The Forgotten People?

Except for the criminally insane, institutional care is very hard to come By for people with mental health problems, so many are smelling the ranks of the homeless and filling up hostels

There are more than a few stories of awful tragedies resulting from the lack of institutions to look after the mentally ill. There's Lisa Brady who has Prader-Willi syndrome -- she will, literally, overeat herself to death if not supervised constantly. The Ontario government doesn't want to pay the $132,000-a-year bill for keeping Lisa alive. Ruth Millar was killed by her son. He has schizophrenia, and Ms. Millar was caring for him at home because the government-supplied help available for him was inadequate. Charlene Minkowski, 23, was pushed under a subway train in Toronto and killed. The man who pushed her has a long history of mental illness.

The core issue is society's failure to care for its mentally ill members. Many patients have been discharged from mental hospitals with few supports provided for them in the community. At the same time, mental hospitals that are still operating are short of funds.

This doesn't apply in New Brunswick. The province has been held up as a model of successful mental health reform. New Brunswick has a double-funded system, paying for community supports and hospitals at the same time. People were not released from hospitals until supports were in place. As the assistant deputy minister of New Brunswick's Mental Health Services Division said in 1998, "It's not rocket science." Research has shown not only that people with mental illnesses prefer to live in communities rather than institutions, but that long-term institutionalization can have negative effects on mental health, making independent living even more difficult

New Brunswick set up its policy for mental health services in 1988. The province wanted to:

* establish a network of institutional and community-based mental health services;

* introduce a 10-year plan to shift resources from institutions to the community;

* create a network designed to meet people's needs, where possible, closer to their homes;

* explore all community-based options before recommending that an individual be admitted to hospital; and,

* make a commitment to spend money on new, community-based services.

The province accomplished the plan in six years. Ontario, which also planned a 10-year shift of resources to the community was only halfway through the process by 1998. Some say Ontario is lagging because it has 10 times the population of New Brunswick. Others say it is a question of political will and priorities. New Brunswick's Mental Health Commission was seen as a crucial part of the reform process because its mandate was to overhaul the system and it was given the authority and the money to do it. But, that's a political issue that hasn't been resolved in other provinces.

While provinces are shutting down the institutions that once warehoused people with mental disabilities, they are not providing the 24-hour-a-day care to allow severely disabled people to live at home.

Early in 1998, there was a conference in Toronto; it involved about 30 doctors, other care providers and relatives of those with mental illnesses. The conference recommended that no psychiatric beds be closed unless the necessary treatment and community support services were in place. It also called on the government to amend the Mental Health Act to ensure that those who need medication take it, whether they want to or not, and to balance the rights of the mentally ill with those of their caregivers and the communities in which they live.

Such a change might have saved the life of two-and-a-half-year-old Zachary Antidormi, the Hamilton child who was stabbed to death in 1997 by a demented woman who is a paranoid schizophrenic. (Schizophrenia clouds the ability of its victims to tell the difference between delusion and reality and often leads to them feeling threatened where no real threat exists.) Zachary's attacker thought he contained the soul of her dead son begging for release. Subsequently, she was placed in a psychiatric hospital. Prior to this tragedy, she had not received the treatment she needed.

As one psychiatrist working with the Schizophrenia Society pointed out, "Psychiatric patients at the moment have to deteriorate to the point where they are really quite dangerous ... before they can be admitted to hospital."

And, many of them end up in jail instead of hospitals, condemned for being victims of mental illness themselves. While the police previously would have picked them up and ushered them into hospitals, now there are no beds for them. The beds that weren't cut are for more seriously disturbed people who can't be let out, or they're held for emergencies.

So, no hospital beds plus a shortage of community supports and housing equals disaster for the unfortunate mentally ill. It also poses a potential danger to society as a whole. It leaves sick people on the streets; people who might have a reasonable quality of life with proper medication but who often stop taking it when not supervised. Those involved in the Toronto conference also recommended creating a network of 80 to 100 clinics to provide much needed care in the community. The clinic network would include 24-hour crisis hot-line access, mobile response, and specialized accommodation for people in crisis.

Later the same year, a Toronto task force provided some figures that confirmed the strong link between mental illness and homlessness. The task force reported that 66% of 300 homeless people interviewed had been diagnosed with a mental illness - most often depression - at some point in their lives. That's two to three times greater than in the general population. Almost 11% had been diagnosed with a severe mental illness, such as schizophrenia or manic depression, and 86% had an abuse problem or a mental illness.

The task force report said those with a serious mental illness would be best served by housing with mental health supports. But, the waiting list for self-contained supportive housing units was five years in 1998.

According to the report, Toronto alone needed an additional 5,000 supportive housing units, most of which would house the 4,400 chronic users of the city's shelter system.

Shelters for the homeless are struggling to do a job they hadn't counted on doing.

Seaton House, for example, is a shelter for homeless men in Toronto that has become a makeshift mental-health clinic: mentally ill people turned out of hospitals sometimes move directly from the hospitals to hostels. However, most hostel workers don't have psychiatric training.

In 1998, clinics were planned for five Toronto hostels and one centre that treats alcoholics in an attempt to help former psychiatric patients who were slipping through the health system. Known as shared mental-health care, the program provides a nurse for routine care, and an outreach worker who wanders the corridors of the shelters talking to the residents and trying to identify those who need help from the clinic. In addition, a doctor drops in twice a week, and a psychiatrist visits once a week. The squeeze on psychiatric services continues. Across Canada, psychiatric hospitals and wards have been closed or amalgamated as the three Rs of health care - re-engineering, restructuring, and restraint - have hit each province in successive waves. The result is that a lot of mental illness continues to go untreated. Canadians who need psychiatric treatment have to wait an average of two months for a first appointment because of a shortage in the profession, according to a 1998 survey of the country's 3,500 psychiatrists. Shortages are particularly severe in the areas of treatment for children and old people.

More than a decade ago, in 1988, the Royal College of Physicians and Surgeons of Canada recommended that the national standard should be one psychiatrist available for every 8,400 people. By 1999, large cities such as Toronto (one psychiatrist for every 5,428 people) and Vancouver-Richmond (one for every 1,730 people) were well served, but many others were not. Burnaby, just outside Vancouver had one for every 13,700 people; B.C.'s Cariboo region had one for every 100,000 people; Corner Brook, Newfoundland with a population of 23,000 didn't have a single psychiatrist with a permanent practice; Welland-St. Catharines, an hour's drive from Toronto, had nine psychiatrists for a population of 450,000.

It's not a happy picture, and we have a history of fumbling when it comes to caring for the mentally ill among us.

Under the Constitution Act of 1867, the provinces were made responsible for asylums for the mentally ill. At that time, it was customary the world over to either keep the insane at home or in institutions where they often were treated brutally. In Toronto, when a new and better jail was built in 1800, the old jail became an asylum.

The Canadian National Committee for Mental Hygiene was founded in 1918, largely due to the efforts of Dr. Clarence M. Hincks who helped raise funds to survey conditions in asylums across Canada. They were found to be generally disgraceful, dirty, and overcrowded. The committee made its findings public, and the provinces started to spend more money on institutions for the mentally ill. By the 1950s, drugs were discovered that could help control the behaviour of many mental patients and that led to a new trend in care. Many patients from psychiatric hospitals were returned to the community. Prior to Medicare, the only treatment available to the less affluent was in provincially-owned psychiatric hospitals. Although the psychiatric care provided in general hospitals has greatly improved, there still are serious gaps in follow-up care for the mentally ill.

SUGGESTED ACTIVITIES:

1. In 1998, B.C.'s health minister announced a seven-year program to revamp the mental-health system in the province and provide more institutional beds and more community support for the mentally ill who are able to function and get treatment at home. Find out where the program stands now. Also, do a report on what other provinces are doing, or have done, to impove their mental-health programs.

2. The president of the victims' rights group Canadians Against Violence Everywhere Advocating Treatment, was quoted as saying, "Society condemns its mentally ill to rot in prisons, and to die in the streets." Discuss this comment. Does our society lack compassion and, if so, why? Research countries, such as Sweden, which is renowned for its fine social security system, and report on how it treats its mentally ill.

Websites

Canadian Mental Health Association - http://www.cmha.ca/english/homeng.htm

Centre for Addiction and Mental Health - http://www.camh.net/

Mental Health InfoSource - http://www.mhsource.com/

FACT FILE

After several subway shovings in Toronto in 1998, it was suggested that Plexiglas barriers be installed at platform edges. These would open only when an incoming train comes to a full stop. But the Toronto Transit Commission security chief said he would prefer to see the money spent on mental-health-care programs.

RELATED ARTICLE: SOME FIGURES

One in four Canadians will suffer from an addiction or mental illness in their lifetime Depression costs the Canadian economy more than $12 billion a year More than 300,000 Canadians have Alzheimer's disease More than 200,000 Canadians suffer from schizophrenia, which requires a greater use of hospital beds than any other medical or surgical condition in Canada One-quarter of the 34 million hospital days used in Canada each year are for the treatment of people with mental illnesses Four percent of government health-research funding goes to mental illness Nine percent of health budgets is spent on mental health Substance abuse costs the Canadian economy $18 billion annually Each dollar spent on the treatment of addiction saves $7 in legal and social costs A Canadian company can expect to have about 4% of its workforce absent on psychiatric disability at any given time

RELATED ARTICLE: A STEP BACKWARDS

It sounds like a return to the 1950s-style insane asylum. The Globe and Mail reported in 1999 that scores of patients were being kept locked up in a Montreal psychiatric hospital even though they didn't suffer from any psychiatric disorder. In the city's 567-bed Rivieres-des-Prairies psychiatric hospital, patients were strapped to their beds all night, kept abusively in straitjackets, or left zombie-like from too many drugs.

A report by Quebec's Public Curator, who acts as guardian for incapacitated Quebeckers, found a string of inadequate diagnoses, poorly kept patient files, and a drab and constrained world of electronically locked or padlocked doom. A team of experts investigated the hospital and found that 155 patients didn't have psychiatric problems at all, but suffered from conditions such as autism, epilepsy, Down's Syndrome, or mental retardation, and should be out of the hospital and getting help in the community. "We know that mental retardation is a permanent life condition and not an illness, strictly speaking," the report says. "Generally, these people ... should be followed in the community, by a completely different type of service."

RELATED ARTICLE: DEPRESSING STATISTICS

Depression is the leading cause of disability in the world; there are an estimated 330 million people worldwide who suffer from it, including more than 670,000 Canadians. It's also estimated that 90% of victims won't get adequate treatment. According to an article in The Economist in December 1998, the disease afflicts more people than heart disease - far more than AIDS - and most cases are not diagnosed. One doctor at the World Health Organization (WHO) in Geneva predicts that it will be the world's second most debilitating disease by 2020, surpassed only by cardiovascular disease. It's estimated that 15% of severely depressed patients kill themselves and that two-thirds of sufferers contemplate suicide. The WHO calculates there are about 800,000 suicides a year globally that are attributable to depression.