Sunday, February 28, 2016

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Paula Simons: Vacuous new mental health review no cure for our crisis

Almost everything that’s wrong with the vacuous new Alberta Addiction and Mental Health Review can be summed up with this one fact.
The word “psychiatrist” never appears once — not once — in the 37-page report.
You will find the word “psychiatric” — but only in the fine print of one footnote, and only because it happens to be in the title of an academic journal.
Oh, the report talks about the roles of social workers and psychologists, teachers and peace officers, multi-disciplinary teams and “natural supports” and holistic treatment.
The word “wellness” appears seven times. 
But there’s not one word about Alberta’s chronic shortage of psychiatrists, especially child psychiatrists. There’s not one word about the future of Alberta’s aging psychiatric hospitals. There’s virtually no mention of the shortage of psychiatric beds in our acute-care hospitals. There are no mentions of the challenges people face in accessing anti-depressants or anti-psychotic drugs. 
In fact, there’s precious little acknowledgment of patients who are schizophrenic or bipolar or psychotic. Instead, the report focuses primarily on those suffering from depression, anxiety and addiction. Those are all very real mental health issues, common conditions that affect thousands of people. And we need to do more to provide front-line and preventive care for those who face them.
Yet by putting so much emphasis there, the report’s authors end up marginalizing those who are already the most marginalized by our society — even though the treatment of those with serious psychiatric conditions accounts for about 80 per cent of our annual mental health care budget.
How can we possibly have an honest conversation about the state of psychiatric care, if we can’t even say the word? How does a refusal to acknowledge the vital role of psychiatrists do anything to help us create good public policy or reduce social stigma? 
There seemed reason to be hopeful when Premier Rachel Notley struck a blue-ribbon mental health panel this past summer, co-chaired by NDP MLA Danielle Larivee, now minister of municipal affairs, and Liberal leader David Swann. Instead, when the report was released Monday, we got a collection of 32 amorphous, anodyne recommendations.
Some of them are common-sense bromides. A few, like the suggestion to create a special mental health care court, are intriguing. But mostly they’re long, windy, empty things.
Things like “Create public awareness opportunities and programs to enable people to support their own mental health and the health of those they care about through collaboration between the government of Alberta and non-governmental organizations.”
Or “Provide consistency across all services to support transitions and integrated care planning by the Government of Alberta, Alberta Health Services and non-government organizations using standardized tools.” 
It’s hard to tell what such word jumbles really mean. On Monday, Health Minister Sarah Hoffman went only so far as to pledge $4.5 million to tackle six priorities.
That includes money for about 30 new and upgraded addiction treatment beds in Lethbridge, Calgary and Red Deer, and money for a new mental health website for children and youth. And there’s money for yet more consultations, action plans and frameworks. Hoffman says her government broadly accepts all of the recommendations, and they’ll act on them as funds become available.
Albertans might be forgiven a smidge of cynicism.
In 2008, you may vaguely recall, the Stelmach government announced a new $50-million plan to improve mental health care services for children and youth. That “plan” got lost somewhere along the way, when then health minister Ron Liepert amalgamated Alberta’s health regions. 
In 2011, the Conservatives released another mental health strategy. It was never fully implemented.
In 2013, legislature researchers wrote a report on the mental health system for the legislature’s Families and Communities Committee. And in 2014, the province made public yet another comprehensive review from University of Alberta researcher Cameron Wild, a “gap map” that delineated holes in the mental health system.
We study and report and pledge. But the basic impediments don’t ever seem to get fixed.
The problems are profoundly real. But recommending, as the report does, that we create “navigators” to help people through the mental health system, doesn’t help if there’s no functional system to navigate.
The definition of insanity, Albert Einstein supposedly said, is to do the same thing over and over again and expect different results. Please, let’s stop “reviewing.” Let’s stop ignoring the research we already have. Let’s invest, instead, in frontline services, backed by the best medical science. I’m betting we’d save more money in our health care, social welfare, and criminal justice systems in the long run.

Julie Ali · 
Thank you Paula Simons for saying it like it is for citizens with serious mental health issues who are continually treated like disposable entities in our society.

The people with the most needs are ignored while the minor number of folks with fentanyl addiction gets all the attention.

You indicate where the real crisis is and that this report has ignored this larger crisis in folks with severe mental illness who won't be helped by an increase in medical detox beds.

This mental health report --like the endless reports on the abuses and problems in the continuing care system --seems to provide directions but no ultimately map and the travellers all seem lost.

I begin to think that government produces these reports for photo-opportunities.

This sort of report generation is busy work that does not solve real problems in access to psychiatrists. For example the access to a psychiatrist in the continuing care system is almost negligible. If your psychiatrist decides to dump you (and doctors do dump their patients for nebulous reasons), then good luck finding another psychiatrist.

Besides the paucity of psychiatrists, it is difficult to get coordination of psychiatric and physical conditions. If you have a respiratory illness that compromises cognition, you may end up being treated for psychiatric problems when it is really the pulmonary condition that is not being addressed and treated.

Because of the problems of such mixed bag conditions, and the seeming inability of staff all through the healthcare and continuing care system-- to recognize the difference between problems due to pulmonary conditions versus those due to psychiatric ills-- there are further insults to the psychiatric patient who is then put at risk for being considered non-compliant and is not resuscitated but simply monitored when he presents repeatedly at the emergency.

So not only do we have a psychiatric patient who can be labelled non-compliant, assigned an arbitrary DNR ( do not resuscitate code) but that patient may end up dead because he had no advocate to help him.

If such a patient does not have a determined advocate, the consequences of system failures in managing complex cases is the early demise of the patient.

Not only are such patients misdiagnosed, they are ignored in terms of providing a program to increase compliance. The health care and continuing care sytem would rather have a patient be non-compliant, go repeatedly to emergency and almost die on multiple occasions rather than set up a compliance program to help the patient get to compliance. There is no intelligence in the system and yet we expect mentally ill patients to survive this system.

What is the solution to these problems? Instead of studies like this one where the government pretends to be tackling the issue of mental health-- it might be more useful to provide actual training to staff at schools, continuing care facilities and all through the health care system where ignorance abounds.

You would think that staff in these critical areas of education, health care and continuing care-- received training and have sensitivity to the mental health issues of clients they serve but this is not the case.

Training staff throughout the system would help clients immediately because staff would then have a basic understanding of what psychiatric illness is. This training would have hopefully include strategies that would enable them to work with patients rather than send them to emergency repeatedly.

It begins with an integrated care plan from the start of the appearance of psychiatric difficulties. It continues with working with families openly and respectfully.

The exclusion of families from planning events that occur between AHS, Covenant Health and continuing care providers with reference to patients--is not acceptable.

Families should be in these meetings and should not be learning about the planning for our family members from medical records that have to be requested to find out what sort of shenanigins are occurring with reference to patients with mental health issues.

The incredible disrespect for psychiatric patients and their families is clear just from this sort of private meeting junk between AHS, Alberta Health, Covenant Health and continuing care providers. Families are not included in these meetings.

The sad facts of the lives of many patients without family support who end up dead in hospitals, prison and on the street is an indication to all of us that the stigma that is associated with mental illness is a life threatening one.

Alberta Health needs to take a leadership role in oversight of mental health issues because it simply won’t happen in the mess that is currently present in Alberta’s healthcare system. If Alberta Health cannot do it's job then it should stop pretending with the use of placebo mental health reviews of this sort.
Like · Reply · 9 · Feb 22, 2016 9:11pm
Kirstin Morrell · 
Don't pit one group of people against another. Medical detox beds and addiction treatment programs are so undersized for this province that people who want to get off drugs can't get space in these facilities. Full stop. So don't blame those folks for getting a share of the pie. They're not the problem.
Like · Reply · 8 · Feb 22, 2016 10:34pm
Julie Ali · 
Kirstin Morrell Hi Kirstin, I never said the folks on drugs were the problem.

They do represent a solvable problem that the government (in my humble opinion) can immediately address and in this way seem to be doing something about the major problems in the area of mental health in Alberta. The medical detox beds are a media friendly response to a poor mental health review report.

Government does this sort of stuff to increase the profile of MLAs. This is fine. But we also need to address the issues that aren't being addressed by the creation of these medical detox beds.

There is a real difficulty for folks with serious mental illness to get the continuity of care and the integrated care planning that would keep them alive. There is a failure to consider their cognitive abilities in following the care plans created. There are problems with their inability to communicated (lack of insight) and we don't have good responses in helping them to deal with their frustration, sadness and stress at not being who they want to be in the world.

There is no sort of pitting of one group against another in any of my chatter. I believe as a society we have to help our most vulnerable citizens --many of whom struggle to get help.

Currently in Edmonton, young people in the school system are asking for help. There are increasing numbers of kids with anxiety disorders that are not seen as significant enough to get special education coding that would provide them with the supports/ services to ameliorate their difficulties. I see no reason why kids with anxiety disorders cannot get help. Anxiety disorders are often associated with neurodevelopmental disorders such as ADHD and auditory processing disorders and are significant indicators of future mental health problems. In other words, anxiety disorders are precursors of major psychiatric conditions and must be treated early on to prevent such consequences.

No one speaks of why kids have psychiatric problems. We have to begin to address the problems in mental health at the beginning-often in childhood abuse situations; these abuse cases are ignored or written over but the trauma often manifests itself later on so that there is a breakdown. While it is difficult to address the problem of childhood sexual abuse, if we don't address these abuse problems we will have many silent sufferers who develop mental illness because of a lack of responsive treatment.

If we do not help young people who have suffered such trauma, there will be more severe problems to deal with further down the line.

While addictions is a problem, in my opinion it is often not the first problem; it is often a result of mental illness. So we need to treat the mental illness before we treat the addiction problem or there won't be a lasting solution. A medical detox bed somehow does not seem like a productive solution to the requirement to provide ongoing counselling and support. I'm not the only one who thinks these beds are just the first step in a long process of evolution of the mental health system in Alberta:

Kate Hawksworth with the Alex Youth Health Centre says the beds are a great start, but really only scratch the surface.

"We've got a lot of young people that are really, really desperate to get into treatment, especially residential treatment, and the waitlists can be three to six months long just to get a bed. So again, we need the services everywhere, not just in detox, but in treatment."
Like · Reply · 4 · Feb 22, 2016 11:00pm
Jerry Macdonald
One possible reason Psychiatrists aren't mentioned is that they are, by and large, not truly part of the "system". Like most other physicians, family practice and specialists alike, they are autonomous practitioners paid on a fee-for-service basis. They may have admitting privileges in a hospital, either for the mental health beds of a general hospital, or in a mental health referral centre, but as consultants, they are largely at arms' length from the management of the health care system. That means the supply of psychiatrists is largely out of the hands of the health system; it's the physicians themselves that decide where they will open up a practice.
Like · Reply · 19 · Feb 22, 2016 7:21pm
Joseph Andrus
I am so very pleased to read a comment that isn't full of hatred, and which instead offers insight into an issue. I also see that you didn't suggest that we tear down the government and do something horrible to our premier.

It's so rare. Thank you.
Like · Reply · 13 · Feb 22, 2016 8:24pm
Paula Simons
That is a fair point - and an important one. But there are also staff psychiatrists, of course. And I'd argue AHS still has a role in recruiting private practitioners. But let's take your argument a step further: maybe we should see an argument for putting more psychiatrists on salary, as AHS staff, if that's what it takes to make up the shortfall.
Like · Reply · 9 · Feb 22, 2016 11:21pm
Devon Smith
Physicians have a limited ability to decide where they will open a practice, if they want admission privileges in hospitals. Physicians don't get to decide if they will receive those admitting privileges. So, that is part of the reason for the shortage of psychiatrists.
Like · Reply · Feb 23, 2016 3:23am
Marie Frances McLeod
Paula Simons perhaps we should put all doctors on salary.
Like · Reply · Feb 23, 2016 11:38am
Linda Ellis Yestal · 
i agree that we have the studies and understand much more than we can fascilitate. We have a system that still treats addiction before mental health and continue to react instead of being proactive and working in the early stages of the illness. If you have ever known anyone that has been diagnosed with a mental illness as an adult, they will tell you they had early signs that were never treated. They will also tell you that they struggle every day in our system to be peoperly diagnosed... They will tell you that many of them have walked into psych wards with suits on because no one else will help them. They do not fall in the lines of our medical systems support, because we are behind in treating and diagnosing our mental health patience. My hope is we have earlier diagnosis and we treat the disease as the cause that can then lead to addiction, unemployment, being homeless and so forth. That is my hope.
Unlike · Reply · 13 · Feb 22, 2016 9:18pm

Laurent Jeff Dubois · 
Well said.
Like · Reply · Feb 23, 2016 10:52am
Jim Besse · 
Bt their nature, mental illness and emotional damage are resistant to treatment, the causes often found in childhood trauma or in neuro-chemical imbalances. There is no panacea, usually the best that can be hoped for is making the best of a challenged circumstance. Yes, psychotherapy and meds can help. The larger long term solution is for a societal culture that is aware and compassionate for those whom suffer.
Like · Reply · 3 · Feb 23, 2016 9:28am

Dianne Slade · 
Our health care system...all of it....has been going down the drain slowly since the Klein cutbacks. Many doctors of all specialities left the province. The hospitals in Edmonton area have not been able to handle the increase in population. The waiting times for most kinds of surgery are obscene. We needed another hospital built and ready to go ten years ago already. Exactly the same situation with mental health. Impossible to access a psychiatrist even on an emergent basis. Why a modern psychiatric hospital hasn't been built yet is pure insanity. Human services have never been a top priority of the Progressive Conservatives. Remember when Klein emptied out Alberta Hospital....most of those people ended up living on the street. Now we are left with one hell of an expensive mess to fix and not enough money.
Unlike · Reply · 3 · Feb 23, 2016 4:09pm
Carol Rodd · 
Could the NDP's myopic view that everything fits into a politically correct/popular culture thought process. That mico aggressions, bullying, victimhood and safe spaces are more their speed while more serious issues like schizophrenia are over their heads?
Alvin Finkel · 
I partly agree with Paula's analysis. But I don't think that psychiatrists are, on the whole, all that helpful. Mosf of them only deal with prescribing of medications. That's helpful but not enough. The Swann Report is correct in suggesting the need for teams to deal with mental health problems. But it deals with the issue superficially. It looks at no models outside Alberta, such as the Open Dialogue program in Finland, which claims a success rate of about 70 percent (with success meaning full integration of a schizophrenic back into the community, with a job and friends, and no meds needed, not our Alberta standard of sitting all day at home watching TV and swallowing pills). But yes, more psychiatric beds are needed. The shrinks have become about as human as stone at facilities where they know there are fewer beds than patients needing admission. As the police will tell you, there are hospitals where they bring people desperately needing help to Emergency only to see them sent away without being admitted. It is indeed strange that a report about mental health does not deal with any particular mental health issue separately. Still, I applaud Dr. Swann for focusing on the "social determinants of health," particularly housing. The statistics are clear: in countries with greater economic equality, reported cases of mental health problems are far smaller than in countries with large economic inequalities.
Columbia Ice
What needs to be looked at is the time it takes to see a shrink for the different age categories? In some cases people are told to wait 2 years to see a shrink. The only way to get help quickly is to be a threat to yourself or others. You want help fast in Alberta, slash your wrists cause seeing a doctor won't get you help in a timely manner. Another aspect is looking at how many different people a person has to go through to talk to one proffesional more than once. Meaning getting to see a Psychiatrist, not a social worker for more than an hour. There are some mental illnesses in the world a social worker is not even remotely qualified to deal with. The last thing a mentally ill person wants people to know is they are mentally ill. Mental health clinics should be like rub and tugs where there is a backdoor entrance. Our healthcare is setup for the physically ill, not the mentally ill who generally get to suffer in silence unable to deal with the prison that is the brain. We wouldn't ask a cancer patient to wait for chemo but we will ask an adult male who cuts himself on his arms, takes a dangerous amount of pills to get to sleep and can't make it out the front door on most days to wait to get help. You want to do more than bandaids then psycologists should be covered under universal healthcare. Anything else is just more govt smoke and mirriors. It won't happen because at the end of the day mental illness isn't something you can see.
Unlike · Reply · 2 · Feb 23, 2016 2:27pm
Julie Ali · 
I think you do have good points here.

1) It is hard to see a psychiatrist on a routine basis.

2) It seems even harder to see a psychiatrist on an emergency basis.

I have heard of mentally ill citizens dying in emergency with medical staff around them.

3) Most psychiatrist focus on medication.

The science is not fixed. So they experiment. It's not easy it seems to find the right mixture of drugs. Sometimes this sort of therapeutic experimentation takes years/ decades to result in equilibrium.

4) If there is a combination of mental and physical problems things fall apart in the system.

The health care system is not trained to handle both a mental illness and a physical illness together. There is a lot of ignorance even among medical staff about the mentally ill. Usually they confuse the physical ailment with the mental illness. Or they stigmatize the patient as being lazy when in reality the patient is very sick.

4) You should have access to psychologists if you can't get psychiatric help and certainly a combination of psychiatrist doing the medication presciptions and the psychologist helping with the trauma might help.

5) There appears to be an increasing number of children who are suffering from anxiety disorders in Edmonton.

I am curious why we don't have more child psychiatrists to handle the work. The ones we have are very good like Dr. Levinsky. Dr. Lappa is a pediatrician who is also good with kids with anxiety. But I have a feeling there needs to be more such specialists as there will be more kids with anxiety.

6) Waiting will make things worse for such kids and I can't imagine how anyone with a severe mental illness would suffer waiting two years.

That's just ridiculous. There needs to be quick access to psychiatrists provided and if this costs more money I guess we need to do this.

We don't leave cancer patients waiting for chemotherapy and radiation so why would we expect folks suffering mental illness to wait it out for no darn reason other than our society is so dense about mental illness?

7) It does feel that we don't get to see the specialist we need to see but have to go through substitutes like social workers.

It's the downgrading of care in the system that is everywhere.

Obstreticians are replaced by midwives, the doctor is replaced by a pharmacist who can now do prescriptions, the specialist is replaced to some degree by the nurse practitioner.

In my mind this downgrading of skill sets is not a good thing.

8) Don't even think of asking for a second opinion when you have a psychiatrist.

This is the best way to lose the one you have got. I've never understood this sort of stuff but apparently asking for a second opinion indicates a lack of trust in the first psychiatrist. This is nonsense of course but you have to see it their way. Psychiatrists like other doctors don't like to be questioned. Heck it appears that no one in any government department, public agency or professional body in Alberta likes to be questioned.

9) It's a good idea for the government to provide coverage for psychologist visits.

I've never understood why they didn't do this unless of course government has no interest in the mentally ill folks and simply wants the citizens to believe it cares by doing these pointless reviews every few years.

10) It is discouraging seeing even the NDP folks do nothing yet again but this should not stop citizens from doing something about issues that matter. This issue matters.

The sad situation of the mentally ill citizens in our society should encourage each of us to ask our MLAs to do more than these placebo reviews. They need to provide housing, enhanced AISH payments; they need to ensure psychiatric / psychologist support that is covered; they need to provide job opportunities for the mentally ill that allow full integration; they need to ensure that the mentally ill have community advocates since the Office of the Health advocates won't be able to help these folks being as they are overrun with citizens seeking help for problems in the continuing care system.

There are many practical ways to help the mentally ill such as increasing supports for their families so that they don't burn out when their beloved children are at home. Many parents help their loved ones until they are too old to look out for them; they need help. And of course, we can be kind, loving and accepting with everyone. Mental illness, as you pointed out is invisible and anyone we meet might be so afflicted.
Like · Reply · Just now
Laurent Jeff Dubois · 
Paula, your column offers more insight, clarity, and direction than the entire report.

Thank you once again for your insights.