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With Mental Health Care, the Most Serious Cases Need Help First

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DrAfter123 via Getty Images
DrAfter123 via Getty Images

While researching a topic, I came upon a 2006 report by the Canadian Psychologists Association (CPA) that I found quite disturbing but that turned out to emphasize a major problem with efforts to resolve the mental illness crisis.

In Canada and the U.S. those with the most serious mental illnesses get little care. It is well established that we do not have enough resources thanks to our emptying of psychiatric hospitals that began in the '50s and '60s and the failure to put the promised resources into community supports and services.

While working on his report, Out of the Shadows, Senator Michael Kirby told the Canadian Psychiatric Association that "mental health and mental illness receive little attention and fewer resources, compared with physical illness, and that government funding is channelled to the acute care of physical illnesses because of the pressures on government to treat the sick."

He said that there are two "bipolar" and conflicting approaches of mental health versus mental illness when there needs to be just one approach.

And that is the problem.

Do we need one approach which is what we have in the Mental Health Commission (MHCC) that came out of his work?

Mental health exists on a continuum from existential angst of the worried well to the serious illness of schizophrenia -- a disease of the brain. There is a concept in medicine of triage -- the one who is sickest and in most danger gets treated first and with the most resources. In mental health, that should be those with schizophrenia, bipolar disorder and the other serious and debilitating illnesses and not those with existential angst.

When the MHCC was created many of us had high hopes that it would help to bring about real changes so that the sickest of the sick would get more help. But, as was intended by Kirby, the MHCC is focused on the full range from existential angst to the truly serious. That is reflected in their terminology of "mental health problems and illnesses."

But, is that broad focus even realistic?

The MHCC became the elephant and those of us in our blindfolds felt it and interpreted its mission based on our own interests. I mistakenly saw serious mental illness.

The "blindfolded" CPA didn't and wrote this:

The danger is that the Commission will take a very traditional view of mental health. This would be a serious mistake. A traditional view would mean for example:

1. an medicine centric system (sic) to the exclusion of other points of view and delivery systems,
2. a focus primarily on publicly funded services to the exclusion of programs that provide access regardless of their public or private source of delivery,
3. an overly strong focus on the serious and persistent mentally ill to the exclusion of other issues,
4. a focus on mental illness to the exclusion of mental disorders and behavioural health,
5. a strong focus on illness and a lesser focus on promotion, prevention and resilience, and
6. possible Commission membership composition that has an overrepresentation (sic) of one or two professions to the exclusion of others such as psychology.

My reading of this is that they are not really all that interested in the most seriously ill who need medical intervention and get very little (points 1,3,4 and 5). And, because they are not part of medicare, they were worried that they might not get a piece of the pie (2 and 6).

When I showed the above comment to a psychiatrist, his interpretation was the same as mine that they were ignoring those truly suffering and were looking for a larger slice of the pie.

A mother whose son has a serious mental illness commented "incredibly self serving" when she saw the CPA statement.

I asked the current executive director of the CPA, Dr Karen Cohen who did not write the above, for a comment and she sent me a five page response with links to more recent papers they have produced.

I was pleasantly surprised that we agreed on what I consider the absurdity of a mental health commission. She said that we don't have a physical health commission as there are too many illnesses but we do have an MHCC trying to address a broad number of conditions. "Not every illness or health problem has the same determinants or needs the same treatments or supports. In developing or implementing a mental health strategy for Canada, it is a tall order to be able to address this great range of illnesses and needs."

And my comment is that if you try to do that then it is only organizational nature to take the easy route and that is to ignore the difficult area of serious mental illness which I feel is happening. We need a strategy to address the crisis and lack of proper resources for serious mental illnesses and to actually do something positive for a change.

I also agree with her that psychologists can be effective adjuncts to treatment teams for serious mental illnesses using strategies like cognitive behavioural treatment as long as they are trained to understand psychosis. It was nice to see her say:

"medical management of some mental disorders is critical, schizophrenia a notable example. Research shows that for some illnesses, outcomes are enhanced when both pharmacotherapy and psychotherapy are used in concert. The challenge is that while Canadians have access to medical treatments and interventions through our public health care systems, they are less likely to have access to psychological treatments because the services of psychologists are not covered by public health insurance plans when these are delivered outside of public institutions."

I don't disagree. In my opinion, the MHCC is attempting to do too much without any authority to effect change. We need an operational national strategy to improve services for the seriously mentally ill. I think the CPA would agree and I would not disagree with their providing adjunctive treatment to those who they can help when it is based on scientific evidence.

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