The Standing Senate Committee on Social Affairs, Science and Technology, met
this day at 1:25 p.m. to examine issues concerning mental health and mental
Senator Michael Kirby (Chairman) in the chair.
The Chairman: Senators, before we begin this afternoon, Menna MacIssac
will actually represent both the Alzheimer society and the family caregivers
association because Sharon Reashore, who is the Executive Director of the Family
Caregivers Association of Nova Scotia, has just gone into the hospital for
emergency surgery on a detached retina. They have had a conversation and she
will do both. Then we will have a number of questions we would like to raise
Ms. Menna MacIssac, Director, Program and Operations, Alzheimer Society,
Nova Scotia: Thank you very much for having me here today. I have given you
all a copy of the presentation with our annual report.
I have stated our mission up front, which is alleviating the personal and
social consequences of Alzheimer disease and other dementias and promoting the
search for causes and cures. We have been in existence for 20 years, and the
amount of research that has gone on and the contribution to alleviating
Alzheimer disease within that period is very exciting.
Alzheimer disease is a progressive, degenerative disease and the most common
form of dementia, affecting memory, judgment, reasoning, behaviour, mood and
physical functioning. It is not normal memory loss that accompanies aging. It
is, for instance, if you get in the car and you forget how to drive; it is not
forgetting to pick up your children on the way home from work, it is forgetting
you have children. It affects your ability to perform simply tasks, to recognize
family members, and impacts upon the dignity of your cognitive abilities.
Today 420,000 Canadians over 65 years of age have Alzheimer disease, and with
the aging of our population it is expected that by 2031 that number will be
750,000. Twenty-five per cent of Canadians will have someone in their family
with this disease.
The Chairman: Menna, you do not necessarily need to read all of the
pages. If you just want to hit the highlights and then we can talk to you about
Ms. MacIssac: Sure.
The costs of care, both the human cost and the cost to the health system, are
remarkable. It is $5.5 billion in Canadian health care costs at this point.
However, the real cost that we see on a daily basis at the society is the cost
to the caregiver.Ninety-three per cent of seniors are living at home. Many of
them are being cared for by their spouses, and it is a 24-hour,seven-day-a-week
job. Many are living in isolated rural communities. My own experience with my
father andfather-in-law is that a person with dementia, as the disease
progresses, does not even like the caregiver to leave the room, let alone go out
for groceries. It is almost like child dependency. It is very confining and
The impact is such that caregivers for a person with dementia are twice as
likely to experience depression, and often depression co-exists with dementia.
The need for mental health is not well known because people are living in the
community with the disease, being cared for by caregivers who are at risk of
also having depression themselves.
I have come to you today with some suggestions that we feel are significant
health system policy changes that could be incorporated into your
The first is that caregivers themselves and persons with the disease say that
the most important thing is respite. That is their number one priority. There
are many documents and surveys that the federal government has been involved in
that indicate that. By "respite'' I do not mean just respite for the caregiver.
There are creative approaches to respite that also include programming for the
person with the disease, and it is most important to break down the barriers
attached to taking the person outside the home and actually bring respite to the
home, allowing caregivers to go to their own appointments and to attend support
groups and other activities that are available to them.
The Chairman: What does ADRD mean?
Ms. MacIssac: Alzheimer disease and related dementias.
The second point is the significant impact that community capacity
initiatives can make. Alzheimer societies across Canada are moving in a
direction where they want dementia networks to exist at the community level. The
dementia networks bring together groups of at least three health profession
organizations at a local level — and this can be replicated across Canada if so
desired — to do an inventory of what health services exist at the district or
community level and which ones do not. Then, using the local providers who are
around the table, they look at the means within their own community to address
those deficits and to better integrate services for dementia within their
community. In addition, those providers become engaged in a variety of
subcommittees that address services, education, promotion of research, and
service integration. That would be one of our recommendations.
The other is that in order for integration to truly occur, we would like to
see a referral system called "InfoLine First Link,'' which would begin at the
time of diagnosis and follow the person through a referral to the Alzheimer
society, and then to the networks that would be newly created. That is the
second point about community capacity.
The third is around the need for an enhanced curriculum in mental health
within the medical schools and other professions.
The fourth is to expedite approval of and access to medications.
The fifth is to establish and fund a national Alzheimer strategy.
There are a couple of points I would like to make around the community
capacity initiative, which has the two components of networks and the
third-party physician referral. This has been tried in Ontario. The Ontario
model may be a little rich for some of the other provinces, but it has been
evaluated and is based on best practice and evidence. The findings are that with
these informal networks of caregivers coming together, 93 per cent of families
and persons with dementia were able to handle a crisis situation more readily.
Often as a society we only hear from people when they are in crisis because they
cannot cope with the isolation; they cannot cope with watching the one they love
lose their cognitive ability.
With this link from the physician's diagnosis right through to a network,
people are provided with proactive supports as opposed to waiting until they are
in crisis. It is a referral system.
Also, once the networks were developed and the health providers came together
to address gaps, 63 per cent of people with the disease and their families
indicated that they stayed at home considerably longer or were able to retain
their loved one at home, as opposed to an early admission to long-term care,
because the networks were providing broader services.
Given the aging population, we cannot fix the demands on the health care
system by putting more acute care and long-term care beds in place. We have to
partner with the community. If Sharon Reashore were here she would say that so
much of the care goes on in the community and more could be done with the right
supports, including the networks and a better referral system.
Other provinces are going in this direction as well. Tomorrow I have a
conference call with the other societies across Canada. They are all moving in
this direction. The Ontario provincial government is providing $100 million
towards this initiative through their Trillium Foundation, which I believe is
funding from their gambling casinos or something of that nature. The Alberta
society is also receiving some funding from government. However, the rest of us
are struggling to do what we see needs to be done to give better care to people
in dementia services through fundraising.
The Chairman: Describe to me in a bit more detail what exactly is
included in a local network. You say you have to have three professionals.
Ms. MacIssac: Yes, three organizations, not just three professionals.
They are there to represent their organization.
The Chairman: What kinds of organizations?
Ms. MacIssac: It could be VON. It could be home care under the
district health authorities. It could be mental health providers, GPs. We are
looking to get primary medical care people involved.
We have the first pilot on the go right now in Cape Breton. Ten provider
organizations have become part of this. In the year and a half since they have
been in place they have done an inventory of existing services, but they have
also looked to develop certain things on their own. In the last year they have
developed education modules that the providers can put on in the community for
people who have dementia and their caregivers. They have put on six education
forums. They have developed a home care toolkit for people who work in home
care, and I would like to take it to the Department of Health to see if we can
give it to home care workers throughout the province. It is recognizing and
supporting people with dementia in home care situations.
They have developed two support groups for caregivers. Once the networks are
developed, they assess the gaps and begin to figure out local ways to address
them, and they work with the society. For instance, we have volunteers on the
ground in Cape Breton who are connecting now to the network and providing public
education. All of our materials are now moving to the network and being used in
their work. We would like to create an info-line there, but we currently do not
have the money for the third party referral.
We want to work with the medical staff in Nova Scotia to create what is
called "referral pads,'' which is what they are using in Ontario. When people in
Ontario are diagnosed with dementia they get a referral to the society. From the
society they get a variety of education materials and support groups, and then
they are also linked to the local networks. That is the model we would like to
The Chairman: I am surprised at your $100-million price tag; that
strikes me as extremely high. Where does the money go? A lot of what you are
talking about is done by volunteers. Correct? So what is the money being spent
Ms. MacIssac: Well, in Ontario they have 33 chapters and they hire
staff to put on the education programs that are delivered in the community. We
would not hire staff; we would use the providers who are around the network
table. We have submitted a proposal to the provincial government that is based
on that model but uses more volunteers and network members; we have not been
able to determine yet if we have been approved in the budget process.
The Chairman: If you do not mind my asking, what is the cost, roughly?
Ms. MacIssac: We put in for $120,000 in year one to hire three
coordinators in Nova Scotia who would work with the communities on identifying
who the members of the networks would be. Help with the paperwork and running
the networks once they are in place, the administration costs, the travel costs
and the staff fees of the three coordinators are included in that $120,000. In
the first year we said we would develop an evaluation framework, and that by
year three we would do a comprehensive evaluation. In Ontario they hope that
these networks will become self-sustaining. We stated that we feel they can be
self-sustaining within a three-year period because one of the main parties at
the table would be the district health authorities. The only real costs are the
administration costs and the coordinator's salary.
The Chairman: Essentially, you asked for $120,000 a year for three
Ms. MacIssac: It is $120,000 for each year.
The Chairman: The group that was here before lunch had a budget in the
same range, right? It has to be saving the health system an unbelievable amount.
It just seems so obviously cost effective, what am I missing here? Or am I not
missing anything? It really is that cost effective?
Ms. MacIssac: Well, just from what has been accomplished through the
dementia network in Cape Breton, I think the only thing we are missing is an
opportunity. We have a part-time coordinator down there and what they have been
able to produce in the brief time that they have been in existence is amazing.
The Chairman: Now, you are only dealing with dementia and Alzheimer's,
is that correct?
Ms. MacIssac: Yes.
The Chairman: However, logic says to me — and tell me if I am wrong in
this — that the same process ought to work with respect to home care for
individuals suffering from other types of mental illness. In other words, is
there something unique about your structure that makes it work only for
Ms. MacIssac: No. In fact, I would say that the idea of having an
overall mental health network would be a definite step in the right direction. I
think that what could be brought to that is amazing, especially the involvement
of the consumers in a mental health network. The work of the Capital District
Health Authority, and I do not know if Steve Ayr was here —
The Chairman: Yes, he was.
Ms. MacIssac: Yes. That work is phenomenal. A larger mental health
network could work.
The Chairman: It would be a little more expensive because you would
have a few more bodies, but we are not talking about a huge expense, unless I am
missing something. Are you likely to try that in the Cape Breton health
Ms. MacIssac: A mental health network? If the mental health networks
roll out across the province we would definitely be a part of it. The seniors'
population would certainly benefit from that.
Some of the mental health needs that you would find in adolescents, youth and
even young adults are different from those of dementia. I worked in mental
health for five years and with the Department of Health for 20 years.
Youth being cared for do not often see their caregiver as someone that they
want to spend time with or that they want to depend on for care. The opposite is
true for people being cared for by their spouse in their home and who are
fearful of leaving their home, which is not the case for young adults and
adolescents who are receiving mental health services. I would say that the needs
for caregiver education and special home-based support are also very different.
The respite aspect is different.
The Chairman: To that extent, the seniors, the young adults and the
children's services are quite different. The seniors' aspect would not be
dependent on it being Alzheimer's? It is more a function of the patient's age?
Ms. MacIssac: Yes. When I left the Department of Health I said what
was most lacking — and I worked in acute care mental health and drug dependency
policy and planning shops — was adolescent mental health, in particular, day
programs for adolescents where they can convalesce with each other. They have a
program here in Capital put on by Nancy Beck, and I do not know if you have
heard about that or not, but that is a model where the youth themselves talk
about how part of their recovery and healing is a result of that because they
get life skills; they get counselling; a whole variety of services that are
directed toward adolescents.
The Chairman: Who runs it? I know Nancy does, but under what
Ms. MacIssac: It is under Capital District Health Authority. Nancy is
the head of that. It is an outreach day program.
The Chairman: She was here, right? Yes.
Ms. MacIssac: The young people really talk it up themselves.
Coming back to your point, Senator Kirby, about would we be part of a broader
mental health network? Yes. Would we still need better integration of dementia
services themselves? Yes. Geriatrics is not an attractive area, in the same way
mental health overall is not. It is just not sexy in the health care system.
Senator Pépin: It is not attractive to be surrounded by elderly
Ms. MacIssac: Yes. I think people become engaged in acute care right
from the time they are in medical school, whether it is surgery, orthopedics,
oncology or whatever. Looking after the elderly or people with mental illness
just has not been the Canadian health care system's priority.
The Chairman: Tell me about what one really needs to do for the family
caregiver. I understand you said respite is not just time off to go shopping et
cetera, but time off also to go to support groups and take a break. Are there
other supports that family caregivers need? They take on an awful burden.
Ms. MacIssac: I know. I think being part of a support group makes a
huge difference for many of them. We have 33 support groups in the province, so
that support makes a big difference on the ground.
The Chairman: Are the members of support groups all people who are in
the same situation?
Ms. MacIssac: Yes, they are sharing their experiences. The support
groups are not really for people who have the disease. They are for the
caregivers. They talk about the burden that they are experiencing and how they
do not want to make the person with the disease feel bad.
The Chairman: Do professionals attend these support groups?
Ms. MacIssac: We run ours with volunteers, but it just happens that
some of them are people who worked in health care or who have lost a loved one
to the disease.
Senator Cordy: How do you make sure that people actually use these
services? Human nature being what it is, particularly in women — and I do not
want to stereotype but it is true — people tend to say, "I can do it, I can do
it.'' However, a 75-year-old caring for another 75-year-old cannot do it day
after day. You talked about a referral; would that be to the VON? Who would know
that this family needed a referral?
Ms. MacIssac: The referral is for everyone who is diagnosed with
dementia. It is becoming part of the formal health care system to have a
referral to those supports, just as, if you needed a referral for drug
treatment, it would automatically happen. This is a referral for the person with
the disease and the caregiver at the time of diagnosis.
Senator Cordy: Does the caregiver often have to be persuaded to leave
the home? You are absolutely right; the person who needs the care becomes more
and more clingy and does not want the caregiver to leave, and the person who is
leaving tends to feel guilty about it.
Ms. MacIssac: Yes. I think that home care is further ahead in some of
the Western provinces than it is in Nova Scotia. Right now I would say persons
with dementia are falling through the gaps, because once you have met the
criteria for chronic home care, there are 78 respite beds for the entire
province that you have to access through a single entry point. Therefore, first,
there is no assessment tool. One has been researched at Mount Saint Vincent by
Janice Keefe that assesses caregivers' needs at the same time that the needs of
the person with the dementia are assessed. That would make a huge difference in
the care and treatment of people, if you looked not only at the person with the
disease but at the family as a unit, and then the referral would be automatic.
The most important issue right now is it is a burden to try to take people
with dementia out of their home in order to get that respite, and often,
caregivers will not do that. An unfamiliar environment often makes dementia
worse. By using a health care professional, not a volunteer, for this component,
and expanding home care, public health, nurse practitioner or mental health
practitioner services to go into the home to provide respite, you can provide a
service to a person with dementia. Those practitioners are trained to know what
to do, and meanwhile, the caregivers are caring for themselves and going outside
the home for respite.
The Chairman: When people talk about Alzheimer's in ordinary,
run-of-the-mill conversations, you do not detect the same stigma as is attached
to mental illness. Why is that? If you tell someone you have a mentally ill
parent as opposed to saying you have someone with Alzheimer's or dementia, the
reaction is quite different.
Ms. MacIssac: I think actually there is a high degree of stigma,
because when people have a spouse with dementia, often they will be reluctant to
go out socially and take their partner with them because they might do things
that would embarrass them. They kind of hide away in the community and become
less visible.A big part of the reason they do that is the stigma.
The Chairman: It is more than I would have thought.
Ms. MacIssac: Yes.
Senator Pépin: If you say that your spouse is suffering from
Alzheimer's, people will say, "Oh, my God'' and they will be much more
supportive. I think that people will say, "Well, it is a mental disease.'' They
will say, "Oh yes, it is a terrible disease,'' and things like that.
Ms. MacIssac: Yes. I think the fact that there are physical elements
to dementia, more so than with other mental illnesses, is a factor too in
comparison with the increased stigma of mental illness in the younger
population. It is less physical. However, with dementia there is a real physical
element to the disease whereby the brain cells are being broken down and
Senator Cordy: Is it easier to become invisible when you get older?
Ms. MacIssac: Yes.
Senator Cordy: It is easier to say, "I am tired'' or "We are too
tired'' than it is in your 20s or 30s.
Ms. MacIssac: Yes. The fifth point on our list is about medications.
If I have cancer I will get chemotherapy because the health care system does not
want the disease to get progressively worse. If I have dementia, medication will
help me in terms of preventing the disease from progressing. When a drug is not
on the formulary — for instance, right now there is a mid-stage drug in front of
the drug review board — you do not get back that time as you get worse. If you
go on the drug, you do not go revert and get better; your symptoms do not get
better. You do not get that time back. If I had schizophrenia or bi-polar
disorder or something of that nature and went on medications, it does not matter
whether I go on them today or six months from now, we can be optimistic that the
drugs will have an impact. If over six months I have progressively deteriorated
from early-stage tomid-stage dementia, I do not get that time back and the
impact of the drugs will be diminished. Early diagnosis, early intervention and
early support are important so that caregivers are not lost in the system. To do
that, we really need that third-party referral system whereby right upon
diagnosis, you are linked to the society. Right upon diagnosis your community is
working on issues of education, research and coordination of services at the
The Chairman: Are drugs covered?
Ms. MacIssac: Only some drugs. In some provinces, you have to be
tested to prove which stage you are at in order to access them.
The Chairman: What about Nova Scotia?
Ms. MacIssac: Some drugs are covered, but others are still under
Senator Cook: You are back to the formulary. The same thing applied to
the drug of choice for schizophrenia. In my province there has been a hue and
cry about getting the drug of choice for Alzheimer's.
I personally do not see the stigma with Alzheimer's, because it is a part of
the aging process that, if we live long enough, we will all experience; it is a
kind of end of life phenomenon. How often will someone say of an older person,
"Oh, he or she is such an age and as smart as a tack''? There is a qualifier
there. I think Alzheimer's is a fancy name for losing your memory and we know a
lot now that we did not before. My grandfather had Alzheimer's, but we did not
know it. We just thought he was difficult and we cared for him.
The Chairman: Or words like "senile'' were used.
Senator Cook: Yes. In Newfoundland we would say "low minded.''
We noticed with Grandfather Cook that it changed his personality and he swore
like a trooper. He never swore in his life. This amazed us. He was cute. For a
long time he hid it. He was a farmer of the old school. We only noticed it when
one day he asked about my oldest girl, who the little boy was, because she had
overalls on. However, that is part of growing old and I do not see the same
stigma around Alzheimer's that I do around mental health issues.
Ms. MacIssac: I would agree with you to a certain extent that the
stigma is more around adolescent and young adult mental health problems.
However, in terms of whether it is a normal part of aging, we point out in all
of our literature that that is a prevalent myth in society. Alzheimer disease is
not a normal part of aging. It is a disease. It is like diabetes, you either
have the disease or you do not. Most will not suffer from the disease as they
age, but 25 per cent of families will experience someone in their family with
dementia. We are currently working diligently on the cause and the cure and many
advances are being made. The drugs that are being produced now are having an
impact on slowing the progression of the disease. There is new cell research
that may even lead to a cure.
Also, the other point is that, perhaps because we have become more aware of
the disease, it is occurring more and more in younger people — early onset. We
do have to be very aware that it is not just older seniors who are faced with
this as a daily part of life, but it is affecting a large segment of the
population at younger ages.
Senator Pépin: When you say "younger age,'' starting at?
Ms. MacIssac: There can be early onset at age 30, 40, 50.
The Chairman: Some of the staff may remember way back when someone
talked to us, in Ontario somewhere I think, about a 30-year-old individual in a
mental institution who had Alzheimer's, although admittedly it is rare.
It is obvious that the kind of support you people provide is much better for
the patients and more economical than putting them in an institution somewhere,
which is the other realistic alternative. Has anybody done a study of the cost
effectiveness? The reason I ask is that people are always talking about how to
make the health care system more efficient.
Ms. MacIssac: Sustainable.
The Chairman: Have there been any data collected or has a study been
done? Does anybody know if there have been studies on that?
Ms. MacIssac: I do not, other than an analysis of the cost of treating
persons with dementia in acute care and long- term care settings, and that was
$5.5 billion. The Canadian Medical Association did that study and published it
in one of their journals.
The Chairman: However, that is the cost to society. I was trying to
understand the cost if the Alzheimer society, the family caregiver and so on
looked after someone versus an institution. We should try to find that out.
Somebody must have done that work somewhere along the way. When I look at
$120,000 a year and $1,500 a day per hospital bed, just intuitively it has to be
hugely cost effective.
Ms. MacIssac: Well, 63 per cent of people say that it allows them to
keep their loved one at home, which is their preferred option. I can understand
that palliative care research would indicate that some do not want the
responsibility of a palliative care scenario at home. Although we are also
advocating that there are not enough palliative care home- based options either.
The end of life is a very difficult time for a family. However, if 63 per cent
of those assessed in the survey are saying it will allow them to retain someone
in their home longer, it just seems to make sense.
The Chairman: Knowing how everything in the health care system now is
driven by money, it would be nice if we could establish that it is not only the
right thing to do for the patient, but in fact there is no excuse for
governments not to do it because it actually saves them money. That is why I
would like to see if we could find hard evidence. We will check with your
national association. I cannot believe somewhere along the line somebody has not
Ms. MacIssac: — done a cost/benefit assessment. Yes.
The Chairman: Exactly. On the medication side, as you say, it depends
on whether or not it is on the provincial formulary. That is the issue, right?
Ms. MacIssac: Yes.
The Chairman: It is slow getting onto the provincial formulary because
the government does not want to pay the cost. Is that basically it?
Ms. MacIssac: Yes. For instance, just to give you an example, one of
our board members with dementia, Fred West, is doing promotions with the
national society. Before he went on theearly-stage drug he was unable to read,
to drive, and was forgetting everything. It is a bit uncommon, because usually
you do not gain that ground back, but now he is an active board member. He is
reading. He is driving. His entire quality of life and, therefore, the quality
of life of his wife have been affected by access to this drug.
The Chairman: Who pays for his drugs? Who pays for his medications?
Ms. MacIssac: He would have a medical plan, if it is on the formulary.
If not he would have to pay for it himself.
The Chairman: When you say a "medical plan,'' the government is not
paying for it?
Senator Cook: If it is on the formulary the government pays.
Ms. MacIssac: Yes.
Senator Pépin: It is insurance if you have a private plan.
Ms. MacIssac: Right.
The Chairman: The government pays even though you are not taking it in
a hospital; you are taking it at home?
Ms. MacIssac: Yes.
Senator Cochrane: I would like to know how much research is done on
drugs for Alzheimer's. Do you have any idea?
Ms. MacIssac: I am probably not the most qualified person to answer
that, but we have an extensive research group right here in Nova Scotia working
on new drugs in this area. The research community is quite strong.
Senator Cochrane: I have heard concerns from a lot of family members
of people who leave their homes to go into an institution that the nurses and
staff will give these people a drug just to keep them low key.
Ms. MacIssac: A sedative.
Senator Cochrane: Yes, so they are not wandering or shouting out. You
have heard some if it.
Ms. MacIssac: Yes.
Senator Cochrane: I wonder, is that the right way to do it? I do not
Ms. MacIssac: I think that there are important considerations in
creating an environment for people with dementia. One of your colleagues
mentioned earlier that she visited a site in Montreal recently where they had an
external garden, with fences that people could see through and where they allow
There are best practices for facility construction in long-term care for
people with dementia that are progressive. Our province is currently becoming
aware of many of them and is actually looking at them as models. However, we
have a long way to go. I would say there is still some warehousing and
overmedication occurring within the long-term care sector. I think there is an
opportunity to change the physical and pharmacological environment in which
people with dementia are currently living.
Senator Cook: In Newfoundland, the Glenbrook Lodge has a garden for
the Alzheimer's unit.
The Chairman: It is fenced, it is enclosed?
Senator Cook: Yes. It is locked inside. However, the patients on the
unit can wander there and they can wander out through the open door. We had an
architect design it about seven years ago. We have an Alzheimer's walk, because
the patients tend to walk in circles, and that has been an incredible place; and
the calming effect on —
Ms. MacIssac: It would be really helpful if provincial governments
would develop policy around creating friendly environments for those with
dementia when they are building long-term care facilities.
Senator Cook: Ours cost $45,000, and we raised the money ourselves.
The next time you go up Torbay Road, if you look to the north side of Glenbrook
Lodge, you will see a beautiful garden.
The Chairman: I was in one of those actually in Calgary, visiting with
the mother of a friend. It was a long-term care home and the lady I was visiting
was in the nursing home section, not the dementia section. However, I went
through the dementia part, and you are right, it is quite amazing, the effect of
the garden, and patients can go outside. There is a bench where you can sit
Senator Cochrane: I was wondering earlier if that was privately
funded. I have a feeling it is.
Ms. MacIssac: That is the kind of facility that everyone should have a
Senator Cochrane: That is right. Yes.
Do you have many cases where the wife and the husband go into the institution
together? We have had that in our area, where both partners go to the
institution and one has Alzheimer's and the other does not. They go as husband
Ms. MacIssac: Yes. I think that kind of consideration probably needs
to be looked at as well.
There are facilities now, and we have one here in Capital called Northwood,
which have an array of services and housing options under the same facility so
that as people's needs change — and I am not talking about necessarily dementia,
but about a person who has care needs — they can progress through different
options. That should be looked to as well.
Senator Cochrane: Yes, the options are wonderful.
The Chairman: Certainly, if you look at the homes being built in the
private sector, typically, they accommodate stages.
Ms. MacIssac: Yes.
The Chairman: You start off in what I would call a classic retirement
home, and then it just depends on the amount of care you need, because that way
you are not changing your environment. There is a degree of familiarity.
Ms. MacIssac: We would like all provincial governments to have
policies that support dementia-friendly environments.
The Chairman: However, that has not happened anywhere at this stage?
Ms. MacIssac: Not yet. I do not think so.
The Chairman: Any other advice you have for us?
Ms. MacIssac: One of the other important points is the fifth one,
about a dementia strategy, and that has been put forward. There are fundamental
items within that framework — we did not bring copies but we can send you one —
that speak to the federal and provincial governments working with
community-based organizations on a strategy in which both levels of government
can support a variety of the needs of people with dementia. Right now it is a
private member's motion. There is a lot of detail within that to support a
direction for a national strategy.
The Chairman: Yes. We probably have that, but if we do not we will get
it from you.
Ms. MacIssac: It is on the NACA website.
The Chairman: NACA is your national association?
Ms. MacIssac: Yes.
Senator Cook: On your third point here, "Enhance mental health and
dementia education,'' how do you see implementing that in a rural area?
Ms. MacIssac: I think you made a point earlier about nurse
practitioners, and that is important. At one time, mental health was a bigger
part of public health. There were nurses who specialized in mental health, and
that has been lost. The community mental health nurse has been lost. Having
community mental health nurses available, whether engaged in the schools for
younger people or going out to people's homes as age becomes a factor, is one of
the components. Enrolment within medical schools in gerontology is another. More
awareness of dementia among mental health professionals, psychiatrists or
psychologists, is another area.
Senator Cook: The health care professional working in a rural area
could benefit from telehealth. Could that could be another way that person could
Ms. MacIssac: Yes.
Senator Cook: In Newfoundland they are using that for continuing
education in, I think, four disciplines now. The other action you advocate is to
establish and fund a national Alzheimer's strategy. We are looking at developing
a mental health strategy. Do you see yours as a stand alone strategy or part of
the national strategy?
Ms. MacIssac: You have a section within your report directed towards
seniors, and I think a lot of what is being brought to you today in terms of the
five points can be incorporated into your recommendations. Your strategy is for
mental health, but it would encompass dementia.
The Chairman: Whatever our strategy is vis-à-vis seniors — and we will
be holding a day-long session on seniors — obviously dementia will be included.
Senator Cook: I just wonder if your wish was to have it stand alone or
to be integrated?
Ms. MacIssac: I think it is an important part of mental health.
Whether it involves caregivers and families or seniors or mental health, I think
we will try any number of avenues to make people aware of the very simple
approaches that can make a difference in the quality of life of the people we
are concerned about.
Senator Cook: I am just looking ahead to what this might look like,
because there will be a component in it, no doubt, for autism, say.
The Chairman: Just as an aside, we should tell you that interestingly,
we have had, at least I had, several complaints in my office about the fact that
we referred to autism as a mental illness.
Ms. MacIssac: Many people say that.
The Chairman: I did not know that. I was completely surprised. I am
told roughly half of parents of autistic children do not like it referred to as
a mental illness — we may do so anyway — I guess because of the attached stigma.
Ms. MacIssac: I think that comes back to the chemical and biological
The Chairman: Yes.
Ms. MacIssac: For instance, many people say that dementia,
particularly Alzheimer disease, is also a physical rather than a mental illness.
The Chairman: However, by that token, you could say the same of most
depression, which has to do with the serotonin level in the brain being out of
balance, and at that point you have systematically eliminated all mental
illnesses, if you follow me.
Ms. MacIssac: Again, it probably comes back to labelling.
The Chairman: Right.
Ms. MacIssac: Alzheimer disease impacts the cells within the brain and
that is considered a physical condition.
The Chairman: However, we are taking the position that a brain
disorder of some kind is a mental illness.
Ms. MacIssac: It impairs cognitive abilities.
The Chairman: Right.
Ms. MacIssac: The impairment of the cognitive abilities in autism is
probably similar to dementia in terms of people not wanting it to be referred to
as a mental illness.
The Chairman: Because of the baggage that come with the mental illness
Thank you for coming.
Ms. MacIssac: Thank you for having me.
Mr. Chairman: Please tell Sharon you carried her material well and we
hope she gets well quickly.
Senators, our last session before we head for the floods in Fredericton,
where I understand the river overflowed last night, is with a group of people
from a combination of Dalhousie and the IWK Health Centre, the children's health
Mr. Patrick J. McGrath, Canada Research Chair in Pediatric Pain, Dalhousie
University: Senators, I am a professor at Dalhousie in psychology,
pediatrics and psychiatry, but I do most of my work at the IWK Health Centre,
and much of it is on children with mental health problems.
As you know, the prevalence of mental health problems in children is about 18
per cent. There are a lot of good studies: the Ontario Child Health Study; the
Quebec mental health study. There is no doubt that is a significant problem.
What we have to always keep in mind is that treatments work. We know that
there are treatments. They may not work for every child, but there are dozens
and dozens of well-designed, randomized trials, millions of experiences, that
show that treatments work. These are both psychological treatments and drug
treatments. They make a difference to kids. Early intervention is better than
waiting until the problems get more significant.
Access is a significant problem. Again, referring to the Ontario Child Health
Study, studies found that only 16 per cent of children with diagnosable
disorders, not minor worries but diagnosable disorders, had seen a mental health
practitioner in the previous six months. Children with mild and moderate cases
experience a long time on waiting lists, and this is true throughout the
The waiting lists are actually an underestimation, because when you have a
long waiting list, people stop referring patients to the list. Also, families
say, "Well, no, I am not interested in going on a waiting list for six months
for a four- year-old child who is having severe temper tantrums.''
There are lots of other barriers to treatment. Stigma is an important
barrier. Although things have grown much better over the last 20 years, there
still is a serious problem with stigma.
In Canada we have a public health system that supposedly provides free
treatment. However, oftentimes it is not free.If you are, for example, a mother
of a six-year-old child with severe anxiety that is interfering with everyone's
lives and you need to go to a psychologist, if you are working, you have to take
maybe 10 half-days off work. You have to find child care for your other
children. You have to find transportation. You may have to pay for meals away
for home. If you live in a remote area of Canada, it may take several days
travel just to get a couple of hours of treatment.
The question is why do some parents attend? Why does anybody attend for
treatment when you think of the sacrifices they have to make for that?
You have targeted the research issues in your reports and I am very
interested in those also. The CIHR, the Canadian Institutes of Health Research,
actually does a very good job. Rémi Quirion, Scientific Director of the
Institute for Neuroscience, Mental Health and Addiction, is a great leader, as
is Michael Kramer of the Institute for Human Development, Child and Youth
Health. They are all interested in child mental health.
The problem is that there are no targeted funds for that. I would encourage
targeted funds for major national problems such as child mental health.
The CIHR has had a number of different initiatives to bring together
clinicians, communities and academic researchers. One of them is the Community
Alliance for Health Research, and I want to tell you a little, in the last
minute or so, about the program that we have developed under that.
We have developed distance treatment programs, called Family Help. I can
leave some of the manuals, but I do not know how much material you want. We
target high-prevalence problems and treat them at a distance. We use manuals
such as these, videotapes, audiotapes, and a coach, a non-professional, who
talks to the family on the phone.
We are currently doing randomized trials using funding from CIHR to test
whether these are effective, both in rural areas and in the city. These trials
are done in collaboration with our colleagues in the mental health system. Cathy
Thurston, for instance, the Director of Cumberland Mental Health Services in
Amherst, has been actively involved. We have advisory committees and so on to
advise us on how to make the trials responsive to the needs of the mental health
system. Our colleagues are now putting forward proposals that these treatments
be made part of the mental health system. We hope that that will happen.
However, you should note that we recently had a very large increase in the
health budget in this province: $212 million,$220 million, and less than 1 per
cent of that went to mental health. That is just not acceptable, given the
prevalence. Thank you.
Ms. Susan Mercer, Acting Vice-President, Child and Adolescent Mental
Health Program, IWK Health Centre: Senators, thank you for asking me here
today. My name is Susan Mercer and I am the Acting Vice-President of Child and
Adolescent Mental Health Services at the IWK Health Centre. I have been here
seven years, and I came from Ottawa, where I worked for 11 years. I spent my 11
years in Ottawa thinking there were not enough resources for people with mental
illness. I worked primarily with street youth. Then I moved to Halifax and —
The Chairman: You realized how much you had in Ottawa?
Ms. Mercer: Honestly, I did. When I moved here there was no shelter
for street youth, and I spent the first year as a kind of volunteer, trying to
lobby with others for a shelter. I could not believe that there was not even
somewhere for kids to sleep.
At the IWK we offer a lot of mental health services. We have 13 different
teams and are spread out over the province. We have a Maritime mandate. We
support the Friends Exist. We have a clinical team at the youth corrections
centre. We do forensic rehabilitation. We do a lot with kids who are seriously
mentally ill, and we have a relatively small budget, probably $12 million or $13
However, we have a problem with wait-lists, as people do across the country.
I believe that we are not meeting the needs of the children and adolescents who
are sitting on our wait-list. They wait because they have a mild to moderate
mental health difficulty — anxiety, or not wanting to go to school, or parents
have just separated and they are not dealing well with it. That is not to say
that that is not important, but when you look at the other children on that
list, who tried to kill themselves or are hearing voices, we attempt to meet the
needs of those children.
We have done a lot of work in the last year to try to figure out how we can
do things differently with what we get, but we also realize that we do need more
to be able to attack that wait-list. We have 380 people on our wait-list, and
that is just the capital area, because outpatient services are only in the
Halifax-Dartmouth area. That is a huge number, and children are waiting in
excess of a year. I get calls from the parents to tell me what is happening: "I
need my child to be seen.'' We have office-based appointments, and that is not
what that child needs. Often, they wait, and then they come once and do not come
Therefore, we are trying to, one, redesign our system. We are looking at a
new triage system. We are planning to use some of Chuck Cunningham's work from
Ontario. We will specialize within outpatient services, so that when people are
referred we know exactly where they need to go. We are applying for funding from
the government for programs such as Dr. McGrath's.
The Department of Health in the province has worked quite hard in the last
couple of years to develop standards for mental health services, the only
province in Canada to do so. We have been heavily involved with that, as has the
rest of the province. Their standards provide the outline of what services
should exist, and then each year we say how much money we need to meet them.
Within those standards there is a continuum of service, including outpatient,
mild to moderate mental health problems, prevention education — all the things
that we have not been doing. Therefore, when we apply for funding, we are able
to use those standards to justify our requests, and that is a good thing.
The difficultly we face is that we have a very fragmented system here.
Children can often sit in our inpatient unit or in our residential programs for
months because there is nowhere for them to go when they are discharged. That is
very frustrating for children, for families, for all government departments. I
think we have to all figure out how to work together, not just governments, but
everyone, because it is not your kid and my kid, it is this one child going
through the system. I know you have discussed that in your report and have made
those same recommendations.
We have a lot of work to do. I think that we do not reach out to the
multicultural population, the homeless youth, the African Nova Scotian. There
are big gaps in the populations we serve, for a lot of reasons, and if we have
more resources we can spend the time trying to figure that out.
I do not think it is just throwing money at a system, because you can do that
forever. However, it is looking at how to get the best bang for the buck.
Our priority this year is to look at our wait-list and figure out what we can
do differently with what we have, because there is not a lot more forthcoming.
I will leave it at that.
Dr. Herbert Orlik, Clinical Director, Chief of Psychiatry, IWK Health
Centre: Honourable senators, I am the Chief of Psychiatry for the Child and
Adolescent Mental Health Program at the IWK. I am also Head of the Division of
Child and Adolescent Psychiatry at Dalhousie University, so I have
administrative, clinical and academic responsibilities.
I have reviewed the committee's three reports, which meantlots of reading. I
am impressed with the amount of work the committee has done; the research you
have done; the people from whom you have sought and received advice; and a
not-astounding consensus emerging on mental health issues in general terms, and,
to a smaller extent, for children. If I could level one minor critique, which we
are here to correct, I thought that the report so far was somewhat thin on the
children's side and would like to contribute to enlarging that part.
The report also refers to the children under special population groups, and I
have mixed feelings about that. On the one hand, to be special means you might
get special attention. On the other hand, it puts you into a category different
from anyone else. I am reminded that people looked at adolescence that way.
Adolescence did not really exist, because they were only in transition between
childhood and adulthood. I have concerns that to be special in that way could
I think children are as special as young and middle-aged adults, as older
people, and as adolescents. Within the child and adolescent age group there are
special population groups that require attention, but beyond that children need
as much attention as adults, and equal footing, equal funding, equal research
and equal therapeutic opportunities. In that sense, I would not like them to be
special. I would like them to be equal to other age populations.
Comparisons with adults have sometimes been helpful and have sometimes been a
hindrance in the history of child and adolescent mental health. We have wasted
time on arguments over whether the children could have a disorder because
psychoanalytic theory said that you could not have a depression until you were
of a certain age; or that you could not have a disorder, or problems, or suffer
as a child if you did not meet the criteria for adult disorders. The study and
treatment of children has been in the shadow of adult disorders, properly so for
the sake of protection and because they were like-minded professionals, but
improperly so sometimes, because you always had to justify it against the adult
standards. I think the time has passed when that needs to happen. Children need
to be seen in their own right.
I echo what has been said about research, that we do not have enough, that it
needs to be better funded. We are still in the relative infancy of research in
child and adolescent mental health compared to adults, and compared to other
areas of medicine and social sciences. That needs to be understood when
researchers go out there and try to get their feet wet. Due to funding criteria,
we still have a lot to learn, and we have to play catch up or develop new
methods of investigation for young people.
Another area of concern to me and to colleagues is the application to
children of therapies that have not much value, therapies that have either been
disproved to be effective or are unproven — they have not been properly
researched — therapies that have been wasteful in terms of resources; therapies
that have provided false hopes for children, adolescents and their parents;
therapies that at times could be harmful.
We need to go by the existing evidence and expertise and, therefore, apply
best practices, and we need to do the research to create evidence where it does
not exist as yet.
We are truly still applying therapies to large numbers of young people that
are entirely ineffectual and do not stand up to scrutiny. We need to review
theories of disease causation.We used to, years ago, blame mothers. Mothers were
blamed for just about everything. We made mistakes in looking at a disorder like
autism and said, "Autistic kids are that way because of what their parents did
to them.'' No. These are neurobiological, neuro-developmental kinds of
disorders. We used to have incredibly fanciful psychosexual theories about
obsessive compulsive disorder, and again vilified people as a result of that and
applied therapies that did not work.
As a resident, I had to do therapies of that kind. I was told that it likely
would not work, but we had to do it. That was the kind of baptism you had to go
through, but it was bad clinical practice.
We have better therapies now. We know that cognitive behaviour therapy works
for a number of conditions, especially anxiety disorders. We know that
multi-systemic therapy, although expensive, works with children with severe
cognitive disorders. We know some of the kinds of treatment interventions that
are supported by evidence and that we can further develop and refine; and we
know the areas that need to be researched.
I think we need to have the courage to step away from ineffectual therapies
and be open with the public and with our colleagues in saying, "You are wasting
your time, and you need to do something new. You need to change.'' I agree with
what was said earlier about early intervention methods as well.
We need to know what works and what does not. Some of the treatments have
tremendous emotional appeal, and some even have tremendous cognitive appeal. It
appeals to your sense of what seems to be fair and correct, but as a result of
that sense the studies have not been done. At the moment, community-based,
community-centred therapies are where it is at, and that has an appeal, but it
has to be proven to be effective. It has to be compared to other kinds of
The last thing I want to say is that I saw discussion in the report about
models, looking at the provinces or other countries that have developed models
of care and which should we acquire. Which should we apply to our Canadian
populations? I would like to promote having an open mind about that, and trying
on different models in different situations. Primary care models, children's
health centre models, community-based models, may all have valid evidence if we
study them properly.
We should not take a cookie-cutter approach and say, "We will do this on the
cheap for children, and this will work for all of them.'' We have tried that in
the past. It has not worked. We had a mental hygiene movement for children and
child guidance and it did not take care of everything. Children are complex and
they need a range of comprehensive services.
Dr. Wade Junek, IWK Health Centre: Senators, I will state first that I
am the "and now for something completely different'' section. I am a very
visually oriented person. I did give you a handout, and I think it will be
easier if I just walk you through a few pages of that — and there will just be a
I am a child and adolescent psychiatrist, and for 12 years I was the director
of mental health services for the Province of Nova Scotia, so I have a
background in government.
The work that I am presenting arose from the work of a
federal-provincial-territorial committee, which I co-chaired, on the development
of the concept of self-regulating services delivery. It is relevant to much of
what you are hearing today, and in particular to some of the questions you have
raised in your own report, about coordination and cooperation. It also can
present you with hypotheses about why the research that Dr. Orlik orDr. McGrath
talks about does not get used, because that also fits in with some of the
concepts here. It is a population health model.
You raised questions yourselves that I have noted on the bottom of page 2,
but the history of those questions goes back for decades, if not back to the
1800s. On page 3 there are more relevant questions you could have asked, but I
will not go through them.
My goal is to speak about why the collection of services that you people
discovered exists for mental health remains a collection and not a system; to
provide a means to answer some of the questions you raised; and provide some
options that I hope can help things evolve a little further.
On page 5, I start with what happens. All children and youth become adults,
and the whole purpose of everything we are doing in government with children and
youth is to intervene in some way with the hope that we will help them attain
optimal well-being and functioning by adulthood. However, you face three major
On page 6, for instance, are the stakeholders — well known to you. Those
interventions, decisions and actions are made by a large number of stakeholders
with complex interrelationships, including, but not limited to, the people you
see on that page; the governments, jurisdictions, et cetera.
Page 7, challenge number two, all of those stakeholders have environmental
influences on the decisions and actions they take, including, but not limited
to, the other stakeholders, the resources they have, the legislation they have
to operate under, political pressures, media, et cetera. In total, all of these
influences on the decision makers act as positive, negative, and, sometimes,
perverse incentives for the kind of decisions they will make. Many of their
decisions may have little to do with whether or not our children will be
optimally functioning by adulthood.
They know this, of course, so they move onto challenge number three, the
strategies used in attempts to get a better outcome. I have just categorized
them under three major strategies. There is a good list on page 25, but I am not
asking you to go there.
Essentially, there is the strategy to increase resources. We all know that
has a limit.
There is improved efficiency, which is the strength of the free market model
in business, the powerful force of ever more profits driving creative and
cooperative strategies for ever improving products. What are the incentives for
ever improving mental health status of our children and youth?
There is improvement in cooperation, and that is one you have identified.
That is also ongoing at the levels of patients, programs, policies,
organizations and governments. Governments try legislating it, pleading for it,
begging for it, but it is still a problem, which you people have already
On page 8 you go back to that fundamental goal. How will we know if any of
our stakeholders, environmental influences or strategies is helping us get
there? The only way we will know if we are getting ongoing improvements in the
mental health status of our children and youth is if we measure it. If you take
a look on page 10, you need to take some kind of information out of that
process, on adult citizens, and feed it back into those management strategies,
environmental influences and stakeholders to affect their decisions and actions
and allow corrective action to get improvements. We do not do that.
On page 11, the challenge then is how do you reach goal number two? If the
fundamental goal is to improve the mental health status, or maintain even what
we have, for our children and youth, one, we have to measure that status to
determine if the actions are having an effect. We have to have outcomes and
measures. Two, we have to incorporate information about those measurements into
our decisions to allow for corrective action, so we have to evaluate the
measures and give feedback. Three, we have to make baseline improvements in
these measurements as the most significant and important environmental influence
on the decisions and actions.
In the way we look at our sum total of incentives, disincentives, perverse
incentives and rewards, we have to make them powerful and chain them as
positively as possible to outcomes.
Page 12 tells you what we do not have in a system. Frequently, we do not have
a vision of where are we going with our children and youth, the adulthood
outcome. We do not measure the outcomes. We do not provide feedback for
corrective actions. We do not attach powerful incentives and rewards, or make
use of what we do have and force it into outcomes.
When you put those in place, if you will turn to page 13, you suddenly see
that the decisions and actions are constrained by everything else, forming a
Going to page 14 — and this is not what I would do, but it helps illustrate
the point — in practical terms, if you want to reduce the number of young
offenders, you need to identify these kids in the early school years and bring
in child welfare and mental health professionals to help work with them, getting
drug dependency people involved because many of them are likely to get
themselves involved with drugs. You cannot do this without cooperative programs,
but also you cannot force that cooperation.
If we set that as our goal, "reduce your baseline rate,'' let us take 1 per
cent of our total provincial spending on children and youth and set that up as
an incentive or reward. Administrators like to have money for their services,
and if reducing their baseline rate brings them an extra million dollars in
operating expenses for their region, that is a powerful incentive. I am saying
that it is not what I would do, but I want to illustrate the point. That at
least brings about the need for cooperation when it does not exist.
Similarly, you can do the same thing for preventive programs, as I pointed
out with the one on community prevalence rates with drugs. You can use that same
Now, there is much more that can be done about this. However, in conclusion,
I would state that there are additional models to add to our repertoire of
services delivery methodology. The self-regulating services delivery model is an
option that we hope can add to the thinking about health care services, mental
health services, services to children and youth. It is a way of turning a
collection of services into a system of care.
On page 16 is what I am not telling you because I only had so much time.
The Chairman: I must say, in response to your comment on incentives
and rewards, our entire previous health report was built on the notion that you
could only change behaviour in a system that complex by offering incentives. I
think we described it as putting in place incentives such that rational persons
operating in their own self-interest would exhibit the behaviour we want them to
exhibit. That same principle will clearly underline this one, so thank you for
Susan, where can we get a copy of the provincial standards for mental health
services? Whom do we phone?
Ms. Mercer: I brought a copy, but it is also on the provincial
The Chairman: I share the frustration about the amount of research
that is being done on mental health issues, whether as practice research or into
specific mental health issues, as opposed to what I would call basic science of
neurology. The research institute that Rémi Quirion heads has two parts to it.
It has a mental health part and a neurological science part. We have been trying
to roughly calculate the allocation of resources, but somewhere between
two-thirds and three-quarters goes to the neurological part and somewhere under
a third to the mental health part. You also all made the observation that
something clearly needs to be done to correct that imbalance. I have a question
for you, and I want to take off the table the easy answer, which is to get the
federal government to put a lot more money into research. Let us suppose that
the total CIHR pie does not change. Expanding the pie is a simple solution, so
let's take that off the table. From a straight economic return for the dollar
standpoint, more money in mental health research will be infinitely more helpful
than a lot of the other things they do, which is not to knock those other
things. How do we get there?
Dr. McGrath: There are 13 institutes. The institute budgets are only
about 30 per cent, a small percentage, of the total budget. Most of the money is
given on the basis of individual investigators submitting a grant, and that goes
into a large pot. I can submit a grant on anything I want, and then it is peer
reviewed and I just designate which institute it goes to. However, the
institutes do not control the money at all. Most of the money is in"CI trust
central,'' to use that term, and in the individual investigator-initiated
grants. It is not only the mental health institute that would fund mental health
research. I received a grant from Gender and Health on postpartum depression.
Some of the money coming from —
The Chairman: That was from the Institute —
Dr. McGrath: — of Gender and Health. It was on postpartum depression.
I recently got a grant from the CIHR on rural health, and you can see how some
of my work would relate to rural health. That was not from any one institute.
The institute that I am most familiar with is the Institute for Human
Development and Child and Youth Health, and I just helped draft a large RFA — I
am on their institute advisory board — on the developmental trajectories of
children, of which mental health is a very important one.
It is very difficult to find out exactly how much money goes to mental health
research, and part of it is a push by the CIHR in terms of making money
available to the individual institutes, but part of it is a pull from people in
the scientific community developing grants and asking for money. It is a
complex, interwoven issue. It is true that most of the CIHR budget is for basic
science. That is across the board. That is historic, because the CIHR came out
of the NRC. It is only three or four years since it took over from the NRC,
expanded its base from basic biomedical science and lab-based research, did some
clinical work and moved on into health services and psychosocial epidemiological
research. It is not as simple as looking at the budget of the Neuroscience,
Mental Health and Addictions Institute. Just looking at the printouts, it is
hard to know how much money is devoted to neuroscience research. I am sure that
CIHR can begin to look at that and I would be interested in looking at it with
If you want more research, you have to provide more money. You have to give
mental health researchers money. That is what it takes, and that will move them
in the direction you want. If you target money for mental health, they will
come. You can see that very clearly in the research on HIV/AIDS and on breast
cancer. Money moved researchers toward doing that work. Initially, it was hard
to find enough good researchers to take the money. However, in the last 10 years
we have seen a flood of good research into HIV and into breast cancer.
The Chairman: What you are saying to me is — I just want to be clear,
when you said more money — we should say to CIHR, "You have to target X per cent
of your budget, whatever the number is, to issues directly related to mental
Dr. McGrath: I think that the way to do it is to help CIHR partner,
for example, with others to increase the pie. We do not have enough money in
Canada in health research. We are still, even though it has improved
dramatically, in the lower third of the G8 countries. It is not a matter of the
CIHR having a lot of funding and they could just target that. Certainly targeted
funding within CIHR is one good way, but I think it is more useful to
collaborate with CIHR and try to grow the pie.
The Chairman: Sorry, I do not disagree with that, but my fallback
would be to ring-fence the money, even if it meant decreasing the amount they
are spending on other things.
Dr. McGrath: I think that would be one strategy.
The Chairman: I did not mean to monopolize the conversation here.
Anybody else want to comment? Because I think it is a critical question.
Ms. Mercer: Just quickly on research, we have several clinicians who
work daily with kids and would like to advance the research, but again it comes
back to our wait-lists are so long we cannot even free them up one day a week to
do the research. Therefore, after putting funding into the actual research
grants, you then do not have the resources to be able to carry out that
Dr. Junek: If you want adults who will look after their health and
their mental health, you need to start with children, and you need to start with
their mental health. It should be the number one priority. You cannot get there
if you do not look after their physical health. However, many people will stop
at physical health and forget about mental health.
If you make mental health of children the number one priority that in turn
ensures that you are more likely to get adults who will care about and look
after their health. That is an argument from my perspective for putting research
money into children, and into children's mental health. Furthermore, children
constitute roughly 25 per cent of the population, but I can assure you we do not
get 25 per cent of the service delivery money or the research money.
The Chairman: I understand why you may not want to identify specific
practices that you described as unproven therapies and with which there are
problems, because there may be people taking them. However, how the heck do we
attack your best practices?
Dr. Orlik: On the research side first, CIHR also from time to time
invites people to make proposals in an area that CIHR is interested in, or in
which somebody has suggested that CIHR should be interested. To some extent, it
is feeding that information into CIHR in a consensual manner. If we have large
national organizations that could have influence on that, we could have
consensus conferences about what is required in terms of a research strategy
regarding child and adolescent mental health, feed that information to CIHR and
increase the number of proposals that would result.
The other part is Dr. McGrath is a very successful researcher in many ways
because of his output, the grants and his expertise. There are not enough Dr.
McGraths around. There are many young researchers who have a hard time getting
off the ground and need the mentoring of a Dr. McGrath, a research environment,
and to stand up to what Sue Mercer was talking about regarding the service
pressures. How do we develop a cadre of young researchers who will be mentored,
supported, and not be discouraged from clearing what are sometimes very high
hurdles in order to get a CIHR grant.
CIHR is the big national organization. I think we need to think of some other
kind of funding mechanism. Nova Scotia has made a small start with the Nova
Scotia Health Research Foundation; there is the Canadian Psychiatric Research
Foundation. There are other kinds of funding bodies, and perhaps in regards to
children and adolescents, with the help of investments, other research bodies
could make it somewhat easier for people to get their feet wet in research and
develop the initial expertise that will then give them a leg up on the big CIHR
Switching to the ineffectual kinds of therapies, the largest proportion of
kids that we tend to see are those with a group of disorders that we call
disruptive behaviour disorders. These are children with oppositional defiant
disorder, conduct disorder, attention deficit disorder. We have a lot of
evidence that money is being spent by organizations, by government agencies, by
child welfare agencies, by private practitioners, by families — from private
sources and even through insurance money — on providing individual psychotherapy
for these children. There is absolute evidence that individual psychotherapy
does not work with any of these children. Analytic models, psycho-dynamic
models, do not work with these children. A great deal of money is spent on those
kinds of therapies that could long ago have been reinvested in all kinds of
The Chairman: You mean, for instance, when someone decides to take an
8-year-old or a 10-year-old to a clinical psychologist for counselling sessions?
Dr. Orlik: If that 8- or 10-year-old is breaking societal rules, is
violent with his mother, is controlling younger siblings and is disruptive in
the classroom, then individual counselling will be a waste of time.
Dr. McGrath: It is worse than a waste of time. Dr. Orlik is right. It
Senator Cook: Then why are we doing these "best practices''?
Dr. Orlik: Because we had a culture that said thatpsycho-dynamic
therapies are the answer to humanity's ills. We had leaders who were charismatic
in their practices, impressive in what they did and who espoused therapies that
made good sense, or sounded so complex that people said, "Well, it must be
correct.'' These practices have been in place for a long time, and as in other
cultures, it has been difficult to change things around. This culture has
resisted, also through medical-political means, if you like, research
interventions to study its outcomes. It has said, "Our outcomes cannot be
studied. Double-blind trials, control trials, do not apply to what we do. The
outcome is very long term. You cannot study in eight weeks or twelve weeks or
three months what the outcome is. You need to be involved in this kind of
therapy for three years, for five years,'' and things of that kind. There has
been an anti-evaluation component to that culture, and a perpetuation by a large
number of people who have huge investments in it, not the least of which are
financial investments, because you can make good money as a private practitioner
by hanging out your shingle and saying, "I provide this kind of counselling.''
The Chairman: What do we do about it?
Dr. Junek: Well, I will often speak from the standpoint of a
self-regulating service delivery model. The point that I would make here is that
if you are a regional jurisdiction responsible for the delivery of services to
the children within your region, there is no incentive to use a method of
service delivery that will be effective. Your incentives are much more
structured around whether or not the child gets to a service, and whether or not
the volume of services is roughly meeting the number of children and the waiting
lists are too long. Incentives do not exist to find out whether the children in
your region are actually functioning better this year than they were five years
ago or better than in region A or region C. There are no incentives to
incorporate the latest research. It is as though we said to the Ford Motor
Company, "We want to make sure you are making cars, but we do not pay attention
to whether or not you are making cars that work and that people want to buy. Our
job is to set up the factories to produce.''
Senator Cook: I sit here and hear that a child is in need. A service
is available, but does not meet the needs of the child. Within the concept of a
health care profession whose motto is do no harm, how do we find ourselves in a
situation where we are giving inappropriate services with no measurable
outcomes? I am confused.
Dr. Orlik: I said that these kinds of therapies can be harmful. The
proponents of the therapy, the parents, agencies that acquire that service on
behalf of their clients, would not look at that issue at all. They would look at
what Dr. Junek is talking about, which is that they are getting a service, it is
accessible to them, and surely, because they are paying good money for it, they
must be getting a good service. The notion of harm or ineffectuality does not
even enter into it. It is very difficult to debate with those kinds of
practitioners in those kinds of environments.
Senator Pépin: I am confused. We heard how important it was to have
the children see a doctor, not to have too- long waiting lists and things like
that. Now you tell us that the child should not be seen alone, if I understand
you. What then is the best treatment for those children?
Dr. Orlik: I can give you an example of the kids I talked about
before, the children with disruptive behaviour disorders. The parents who look
after these children need to learn a skill set to manage their children's
behaviour. They need to learn where they can inadvertently make the behaviour
worse. They need to desist from certain kinds of practices and reflexive
interventions with these children, and they need to learn in a number of
Dr. McGrath talked about one model of care that he successfully developed.
They need to learn skills to manage disruptive, provocative, interfering,
aggressive behaviour on a behavioural kind of model, rather than on a psycho-
dynamic, psychoanalytic kind of model. They need to do it with their kids and to
do it properly. Dr. McGrath has a system which is manualized, meaning there are
procedures to follow. There is a lot of research to show that if you follow
manuals, that if you follow directions, the outcomes are a great deal better.
You can do comparative kind of studies as a result of that, rather than if you
just follow your own intuition or your own charismatic approach to something.
There are a variety of very effective ways.
More severely disturbed young people can be placed in amulti-systemic kind of
environment where you address various parts of the system that contribute to the
difficulties. For example, children with disruptive behaviour disorders get
ejected from everywhere. They get ejected from school. Now you have a child who
has a behaviour disorder with a parent who is ineffectual. The school's answer
is zero tolerance. The child gets sent home to a parent who does not know how to
manage that child, the child does not get any education, and when he or she
comes back to school, is now disconnected from the rest of the children. You
have perpetuated the problem.
In a multi-systemic approach you would look at aspects of the system. You
would look at the school, the community services, at community-based facilities,
at parenting skills, at the child learning temper management, temper control,
and things of that kind. Put it together into a package and away you go. Those
are effective therapies.
Dr. McGrath: Yes, the type of thing that you would do is to teach the
parents first of all to pay attention to a four- year-old who is disruptive —
not the 12-year-old who is burning down houses or stealing cars. Almost every
one of those kids was afour-year-old who was disruptive, as Dr. Orlik was
saying. You teach them first of all to pay attention to good behaviour. It is a
very simple concept, but very difficult to teach. How do you give attention in
difficult, complex environments? Then you might look at teaching positive
pro-social behaviour by using behaviour charts, by using consequences. Then you
might teach how to use different forms of negative punishment, not severe, but
just some immediate consequences. Then you teach them to problem solve. You
teach them how to deal with the school. That is what you do for parents of kids
with disruptive behaviours.
They are difficult to work with because many of them have the same types of
problems as the children. God does not randomly assign children to parents. She
gives the toughest kids to the parents with the fewest skills. We have to figure
out multiple ways, not just the program that I developed. There are entire
groups of different types of evidence-based interventions that are all similar.
Now, you do involve an anxious kid in the therapy, and the fundamental
psychological treatment for anxiety is exposure. It is exactly what your mother
said, "You fall off the bike; you get back on.'' However, you have to teach some
skills in order to get them there. You use different therapies for different
problems, and if you look at the research evidence, it is very clear. The
psycho-dynamic individual approach, where you see kids with disruptive behaviour
face to face in your office, is disastrous.
When the kids tear up our manuals or hide them on the parents, that is the
major impact they have in terms of dealing with our treatment. We do not talk to
them at all because that is not what works. Now, if future research shows that a
different approach works, that is what we should do.
However, we have to do research. We have to continue to do research, not only
in the universities, but that is integrated with the health system, closely
allied with the health system, where decision-makers are involved right from the
beginning so that we can actually have an impact on services. When Dr. Orlik
talks about the non-evidence-based practice, it is not so much in the provincial
health system. There are some provincial health programs in some provinces that
do not have evidence-based practice, but they are very interested in looking for
that in Nova Scotia and in Ontario. I do not know about all the other provinces,
but B.C. is the same. However, there is an entire history of, "We cannot
evaluate this. We cannot apply science to it. Just do as I say.''
Ms. Mercer: We have a couple of small teams that work with children in
this way. We have a day-treatment program that works very closely with the
schools and with the families. We have an intensive community-based treatment
program where five workers work with the families. These workers and clinicians
are working with very small caseloads because they are not just seeing one
child. They are seeing the family, the teacher, the school and the neighbours.
You know the saying it takes a village to raise a child. Well, it is the same
with mental health difficulties
When you look at the money in relation to the number of children served, it
is an expensive program. However, I said the children who sit on our wait-list
are those with behaviour disorders and conduct disorders, and what we have to
meet their needs is very small.
It takes a shift in thinking and involvement of families right from the
beginning. When I say "families,'' it could be foster families, it could be the
neighbour who takes care of the child every day because especially with children
and adolescents, they cannot sit in an office for an hour and take with them
what they learned. However, they are more expensive approaches than the
traditional office-based treatment.
Senator Cordy: As a former elementary schoolteacher, it is music to my
ears to hear you talking like this, because I remember the frustration level
with one particular case. The foster mother and I had a wonderful dialogue about
the child not having the skills to deal with a group of over 30 children in a
classroom. The doctor was continually saying, "The child is doing fine when he
is alone with me.'' Until the child was being peeled off the ceiling in the
doctor's office and the doctor said, "I thought I told you to give him his
medication before you brought him to see me.'' The foster mother said, "I gave
him a double dose just before we left the house.'' The doctor said, "Then I
guess we had better start to talk about what is really happening.'' To hear you
speaking today is a breath of fresh air.
What happens so often is these children who desperately need socialization
skills are removed not only from the school setting, but, as you mentioned, from
sports, Brownies, Cubs, et cetera. Nobody wants to deal with them because they
have not developed the socialization skills. Then these children often learn
quickly that receiving negative attention is far better than receiving no
attention at all.
Am I right, from what you said, that there is greater cooperation between the
education system and the health system? Or is that a stretch?
Dr. Orlik: There must be better cooperation. Some of that has been
upset by funding cycles. While we may complain in health that we have had
insufficient funding, it has been worse in education, and more recently in this
province, it has also been worse in community services. We had in the past
better collaborative relationships with education, with school boards. We had
teachers from the school board placed into mental health settings. We had mental
health people go to educational settings. Each side has stepped away from this
to some extent, and we have to redevelop those kinds of relationships.
Again, if that was somehow incentive based and there was a collaborative
approach, rather than developing those kinds of silos, I think we could make
some advances. If schools were funded to keep children in school if it were
difficult and if mental health systems were funded to provide the collaborative
expertise to the schools, to work together on it, rather than, let us say,
putting children in institutions, then we might see a change. However, we have
to almost reinvent relationships with the school system.
Dr. Junek: I can speak about many of the same issues, but I do not
want to perpetuate the topic. I happen to be the consulting psychiatrist for the
day-treatment services in the IWK, and I work a lot with children with
disruptive behavioural disorders. You have heard enough about that, so I will
not speak about what I do.
What I would note is that the Department of Education withdrew the $20,000 it
used to spend to allow children to come to our day-treatment service, even
though we were taking them out of their schools four days a week so they could
have relief. They thought the $20,000 to transport the kids from all around the
metro area was too much. As a result, only parents do this now.
I have surveyed the province and services in Canada on this, and there is
only one other day-treatment service in Canada that I could find where the
parents were responsible for that expense. In all the rest at least 50 per cent
was paid by the Department of Education, if not 100 per cent.
In most of the other day-treatment services across Canada, it is also the
education department that provides the teachers. In the day-treatment services
that I am with, it is the health people again.
Senator Cordy: I keep thinking I will not be surprised at the
comments, but you know what, it blows me away when I hear things like that.
Dr. Junek, I am really interested in your self-regulating health care system
and in your vision comment. You said, "Without a vision we do not establish
where the system is going.'' I think it was Yogi Berra who said, "If we do not
know where we are going we might end up somewhere else.''
With any plan, you look at the vision-measures-feedback-reward. We learned
this while at university. Is this your model?
Dr. Junek: In my role as Director of Children's MentalHealth Services
for the province I attended a number offederal-provincial-territorial meetings
as the Nova Scotia representative for children's mental health across Canada.
During one of those meetings I presented the rudiments of this system to people
in equivalent positions, struggling with the same issues again and again. In
conversations with colleagues it became apparent that we were the only group
that understood the problem that we were facing.
One day I did a presentation to tie together the concepts that we were
talking about, fiddling with, et cetera. After one particular presentation I was
asked to develop my ideas into a more complete document, and as a result, Gus
Thompson, and I co-chaired the federal-provincial-territorial subcommittee
onself-regulating services. That developed into the document that you will see
on page 30 of my brief. It is a Health Canada publication, and available on the
Health Canada website.
That document was sent to every minister of health, every community services
department, the Department of Justice, every department of education and to a
number of researchers. In my cover letter I wrote that any questions or comments
would be welcome.
Senator Cordy: How large is your file?
Dr. Junek: It is a huge file.
Having worked in government, I have some forgiveness of this for a couple of
reasons. One of them is that people and committees receive documents like this
all of the time. This document, like many others is dry reading and I have
learned that the best way to get it across is to do it in PowerPoint
presentations with a lot more colour involved. I make it come alive, and it
usually takes me 20 minutes to 30 minutes to do a presentation, after which we
have a half an hour discussion and people begin to grasp the complexity of it,
and the way so many things interrelate. There are 17 potential benefits to that
kind of system, which is item 12 on the list. So that is sort of the history of
it, and that is partly where my role is in it.
Senator Cordy: What is your definition of feedback?
Dr. Junek: The essential thing you need to do is decide whether you or
are you not getting changes in your baseline and then you have to take that
information and feed it back to the people responsible for making decisions. You
also have to give them a reason that attending to that information and making
those changes ought to be the most powerful influence on all the decisions you
are making about your organization, in comparison to that other list of all the
environmental influences on decisions. These are all things that effect
When I went into the government the best influence, the most powerful
influence, on the decisions of the budgets of hospitals was, guess what? If we
go into debt the government picks up our debt, so it does not matter if we
overspend. Now, I was not in government, and I naively thought they understood
some simple things about life, that you know, when you reward people for bad
behaviour they will keep it up. Those are more powerful influences.
Senator Cordy: Ms. Mercer, this morning someone told us that there has
been a patient in the IWK since October only because he has nowhere else to go.
When I think about collaboration and cooperation between departments, this
example suggests to me that it is not happening because the cost of keeping a
child at the IWK for a month would be more than enough to put him in an
apartment with a support person and food.
Ms. Mercer: The funds come from different budgets.
Senator Cordy: It does not matter.
Ms. Mercer: No, that is the rationalization.
Senator Cordy: Food, an apartment and a support person for a year
would be costly.
Ms. Mercer: I am a very strong believer everyone should be able to
live on their own with the right level of supports no matter what they are
experiencing. This young man is no different from several others, where in order
to have them placed either with foster family, on their own with supports, or in
existing supportive housing, requires the intervention of senior level people
everywhere. It is wrong. I totally agree.
We have raised this, and we have met with government officials, and we are
really trying to come together to make this a seamless system because it is not
their kid or our kid. It is someone who, not just this person, but several
examples, who needed treatment or not, but somehow ended up in an inpatient unit
and had nowhere to go.
You are absolutely right: It comes down to different budgets and different
criteria. What some of these young people need does not exist for them.
Senator Cordy: Is there anybody who can make that decision? Would it
be the premier? Is that where you would have to go?
Ms. Mercer: I am sure it has probably gone to the premier. What it
takes is the ability to create what some of these kids need because for some of
them it is so unique that they are notgoing to fit into existing foster homes.
Children between 16 years and 19 years are too young for the child welfare
system, and they do not kick into the adult system until they are 19.
I think it has to happen, and I think it has to be a mandate of all of us,
including the IWK. All three agencies must come together to solve that without
it having to go up to a VP, a director, a senior director, or any of those
agencies. I hear this across Canada, so I know that it is not just us. Even in
provinces where it is all under one ministry, I know there is the same
difficulty. You are right, it seems like logic should come in here.
Senator Cordy: Thank you.
The Chairman: Having been trained as a mathematician, which is
logical, and given all of the public issues I have looked at on and off for 30
years, this is without doubt the most complex issue, full of completely
illogical components, than any other I have ever seen.
Ms. Mercer: Yes.
Senator Cochrane: Are you talking about ADD, FAS, the bullying
disorder, the autism disorder? Are you talking about all of these, or are there
Dr. Orlik: No. I think we are talking about an example of a large
sub-population of children who have so-called disruptive behaviour disorders
into which could fall fetal alcohol syndrome, into which could fall attention
deficit disorder, with or without hyperactivity, children with conduct disorders
and so on. Children with autism and related disorders need a different approach.
Children with anxiety disorders, as Dr. McGrath said, have evidence-based
kind of interventions of what works for them. Under the anxiety disorders are a
large numbers of disorders including phobias, social phobias, post-traumatic
stress disorder and obsessive compulsive disorder. You have a large number of
conditions that have certain things in common and yet also other kind of
differences that require a somewhat different kind of management approach.
You have a range of mood disorders, and they again, by and large, require
different approaches, although, there is a certain kind of commonality. Some of
the medications can work for mood disorders in selected young people, and may
also work in depression in young people. Certain forms of therapy, properly
adapted therapy called "cognitive behavioural therapy'' is effective in anxiety
disorders and in mood disorders, although in mood disorders some other kind of
psychotherapies are available as well. A large portion of our funding should
focus on these large groupings of disorders in their various stages.
Dr. McGrath's suggestion to identify them early, and develop skills in the
parents to manage these in a collaborative approach between preschool settings
and the later on school settings is sound. If on the other hand, these children
get more seriously ill, then you need to invoke other kinds of systems of
therapy, or combination therapies, or expertise to assist in their recovery.
So, for reasons of providing an example, I, when I presented, talked about
this group of disorders of so-called disruptive behaviours disorders because
they happen to be very large, and probably that group has had thrown at it more
ineffectual therapies than any other.
Senator Cochrane: Susan, have you had groups of parents or individual
parents come in to deal with some of those disorders in their children?
Ms. Mercer: As a therapy?
Senator Cochrane: Yes.
Ms. Mercer: We have certainly attempted to offer groups, and it is a
discussion we have had. We need to work with the families, the community, and
the public because sometimes people believe that phone-based therapy, Internet-
based therapy, or group therapy is not treatment and prefer to be on a
Actually, I met yesterday with a group of staff to talk about how we need to
get out there more, work with parents, and explain that the traditional method
of treatment is not available. Best practice shows that for some of these
disorders group therapy is the best method of therapy.
Dr. Junek: With respect to our day treatment services, we bring in 10
kids at a time. We have the compulsory part of it that all the parents come to a
child management training program for eight sessions, two hours a session. So we
do work with the parents in groups. We do teach them the child management skills
in groups, and any of the parents will tell you, and I have taught them myself
over the years, that they actually gain a lot more out of that kind of a session
and especially by doing it in groups where they share their experiences with
other parents. It is a very powerful learning experience.
We start exactly where Dr. McGrath pointed out, training them to observe and
reward appropriate behaviour. It is a very useful way to do this, and we
certainly do it as part of the program.
Senator Cochrane: After three to five years, are they back in a normal
setting where they can function independently?
Dr. Junek: I think the answer I would give you is yes that can happen,
especially if you have children where the major difficulty is in the child
management training that the parents need in managing the children. That group
can benefit especially well from child management training in groups. In our
circumstances, we are frequently dealing with children who started
withpre-existing attention deficit hyperactivity disorder, then developed
oppositional behaviour, and in some cases are moving on into conduct disorder in
the community. It depends on the degree of severity and complexity of the
disorder, the child, the family and the community in which they live. In some
cases, many years later, we receive positive feedback that they are doing very
well, while we are aware that others are going to go downhill even further.
Perhaps the researchers that are more involved in it are people like Dr.
Forehand and Dr. Patterson who are psychologists who have good long-term
follow-up studies, demonstrating that these techniques are useful.
Dr. Orlik: I brought along some books from other jurisdictions where
resources are available for that type of research.
An imminent monograph series, the Child and Adolescent Psychiatry Clinics
of North America is devoted to evidence-based practice in child and
adolescent mental health, so we do have documentation of things that work.
We cannot rest and we have to do that work in Canada. We do have different
environments, we do have different demographics, we do have different resources,
and we do have different political contingencies and funding patterns. We need
to do that work here as well.
Dr. McGrath: You have to understand that we have not funded people to
do research very well in Canada. The CIHR has been a big improvement, and that
is why I maybe am a little bit defensive about the CIHR, but you know people
like Michel Tremblay in Quebec, is a world leader. Chuck Cunningham in Hamilton
has done some outstanding work on large-group parent training where you do 50,
60 parents at a time. I think if you look across Canada there are a small number
of researchers that are doing this type of work.
It is often hard to get enough funding, and it is often hard to keep them. I
mean, one of the most distinguished researchers in this area is now in
Philadelphia. He started off in Kingston. I knew him very well many, many years
ago. We just lost a Dan Waschbusch, who was doing a very innovative school-based
program up in rural Nova Scotia. I mean part of the issue is that is has only
been very recently that we have invested in any research. There is not a large
cadre of researchers in child mental health. We do need more resources to
I am always looking for more funding, so if your committee wants to fund that
type of research, I would be glad to accept. I think the issue is we have only
recently begun to invest in health research of the non-basic science type and
three or four years are not enough to show a huge difference.
There has also been some very good work done here in terms of linking up and
this issue, I think, is very important. Linking up the people who are delivering
service like Sue and Herb, and linking them up closely with researchers is vital
to the success of these programs. Instead, my job is to get papers published,
not to change behaviour in the environment, not to make the children and youth
of Nova Scotia healthier. Sometimes we work at cross purposes but there has been
some very good progress.
The Chairman: You clearly need to change your incentives, you
Mr. MacGrath: Yes, that is what we have to change. I did this work
because the CIHR said they would give us money and we are no different from
anybody else in that way.
There a lot of good people working in this field, as you know. You have said
it yourself, "Child mental health is the orphan of the orphan.'' I thought that
was a very good phrase in your report, and I encourage you to really push for
that because early diagnosis is possible for most of the serious problems. Some
problems do come on in late adolescents but even in there, early intervention
with psychosis is incredibly effective.
Senator Pépin: Dr. McGrath, you spoke to us about your clinical trial
that you are doing with videos, books and via telephone. Could you elaborate a
little bit on that and explain the targets?
Dr. McGrath: We have five modules. Some of them are easier, because I
needed some easy wins. So we do bedwetting, which people say is not a mental
health problem, but if you are 10 years old and wetting the bed, it is a mental
health problem, I will tell you. We also do the disruptive behaviour, both
attention deficit and oppositional defiant disorder, and anxiety disorders.
The whole approach is that in the trial we are taking referrals from family
doctors so we go and detail the family doctors and tell them about the program.
They send a one-page referral with little "tick'' boxes so that it is easy for
them to refer.
Then we do an assessment, and it is a more elaborate assessment than we would
do if we were just providing a service, because it is a trial. We would move to
the assessment system that Sue was mentioning, Chuck Cunningham's approach, if
we were just doing a service.
Then what we do is we contact the family and we talk to them on the phone. We
send them the manuals, the videos, and we deliver service to them in their homes
at times that are convenient to them. My staff works weekends and evenings. I am
on-call for that service. This service is delivered to them in a way that is
easier for them to make it, especially with the disruptive disorders, but also
with anxiety, you have chaotic families that are hard to reach, even when you
make an appointment. It's at seven o'clock on Thursday night. Well, they are out
then, or somebody has just come in, or something has happened. We have to be
This approach is only one approach; it is not a panacea. It is not for
everybody. Sometimes large-group interventions, using basically the
evidence-based treatments that have been shown to be effective, which we have
done, are the best way to go. So, I am not saying that this approach is the best
approach. It is one approach.
Senator Pépin: Have you had many families involved in that process?
Mr. MacGrath: We have had about 280, I think. Some of our trials are
closed now and we are finishing the rest of them. So we should be finished the
trials in 18 months.
Senator Pépin: How long do they have to stay on the program?
Mr. MacGrath: The treatments are about 12 weeks long and then we
follow up with the families. We give some booster sessions to follow up
We would like to expand this to look at other problems. The school-based part
of it is not as strong as we would want, but much like what Dr. Orlik was
saying, we want to follow, we want to look at the data first. I can convince
people to do it, but we want to look at the data to see what works. As Dr. Junek
said, if there were incentives for us to do what works, and if they really
covered the whole system, then it would really be quite a bit more effective.
Ms. Mercer: I have one last quick comment about Pat's program.
Recently in Nova Scotia the wait-list for child and adolescent mental health
has hit the media. Dr. Orlik has been doing the radio station circuit, and
because of that when the provincial government announced their funding for
increased mental health services this year, $2 million for the province, they
added wait-list reduction criteria to it. We are able to apply for funding for
this program this year because of that increase.
We really believe that we are doing a good job with the seriously mentally
ill, but these children that sit on our wait- list, who wait to become seriously
mentally ill, will benefit from this latest development. We are hopeful that
with the media attention and a little bit of money we will be able to work this
group into our system so that we can start to target that population.
The Chairman: That is all the time we have. I thank all of you for
coming this afternoon. I know we took longer than we said we would, but that
always happens to us. You have been very helpful to us.