The Negative Consequences of Canada’s Mental Health Industrial Complex

By Marvin Ross

Back in July, I wrote about the Mental Health Industrial Complex and pointed out that  there are all manner of policy researchers, policy wonks, government officials, social workers, psychologists and god knows who else, sitting around on committees and writing papers trying to develop solutions for what they call mental health. It is a giant make work project for people.

Thanks to the Fraser Institute, the consequences of these activities are exposed in their recently released study Mental Health Care How is Canada Doing? The answer is badly!

Their conclusion is that “the performance of Canada’s mental health care system is not an overwhelmingly positive one.”

The evaluation involved comparing Canada to 27 countries with high-income nations that also have similar policy goals. The Criteria for inclusion in the study was that countries must be a member nation of the OECD; They must have universal (or near universal) coverage for core medical services; and they must, according to the World Bank, be considered a higher-income country with a gross national per capita income of at least US$12,535 in 2019.

However, before looking at that comparison, it is important to review the deterioration in Canada over the years.

The Fraser Institute noted that “From 2003 to 2005, the wait time for seeing a psychiatrist on an urgent basis after GP referral averaged 2.0 weeks, and grew to 2.6 weeks between 2020 and 2022. For non-urgent patients, the wait time averaged 8.0 weeks from 2003 to 2005, and deteriorated to 9.2 weeks between 2020 and 2022 . For treatment on a non-urgent basis after an initial consultation, Canadians could expect to wait an average of 10.4 weeks between 2003 and 2005, and an average of 15.5 weeks between 2020 and 2022 . Overall, the total wait time from GP referral to treatment by a specialist deteriorated from 18.3 weeks between 2003 and 2005 to 24.7 weeks between 2020 and 2022.”

In addition “Survey data from the Commonwealth Fund shows Canadians were the 2nd least likely among respondents from 10 higher-income countries to report being able to get a primary-care appointment on the same day they are sick, and the 3rd least likely to find care after hours. Canadians were also the least likely to receive a same day callback from their regular physician’s office when reporting a concern during regular office hours.”

Canada does spend a lot on health care but has little to show for it compared to other wealthy countries. The Fraser institute pointed out that:

In 2019, Canada ranked 23rd out of 28 countries for the availability of psychiatric care beds per 1,000 population. Canadians had access to 0.36 psychiatric care beds per 1,000 population, while patients in Japan had access to 2.59, patients in Belgium had access to 1.41, and patients in Germany had access to 1.31. The average developed nation maintained 0.75 beds per 1,000 population, more than double the number in Canada. While there may be important differences in care approaches among nations, in particular — by design in some nations — a much greater reliance on outpatient care that results in the need for fewer hospital beds, Canada nevertheless has relatively fewer resources available for patients needing hospitalization than the average developed nation with a universal-access health care system.

Despite that, we do better when it comes to psychologists at only slightly below average of other countries and above average for mental health nurses. But, the shocking finding is spending. It is well known that Canada spends less on mental health services at only 7% while France spends 15%, England 13% and Germany 11%. What came as a total surprise is that the funds devoted to mental health as a percentage of total health spending in Canada was very high. 10.6% of spending went to mental health services when the average for the other countries was only 7.4%

The bottom line is that we spend more of our health dollars on mental health but have very little to show for it. And I am convinced that a big cause of that is all the money we spend on commissions, consultants, task forces all of which hire researchers, policy specialists and other useless bureaucrats who contribute nothing to the care of sick people.

Since writing the mental health industrial complex, I’ve learned that the Standards Council of Canada Task Force on Mental Health and Addictions which has been contemplating the state of care in Canada has hired the PR consulting firm, Hill and Knowlton to survey users to see what is needed. Hill and Knowlton is a US public relations and consulting company based in New York City with 80 offices in 40 countries. They are most noted for the false testimony by Nayirah and a PR campaign on behalf of the Government of Kuwait in the lead up to the Gulf War. That false testimony was that Iraqi soldiers were killing premature babies in Kuwait hospitals.

Rather than running a make work program for researchers and policy types and filling the coffers of consultants, that money should be diverted to actual programs and staff who can help the mentally ill and those with addictions.

Deciding to Kill

By Dr David Laing Dawson

There are a number of ways a boy or a man can come to the conclusion it is time to kill others. And this thought can be transitory or fixed; it can be isolated or socially reinforced. It can include thoughts of surviving or of dying, but it usually includes a fantasy of retaining consciousness, of seeing and experiencing the consequences of the act of killing.

This thought can be the product of a private delusion, or a shared grievance. When it flows from a shared grievance it could be reinforced by anonymous contacts on social media, a cult leader, or a political or military leader.

Just this week we have listened to the phone call home to his father of an excited young man who has just killed a Jewish family in Israel, and now we watch the news as a man flees police after a shooting spree that killed at least 18 people in Maine. In the same time frame a man in Sault St. Marie killed his estranged partner, their three children and himself.

And we are horrified that anyone could do these things. But we should not, by now, be surprised. We should not be surprised because we know there are a number of ways a boy or a man can come to the conclusion it is time to kill others.

The three instances mentioned above are very different. The man in Sault St. Marie was undoubtedly narcissistic, controlling, and probably depressed. Undoubtedly he seethed with anger, resentment, failure and rage. And he had a rifle.

We know the man in Maine is 40, may have been “hearing voices”, and spent two weeks in a mental health facility last summer. He may have developed a treatable mental illness, schizophrenia, psychotic depression, drug or alcohol induced psychosis, or even a brain tumour, leading to delusional thinking and command hallucinations. And he had at his disposal an automatic weapon.

The Palestinian boy is caught up in a cult, a military cult, with his leaders fanning the flames of his zeal, turning his excitement, fear, and terror into blood lust. He seeks his father’s approval. And he has guns.

In the 1970’s I directed a community psychiatry program for a residential, small town, and rural area. We prioritized severe mental illness and saw patients with families. As part of our assessment protocol we asked about guns in the house. When the answer was yes we asked that a family member remove the gun (usually a hunting rifle) from the house, and have it stored somewhere or handed over to the police. We did this because there are a number of ways a boy or a man can come to the conclusion it is time to kill others.

There are other ways of killing of course, but they all take longer, are less certain, require more preparation, and they offer time for the emotion, the fleeting thought to dissipate, or be confronted by doubt, by remorse, by reality. Not so with a gun.

Thoughts on Suicide

By Dr. David Laing Dawson

I listened to a piece on David Foster Wallace, the American novelist and short story writer, the other day. The panelists offered a number of ideas about the man’s life and death, some of them mystical, some romantic, some referencing devils, demons, and struggles. One mentioned Kurt Cobain. One even mentioned that suicide may have been a way of ensuring fame.

David Foster Wallace, Robin Williams, Anthony Bourdain, Virginia Wolf, Sylvia Plath, Vincent Van Gogh, Ernest Hemingway.

All suffered from depression, severe clinical depression. Robin Williams, Vincent Van Gogh and Virginia Wolf were probably bipolar.

All were either untreated or under-treated for their depressions. Of course, we did not have effective treatment for clinical depression before ECT was discovered, and then antidepressant medication (1959 for Imipramine, 1982 for the first SSRI).

I am writing about this because we have a tendency to romanticize this reality, suicide, especially when the sufferer was a writer, painter, performer, or musician. We write and talk of struggles and demons, of overcoming demons and how this is all somehow involved with sensitivity and creativity. We try to understand their actions. None of these people were unsuccessful (although Vincent only sold two of his paintings in his lifetime). They each had families. So we think in mystical, romantic terms about their work, their struggles, their successes, failures, and their suicides. We try to understand, find a satisfying narrative.

But really, they each developed severe depression. The illness depression.

I don’t know the stories of all of them in detail. Ernest was hospitalized with depression and treated with ECT. He returned home and back to writing for six months after treatment. When his illness relapsed (ECT is a very effective but temporary treatment) he was taken to hospital again. This time he talked his way out and went home and fetched a rifle and walked into the woods.

David Foster Wallace’s body was found by his wife.

Anthony Bourdain’s daughter in the USA was notified of her father’s death by suicide in Europe.

Robin William’s body was found by his assistant while his wife thought he was sleeping.

Of course each of these people suffered, at some point, from other problems as well, usually alcohol and/or drug addiction.

Depression: The key here is the way severe depression, clinical depression, diminishes one’s sphere of consciousness. It diminishes the sufferer’s awareness of, and empathy for, others.

When we are not suffering from a severe depression we are aware how awful, how devastating, how traumatic it would be for a daughter, a wife, a husband, a mother or father, a friend, to find us hanging from a rope in the bedroom, lying in a pool of blood, or simply dead in bed with an empty bottle of pills by our side.

It is the key to all of these cases. Clinical depression is not just sadness, not simply physiological flatness, not just struggle and failure and agitation, but an actual constriction of conscious awareness, awareness even of loved ones and the terrible trauma we are about to inflict on them.

And it is, usually, today, a treatable illness.

Update on Andrew Bryenton and the Kafkaesque Attempt to get him Medical Help

By Marvin Ross

Webster’s refers to Kafkaesque as  something “having a nightmarishly complex, bizarre, or illogical quality” and that perfectly describes what Andrew’s parents are going through trying to get him the psychiatric help that he needs. But first, let me recap who he is and his plight. Regular readers of this blog will be familiar with a number of posts and guest posts that have been written about him here.

Andrew is a 39 year old former bank official from Charlottetown, PEI whose dreams were described to me by his mother. “They were dreams of a university education, career, wife and children, and a nice home on P.E.I. He had all of that but it was stolen by a serious mental illness.   His life involved family, church, bowling and baseball friends, colleagues at work and countless others who knew and admired Andrew.  Andrew was patient, kind and compassionate.”

As a result of a psychotic break, Andrew was treated by a local psychiatrist but decided not to continue taking the medication that helped with his symptoms, stopped and took off to live on the streets of Toronto. He became a homeless person with no place to sleep other than the street or parks, no money, nothing, living off the kindness of others for sustenance. He was one of thousands of homeless people wandering the streets of most of our towns and cities many of whom have untreated mental illnesses.

Through the marvel of social media, Andrew’s parents were able to get people in Toronto and the Greater Toronto Area to report on his whereabouts and to give him food, liquids, money and clothing some of which he accepted and some of which he refused. After considerable effort, his mother managed to obtain a Form Two order from a Justice of the Peace to have him taken to hospital for a psychiatric evaluation. As a result of the first one, Andrew was taken to hospital by the police and kept for 72 hours. At that point, doctors could hold him for a further period of time for treatment if he posed a danger to self or others. They decided to release him back to the streets

Marlene, his mother made two further attempts to get a Form Two which were successful and again, he was taken to hospital. Given that, at one point, he was walking the wrong way on an expressway in the rain and at other times he had almost been hit by cars and he was observed deep in conversation with himself on the street, that he was a danger seemed self evident. Not to the doctors. The second hospital turfed him out at 72 hours and the third after a couple of hours in the ER at 2 in the morning.

That third hospital was the much lauded Centre for Addiction and Mental Health which claims it is the largest psychiatric facility in Canada. They are very proud of the work they do in research and teaching.

If I may pause this narrative for a moment, let’s assume that Andrew is not 39 with psychosis but 69 with Alzheimer’s. Would any hospital anywhere in the civilized world decide to toss him out to live on the streets with no money? I truly doubt it but both are diseases of the brain as I’ve written earlier.

In desperation, Andrew’s parents flew to Toronto and managed to acquire a 4^th Form 2. With the help of their many helpful citizens, Andrew was located in front of a Tim Horton’s. Marlene’s host in Toronto approached Andrew and offered to buy him a coke and Andrew agreed. In Marlene’s words “then the two police cars arrived. They were very respectful of Andrew and told him that he had to go to the hospital because a Justice of the Peace had signed a Form 2. They even permitted him to finish drinking the Coke. Andrew got in the police car without incident and went to the hospital.”

It was hoped that within the 72 hour observation period, the Ontario government would start the process to have Andrew transferred to PEI as that government would pay. This is allowed under S 31 of the Mental Health Act. That section states:

Where it appears to the Minister,

(a) that a patient in a psychiatric facility has come or been brought into Ontario from elsewhere and his or her hospitalization is the responsibility of another jurisdiction; or

(b) that it would be in the best interests of a patient in a psychiatric facility to be hospitalized in another jurisdiction, the Minister may, upon compliance in Ontario with necessary modifications with the laws respecting hospitalization in such other jurisdiction, by warrant in the approved form authorize his or her transfer thereto.  R.S.O. 1990, c. M.7, s. 31; 2000, c. 9, s. 12.

Unfortunately, Ontario dropped the ball and this did not happen. Doug Ford, as I’ve said in earlier posts, passed the buck to his Minister of Health and during this crucial time, both she and her associate Minister for Mental Health were at a conference in (ironically enough) PEI.

No transfer but at least the psychiatrists at this hospital have completed a Form 3 which enables Andrew to be held for an additional two weeks less a day. As Andrew is not in agreement with being in hospital, the final decision must be made by the Consent and Capacity Board at a hearing. No treatment is allowed without his consent other than to save his life until the board makes a determination.

Just to get to this point, the Bryenton family needed the help of scores of local citizens who went out of their way to help. As Marlene posted on facebook:

Lloyd and I thank every kind soul who reached out and helped Andrew since January 2023. You gave him food, water, money and clothing. We received hundreds and hundreds of posts, and photos with date, time and location. You helped our son survive on the streets of Toronto. You helped give us peace of mind each and every day for the past 11 heartbreaking months.

We thank people that searched for Andrew and helped me in so many ways. We worked as a well greased machine. We were ANDREW’S ARMY OF ANGELS! How can we ever repay the people of Ontario for your kindness and love shown to our son, Andrew Bryenton?

Marlene did begin a petition to have Andrew returned to PEI and says We presently have 8695 signatures. Let’s rally together and show that Ontario and Prince Edward Island residents believe that Andrew deserves a fresh start in life. Here is the link to sign: https://chng.it/TMKMZfHH2p

For the skeptics who think people with mental illness make a valid choice to be homeless and live on the street, here is a youtube video of Andrew when sane https://www.youtube.com/watch?app=desktop&v=F3GVRyhd4iE

Contrast that to the picture of him sleeping on St Clair Ave W in Toronto or in front of Tim Horton’s when being taken into custody for transport to the hospital by police.

Old Men Send Young Men off to Kill and to Die.

By Dr David Laing Dawson

No one has been able to satisfactorily explain why HAMAS (or the Ayatollah) chose this moment to attack, and attack in such a way that hell would be unleashed as a response. Similarly, why did Putin order an invasion that would, predictably, cost hundreds of thousands of lives and (almost) world-wide condemnation.

I suspect, in part, the answer lies in totalitarian regimes run by aging men, men who retain power and leadership through fear and intimidation and the vilification of an enemy; and who’s armies are comprised of restless young men.

How long can that work without a demonstration? Without action? Two years? Five years? Seven years? For Russia, history indicates two years, tops. Maybe less in the Middle East.

The young men are aging as well. Their willingness to believe their elders, their adolescent sense of immortality and invulnerability are waning. They might even be wondering about loved ones, family, settling down, having children, and they may even be developing some empathy for others, that is for others unlike themselves. (It can start to happen about age 24.)

How long can they be kept on the bench, fired up, preparing, chanting, threatening, training?

I watched a video of boys and young men building a tire fire in the middle of a busy thoroughfare. They fetched tires, pushed them, rolled them, kicked them toward the fire, retrieved them when they rolled back and tried again as the fire grew. From their movements, actions, exclamations they might just as well have been playing a volleyball or soccer game. Wish that they were. (We humans do have a long history of sporting contests, in enlightened times, replacing war.)

But my point is that any social organization, culture, country, built on hatred of another, totalitarian in nature, theocratic or secular, lead by aging men, must at sometime unleash their young males, provide them with action, before they grow older and wiser.

The answer, eventually: Democracies with strict term limits for leaders (leaning right, center, or left), a dying out of primitive religions and old men dreaming of glory, and, and more women in positions of power.

Ontario’s World Mental Health Day Meaningless Platitudes

By Marvin Ross

October 10 was World Mental Health Day and even Ontario Premier Doug Ford took the time to make an announcement of support. He told Ontarians that we must fight stigma, help people get support and about all the innovative programs that Ontario has introduced to support people in their quest for help.

He didn’t explain what those innovative programs might be but maybe he was preoccupied with the announcement that day that the RCMP has begun a criminal investigation of him and his government over the sale of some of the Greenbelt protected lands to developers. He might have been referring to his government’s efforts to introduce privatization into our public health care system as he admits at 32 minutes into this press conference .

In an article by Health Care Providers Against Poverty, the impact of privatization on mental health care is outlined. The authors point out that this has resulted in longer wait times and less access for those who need it. While Ontario is adding more money to mental health care, it is still not as much as the “Canadian Alliance on Mental Illness and Mental Health (CAMIMH) and the Mental Health Commission of Canada recommend and is less than what other G-7 countries spend.”

Regular readers of this blog will be familiar with the case of Andrew Bryenton, a 39 year old former bank official from PEI who developed a psychotic illness and has been living on the streets of Toronto. Three times his mother obtained form 2 documents from the court for the police to pick him up and take him to hospital for a psychiatric assessment and to have him returned at no cost to Ontario back to PEI. His Charlottetown psychiatrist was willing to treat him and felt that he could be restored to 90% of his previous self.

Three times Toronto hospitals ruled that he was fine and discharged him back to the streets with no money or place to stay. He is so fine that people have reported seeing him talking to himself, gesticulating and, just the other day, talking animatedly to a telephone pole. Concerned citizens began e-mailing Premier Ford to do something to help this poor man and his distraught family and Doug replied to the mom that he was sorry for her troubles, wished her well and said he was referring the matter to his Minister of Health, Sylvia Jones.

Ms Jones has done nothing but the Premier’s office advised that they had received so many e-mails that they would simply send an automated “out of office” type response. Just recently, a member of the opposition wrote to Ford asking for him to help. This was his reply:

Thank you for writing and sharing your views about Andrew Bryenton. I appreciate the opportunity to read your comments and get a better understanding of your perspective.

I’ve shared your email with the Honourable Sylvia Jones, Minister of Health, for her information.

Your input is important. You can be sure our government will consider it when developing policies and deciding how to address the various challenges we face today. It’s with your help and through this collaborative spirit we will build a brighter future for Ontario.

Thanks again for reaching out.

Note that he is telling his minister about this for her information only but not suggesting she take any action.

In a guest post on this blog, psychiatrist Richard O’Reilly pointed out that:

“The problem is our society’s reluctance to spend money on services for people with severe mental illness. Governments repeatedly trumpet increased funding for “mental health services.” Bizarrely, few of these additional dollars go to services for people with the most severe illnesses such as psychosis. In other areas of health care, we prioritize the needs of the those with the most severe problems. I can’t think of another area of health care in which we prioritize spending on less severe problems while ignoring the basic needs of citizens who are the most severely ill.”

If Doug was truly interested in providing innovative programs as he claims he has already done, then Dr O’Reilly suggests this would solve the problems faced by Andrew and the thousands upon thousands of homeless mentally ill people wandering our streets or being cared for by overwhelmed families.

“First, we can reverse the decline in the availability of inpatient care. A reasonable availability of hospital beds would enable doctors to admit people like Andrew and to provide treatment in hospital until the patient’s hallucinations and delusions are controlled. Critically, it would also allow the hospitals to care for very disabled patients until a residential placement could be found that would provide the person with an appropriate level of support. In relation to this second point, Ontario needs to develop high support group homes in the community for the small percentage of people with marked psychiatric disabilities so that they can live with dignity. Finally, we need to fund more assertive community teams (ACTs). The Ontario government promised to fund a network of ACT teams when it closed the freestanding psychiatric hospitals. But the Ontario Association for ACT teams notes that the province is 50 ACT teams short of the required target and that many of the existing teams are underfunded.”

There is time Doug to do the right things but do you have the balls to do them?

PS. I will be providing an update on Andrew in the not too distant future.

Involuntary Treatment and Addictions – Part Two

By Dr David Laing Dawson

What would that actually look like? In a few words, to start: Something like the infirmary of a prison.

Involuntary treatment for addiction would entail:

1. Police apprehension on some legal basis: (?Family to JP, ?police judgement of risk )

2. Escort to a medical facility for examination to be certain the addict is sufficiently healthy (no communicable diseases, not in organ failure, does not have head injury, pneumonia) to undergo the second phase.

3. The enactment of a second phase of legal incarceration for the purpose of withdrawal. (?involuntary commitment after examination by two doctors, special tribunal?)

4. This second phase is forced withdrawal. This requires a special locked facility with adequate monitoring of the consequences of withdrawal, plus available medical and emergency services for the sometimes severe consequences of withdrawal.

5. The administration of drugs and supplements that alleviate the worst symptoms of withdrawal. The length of time required differs depending on the particular drug and severity of addiction. Usually day four is the worst but the withdrawal symptoms can last for weeks and months.

6. A period of time still in lock-up for physical recovery: nutrition, medication, sleep, exercise, abstinence. Length of stay? Two weeks or more.

Now What? Discharge at this point would ensure over 90% relapse. So:

7. A comprehensive assessment to ascertain the factors in this particular addict’s life, beyond biological craving for relief, bliss and ecstasy, that contribute to his or her addiction.

The possibilities range from mental illness, trauma, loss, personality disorder, ADHD, intellectual disability, to lack of housing, lack of regular income, family support, social connections, skills, friends who are not addicts, life skills, belief systems (meaning), lack of membership (belonging), lack of primary relationship, lack of meaningful activities, job….

8. Address the above, with our now voluntary addict-in-recovery, within well funded comprehensive programs, over an extended period of time, some of which must be residential, or removed from the addict’s addicted friends and sources.

9. Plan on large numbers relapsing and requiring a second intervention or moving to an addiction maintenance program.

The above would be very expensive, fraught with legal and civil rights questions; and partial implementation would not be effective.

Lancet Study by Moncreiff on Reducing Schizophrenia Medications Should Not Have Taken Place!

By Dr. David Laing Dawson

Chlorpromazine was first synthesized and used in France in 1951. Before this there existed no effective or successful treatment for the psychoses of schizophrenia or bipolar illness. Hundreds of things were tried through the centuries, from stockades, banishment, exorcism, punishment, to spinning chairs to wet packs to teeth extraction, barbiturates, insulin coma, and, of course, various forms of psychotherapy, work programs, and behavioural modification. None of it worked. None of it worked beyond the small improvements brought about by support, encouragement, hope, and wishful thinking. Of course a kinder, better, more supportive, more understanding environment helps. But it does not change the course of these illnesses.

ECT provided temporary relief. But, for the most part, those residents of mental hospitals trapped in psychosis remained trapped in psychosis prior to the introduction of chlorpromazine. Many of the severe symptoms of those illnesses cannot be found today on our psychiatric wards, but prior to the introduction of chlorpromazine, medical students could be taken to the wards of mental hospitals to see examples of mania, catatonia, bizarre compulsions and the enactment of delusions.

Chlorpromazine was brought to Quebec and North America in the early 1950’s.

By 1967 I was prescribing chlorpromazine for mania and schizophrenia in the emergency ward of a Toronto Hospital . By late 1968 I was treating, on an inpatient ward and in outpatients, people suffering from bipolar illness and schizophrenia.

Chlorpromazine and other new anti-psychotics were amazingly effective in the treatment of acute psychosis. Improvement occurred within days, and full resolution of the psychosis within 4 to 8 weeks.

So, how long should we keep people on these medications? In 1969 it was reasonable to try removing the medication once full recovery had occurred, within, say, 6 months. THIS DID NOT WORK. All relapsed. The next logical step was to try reduction and cessation of anti-psychotic medication after at least a year of recovery. THIS DID NOT WORK. Relapse was not always immediate, but it inevitably occurred.

By the mid 1970’s we knew people who suffered from schizophrenia could only be protected from relapse by remaining on anti-psychotic medication for years, perhaps for life. And we knew that each relapse caused more damage and was more difficult to treat.

We needed better medications with fewer side effects, not anachronistic anti-pharmacology psychiatrists.

Removing patients from a treatment we know works (evidence based and scientifically proven) for experimental purposes is, simply, unethical.

Anti-Medication Psychiatrist Proves Herself Wrong – And Patients May Have Been Harmed in the Process

By Marvin Ross

Dr Joanna Moncreiff is a British psychiatrist who has long been skeptical of the role that medications play in treating mental illnesses like schizophrenia. Two of her best known books are The Myth of the Chemical Cure and The Bitterest Pills and she is also a regular columnist for Mad in America. Her latest research project was a two year study called Radar. It was designed “to assess the benefits and harms of a gradual process of antipsychotic reduction compared with maintenance treatment. Our hypothesis was that antipsychotic reduction would improve social functioning with a short-term increase in relapse”. It was just published in Lancet.

Not surprisingly, it proved the value of anti-psychotics.

What she and her colleagues did was to randomly assign 263 people to either a dose reduction group or to a maintenance group who all remained on their usual dose. The median dose reduction at any point in the trial was no more than 67%. At the end of a 24 month follow up, 90 of 126 in the reduction group and  94 of 127 assigned to the maintenance group were assessed. The anticipated improvement in social functioning for the reduction group did not occur. Both groups were the same.

Reducing meds improved nothing but made things worse for those who reduced their meds.

The first red flag for me was the large number of subjects (about 30% )who were lost to follow up. Reasons for this was that some subjects withdrew, some died and some were either in hospital or simply could not be found.

Even worse was the high number of adverse events. “There were 93 serious adverse events in the reduction group affecting 49 individuals, mainly comprising admission for a mental health relapse, and 64 in the maintenance group, relating to 29 individuals.” In the reduction group, that’s 54% of subjects who had adverse events compared to 30% for the maintenance group.

Shockingly, 8 people in the reduction group died compared to 4 in the maintenance group. In addition, 49 people in the reduction group were admitted to hospital for mental health problems compared to only 27 in the maintenance arm of the study. To be fair, these illnesses are serious and complex so adverse events are not surprising but why tempt fate by messing with what is working and reducing meds.

Way back in 2008 when my book on schizophrenia came out, I quoted Dr Robert Zipursky saying:

about 80% of patients will relapse within the first five years if they stop taking their medications. But, even if they are in remission, they should stay on indefinitely because of the cumulative damage each psychotic episode inflicts. “Recovery from relapse may take a long time and it is uncertain,” he said. Scientists, he added, still don’t know if someone can remain well for five or 10 years without medication, and the risk of not recovering from a relapse is too great. “If you’ve spent a year or two getting someone well and watching them rebuild their lives . . . to watch them get sick again is not something you would wish on anyone.”

What particularly baffles me about this research is how it ever got ethics approval. All human research must be approved by an ethics board in order to ensure that nothing dangerous is being done to patients and that patients have given proper informed consent. Dr Moncreiff does not mention if she had ethics approval but I would be surprised if she was able to conduct her research and have it published in the Lancet without it.

One key feature of ethical research is that it not be done with placebo if there is a treatment available for whatever condition is being studied. In this research, a placebo was not used but people were weaned off a drug that is well known to be beneficial and needed for those suffering from schizophrenia and/or psychosis. Most psychiatrists and family members know only too well what happens when people reduce their medications and go off them and do not want to see the result. Moncreiff and her colleagues did not seem to be concerned but, for most, it is a concern.

To try to understand the ethical dilemmas posed by human research, I would suggest reading this https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3844122/ From my perspective, this study should never have been approved and had it been done in a litigious country like the US, I would suspect that legal action would be warranted by those harmed.

Involuntary Treatment and Addictions – Part One

By Marvin Ross

As the number of those addicted to substances increases and the deaths as a result continue to rise, people are clutching for solutions. One potential solution favoured by some families is involuntary treatment and that is now being proposed by some right wing governments like Alberta and New Brunswick. The $64,000 question, however, will that work?

Involuntary treatment for those with serious mental illnesses does work despite how controversial it is with civil libertarians who would prefer to see people die in back alleys but with their human rights intact. It works because mental illness is a no fault condition caused by various abnormalities many of which have yet to be completely isolated and defined. Science does know, however, that certain drugs will alleviate depression, the worst symptoms of psychosis, the mood swings of mood disorders and the obsessions of OCD.

These drugs have been developed with an hypothesis as to why they might help and then carefully tested over years through various clinical trial stages until the developers can prove to the regulatory agencies that the benefits outweigh the harms. I’ve personally seen them perform miraculous transformations in people as have many others. Involuntary treatment is needed in a number of cases because the ill person lacks insight into the disease. That lack of insight is part of the disease called anosognosia.

In some ways, drug addiction is more complex than serious mental illnesses. No one with a serious mental illnesses decides to become ill, but as the National Institute of Drug abuse states:

“Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent, which is why drug addiction is considered a “relapsing” disease—people in recovery from drug use disorders are at increased risk for returning to drug use even after years of not taking the drug. “

Proponents of involuntary treatment for addiction, I’m told, are citing anosognosia as a reason why it is needed. That concept is valid for those with serious mental illness but does it translate to addiction? It turns out that there is very little in the research literature on anosognosia for addiction. One paper from 2016 suggested that “In addiction, notably Alcohol Use Disorder (AUD), patients often have a tendency to fail to acknowledge the reality of the disease and to minimize the physical, psychological, and social difficulties attendant to chronic alcohol consumption. This lack of awareness can reduce the chances of initiating and maintaining sobriety.” 

All of this is speculation.

A more recent paper also suggested this might be a relevant avenue for research and concluded that:

“Compromised insight in substance use disorder may be relevant to a constellation of behaviors that suggest a lack of behavioral awareness linked to drug use. Future work needs to refine and advance the measurements, continuing to investigate insight problems in addiction that may become important therapeutic targets. “

At the moment, all of this is also speculation.

One cynical (ie realistic) physician said that “All addicts know they are addicts. They just lie to themselves (and others) about how often or how recently they relapsed. And all alcoholics know they drink, they just lie to themselves and the docs about how much they drink. And this kind of lying really demonstrates they do not suffer from anosognosia, they are merely human.”

What is most important is the availability and cost of treatment for that addiction. When it comes to mental illness which is covered by universal health care, Canada is deficient. We do not have enough psychiatrists treating those with serious mental illness with only 13.1 psychiatrists/100,000 population. Switzerland has 52, the UK 18 and Norway 25. The Canadian Medical Association suggests we need 15.

The Canadian Psychiatric Institute and the Treatment Advocacy Center in the U.S. suggest that an appropriate number of psychiatric beds be 50 per 100,000. In a comparison of 35 countries, Canada ranks 29th in beds slightly ahead of New Zealand, the U.S., Chile and a few others.

Addiction treatment in Canada is a mix of public and private programs and many of the programs insist that new patients be sober when they join. Canada Drug Rehab provides considerable information on the various programs that exist and evaluations of the types of programs. In a blog on private versus public rehab in BC, they point out that public programs often come with major downsides including:

• Wait times
• High patient to doctor ratios
• Outdated practices
• Lack of personalized care
• Poor post-treatment care

Those who have access to private addiction or substance abuse treatment can access the core advantages of private care, which are:

1. Fast admission (sometimes in just days)
2. Long and thorough treatment
3. Personalized care
4. Choice over environment and amenities
5. A diverse range of therapies and treatments
6. Post-recovery services

What is evident is that if we are serious about rehab, we need a lot more publicly funded evidence based programs that are accessible for those who need them. This is far more crucial than arguing about the need for involuntary treatment when the programs that can successfully treat people are not really there to begin with.

The need for adequate resources for both mental illness and addictions should be the focus for all.

In Part Two coming next week, Dr Dawson will outline what an involuntary program for those with addictions might look like.