The orphans of medicare

Posted on June 23, 2008 in Health Debates, Inclusion Debates – BNStory/mentalhealth – The orphans of medicare: Jennifer Clark has been living for two years in a stark room in Victoria’s Royal Jubilee Hospital. In fact, patients with mental illness — unwanted and forgotten — account for an astounding one-third of all hospital time
June 23, 2008. ANDRÉ PICARD

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

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

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

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

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

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

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

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

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

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

Asylums phased out

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

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

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

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

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

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

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

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

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

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

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

A big bright oasis

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

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

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

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

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

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

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

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

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

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

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

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


By the numbers

9: percentage of visits to the emergency room that are related to mental health

24 to 72: the number of hours a patient with severe depression can wait for care at the ER

16: percentage of hospital stays in Canada related to treatment for mental illness

75: percentage of patients treated at Victoria’s Archie Courtnall Centre who have substance-abuse problems

38: percentage of schizophrenic patients discharged from hospital who are readmitted within a year

80 percentage of sufferers of mental illness treated primarily by a family doctor

34,418: the dollars required to support someone with serious mental illness to live in the community for one year

170,820: the dollars required to keep a mental-health patient in hospital for a year

Sources: Canadian Institute for Health Information; Centre for Addiction and Mental Health

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