been called upon to evaluate services and most would agree that their opinions are important. However, consumers have very little power in the mental health system and it is often difficult to engage them in this task. They are afraid, intimidated, or worried about the repercussions of giving feedback to professionals who provide services.

Currently, I am principal investigator on two Canadian Institutes of Health Research grants, where we are attempting to evaluate consumer satisfaction with services in foster homes, better known as family care homes, in Montreal. We have over 800 deinstitutionalized persons living in these community-based homes. In one study, we used focus groups to develop a questionnaire designed specifically for these homes. In another study, we are interested in evaluating how people are helped. In both studies, the focus is on the consumer's evaluation of the services he or she receives in the community.

It is worthwhile noting that although the multidisciplinary teams initiated these projects, we are currently encountering certain difficulties in recruiting consumers for these studies. We are learning that a great deal of effort must be made to encourage consumers to become involved in evaluating services. It is also crucial that mental health professionals participate in identifying the areas for evaluation. The role of multidisciplinary teams in developing evaluative research is the second issue I would like to address.

In order for any evaluation to be meaningful and useful, there has to be collaboration between the multidisciplinary teams and evaluators. Evaluation has to be driven from the grassroots up. I mean that the decision to evaluate a specific program or service should emanate from the multidisciplinary team. I am convinced that mental health professionals, including social workers, nurses, psychiatrists and psychologists are more than qualified to invest in this process of developing an agenda for the evaluation of mental health services.

Although some health professionals will complain that they are overworked and have little time for evaluation, I believe firmly that involving them in this process is crucial. Additional monies must be invested in order for this to take place. In my current position, we have been successful in developing several evaluations with different multidisciplinary teams. Ultimately, these efforts will result in improved services to persons with serious mental illness.

Finally, I would like to address the issue of housing as the cornerstone of the delivery of mental health services. One cannot overstate the importance of providing decent, affordable housing for persons with mental illness. Without this, all our efforts to deinstitutionalize may be jeopardized. The situation in Montreal, as elsewhere in Canada, is problematic. Despite the best practices literature, previous research and government orientations, we still do not have a full range of housing available for persons with serious mental illness. Very little choice is offered, as the majority of housing available is limited to family care homes or foster homes.

Clearly, additional monies from both provincial and federal governments are required to develop new forms of social housing that will better reflect the diverse needs of this population. Improving the quality of our mental health services is very much dependent on investing in new and innovative housing for this population.

The Chairman: Thank you very much. Next we have Amparo Garcia from the Adult Ultraspecialized Services Division of the Douglas Hospital.

Ms. Amparo Garcia, Clinical-Administrative Chief, Adult Ultraspecialized Services Division, Douglas Hospital: Thank you, senators, for your invitation. I am pleased to be here to share my ideas concerning the role of different professionals in mental health practice, both hospital and community based. As a clinical administrator of ultra- specialized services at Douglas Hospital, I will emphasize my experience with the severe and persistent population.

The lack of an adequate, agreed-upon paradigm is a major problem in mental health services, particularly for the rehabilitation of people with disabling mental illness. The judgments of clinicians and community workers and the choices of service recipients, consumers and advocates are all based on some underlying set of logical and philosophical premises. However, because of the absence of a commonly accepted paradigm, each individual has a unique and idiosyncratic set of premises and practices. When it comes to staff, they all answer according to their particular profession — nursing, psychology, social work, psychiatry, et cetera; and/or location, whether hospital based or community based.

In the case of mental illness and rehabilitation, there is no paradigm that enjoys the degree of consensus found in medicine or law. As a result, there is a pervasive ambiguity about what the goals of rehabilitation should be, who can benefit, or even what ``rehabilitation'' and ``disabling mental illness'' really mean. As a result, decisions and choices that make sense to one individual may make no sense to others. Without a paradigm policy, the mental health service system is driven too little by science, technology and real social needs and too much by politics and misconceptions.

The current dominant paradigm for mental health, the medical model, has been in place for a least a century. A rehabilitation paradigm has emerged from the challenges of deinstitutionalization. It views severe mental illness as ``disabilities to be overcome'' rather than a ``disease to be cured.'' Treatment usually includes psychiatric medication to suppress psychiatric symptoms, but the emphasis is on functional recovery, overcoming disability and living as normal a life as possible. Most importantly, treatment includes a process of evaluation and appraisal in which the client, the identified ``patient'' in the medical model, is a key participant.

This process identifies the client's desires and needs and the conditions or circumstances that prevent their realization. Then a plan is formulated by the interdisciplinary team for acquisition of new skills for overcoming those barriers, which the client acquires in an educational rather than a clinical format.

Similarly, the structure of clinical decision-making and service administration associated with the conventional medical model are under attack by forces ranging from practical limitations to health care policy and consumer and community activism. A new, more inclusive, integrated paradigm is evolving. A new way of working among all stakeholders must be created.

In an integrated paradigm, team organization should be determined by the nature of the problems and the technologies, not by the professions or the power of selected team members. The rehabilitation team consists of the recovering person, significant others in the person's social environment and providers of rehabilitation services, the last two also including community workers.

The specific representation of clinical disciplines and specialities on a team vary over time, as the recovering person's rehabilitation needs evolve. The particular activities performed by team members from various disciplines vary, due to variation in local practice and individual backgrounds. It is therefore unhelpful to define rehabilitation in terms of representations of specific professions, disciplines or individuals, with the exception of the recovering person, of course. However, it is possible to identify particular roles that generally need to be performed by one team member or another. Team members often perform more than one role, and roles are sometimes passed back and forth as circumstances change and rehabilitation and recovery progress.

Both excellent and inferior treatment and care are found in both community- and hospital-based service settings, and neither can be described unqualifiedly as inherently better for all patients under all circumstances. Thus, efforts to reach not only productive coexistence, but also productive unification are definitely in order at this time. It is important that we attempt to de-polarize extreme views on the issue of psychiatric hospital care. People whose lives are affected by severe mental illness must not be further victimized by the intransigence of ideologies or by the political correctness in fashion.

The psychiatric hospital has an important role to play in research and training, as well as in the development of state-of-the-art, specialized interventions. The transfer of this knowledge to different stakeholders is an essential part of its function. It is also the role of a psychiatric hospital to continue to provide treatment, care and protective services within a comprehensive system of care that should be integrated with community services.

An important fact about evaluation is that quality control is only as effective as the management actions undertaken in response to its results. It does not much matter what data reveal, if nobody has the accountability or authority to act on the problem. This might be especially problematic in medical settings, where demands for procedural fidelity are sometimes interpreted as violating physicians' prerogatives.

Planners and administrators must, whenever their programs are evaluated, use as outcome criteria more subtle measures of appropriateness of services such as quality of care and quality of life measures, instead of the traditional indices of the hospital tenure — declines in numbers of admissions and length of stay.

The Chairman: Thank you. Finally, we have Manon Desjardins, the Clinical Administration Chief of the Adult Sectorized Services Division of the Douglas Hospital.


Ms. Manon Desjardins, Clinical Administration Chief, Adult Ultra Specialized Services Division, Douglas Hospital: Thank you for the invitation. It is a pleasure for me to share with you my thinking on the issue of mental health service delivery.

I see that you have listed doctors, psychiatrists, nurses, psychologists and social workers. I would add occupational therapists, who play a very important role in the integrated services system for people with mental health problems.

With respect to doctors, psychiatrists, nurses, psychologists, social workers and occupational therapists, there are three major points to consider.

First, there is the labour shortage. Whatever the desired quality of service delivery, there is no getting around the fact that we currently have problems with recruitment and retention of staff in our establishments for the types of services we deliver.

For example, I can tell you that out of ten nurses who will graduate this year, only one will choose psychiatry. It is therefore very important for our national planning to include measures to encourage people to work in the area of mental health, to show them how rewarding, motivating and stimulating it can be.

So we need to encourage people to work in the mental health field earlier rather than later in high school, and certainly well before college or university.

The labour shortage also requires that we consider reorganizing the work of all of these professionals, including doctors. If we retain the conventional hospital model, we will not be able to provide the clients we serve with all of the services we would like to.

Second, I would like to talk about intradisciplinarity. We often say we want to deliver quality services to clients. I think intradisciplinarity could be a good way to provide rapid access to quality service.

We already have intradisciplinarity within our institutions. But we can also do intradisciplinarity work with lots of partners around us. And that is probably the key to success for the type of mental health intervention we are proposing.

Third, we are talking about service integration, partnership with the front lines in the areas of screening, monitoring and service continuity for our clients, with service and case-management plans, when necessary.

As for doctors and psychiatrists, we currently have in Quebec an organization of general practitioner services called family medicine groups. It is still in the early stages. The idea is to provide services to the general clientele 24 hours a day, seven days a week, etc.

In order to better monitor clients with mental health problems, general practitioners should be supported by services provided within this type of group, by funding psychologists or social workers to lighten their load. This means that there would no longer be such ready access to secondary care, because a lot of problems could be dealt with right on the front lines, such as identifying and treating depression.

Joint monitoring is the way to go. The Douglas Hospital, among others, could surely be a special partner, given its expertise in planning this kind of services.

As for nurses, let me say that it would be important to recognize their expertise as professionals and that specific training would allow them greater autonomy, particularly in the area of triage or referring clients to the appropriate services.

As for psychologists, social workers and occupational therapists, they should be more integrated into institutional practice, particularly psychologists found mainly in private practice and to a lesser extent in our CLSCs, or local community service centres. At the Douglas Hospital, we are fortunate. We have about 40 of them, but that is surely not enough to provide services in the community and in our sectoral teams, for example.

We should therefore contemplate practice by specialized professionals that would increase the accessibility of various services. They are fully capable of dealing with specific problems like anxiety, phobias, etc., because they now have master's or PHD training.

As for social workers, I think they will be invaluable in terms of continuity of care and integrated services, especially with respect to desinstitutionnalization. That was a huge movement. The idea was to make life more normal for people who were formerly in psychiatric hospitals or asylums, and I think this movement is worthy of mention.

Community supervision has proven difficult. They may have been a desire to save money, but I think you have to work with professionals who fully understand the impact of family, society and the community in order to help clients with mental health problems to fit back into society better instead of feeling abandonned by the health care system.

As for occupational therapists, I would obviously say that they are very important in all rehabilitation programs for clients to regain control over their lives, to relearn how to do things they had forgotten, to relearn things that they were no longer able to do for some time, but that they can surely get back.

Self-esteem and independence make people happy and cost less, in general, than health care services.

Unlike hospitals and community services, clearly the Douglas Psychiatric Hospital provides specialized services according to very strict criteria.

We can therefore be a special partner for a specific clientele, but we can also be a specific partner for people having problems on the front lines, such as Quebec's CLSCs. We can enter into partnerships with universities to develop innovative practices and also with the research and teaching network to come up with new ways of doing things.

We can also develop partnerships to evaluate the services provided. In the area of mental health, it is often difficult to evaluate an approach, a way of doing things, after one or two years, according to the set criteria.

In the area of mental health, you have to accept that service evaluation sometimes takes longer, and costs a little bit more, but the results can reliably be used to provide higher quality services in the future.

The Douglas Hospital and other psychiatric hospitals in Quebec can surely also be special partners in desinstitutionnalization.

Since the goal is to improve the client's well-being, it is clear that outpatient clients may not need the same supervision, the same environment, but they do need specific services. Desinstitutionnalization is not necessarily a source of direct savings, and you cannot put a price on quality of life.

Given the position of a psychiatric hospital, I think that we have a valuable role to play and can be a leader in terms of innovation. There are many needs, many responses to those needs and many places for treatment. In order to succeed with this kind of model, moving from the emergency department to community services, to temporary admission or care, we need to choose a model that does not simply reproduce the hospital model, but in fact allows for trying new ways of doing things.

Last, I think that community services are indispensable if we are to organize those services along an integrated continuum. And the documents you have provided us indicate that if the indirect mental health costs are ever increasing and the direct costs could be changed, investing in health would be worthwhile. We may not save as much money as we would like, but we will certainly make a lot of people's dreams come true.


Senator LeBreton: You said something that really caught my attention when you talked about mental health and mental illness, in terms of the kind of bureaucracy and different jurisdictions. Some provinces have a ministry of health and a ministry of social services, or a ministry of community and social services. I was wondering, as I listened to you, whether in developing a national plan to deal with mental health and mental illness, there are too many levels of government that you have to deal with — for instance, for funding. You are attached to McGill University. Do you have to run around to several different departments, or how does this work for you?

Mr. Hendlisz: No, we are spared the running around, but the different pockets of money exist at different levels. The most trying example of that would be what we call ``PACT'' teams, or ``Program for Assertive Community Treatment'' teams that in the United States are over 20, 25 years old. When Ontario decided to develop these community active treatment teams, within a few years there were 60 of them.

In Quebec, since these teams operate in the community, the big discussion at the ministerial level was whether this is community funding, in other words social services, or medical funding. Consequently, we still do not have a government that is willing to say, ``We are funding active community therapy teams.''

The Chairman: Do you mean that they are just not funded?

Mr. Hendlisz: They are just not funded because the discussion is about whether this is a community or a medical service. Finally, this year, developing active community therapy teams or treatment teams has been included in some of the ministry's mental health objectives.

Senator LeBreton: Since they have not decided whose responsibility is it to fund it, you are without the funds?

Mr. Hendlisz: Yes. Behind all of this, you know, are ideas like, if you give treatment to citizens in the community, then it is community care, it has nothing to do with expertise. However, we are saying that we have to move ``le lieu de service.'' When services are provided in the community, it does not mean that the providers have lost their expertise. It means physicians, psychiatrists, nurses, et cetera, no longer work only in their offices. At a conference organized a couple of years ago by some of our people, I was struck by an indicator that a particular American team used for successful reintegration of patients, in which they said that 80 per cent of the client's contacts must be with non-paid people. It does not matter whether they are paid by community services or the hospital service, or if they are street workers or nurses. It does not matter if your client says, ``My best friend is my nurse,'' or ``My best friend is my community care worker.'' You have missed the point. That is a major problem.

Senator LeBreton: It certainly is.

Senator Cook: I think there is an assumption in the land that governments know how to deliver health care.

I would like your comment on the concept of the psychiatric hospital, because with the arrival of SARS in our society, the way that we deliver health care is going to be forever changed. Nothing will be the same, and maybe the role of tertiary hospitals will, of necessity, have to change because of double gowning, double gloving, air ventilation and the rest of it. Maybe this is the time to be on the cutting edge of psychiatric hospitals. The model that is in my head covers a wide range, from the disease itself and the needs of the consumer of services, all the way to housing, poverty, literacy and a whole gamut of things.

My other question is would you build on the role of the nurse practitioner in primary care in a mental health setting? I would like to hear about that.

Given that as the SARS epidemic wears on society and we have to look at things differently out of necessity, it might be time for a new beginning in other health disciplines. I believe the roles of hospitals will have to change. They will have to be structured to deal with the unknown. There might be an opportunity now for psychiatric hospitals to emerge and take care of that segment of our population. However, I want to make sure all the elements are included. I do not want the idea of a mental institution.

Mr. Hendlisz: Psychiatric care tends to deal with chronic conditions and is quite distinct from acute care. In acute care, episodes will be, if not brief, certainly time limited to a degree. I realize there are many other diseases that can have chronic consequences, and some mental illnesses do have a chronic component. You do not necessarily have to give treatment in a hospital. There is a need for beds in particular places, which could be general hospitals as well as psychiatric hospitals, but the role of the psychiatric hospital should be that of an academic centre. As academic centres, they can be repositories of knowledge that can then be given out to different people through technology transfer.

Senator Cook: Yes. However, the reality of it escapes me, because I come from Newfoundland, where there is one tertiary care hospital, and I am wondering if there is a model somewhere in your vision of a holistic psychiatric hospital that puts out linkages into the population or community homes.

Mr. Hendlisz: You do put your linkages out into the community. The way we have reorganized ourselves is to have all the, what we will call ``second-line services,'' outside the hospital. We have purchased or rented clinics and they are out there.

Senator Cook: However, the linkages will be into the core centre of your psychiatric hospital? No?

Mr. Hendlisz: Not necessarily. The patients do not have to go back, necessarily. It depends.

Ms. Kershaw-Bellemare: If you picture it as like the hub of a wagon wheel and at the centre there is a limited number of professionals with a lot of expertise, not all of which is the first response in terms of the needs of people at the outer edge of the wagon wheel. We have only 254 inpatients. We have over 6,000 outpatients. We do not want to continue to assume the responsibility for those 6,000 outpatients, and we are even trying to reduce our inpatient quotient.

The kinds of things we would like to develop, and are working on actively, are shared-care initiatives. In concrete terms, our psychiatrists are talking to general practitioners and helping them follow people who are holding down a job and living with their family, but need periodic help. Every now and then, they may need to be admitted, have their medication adjusted or other treatment regimes initiated, and then go back to their life.

We can think of nurses in the hospitals teaching nurses in local community health centres about what to look for when a patient is on a specific medication. We can talk about psychologists helping their colleagues in crisis centres learn about specific measures to deal with borderline personality disorder, which is a difficult issue in anybody's book. It is a very concrete sharing of knowledge, preferably outside the hospital, and preferably maximizing what is being done in the community with and for the people who use the services. I do not know if that helps.

Senator Cook: That helps, but the other piece that I am trying to fit into my picture is the role of the nurse practitioner in a primary care setting in mental health, given the shortage of human resources and the dollars. In my province, they were born out of necessity.

Mr. Hendlisz: Absolutely. Necessity is very often the mother of invention, and health professionals are very traditional and not the most flexible people.

The requirements to become a nurse now are very different from 20 years ago. There has been a kind of democratization of knowledge and other people can now do many things, but the general practitioners also have a major role. The first instinct of general practitioners, if a particular medication does not work, is to send patients to the hospital, as opposed to sending them to a consultant and then carrying out the treatment.

We do not want to look at our institution as a place to keep patients, because even in the model that you may be thinking of, we end up looking at psychiatric hospitals as the end of road, and as soon as you do that, you are rebuilding an asylum. We do not want an asylum.

Senator Cook: Thank you for capturing my wandering thoughts so vividly. What do you say to a national action plan with an integrated approach?

Mr. Hendlisz: I think that would be wonderful in terms of aims, but we may run into certain kinds of problems. As Amparo Garcia was saying, everybody has a slightly different version of it and that is going to be a big job. For example, I know addressing stigma may not look like much, but it is a huge task. However, a national action plan would be good, yes.


Senator Pépin: Senator Cook spoke about nurse practitioners. My comments concern both nurses and nurse practitioners: we have to increase salaries and change the quality of life in the working environment.

Ms. Bellemare, you told us that we are not using our resources properly. Could you elaborate a little, please?

Ms. Kershaw-Bellemare: Today all non-doctor professionals have specialized training. In our interdisciplinary teams — and we like to see the patient as being the focus of all the attention, of course — because of present lack of psychiatrists, there are often more non-psychiatrists than psychiatrists.

It is important to note that nurses, psychologists, social workers, occupational therapists and so on can work more independently and even evaluate and possibly admit a patient without necessarily waiting before a formal evaluation done by a psychiatrist.

I think we should review our care systems, our ways of sending the person through the system, to eliminate barriers, and think in terms of the needs of the person when that person needs our services. Perhaps an interdisciplinary team supported by a doctor could admit someone immediately from the emergency room or even from a community clinic, simply for a brief stay, based on another professional's evaluation?

Once we have agreed on the protocol, once we have agreed on the training supporting what is being done, why not admit that different people can play their roles differently?

It is embarrassing, but we are one of the last provinces to accept that the entry level into practice can admit nurses who do not have a bachelor's degree. In my opinion, it is unacceptable to have a training lower than a bachelor's degree. Like all perfectionists, I am aiming for a master's.


I think you have to ask concrete questions in terms of nurse practitioners. Picture a community health centre with 3 or 4 GPs and maybe 10 to 15 other professionals; in a perfect world there would also be non-professionals, people who are well known in their community for being able to help people who need help. There would be maybe one or two nurse practitioners in that context. For example, one could have advanced practice training in psychiatry, could differentiate certain diagnoses and be familiar with the medications and the different nuances that have to be brought to bear. That nurse can sit with the team and say, ``Just wait a minute. We are getting a little off track with this one,'' and could, if the need arose, admit to the local emergency room. It would be a partnership where a call could be made to the other nurse who works there, because they are working for the same entity. They can make a transfer, because transfers happen between people and not systems. It can be that concrete.

Senator Cook: In my province of Newfoundland the entry point for the nurse practitioner is a Bachelor of Nursing, and when people go into the nurse practitioner program, they quite often choose the discipline, the special area, in which they would like to work. Nurse practitioners in my province have a master's degree.

Ms. Kershaw-Bellemare: That is what we are hoping to attain, as well. At a minimum, it will be a nurse with a master's degree who has training beyond that level in a given specialty, for example, in psychiatry, cardiology, or whatever.


Senator Pépin: You have said there are very few nurses going into psychiatry. We also know there are very few doctors taking up psychiatry. What could motivate more people whether they are nurses, social workers, doctors or occupational therapists, to take up psychiatry?

Mr. Hendlisz: Once again, I think that has to do with prejudice. We know that all mental diseases, even severe depression and so on, that are not permanent diseases, do have a neurological component. We have a neurological Institute that considers that some diseases such as cerebrovascular accidents or others have an impact on behaviour but they are considered as being brain diseases.

However, when we look at mental health diseases we do not see them simply as brain diseases but we also see them as behavioural diseases. But I can assure you that the same organ controls both. Perception is what makes the career less attractive.

Ms. Bellemare: I will say something rather ironic: there was a time where one went into psychiatry when one could not practice in a more complex and more difficult discipline.

And that way of thinking still exists for some people. The marketing of that specialty has not been done very well. There is also the impact of a problem that is often judged by the population at large as being something shameful.

That said, I think that as far as training is concerned, it is important to upgrade our requirements concerning the practice of psychiatry in general.

Integrating research with clinical programs is one way of getting the following message across: we are dealing with a scientific practice both clinically and administratively.

So we have to change the structure to change the perception and increase the requirements for all professionals who want to practice psychiatry.

Ms. Garcia: I agree with Ms. Bellemare and Mr. Hendlisz. I would add that it is too bad, because people working in psychiatric hospitals stay there. They love and adore their work. People do not leave. It is too bad there are not more people choosing to work in the field of psychiatry.

Ms. Desjardins: I would like to add that it is very important for students to get into practical training as soon as possible. We should not wait for the third year in nursing. The students have to see what the environment is like.

In universities, it is still far more prestigious to go for cardiac, surgery, intensive care rather than psychiatry or geriatrics. Geriatrics and psychiatry are seen to be at just about the same level: they are not very attractive.

It is as though you had to not be as good if you are choosing those specialties. But as Ms. Bellemare was saying, practice is so different, it is so motivating. You have to know how to ``sell'' the product to students because as Amparo Garcia said, students in training in psychiatry stay. You should not choose psychiatry because it is the last on the list, people have to choose it because it is interesting. So you have to make an effort at the university and college level to tell students: come see, you will discover an extraordinary world where you will feel useful; there are few other areas where you can get that feeling.

We know it is motivating for a professional to fulfil his professional potential while knowing at the same time that he is doing something good for others. In psychiatry, we can offer that motivation but people do not know it.

Ms. Kershaw-Bellemare: I think that interdisciplinary training is very important. If, at the end of the day, we want interdisciplinary teams, we have to start with interdisciplinary training. We can have interdisciplinary training, and then, the students can pursue different specialties.

Second, in the psychiatric environment — I do not even like the term — whether it is in a hospital environment or in the person's own environment, you are dealing with chronic disease and the problems of everyday life: how to feed your family, how to keep your job, how to take the bus without getting lost on a Friday afternoon.

When we are recruiting our student trainees, we tell them: if you want to learn anything about families, environments, adjustment problems, care and resourcefulness, then we are there for you.

Often, the trainees only remember this: our patients have mental diseases.

One of the approaches that penalized us in the past, but that we found very advantageous, was to say: no, we do not want just anybody; you are going to prove to us that we have to accept you. At the beginning, students were totally upset by our approach, but things have changed since then.


Senator Keon: Madame Garcia, I am going to ask you a difficult question, so I would ask the other members of the panel to assist you in this. Perhaps it is almost unfair, but I will ask it anyway. This morning, I tried to ferret out from Dr. Israël and Dr. Farquhar what is really missing that would make the system work. There is a regional structure in place, but somehow the network is not succeeding at picking the people up, getting them to the right place at the right time, getting them back to the right place at the right time, and looking after them in the broadest social context of mental health.

The reason I have buttonholed you is that you referred to the integrated paradigm, and I want to hear what is missing in the system now in the way of structure, function and people to make it work.

Ms. Garcia: I will try. One of the problems is the lack of integration. No one service or service point can do it all. For example, even within the hospital we have to integrate the services, we have to break down the barriers. In my division, my first objective is to break down the barriers within the services and have them work together, and then have them work from the units in the community and reach out and work with the families, the CLSC, the community resources. You have the same problem in trying to work more in the community. People are trying, but at the same time, they are still staying with their own way of working, so it is very hard to unify the system.

When you make an intervention plan, everyone talks about being client centred, but if the members of the multidisciplinary team stay at the level of their profession and do their little part, you do not have an integrated way of working. You have a doctor who wants to have control and to have the last say; then you have one person doing placement, another person doing activities — that is the OT — another person doing psychological testing; then you have a service within the hospital that has to follow patients.

Therefore, you will hear a nurse saying, ``But I am not an outpatient nurse. I was not trained to follow people outside the hospital. The PACT should do that.'' Well, maybe. We are lucky to have a PACT, but there is already a waiting list and the PACT cannot follow everyone. This nurse will have to go into the community and follow this client for three months. We will have to let the community walk into the hospital and take the patients out into that community.

Presently, we are looking into a model whereby what is today long-term, intensive care in hospital is put outside in the community, 24 hours a day for 7 days a week. It would be a supervised apartment setting.

Again, one of the answers we will get from the regional board is, ``Well, but this is inpatient treatment. How will you do that? Does that mean you have to cut beds? Does it mean that you have to cut financing and then find community financing, because the house is in the community?''

We are talking a lot about putting services together, but we are still very much working each in our own way, and we do not have to go very far to see that. All we have to do is look into what goes on in our own services. Breaking down the barriers around our own services is already enough and it shows where the problems are.

One of the problems I have seen often is that the community resources people will say that they are taking care of severe and persistent clients. In fact, I think there is a difference between the type of client that the hospital follows and the type of client that the community follows. They will say it is the same, but in some cases, it is not. Again, we have to come together and share expertise. There are certain things that they can do and there are certain things that only the hospitals can do at this point because of their expertise.

Mr. Hendlisz: You talked about structure, function and people. We have to remember that deinstitutionalization, although it has been a long process in terms of the many years it has been going on, had its major push in the last five to ten years, in the same way as day surgery.

The retraining of people to do the work outside the institution versus inside was not there. People who have worked for 20 years protected by the walls of the institution know that they are leaving at 4:00 and somebody else is going to be there — then suddenly, they are not there. You have to take care of your patients at 4:30 and at 5:00, make sure the phone calls are made and what have you.

People who are used to working in a hospital in a very structured environment are lost. This is a relevant whether you are talking about nurses or outpatient services. The training model was not there and is still not there. With all due respect to our union colleague leaders, they still say, ``Well, it is after 4:30; that means it is overtime.'' You get into these incredible situations.

Let's be clear that working in the community is a different kind of job and people have not been trained for it. That is on the staff level.

At the structural level, we have the understanding that, ``Well, this is a community model and that a hospital model,'' and it is not based on the patients' needs at all. My own suggestion is to have a relatively small project involving a number of people who are committed to it with a timeline of two or three years. That will work.

Although I certainly believe in a national program that will provide structure, et cetera, it has to work on the ground. We know that certainly in major cities, mental health services tend to be divided into sectors, and we know what they are. We know the community groups, we know the CLSCs in Quebec and we know the hospitals. We have to say, ``You must come up with a concrete model for your area and you have a year to do it. You have to figure out how to do it.''

Also, physicians tend to work apart from the system and you have to bring them into that model without forcing them.

We know from our everyday experience that that kind of thing works. You get a small group of people together and give them a problem, which is relatively simple. You do not have to talk to 4,000 people. That is how I would do it. I would say to a certain sector, ``You tell me what your model will be,'' because it all has to do with integrated care.

We have deinstitutionalized people who have been severely ill, but are stable. They should be taken care of by community care, but no, they are ours still. Why are they ours? They are in the community and they are stable. The response is, ``No, no. That is mental illness. That is you.'' It is that kind of attitude.

Ms. Kershaw-Bellemare: I would add that we need more stable funding. The reality is we are constantly running downtown to renegotiate a few dollars. We understand the importance of spending money wisely, and it is much more advantageous for the client at the end of the day if you can go into a project knowing what the funding is and how long it will be there, and I do not mean in terms of months.

The other issue is joint education. We have to change the structure and train future professionals together. We have to create joint community/hospital-based positions. The unions will react strongly to that, which is just too bad. We will have to give professionals more autonomy so that when they are outside the walls, they do not have to ``phone home'' every time they need to do something slightly outside the realm of their traditional practice. Our laws have to back them up in that. We have to give them healthy workplaces.

Most of the people in our establishment are willing to make the switch. They just need us to take a little of the pressure off them. They need us to be able to replace them so that we can give them some retraining; and they need us to run interference with the unions and others so they can operate in new and creative ways. It is not really very complicated.

If the national strategy addresses all that it will give us the power to actually perform administratively. There is a myth that, ``If you cannot do, you teach, and if you cannot teach, you administrate.'' I beg to differ. We keep the system running. Now, it is not in the best state in the world, but you cannot just administrate because you have nothing else to do. It has to be based on some evidence.

Those are the structures we have to change to be able to function differently and reach the people who are still in the system.

Senator Keon: Mr. Chairman, I must tell you that the way I heard it is, ``When you are too old to do, you teach, and when you too old to teach, you administrate.'' It seems to have been the story of my life.

The Chairman: In case you did not know, Senator Keon is currently the CEO of the Ottawa Heart Institute, in addition to being a member of the committee.

That was an excellent question with which to finish. I want to put a challenge to the panel and have you reflect on whether you are willing to accept it. I am not asking for an answer now. All of you have talked about something that we have kicked around, individually and among ourselves. Mr. Hendlisz began by referring to it as the need for a different paradigm, and several of you have talked about it in different ways. It would really help us if sometime in the next two or three months, certainly before the end of the summer, you could give us a proposal of what such a new paradigm might look like. Clearly, we are not talking about the classic health care paradigm.

In the early days of primary care reform, there was a significant role for the federal government in funding a variety of experiments around the country. The provinces did not object to that because it was understood that these were pilot projects. It was understood that it bordered on classic applied research. We would benefit a lot if you could give is one, two or three paradigms, although it may well be only one, with which you think it would be truly worth experimenting in different parts of the country, making it as practical and non-theoretical as possible. We around this table are not abstract policy-makers, as you know from our last report. We were far more detailed than the other report that Mr. Romanow put out and we were very concrete. One can say we were wrong, but we were not in doubt, and it was easy to tell where we stood.

We would look at doing something like that, but we desperately need the help of people like you. The academics can say, ``We need a new paradigm,'' but we have to say, ``This is what it ought to look like and here are the experiments one ought to try to see how it works.'' None of us are going to get it right, right off the bat. We have to do some experiments. To the extent that you can give a considerable amount of thought to that as a group, because it is not just one person's idea, it would be extraordinarily helpful. If you could give it to us in written form, some of us will probably come back to meet with you at the hospital and talk to you about it. If you do not mind doing that, believe me, you will not be wasting your time.

Senator Morin: Can I just caution against the creeping up of professional standards.

Chairman: What we call the ``credential creep.''

Senator Morin: The reason for that is it is not without consequences for the resources, and so I would beware of that in the paradigm.

The committee adjourned.