Category Archives: Psychiatry

More on The Continuing Proof of the Efficacy of Anti-Psychotics

By Dr David Laing Dawson

The narratives from the proponents of Open Dialogue remind me of the narratives arising from the psychoanalysts working in private psychiatric hospitals in the United States in the 1950’s and 1960’s. Many case studies were available and even books written on the subject.

In the late 1960’s we were unlocking the doors of the mental hospital in Vancouver and applying therapeutic community principles. The principles and ideas of the therapeutic community can be found in the activities of the Open Dialogue program. And before that they can be found in the practices of small hospitals from the Moral Treatment Era of the 1850’s to 1890’s, and again, briefly, in some mental hospital reforms shortly after WW1 and before the Great Depression, albeit, in each case, within the language and pervasive philosophies of the time.

In the late 1960’s we had already discovered how wonderfully effective chlorpromazine could be in containing mania and reducing the psychotic symptoms of schizophrenia.

So in this context, knowing the evidence, the clear evidence of chlorpromazine being the first and only actually effective treatment for psychosis, and lithium for mania (beyond containment, sedation, shelter, kindness, protection, food, routine grounding activities, time and care) it behooved us to look closely at the claims of the psychotherapists who were writing such elegant and positive case studies from the American private hospitals.

So I read them.

They were interesting reading, detailing the relationship of therapist and psychotic patient, interpreting the content of the psychosis, and the painstaking time consuming process of building a relationship, working to help the patient view the world in a different manner, and always, through the pages of these reports, it was said great progress was being made. And they all ended with something like (this is the one I remember best) “Unfortunately, despite showing so much progress, patient X assaulted a nurse and had to be transferred to the State facility.” Curiously, as with many “studies” I read today, despite the obviously bad outcome, a paragraph is added at the end extolling the progress made (before the unfortunate outcome) and recommending we stay the course.

There are many interesting explanations for the continuing anti-medication (for mental illness) philosophies. (Note that almost nobody objects to taking medication for other kinds of suffering and illness). Marvin and I have written about a few – the preciousness of the sense of self, the wish that there be an immortal mind that can outlive a brain, the fear of being controlled, distrust of Big Pharma, professional jealousies, and turf wars. But writing the above reminds me of another reason this irrationality persists.

It was clearer to me then (1960’s/1970’s) than it is now, because we really wanted to find ways of helping without medication: It is much more ego gratifying to mental health workers of all stripes when our patients get better simply because of our presence, our words, our care, ourselves, than if we just happen to prescribe the right medication.

I remember well a patient, a professional, a few years ago, thanking me for helping him overcome a severe depression. “Nah,” I said, “I just managed to prescribe the right medication for you.” “No, no,” he said. “It was more than that.”

All right. There are a few moments when I can be attentive, thoughtful, kind, and even find the right words. But to try doing that alone while withholding medication for severe mental illness would be malpractice, cruel, egotistical, even sadistic.

 

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The Continuing Proof of the Efficacy of Anti-Psychotics

By Marvin Ross

Despite the protestation from the anti-psychiatry advocates, medication for schizophrenia works and another study has just been published to support that position. A new study based on a nationwide data of all patients hospitalized for schizophrenia in Finland from 1972 to 2014 found that the lowest risk of rehospitalization or death was lowest for those who remained on medication for the full length of time.

The risk of death was 174% to 214% higher among patients who never started taking antipsychotics or stopped using them within one year of their first hospitalization in comparison with patients who consistently took medications for up to 16.4 years.

It should be pointed out that this is real life data rather than a clinical trial involving a total of 8,738 people.

What is particularly significant for me in this study is that it is from Finland which is the home in one isolated part of that country (Lapland) to the alternative Open Dialogue espoused by the anti-psychiatry folks including journalist Robert Whitaker of Mad In America fame. Whitaker claims that 80% of those treated with Open Dialogue are cured without need for drugs.

I wrote about Open Dialogue very critically back in 2013 in Huffington Post and pointed out that there is very little research to demonstrate its efficacy. I actually asked a Finish psychiatrist, Kristian Wahlbeck who is a Research Professor at the National Institute for Health and Welfare, Mental Health and Substance Abuse Services, in Helsinki about Open Dialogue.

This was his answer:

“I am familiar with the Open Dialogue programme. It is an attractive approach, but regrettably there has been virtually no high-quality evaluation of the programme. Figures like “80 per cent do well without antipsychotics” are derived from studies which lack control group, blinding and independent assessment of outcomes.”

He went on to say that:

“most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise.”

As for the claim that psychiatric hospital beds in Finland have been emptied, he said “in our official statistics, the use of hospital beds for schizophrenia do not differ between the area with the Open Dialogue approach and the rest of the country.”

My blogging associate, Dr David Laing Dawson also wrote about Open Dialogue in this forum with very skeptical view. He stated that the director of the program admitted that about 30% of the patients in Open Dialogue are prescribed medication so arguing that medication is not used is not correct.

At the time my article appeared in Huffington Post, someone on Mad In America agreed with me that there was insufficient evidence on the efficacy of Open Dialogue and said that a US study was set to begin in, I think, Boston. I did find a completed study on Open Dialogue done by Dr Christopher Gordon. His study involved 16 patients and he states at the outset that

“Since this was not a randomized clinical trial and there was no control group, we cannot say that these outcomes were better than standard care, but we can assert that they were solidly in line with what is hoped for and expected in standard care.”

In the paper that is in a legitimate psychiatric publication, he states that of the 16, two dropped out and a further 3 had disappeared at the end of the study so no data is available for them. This is a study of 11 people who completed the one year term.

He then points out that:

“Of note, four individuals had six short-term psychiatric hospitalizations (two involuntary).”

and that:

“three of the six individuals who were not on antipsychotics at program entry started antipsychotics. Of the eight already on antipsychotics, four had no change in their medication, and four elected to stop during the year. Both groups of four had similar outcomes and continued to be followed in treatment. Shared decision making and toleration of uncertainty contributed to these choices.

Hardly the success he suggests if the goal was to help them get well without medication.

But, coming up at the end of May in Toronto we have a conference with Robert Whitaker and others on Shifting the Narrative on Mental Health from the psychiatric disease model to the relational/recovery model, and on the challenges that are stacked against that eventuality.

Now I would say that the challenges against that shift are science but they define it as “The challenges and resistances to progressive change are of an ideological, macro-economic nature guaranteeing a protracted and difficult struggle for recovery advocates.”

Dwayne Johnson and Heroic Narratives

By Dr David Laing Dawson

Within the same time frame I was reading Marvin’s blog on the Mental Health Commission and the associated commentary, Dwayne Johnson’s story of depression popped up on multiple news sites. None of the sites gave much detail and I remain unsure if he suffered bouts of what we used to call “clinical depression”, and before that “endogenous depression” or if he simply suffered some difficult discouraging periods in life when his football career and a relationship ended.

In these brief news items Dwayne’s story is shaped as the narrative of an “heroic struggle”.

And I realized that most such stories are shaped and told in that form. It is a classic narrative form, and one we all want to hear.

Facing great odds, our hero, perhaps after learning some life lesson (humility, confession, love, trust, openness) battles his way through to success, health, and happiness. His weapons are will power, strength, hope, perseverance, and a little help from his friends.

It is the narrative form in the story of A Beautiful Mind’s John Nash. And it is the narrative form when the story is told about a victim of cancer.

The difference is that when we read the story and see the pictures of someone’s struggle with cancer, we know he or she has undergone one or many courses of radiation or chemotherapy, that he or she is still undergoing treatment.

The focus of the story may be on the courage and optimism of the patient, their loving  family, a special group of supportive friends, a cancer support group, or all that the patient is able to accomplish despite their illness – but we never lose sight of the fact of medical treatment for cancer.

It is good to bring mental illness out of the shadows. It is good to tell our stories. But we need to drop the euphemisms of mental health issues, and (a new one for me) mental health “situations”, and we need to include the fact of medical treatment for serious mental illness, because we don’t assume it as we do with cancer narratives. In fact, a very popular heroic struggle narrative is “I overcame my (illness, depression) without resorting to medication.”

This heroic struggle narrative has shaped the recovery movement; it has clearly influenced members of the mental health commission.

And who would bother watching a show, or reading a story with a tagline of: “A man develops depression, goes to his doctor; the doctor treats his depression and he gets better.”

This is not to denigrate the role of courage, optimism, hope, and support required to live with a chronic illness, or recover from an acute illness. But…

Update:

Another day, April 5 to be exact, and it seems it is OCD Day with several news items and videos appearing. Much is shared in these articles and videos, distinguishing crippling OCD symptoms from mild everyday forms of compulsions and obsessions. Psychological treatment is also explained, exposure and desensitization therapy. But not once, not once in the articles and videos I watched was it explained that there are medical pharmacological treatments that work with great success for about 90% of sufferers. Not once is this mentioned.

One of these medications has been around since the 1960’s, though at the time we didn’t know how effective it was for OCD and psychological/psychoanalytic thinking about the illness dominated.

I am not sure who or what is to blame for this. But for the psychologists who were interviewed to not mention this readily available medical treatment is akin to naturopaths not mentioning antibiotics when discussing the treatment of pneumonia.

Paradoxically, Jack Nicholson starred as a novelist with OCD in “As Good as it Gets” 20 years ago. At the end of the movie Nicholson’s character decides to be a better man and go back on his medication. Critics were not happy with that ending, and it did ruin the “heroic struggle” narrative. It was, as the third act of a story, very unsatisfying. “What? To quell his OCD all he had to do was take his medication?”  Well, yes.

 

Is This The End of the Mental Health Commission?

By Marvin Ross

In December, I wrote a blog pointing out that the Mental Health Commission of Canada should be disbanded. Those of you who follow my writing on Huffington Post know that this has been a constant theme of mine over the past few years. Last Fall, the Federal Health Minister set up an inquiry into what they called Pan Canadian Health Organizations (PCHOs). These are federally mandated groups established to carry out specific tasks in health across the country when, in fact, health care comes under provincial rather than  federal jurisdiction.

The review was to evaluate the role and relevance of these groups in advancing federal health policy objectives and meeting national goals. One of the PCHOs is the Mental Health Commission and my advocacy colleague Lembi Buchanan and I submitted a brief on the Commission through the Best Medicines Coalition.

With amazing speed for a government report, the findings were just released. Much to our delight, the Commission recommended that the Mental Health Commission either be ended or radically altered.

The basic premise for health care in the 21st Century as outlined by the World Health Organization and endorsed by most countries including Canada is that it be people centred. “It puts people at the centre of the health system and promotes care that is universal, equitable, and integrated. The framework emphasizes a seamless connection to other sectors, notably those focused on the social determinants of health. This framework also promotes providing a continuum of care that requires high-performing primary care.”

The conclusion the reviewers reached about the Mental Health Commission of Canada is that “Mental health is now “out of the shadows”. The integration of mental health care services into the core of Canadian health systems requires a different type of leadership, capable of driving a bottom-up approach in which patients and families, providers, researchers, and the broader mental health community come together to break down silos.”

As a positive, the report states that “The MHCC has been particularly effective in developing strategies around mental health, along with initiatives and campaigns to increase awareness and reduce stigma. It has made great strides in delivering on its objectives and helped to bring mental health “out of the shadows at last.” It has also created valuable contacts and built trust among its closest stakeholders.”

It did develop a mental health strategy mostly ignored and it did help to raise the awareness of mental illness. However, the report states that:

“The need to build greater capacity in Canada on mental health is still as pressing today as it was when the MHCC was established. What has changed, however, partly as a result of the advocacy work undertaken by the Commission, is the overarching policy goal. What Canada needs today is the complete and seamless integration of mental health into the continuum of public health care. What Canadians want is public coverage of proven mental health services and treatments, beyond physicians and hospitals. To be successful, those services must be integrated with primary care and supports for physical health, rather than isolated from them. We came to the conclusion that MHCC, in its present form and with its current orientation, is not the best instrument to achieve the objective of integrating mental health into Medicare.

They then state that these goals might be achievable if the MHCC changed itself but suggest that to accomplish this they would have to engage “health leaders at provincial and territorial levels in joint decision-making over service funding and quality standards; a different “knowledge base” in support of evidence-informed advice and performance evaluation; and a different, more flexible, and less centralized structure.”

This, in fact, is one of the many criticisms I’ve made over the years. The MHCC churns out papers but has zero influence in decision making and that is exactly what is needed. Policy papers are fine but they need to be implemented and the MHCC has yet to accomplish that from what I’ve seen. The report concludes in its section on the MHCC that “It is because mental health is so critically important to Canadians- and their governments- that a new approach is now needed.”

I was impressed with the team tasked with this job and I’m impressed with the speed in which it produced its report (October 2017 to March 2018). Let us hope that the Health Minister implements the recommendations.

And, a documentary we did on schizophrenia

Donald Trump is Helping My Psychiatry Practice – An Open Letter

Dear Donald from Dr David Laing Dawson

As much as I dislike your intrusion into my thoughts and my life several times every single day, Donald, I must say you are a gift to clinical work. No longer do I have to rely on obscure references, examples that may or may not be known to my patients; no longer do I need to dream up ice breakers to relax an anxious family; no longer do I need to struggle to find a topic that will provoke an emotional reaction in a silent, sullen teenager; no longer do I need to search for a way of introducing the topics of narcissism, empathy, sociopathy, and adolescent cognitive development.

Just today I asked a 17 year old how he thought he might react if he were outside the Florida school while the shooting was occurring. He thought for a few seconds and then said he would probably take cover and call the police. Seventeen Donald, and he has already outgrown that adolescent fantasy of yours you told the governors. Or at least he has reached a level of cognitive development when he understands those common male heroic rescue fantasies are just that, fantasies.

At what age does one still boast about these superhero fantasies? I suspect thirteen, fourteen maybe. And then, usually, a little more self awareness creeps in. I was able to congratulate my patient on being more thoughtful and mature than the President of the United States. He didn’t think it was much of a compliment.

An anxious family, a parent with unruly or sullen child seeing a psychiatrist for the first time: I’m getting cautious one-word answers; I throw “Donald Trump” into this and the parents and the child all start talking with hand gestures, vivid facial expressions.

The mother tells me the 14 year old boy stole money from her purse. The boy launches into his defense, following the exact pattern of Donald’s tweets that very morning: Denial, fake news, someone else did it, you shouldn’t leave your purse out, I don’t get an allowance, my sister did it, you never blame her, she gets away with lots, you don’t like me, you’re unfair.

I point out the similarity. The mother smiles; the boy is insulted.

The teen girl over thinks everything. It is part of an OCD/anxiety problem. She is so worried and conscious of what she might say, and what she has said, that she avoids talking to all but family. I tell her I would like to inject her with a half ounce of Donald Trump. And there we have an extreme opposite to her problem that we can talk about.

The parents are very upset their child lies. I talk about lying, for a child, is natural, and how a developmental task for the child and teen, aided by their parents, is learning, by adulthood, when to lie or obfuscate a little bit, and when to tell the truth. At this age, the boy’s lying does not mean he’s going to grow into a Donald Trump or a career criminal.

It’s a measure of severe depression when someone does not have the energy to become animated by the topic of Donald Trump.

It’s a measure of excess idealism when a teenager is extremely distressed, outraged, horrified by the very mention of the name.

And there was a time when a fairly large percentage of teenagers, unable to answer any questions on current events, politics, governance, would explain, “It doesn’t effect me; I’m not interested in it.”

But they all now pay some attention to American Politics. They know your name and they all react. So there is one demographic the better for your existence: teens and youth. Let’s hope they maintain their awareness and idealism.

How to Achieve Medication Compliance

By Dr David Laing Dawson

Anosognosia is an unwieldy word meaning lack of insight, or, literally in translation, `without- disease- knowledge`.  In the case of some brain injuries or stroke the brain may become quite specifically unaware of what is missing. The part of the brain that would perceive this is damaged. With mental illness, schizophrenia, bipolar, the apparent lack of insight  or denial of obvious impairment or implausible grandiosity may be more nuanced and variable. It may be part defensive in nature; it may be more a denial of the consequences imagined; it may be more about the power relationship at hand. Some of it may be merely human, the unwillingness to give up a longstanding belief, whether that be of the second coming,  CIA surveillance and persecution, or of being chosen, special, destined for greatness.  Some of it may be a distorted form of the normally complex parent – adult child relationship.

But almost every family with a severely mentally ill member must deal with, at least once, that time when the ill member claims to be fine when obviously not, and refuses to take medication or go for an appointment to the doctor.

How to approach this. What options do you have. Below is an outline for talks I have given on the subject:

Stage 1

  • Calm and slow
  • Non-threatening (posture, position (e.g. side by side), distance, tone, pace)
  • Aim for a negotiated reality. (not the acceptance of your reality)
  • i.e. He may not be willing to admit he is ill or delusional or needs medication but may be willing to agree that he is in trouble, anxious, not well, in pain, not sleeping, and that in the past the pills have helped with that. He may by his behavior be willing to take pills or come for an appointment as long as he doesn’t have to admit to need or illness.
  • Gently find out what he or she fears.
  • Gently find out what his objections are.
  • Allay these objections and seek a “negotiated reality”.
  • Stay away from labels, declarations, and you defining his reality.
  • Offer pill with glass of water without saying anything.

Stage 2

Family intervention, same tactics as above but with whole family or available members, or a specific family member with influence.

Stage 3

Ultimatums. (You can`t live here unless…..)

But before doing this you should assess the level of risk (provoking violence, and/or leaving and putting self at risk). Discuss in family plus with a professional. Must also assess realistically your tolerance for confrontation, anxiety, worry, guilt. And ultimatums are only effective if truly meant, if you are truly willing to carry through with the ultimatum. If the ultimatum works, do not reiterate it unnecessarily.

Stage 4.

Form 1, J.P., Court order, Police intervention.

Before doing this decide on desired outcome, assess odds of achieving this desired outcome as best as possible (i.e. is there a treatment that works? Will they keep him or her long enough? Does the trauma of this kind of intervention justify the long-term outcome?)

Having decided on desired outcome, use all resources to achieve this. Learn the wording of the Mental Health act to get desired outcome. Use this wording to your advantage. Find family mental health friendly lawyer. Discuss with the health professionals who will be receiving the family member.

Family Doctors and Psychiatric Medication

By Marvin Ross

I’ve heard this more than once but family doctors who wonder why their patient with a serious mental illness is on the psychiatric medication they are on when they seem to be fine.

And so, they suggest that the patient either go off the meds or start to taper them with, of course, disastrous outcomes. The latest case I heard was of a woman I know with stable schizophrenia who has been stable for many years. This is a woman for whom it took years to stabilize and get her to the level she is now.

The patient in question is so in favour of medication that she has been active giving lectures to health care students and other professionals on the importance of them for stability.

But then, her family doctor wondered why she was on the dose she was on. He told her that as you get older, your metabolism slows and you do not need as much medication as before. She agreed to start lowering her dose with the expected result. She slowly became more psychotic to the point where her family had to to go to court to have her hospitalized and forced back on medication.

She is now back to normal stabilized on her meds but considerable time and anguish was wasted on something that did not need to happen.

Of course, my anti-psychiatry critics will suggest that she was addicted to the medications and that her descent back into psychosis could be predicted by her body reacting to the poison that was cut off. That, of course, is nonsense. She needed the medication and when it was taken away, her illness returned. In one of his earlier blogs, Dr Dawson mentioned that when psychosis returns, the individual develops the same delusional thoughts as they originally had. That happened in this case.

Regardless of the illness, if you are on medication, you are doing well, and there are no side effects, then why mess with it. One psychiatrist I quoted in one of my writings pointed out that it is so difficult and time consuming to find the right medication at the proper dose to help a patient, why mess with it when it is found.

Unless there is a really good reason to do so, continue with your dose.

The Decline of Mental Illness Treatment from the 1980s On

By Dr David Laing Dawson

Through the 1970’s into the 1980’s I ran what we called Community Psychiatry Services. They were General Hospital based and consisted of teams of psychiatrists, nurses, social workers and psychologists. We used what we called an “Active Intake” process that ensured that the severely ill received appointments very quickly and the worried well were rerouted to other agencies. The “active” part of the intake process was a pre-appointment engagement of the patient, the family, the other caregivers. Doing this required that the clinic not become specialized, and that it did not have exclusionary criteria.

The second component necessary for this is a true team, with each member involved, the care plan decided by the team led by a psychiatrist, and that the nurses and social workers be willing to function as case managers. It also required that each member of the team be prepared to help with medication compliance and monitoring, medical care, budgeting, finding bus passes, talking to families, giving shopping lessons, helping with all activities of daily living and also counseling.

Doing this work requires a high tolerance for chaos, uncertainty, anxiety, and insanity.

What happened?

Several things I think, though it is difficult to see the forces of change while living within them.

1. The length of stay in hospitals for the mentally ill became shorter and shorter, driven at least in part by spurious management and budget ideals.

2. The mental hospitals continued to downsize, in some part as a naive ideal, but mostly as a means of shifting cost (and responsibility) from Province and State to Community and Federal Governments. (Note the stats of the Chicago area show an exact mirror image between the declining numbers in hospitals, and the inclining numbers in jails and prisons from 1970 to 2010)

3. The general Community Psychiatry Service is not a good academic career choice. Academics need to specialize for teaching and research opportunities. Hence the development of Anxiety Disorder and Bipolar Clinics. This doesn’t work for the severely mentally ill because to satisfy all the research and protocol needs the waiting list is long, the assessment phase onerous.

4. Again, based on naive idealism, many community services shifted location from the hospital to the community. But once a clinic is moved away from the hospital (geographically and managerially) several things happen:

a. They can no longer risk taking disorganized, chaotic and potentially dangerous patients and

b. Non-medical and non-psychiatric philosophies start to dominate, and the severely ill are excluded. And

c. (at least in my experience) away from the stable budget and managerial practices of a hospital, strange things happen, all the way from pop psychology to fraud.

5. I suppose it was inevitable that each discipline develop more of a sense of autonomy and independence. Social workers and other mental health professionals are no longer case managers working with psychiatrists. They are independent counselors. The development of simplistic models of counseling (CBT and DBT) which can be applied once per week for ten weeks helped this along. This has also contributed to something of an anti-pharmaceutical attitude. (By the way, there is no evidence that CBT is any more helpful than any other professional counseling relationship, but being a rigid simplistic set of responses it is easier to study)

6. I am also convinced that by putting addictions and mental health (illness) under the same umbrella, we diluted what sympathy and empathy the community was developing for the seriously mentally ill.

7. This was compounded by the so-called recovery model, which at its heart, really means (and this may be appropriate for addicts) that if you really try hard enough and think only good thoughts (CBT), and are sufficiently “supported”, you can get well and recover fully.

8. The corollary of this being that if a person with a psychotic illness is not recovering it just means he is not trying hard enough.

9. De-stigmatization. I just happened to watch “Big” the other night and noticed that the actor who played a walk through part, non speaking, looking homeless and mumbling to himself in downtown New York, was listed in the credits as playing “Schizo”. The real way to de-stigmatize any illness is not by feel good infomercials, but by providing adequate and successful treatment. Think Leprosy, AIDS, cancer.

10. Without a team to work with, to case manage, to field crisis calls, to make home visits, to check on progress more frequently, a lone psychiatrist will find it difficult to treat the severely ill.

11. The tightening of the mental health acts and processes in each state and province,  the protection of individual rights and the provision of due process (as defined by lawyers), again based on a sort of naive idealism, resulted in four unintended consequences: thousands of people suffering from untreated psychotic illnesses in the streets and shelters, a burgeoning population of mentally ill in the prisons, the dramatic growth of locked Forensic Psychiatry Units, and a sad return to locked doors for the rest of the hospital now dominated by the Forensic units.

Between 1900 and 1960 the severely mentally ill were mostly institutionalized, treated in mental hospitals for long lengths of stay, by doctors who were often imported and/or had limited licenses. Then as now, the Academic and North American trained psychiatrists worked in private offices treating a small number of patients over many years. These patients could be counted on to be articulate, educated, and at least middle class.

Between about 1960 and 1990, with new effective medications and the move to de-institutionalize, community clinics like the ones I worked in developed in many parts of North America; the General Hospitals developed psychiatric programs, and for at least two decades, perhaps three, we seemed to be moving in the right direction. In parts of Canada incentives were developed to keep psychiatrists working in hospitals with the severely ill or as they were called then, the seriously and persistently ill. And the University Departments of Psychiatry finally took an interest in the medical treatment of the severely mentally ill.

We were going in the right direction.

And now it seems we must re-invent the wheel.

For more information on schizophrenia, check out the documentary Schizophrenia in Focus

Time to Scrap the Mental Health Commission of Canada

By Marvin Ross

Psychiatric care in Canada for those who are sickest is virtually non-existent according to a new study just published in the Canadian Medical Association Journal.

Looking at Ontario, the research found that the majority of people treated in emergency after a suicide attempt do not see a psychiatrist within six months after discharge. Two thirds of those released from hospital after a stay for a serious mental illness do not see a psychiatrist in the first month post discharge.

None of this is unique to Ontario. In a BC experiment referred to in the link above, researchers tried to book a patient from a family doctor’s practice quickly. Of 230 psychiatrists, only six could see that patient in a timely manner.

For those who read me regularly, none of this is particularly new. I’ve been pointing out the deficiencies of our mental health services for years and criticizing the Mental Health Commission of Canada (MHCC) which should be scrapped.

The MHCC arose out of the excellent Senate Committee Report called Out of the Shadows at Last — Transforming Mental Health, Mental Illness and Addiction Services in Canada in 2006. It received federal funding in 2007 to act as “a catalyst for transformative change” with the goal to “improve services and support.”

Today, MHCC’s vision according to its 2017-2022 Strategic Plan is to “raise awareness of the mental health and wellness needs of Canadians and to catalyze collaborative solutions to mental health system challenges”. That is far removed from the original goal to improve services for the mentally ill and their families.

The original research for the Senate Report was based in large part by submissions made by citizens from every region of Canada who were affected by mental illness. Many of them related their difficulties in accessing adequate care and treatment.

In 2015, the MHCC looked at indicators of mental health in Canada and found very few areas that were adequate despite eight years of funding to improve services and supports. Louise Bradley, the CEO of the Commission, was refreshingly honest when she was asked in 2016 if services are more readily available today compared to 10 years ago.

“I would really like to say yes, it is dramatically better but I can’t say that. Access to services is really a big problem.”

I am encouraged by the fact that the Federal Minister of Health appointed two experts to review Pan Canadian health agencies in order to improve their services to Canadians. These are federal organizations that deal in substance abuse, mental health, patient safety and information. The two reviewers requested submissions from the public and since I have been a very vocal critic of the Mental Health Commission of Canada, I submitted a critique with my advocacy colleague, Lembi Buchanan of Victoria, BC.

One very significant reason for the failure of the MHCC is its lack of jurisdiction on health and funding. The original Senate Report stated that the Federal Government cannot effect change in areas like health which are the jurisdiction of the Provinces but they can influence it with grants. They said that “the provinces and territories receive federal grants in exchange for agreeing to respect certain conditions on how they use these transfers. This is how federal legislation such as the Canada Health Act works.” (Sec 16.1.1). Therefore, improvements to mental health care in the provinces could be encouraged by providing the provinces with funds specifically for mental health.

“The creation of the Mental Health Commission is, in the (Senate) Committee’s view, one of the two key components of what could be called a “national strategy” contained in this report. The second involves the creation of a Mental Health Transition Fund. If agreed to by the federal government, this Fund will permit the transfer of federal funds to the provinces and territories for their use in accelerating the transition to a mental health system predominantly based in the communities in which people with mental illness and addiction live. (S16.1.4)”

The MHCC was doomed from the very beginning because of the lack of jurisdiction and funding, The Transition Fund was never approved. Had it been given, it would have made available $519 million/year for 10 years:

When the MHCC was established, it was to develop a mental health strategy. The 2011draft strategy was leaked to the press and universally criticized for “the scant reference to the urgent needs of people with severe mental illnesses including individuals who have been diagnosed with schizophrenia and bipolar disorder.”

While the sickest of the sick cannot get timely treatment, the MHCC, we pointed out, has spent money, time and resources trying to destigmatize mental illness. Part of the MHCC’s stigma strategy was to influence how the press writes about mental illness. The Commission spent time and money holding seminars across Canada to convince journalism students to write more positive stories. But, the very nature of journalism is to write about violence.

The futility of this exercise was summed up by Andre Picard who took part in those seminars with students. He said, “We don’t cover normalcy, we’re drawn to the spectacular.”

If these destigmatizing campaigns are successful and more people seek out services, they simply won’t find them.

Another focus of the commission is Mental Health First Aid. Like conventional first aid, the purpose of the program is to offer assistance and relief to someone experiencing a mental health crisis until expert help arrives. Sadly, there is no evidence that the program benefits anyone for whom it is intended.

A very large evaluation of the program at 32 colleges in the United States found that the program helped those who took the course but no one else: “Training was effective in enhancing trainees’ self-perceived knowledge and self-efficacy, but these gains did not result in effects for the target population. The trainees were more likely to seek professional mental health support for themselves, a finding consistent with at least one other recent study.”

Our suggestion is to end the commission and spend the money to provide services and to improve a health care sector that is more reminiscent of a third world country than one in one of the wealthiest nations in the world.

Mark Vonnegut, Schizophrenia and Mother Blaming

By Dr David Laing Dawson

Mark Vonnegut, the son of Kurt, had (has) a psychotic illness. In his autobiographical novel he explained delusions in this way: if you were being chased by a pack of wild dogs, wouldn’t you rather think that somewhere there was a hound master who could call them off if he chose to do so?

I have always thought he was right, at least with respect to delusions. They are explanations for experiences that, in the case of mania, cannot be explained within the accepted laws of physics; in the case of schizophrenia, cannot be explained by a diminished social perceptual and information processing system; and, in the case of dementia, cannot be explained by a diminished cognitive apparatus.

The invented explanations are usually quite simple and usually involve blame in either a positive sense (God has granted me…) or a negative sense (the CIA is…). The target for blame (or perceived source) in a delusion is always standard fare. The source of extraordinary power and well being is God; the causes of failure, constraint, weakness, control, are parents, the police, a disease, or Aliens. The methods are always contemporary:  in pre-industrial  cultures, by curses, spells, hexes, and evil eyes, through the 20th century by radar and radio waves, and now through a variety of electronic devices, bugs, and micro implants. And as per the topic of a recent blog, note that parents make that list.

But beyond an explanation of delusions, this wish for a hound master who could, if he chooses, call off the dogs of hell, is really quite universal. Historically we have used, or fallen into, just such an explanation for every sin, illness, climatic event, and tragedy that befell us. And, almost always, we have been wrong.

But this need, this psychological human brain imperative, continues. The value of this trait of the human brain (mapping, organizing, understanding) lies in the advancements of science. We want to understand why things happen as they happen. The downside to this need, this wish, is the continuing enthrall of astrology, a myriad other nonsense fads and conspiracy theories, and the wish to find someone to blame  for schizophrenia.