The orphans of medicare

Jennifer Clark has been living for two years in a stark room in Victoria's Royal Jubilee Hospital. In fact, patients with mental illness — unwanted and forgotten — account for an astounding one-third of all hospital time


From Tuesday's Globe and Mail

Jennifer and her husband Rhys Clark in her room at the Royal Jubilee Hospital May 17, 2008. (John Lehmann/The Globe and Mail)


June 23, 2008 at 10:34 PM EDT

VICTORIA — Jennifer Clark was brought to the emergency room at Victoria's Royal Jubilee Hospital after a gas-station clerk found her wandering around in circles, dazed and disoriented and pulling out her hair.

Ms. Clark, a hairdresser who suffers from bipolar disorder and paranoia, had been to the emergency room earlier and was discharged. She walked out the front door and roamed the streets for 11 hours before the clerk called for help. She was admitted to hospital that night, June 30, 2006, and has been there ever since – a staggering two years living in a stark room that she shares with a rotating cast of three other psychiatric patients.

“Everybody agrees that hospital is not the place for Jennifer,” her husband, Rhys Clark, said in an interview. “But nobody can do anything about it. It's exasperating.”

Ms. Clark's story reflects a sad reality: Patients with mental-health problems remain the orphans of medicare – unwanted and forgotten.

One in every 11 visits to ER is for a mental-health issue. So is one in every seven hospital admissions, and, because these patients stay much longer, they account for an astounding one-third of all hospital time.

Like Ms. Clark, they can wait years for a bed in a long-term care facility or a spot in supportive housing, so they end up as detested “bed blockers” or sometimes on the streets. In the community, family doctors do the bulk of treatment by default, but they are rarely equipped to deal with the complexity of care required by patients with severe depression, bipolar disorder or schizophrenia. Often, they just prescribe drugs.

In fact, Canadians are among the biggest consumers of psychotherapeutic drugs in the world: They picked up 53 million prescriptions for them last year, with a value of $2.2-billion, according to IMS Health Canada, a private firm that tracks prescription drug sales. In addition, direct-treatment costs for those suffering mental-health problems exceed $5-billion annually, according to a study by the Centre for Addiction and Mental Health in Toronto; the overall economic impact of mental illnesses is 10 times that amount.

Yet there is no national strategy for dealing with mental illness.

“The system is in chaos,” said Donald Milliken, former president of the Canadian Psychiatric Association and a practitioner with nearly 40 years of experience. He said patients such as Ms. Clark are getting good care but not appropriate care. The fundamental trouble is not necessarily a lack of money or a shortage of beds but a lack of organization.

“If you take the same amount we spend on ad hoc care and spend it on organized care,” he said, “the care and the outcomes would be better.”

Asylums phased out

When it comes to care, mental health has always been the poor cousin of physical health. This is partly due to a legislative anomaly: Half a century ago, when medicare was created and Ottawa started funding hospitals, asylums for psychiatric patients were excluded.

Those suffering from severe, persistent mental illness were warehoused in institutions paid for solely by the province. Then came the civil-rights movement, coupled with the advent of effective drug treatments, which led to policies of massive deinstitutionalization. Dr. Milliken recalls his experience as a medical resident in 1970: “They gave me the keys to a ward and said, ‘There are 100 patients in there. Discharge 50.' ”

The number of long-term psychiatric beds in Canada plummeted from a high of close to 60,000 in the 1950s to just over 6,000 today. That, in itself, was not a problem. But mental illness did not miraculously disappear and governments did not invest in community supports for sufferers.

What many patients need is stability – a place to live, a basic income, assistance with daily activities, monitoring of their medication. When these are not available, illness can flare up and hospital visits follow.

“Hospitals are just trying to ‘deal' with this – and I use that word in its most Spartan sense,” said Pamela Fralick, executive director of the Canadian Healthcare Association. She said health-care professionals are compassionate people, but “these are cuts that can't be sutured in hospitals.” Also, while most people recover from bouts of mental illness, a minority of cases are simply intractable.

Ms. Clark, 52, has been admitted to hospital 36 times during the past 29 years, often for months at a stretch. Her current stay alone has cost the health-care system close to $1-million.

But three decades of dealing with her illness – including episodes of mania, severe depression, paranoia and suicide attempts – have cost her family much more, emotionally if not financially.

“It's hard sometimes, I won't deny that,” Mr. Clark said. “The reason I hang in there is because my mother brought me up right. When I said my vows – ‘in sickness and in health' – I meant it.”

While the public face of mental illness is often the homeless street person who rants aloud, the reality is that most people with psychiatric problems are hidden in plain sight. They work and raise families but, in times of crisis, depend on their families for support. Home care is virtually unavailable to mental-health patients. It can take months just to get an appointment with a psychologist or psychiatrist, and waits are particularly long for children.

“There is an inordinate burden on family caregivers – they just don't have adequate support,” said John Service, a psychologist and executive director of the Mental Health Commission of Canada.

Stigma and discrimination are also commonplace, even among health professionals. As a result, people with physical illnesses often get far better and quicker services than those with mental illnesses, Dr. Service said. It is not unusual for someone with severe depression to wait 24 to 72 hours for care in an emergency room – yet these numbers provoke little outrage in the waiting-times debate.

A big bright oasis

Royal Jubilee has tried to tackle this bedevilling problem by creating an emergency room strictly for mental-health patients.

The Archie Courtnall Centre – named after the father of former National Hockey League stars Russ and Geoff Courtnall who suffered from bipolar disorder and committed suicide – is an oasis. “If a facility like ACC had been available in my father's time in need, there is no doubt he would be alive today,” said Bruce Courtnall, an investment adviser at CIBC Wood Gundy and a spokesman for the family.

The centre is a big bright place with a dozen La-Z-Boy chairs and four short-stay beds where psychotic or suicidal patients can remain until a crisis passes. “This is a safe place, where patients get treated with respect,” said Rivian Weinerman, the site chief for psychiatry.

In particular, there is more privacy than in the general ER waiting room, where a person weeping uncontrollably, muttering loudly about conspiracies, going through withdrawal, or wearing leg irons and handcuffs is bound to draw a lot of unwanted attention.

Tellingly, about three in every four patients treated in psychiatric emergency have some sort of substance-abuse problem. Many people with mental-health issues turn to alcohol and drugs to chase away their demons. Some drugs, such as crystal meth or crack cocaine, can also trigger psychotic episodes.

Dr. Weinerman stresses that most psychiatric patients control their illnesses with medication and counselling, but they retreat to hospital when there is an upheaval – either an internal breakdown in brain chemistry or an external collapse such as a relationship crumbling.

So, in addition to the psychiatrists and psychiatric nurses, the Archie Courtnall Centre also has a staff social worker who plays a crucial role in trying to stop the revolving-door syndrome.

“I do the practical stuff,” said Paul McNamara, a former health-care manager who decided to return to the front lines. “Once you're medically stable, I ask: ‘How can I help?' ”

On a typical day, he will make calls to ensure a patient's pet is fed, set up counselling for a family whose son has attempted suicide, negotiate with a landlord about the return of a tenant who has the occasional bout of psychosis, and find a bed in detox.

“This is real. What we do here makes a difference,” Mr. McNamara said.

He said people who show up at the hospital emergency room come from across the social spectrum and they all need the same thing – “a place to go when things fall apart.” There is some evidence that a dedicated psychiatric ER such as Archie Courtnall does reduce return visits and admissions to hospital. But Dr. Weinerman says the success of mental-health care cannot be measured in mere dollars.

“This is not a money-saving business we're in, it's a life-saving business,” she said. “And what troubles me is that there's a ton of people out there who haven't reached our doors.”



Ottawa Mens, from Ottawa, Canada) wrote: Congratulations Andre on a great article.

Canada has a "taboo" on the subject of mental health. Our federal and provincial governments turn a blind eye as the mentally ill and their relatives simply don't buy votes, such is the corrupt nature of Canada period.

Canada has a very simple minded attitude of "it wont happen to me" or "its none of my business" or "they must have done something to get it" or, they are contagious and by ignoring it we wont see it and it will go away. Thats a summary of the Canadian Governments attitude to mental illness.

The reality is mental illness is filling our courts, either by litigants or out of control judges and yes, some judges are very obviously suffering from a mental health problem and or a severe personality disorder that would not get past first base of a triangulation employment interview for say CSIS , the RCMP, any major police force, or for most airlines as a pilot.

Mental health is costing Canada billions of dollars, it overwhelms our legal system.

The Merk manual defines "endless legal litigation" a symptom of a mental illness. Unfortunately, society fails to realize that not only do the litigants suffer mental health problems but so do our judiciary.

Take any large legal community, its riddled with brilliant highly intelligent lawyers who can no longer function as lawyers or can only do so under very limited capacities or duties due to diagnosed and treated mental health problems.

When our Canadian Government deals with the problem of mental health in our judiciary, such as by introducing employment screening, it may just start solving the one of the causal problems of endless litigation that clogs our courts.



Ottawa Mens, from Ottawa, Canada) wrote: When will the Attorney General deal with the well known and obvious problem of judges who dispense "justice"while suffering a very obvious mental health problem and or equally disturbing
"personality disorder" whose major symptom is a "a lack of empathy or compassion" or "extreme anger".

Those two characteristics are typical of those who kill and torture for very little in the way of reasoning. Take every major psychopath in recorded history, they too have a lot in common with the underbelly of judicial personalities in Ontario that sicken society not to mention destroy what it jokingly called "the rule of law".

Ottawa Superior Court has a couple of them. Start with Justice Catherine Aitken, known for her decisions that leave newbi lawyers standing with they jaws open in shock at her decisions. Known as a "fembox" judge she has been leaving a trail of destruction for years. Every lawyer in Ottawa knows about it as do all the other 'sane" judges.

Then we move on to those judges like Dennis Power and Aland Sheffield who suffer what can only be called "severe personality disorders" who demonstrate "court rage", yes, its like road rage, except instead of killing another innocent motorists, they leave a trail of very callously and carefully destroyed lives by flagrantly abusing their judicial powers to ensure that those litigants who "piss em off" never get to set foot in a court room again probably because they suffered an accident at birth and were born with testicles. Yes, the judges who hate men the most are actually male. Corrupt? thats an inappropriate polite term for these examples of the underbelly of the Judiciary



Ottawa Mens, from Ottawa, Canada) wrote: At the Ottawa Court House, we are seeing incredible security and rightly so, why? because the accused is charged, yes charged, not convicted of the the most vilified crime in history of plotting to kill thousands of INNOCENT victims.

In the same court house, we have judges who also commit crimes against society that rival the most vile in society. Just how do they do it?
Take Justice Dennis Power and Alan Sheffield for example, They pick on the most vulnerable in society, male self represented litigants who suffer the double indignity and disadvantage of being born with testicles and, heaven forbid, doing an injustice to the legal profession by not paying a lawyer tens of thousands of dollars (not that they don't deserve it).

These insults to justice routinely "strike pleadings" and issue "vexatious litigant orders' thats right, they ensure that anyone they don't like never gets to set foot in a court room AGAIN!

Can you imagine a doctor poisoning the sick? or a pilot throwing his passengers out at 30,000 feet? Well take a close look at the most despicable examples of the Judiciary Denis Power and Alan Sheffield.

The word from Judges Chambers is that these two judges are rapidly burning their bridges and running out of rich and powerful friends who are not disgusted by their increasingly draconian decisions to exact vengeance against anyone who "pisses me off".

One of the biggest problems in the judiciary is you never know who you can actually trust. Those entrusted with the supervisory role are powerless to act, they find it easier to "go with the flow" that is turn a blind eye to the injustices and actually "go along with it" and become co conspirators to what can only be called "obstruction of justice by the judiciary". The same judges are experts at turning on the charm and convincing all around that the sun shines out of their rear which we all know is a legal and practical impossibility.