Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 11 - Evidence of March 20, 2003
OTTAWA, Thursday, March 20, 2003
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:05 a.m. to study issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002 and, in particular, to examine issues concerning mental health and mental illness; and to consider a draft budget.
Senator Marjory LeBreton (Deputy Chairman) in the Chair.
[English]
The Deputy Chairman: We are meeting today to examine issues concerning mental health and mental illness. We realized when we were doing our major study that it was the issue that was the most prevalent in people's minds and required immediate attention.
We have a large group of witnesses with us this morning.
Ms. Carolyn Pullen, Consultant, Canadian Institute for Health Information: Honourable senators, if you refer to your packages, I will be speaking to the handouts that are entitled ``Standing Senate Committee on Social Affairs, Science and Technology: Mental Health Information in Canada.'' We have broken down our information into two short sections. I will speak first on the availability of national health information for mental health and addiction services in Canada. Dr. Millar will pick that up.
I will move down to slide No. 3, which is entitled: ``Mental Health Information Currently Available.'' The Canadian Institute for Health Information has been the keeper of the national mental health database for the last five years. There are a few points that describe the contents of the database, but the important one is that it is 80-year-old data that was previously held by Statistics Canada. It contains exclusively information about in-patients in general hospitals and psychiatric hospitals in Canada. Compared to other databases, it is quite limited in the number of data elements or the type of information that it contains.
The database is primarily diagnostic and demographic information. It is quite limited. It does not capture any out- patient, group homes, community-based services or consumer group information. As is known in mental health services circles, those are where the bulk of mental health services are delivered. We capture the tip of the iceberg in terms of the services that are used in Canada, because in-patient hospital services are sort of the end point of that type of service.
CIHI also has some emergency information from hospitals, but it is quite limited and only from a couple of provinces.
Statistics Canada has two surveys that do provide some national information. There is the National Population Health Survey, which has been in existence since 1996. It is conducted every two years. It collects some information on topics such as depression, emotional disorders, and alcohol, tobacco and medication use.
There is also the Canadian Community Health Survey, which is more recent. Cycle 1.2 took place in 2002 and was focused on mental health. It collected information on topics such as stress, anxiety, depression, et cetera. My colleague, Ms. Bailie, will give you more detail about those surveys later.
There are also various kinds of information collected in other places in Canada, but the important thing to know is that it is not standardized and is collected in small pockets across the country. It is not the type of information that we can compare on a regional or provincial basis.
The next slide has a ``bull's eye'' diagram. This was created to guide our expert working groups as we did some indicator development for mental health services in Canada. There is a supplementary document in your package called ``Mental Health and Addiction Services Framework.'' If you do read it, you will get a description of the different components of the framework. However, it essentially describes the areas where we need to have information about mental health services, including characteristics of populations, the different types of services that are available and the governance and management of mental health services.
The big arrow at the bottom of that slide indicates that currently we only have information for in-patient hospital services. That shows that information is limited.
My final few slides highlight the areas that our expert working groups have identified as those in which we need to improve our health information.
These priority areas were identified by various groups, including consumers, service providers, different levels of government, researchers, et cetera. It is a fairly consultative process.
We need better information on outcomes of services. Are the services effective in achieving the desired short-term and long-term results? We need to know more about continuity of services, because mental health services expand far beyond institutional and even health services. We need to know more about housing, jobs, training, education, et cetera.
We need to know more about the use of services — how, when and where services are used.
What are the best practices of service delivery? What is working and what would be beneficial to adopt more broadly? Appropriateness of resource intensity speaks to the degree to which the level of services provided matches the need or the demand in the population. We need to know more about the characteristics of clients who are using the services, who needs services and whose needs are not being met. We need national benchmarks that will speak to best practices, goals and targets for service delivery across the country. We need to know more about the prevalence and incidence of illness, and to what extent the needs that exist are being met by the services available.
Having said that, I will pass things to Dr. Millar.
Dr. John S. Millar, Vice-President, Research and Analysis, Canadian Institute for Health Information: Honourable senators, I wish to stress one particularly vulnerable area in terms of mental health, which is the Aboriginal population. I wish to point out some research that we are participating in, as part of the Canadian Population Health Initiative, which is showing some evidence that the preservation of culture, self-governance and self-determination can eliminate or prevent youth suicide in certain groups. I have included that information at the end of the presentation for your information.
Continuing from Ms. Pullen's remarks, we see several challenges in getting better information on mental health. First, we need better information systems, particularly electronic health records. This seems to be unfolding somewhat slowly in the country and could be accelerated. There are major challenges, particularly with mental health information, around privacy, confidentiality and consent to the use of data. We have Joan Roch, our privacy officer, here. If you have any questions about that, we can entertain those later.
There are major issues around expanding services in mental health and, as Ms. Pullen has outlined, getting a handle on the care being provided. Increased resources are needed. In this diagram, the significance of this ``flat of the curve'' is that there is growing evidence in Canada, the U.S. and other countries that despite increased dollars going into health care overall, we are not getting better outcomes. We do not know anything about that in mental health, but we do know about it in some of the clinical areas. The reasons for the flattening of that curve and the gradually worse outcomes as money is spent are outlined in the following three slides. There is a lot of waste in the system; there is underuse of effective services; and there is misuse. There is a significant amount of both adverse use and errors in the system. Those contribute to the flattening of that curve and the waste that is clearly there. This is important background information when thinking about how we address this mental health issue. With a limit to the amount of dollars we have, we must spend smarter rather than more.
Of course, the slide entitled, ``Opportunity costs,'' captures the notion that every dollar that we pump into the health care system that is being used ineffectively is a dollar less available for education, social services and various other public goods that do have a powerful impact on mental and general health.
Investing in health information will be necessary. We will have to invest much more. Other countries are well ahead of us now in how much they are investing in health information. There is emerging evidence that this investment pays off by reducing waste and errors and increasing the effectiveness and value of dollars spent in health care. There will be a need for substantial increased investment in the country, well above what is currently contemplated or available. How will we do this without growing budgets? Obviously, it is not this simple and your committee has already considered this in a broader context, but essentially, by investing up front we can collect and use better information. We cannot manage the system, including the mental health component, and create effective services without better information. As Ms. Pullen has said, what are the outcomes and how are we delivering care? There must be some up- front investment and information that then can be used to better manage chronic diseases generally, including mental health issues. That can then translate into better-coordinated primary health care, public health and mental health services, which I believe need to be integrated and served in that way.
Thank you for the opportunity to appear before you this morning. Some of the references that support this presentation are included at the end.
Ms. Lorna Bailie, Assistant Director, Health Statistics Division, Statistics Canada: Honourable senators, until relatively recently, the population health surveys conducted at Statistics Canada contained very little content specific to mental health, and almost nothing on mental illness. In general, stress, depression and anxiety have been assessed since the first National Population Health Survey, which took place in 1994, and more recently, in the first cycle of the Canadian Community Health Survey in 2000.
This has been a cursory look. We have been collecting comprehensive data on chronic conditions and determinants of physical health for many years. In some ways, perhaps this is testimony to the lack of priority that has been given to mental health until now. Today, my presentation is broken down into two components. I will share some of the information that we have collected, some of the results of our surveys. In the second part, we will give you an idea of this new mental health survey for which we have just completed collection, to give you an idea of what is to come. In some respects, I wish I could be here in about four months' time, when I would have more to tell you. Right now, I just have a little information.
The Deputy Chairman: We can arrange to bring you back in four months' time.
Ms. Bailie: That would be great.
Before I begin, I just wish to set the stage for what a population health survey is or is not. Health is more than the absence or presence of disease. A population health survey can bring in many of the other dimensions around illness. We can look at the determinants, such as physical activity, nutrition, diet and different kinds of behaviour. We can also look at the population as a whole. Certainly, there is existing information and administrative data from clinical sources, but what the population health survey can give us is a picture of the whole population, both those who have gone through a health care system and had some treatment and those who have not.
My first slide shows some data about depression. This provides some historical information on the evidence of depression since 1994-95. Depression is an illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, and the way one feels and thinks about one's self. People with depressive illness cannot merely pull themselves together and get better. Without treatment, the symptoms can last a long time. Treatment can help most people.
The data from the three cycles of the National Population Health Survey and the most recent data from the Canadian Community Health Survey indicate a number of things. This graph illustrates the differences in the rates between females and males, with females suffering almost twice the prevalence of males.
The information also shows us the trend over time. One particular note of interest is the increase in 2000-01.
The rate for males has gone from three per cent in 1998 to five per cent, and for females from six per cent to nine per cent.
I must admit the Canadian Community Health Survey was new. In 1998 and before, there was the National Population Health Survey. We have reviewed the methodology of these two surveys and we feel quite confident that that is an increase and not due to different statistical platforms.
We have been following a panel of individuals through the national population longitudinal survey, and we have been able to identify environmental factors contributing to depressive episodes. Daily smoking, lack of social support, diagnosis of chronic illness and being a woman increase the odds of having a depressive episode. The analysis also found that marital status, educational attainment and income inadequacy were not predictors of depression.
Page 4 is a graph showing the most recent data from the 2000-01 Canadian Community Health Survey. It does show in greater detail the differences between men and women, and also in age groups. Historically, we have seen a shift. In 1994-95, it seemed the greater prevalence was in the 15- to 19-year-old age group. You can see now that it seems to be more prevalent in the 20- to 44-year-olds.
I will change topics now. That is all I have on depression.
Moving to the subject of suicides in Canada on page 5, according to vital statistics, 3,700 Canadians took their own lives in 1998. That was an average of 10 per day. Between 1993 and 1998, suicide claimed more lives than motor vehicle accidents. Again, according to 1998 information, suicide was the leading cause of death for men aged 25 to 29 and from age 40 to 44. It was the leading cause of death for women age 30 to 34. Based on 1998 vital statistics, the crude suicide rate for men was 22.6 per 100,000, which is much higher than the rate for women, at 5.8.
The Deputy Chairman: As a point of clarification, even though the graph showed that women tended to have higher levels of depression, they have lower levels of suicide?
Ms. Bailie: That is correct.
The next slide on page 6 takes a different look at suicide. This is age-specific hospitalization rates by sex for suicide attempts. This graph shows that the female hospitalization rate for attempts, at 103.9 per 100,000, is much higher than the 69.2 per 100,000 for men. Females are at greater risk for attempts; males are more likely to succeed. The data we have collected on the methods of suicide would also support those statistics.
According to 1998 data, 1 in 10 persons hospitalized for attempts had been hospitalized for previous attempts, thus the burden on the health care system.
Again looking at age groups, we can see that the group 15 to 19 has the highest hospitalization rates for women, and for men it seems to be age 20 to 44.
Senator Morin: Older men do commit suicide. We do not see this in your information, unless there is a slide missing. We have suicide attempts, but we do not have age-specific data for suicide.
Ms. Bailie: I did not include that in the package.
Senator Morin: Perhaps you could. It is a surprising notion. They are less depressed, but there is a very high prevalence of suicide in elderly men. Am I right in saying that?
Ms. Bailie: It is certainly not as high as the middle-age groups, but it does exist. I can provide you with the suicide rates for all age groups.
Senator Morin: If you could do that, please.
Ms. Bailie: We will provide that.
The next thing I wish to speak about is some of the results from the Canadian health survey. For the first time, we asked specific questions about use of and access to health care for those who consulted health care providers about emotional or mental health. We have been asking about access concerning physical health for a while. This was the first time we attempted to ask about emotional and mental health needs.
We see that 8 per cent of all respondents age 12 and over reported consulting a health care provider about their emotional or mental health. This graph illustrates the type of health care professional whom respondents consulted. I must caution that respondents could have indicated they consulted more than one. It could have been a family doctor as well as a psychologist. Obviously, the health care provider most often consulted was the family doctor, with psychiatrists, psychologists and social workers being consulted much less often.
The Ontario Ministry of Health did a mental health survey in 1990-91 that uncovered many issues. One of the things they found was that most individuals would seek treatment first from a family doctor, often under the auspices of a physical condition. One of the outcomes of this study was to provide training to family doctors on diagnosing mental illness and treating and referring individuals.
The graph on page 8, with information from the Canadian Community Health Survey, shows respondents who were asked about care they felt they needed but did not receive, and 12 per cent reported not being able to obtain such care. The reasons for this run from too long a wait time, not being convenient, no transportation, to decided not to go. There are a number of reasons for this. This graph shows specifically that of the 12 per cent who reported not being able to get care, 72 per cent reported they were looking for care for a physical health problem — obviously the most in need — and then 9 per cent were wanting care for emotional or mental health problems. It is interesting to note that this percentage is very similar to those who were looking for care from a regular check-up point of view and from an injury point of view.
What is missing in this access-to-care data is a true indication of the denominator. What is the demand side of this equation? That segues into the next part of my presentation, where I want to bring you up to date on the information we have been collecting specifically on mental health and mental illness.
In 1999, there was an initiative called the health information road map, intended to enhance health information in Canada. It really was the first breakthrough in terms of recognition of the data gaps. It also provided financing to address some of these gaps. This initiative is a joint venture between Health Canada, Canadian Institute for Health Information and Statistics Canada. As a result, we have been able to launch this first ever, nationwide mental health survey.
There are no national-level estimates to indicate the prevalence of selected mental illness in Canada. We have clinical data that tells us a significant amount about who is in the health care system, but how many are undiagnosed and have not been able to obtain care?
Launching this survey was a challenge for me and for Statistics Canada. It also testified to the lack of understanding, of comfort level around talking about mental illness and the stigma associated with it. We had major concerns about public reaction. We were concerned about negative repercussions from asking respondents very sensitive, intrusive questions. We had increased concerns around privacy and confidentiality. We were already addressing privacy and confidentiality in a very significant manner around most health issues.
The development leading up to the launch of the collection was extensive and we learned a great deal. We focus- tested the survey with the general population as well as with those with a known diagnosis. A common message emerged from the testing that it was about time. People had their own stories about how mental illness had affected them personally, their family or their friends, and they were willing to share them. Those who had been diagnosed thought that the survey was a positive sign — finally something was being done.
We were successful in collecting the data. The survey's response rate is 78.4 per cent for a 60-minute interview, which is burdensome. We had excellent cooperation. Our regular response rate is 80 per cent for a normal 45-minute survey, so it is right up there.
The objectives of this survey were to determine the prevalence rates of selected mental disorders in Canada and to juxtapose the access to and utilization of mental health services with perceived needs. We have collected a great deal of information on the kinds of care services that people utilized and the kinds of care for which they were looking.
We were also able to assess the disability associated with mental health problems by looking at the individuals and the social implications. Again, we put this together with the socio-economic and demographic information that comes from a population health survey.
I will move to the survey details on page 11. The computer-assisted personal interview was done face-to-face in the individual's home. The collection was completed in December 2002. A sample of 38,500 individuals aged 15 and older will give us national and provincial estimates.
The set of questions that were asked were based on a World Health Organization non-clinical approach called the ``Composite International Diagnostic Interview.'' It has been developed and utilized around the world. Currently, more than 27 countries are conducting similar surveys. Thus, we will also have the benefit of international comparability. This approach includes questions about symptoms, duration and severity. With such data, we are able to derive the probability of having a diagnosis.
One part of the survey is not indicated on your overhead. We surveyed the general public, Armed Forces personnel and reservists. When we launched this survey the Department of National Defence came to us to ask if we could include that element of the population.
On page 12 you will see the kinds of mental disorders that we will cover in detail. We will look at first-time experience, most recent episode in the past 12 months, lifetime experience, the interference with life and activity and professional services and treatment. All those components will be looked at for depression; mania, which is associated with abnormal or persistent elevated mood or irritability; panic disorder — unexpected panic attacks and intense apprehension; social phobia — the fear of being in society and performance situations; and agoraphobia — the abnormal fear of the environment. For the Department of National Defence sample, we will also include post- traumatic stress disorder, dysthymia and generalized anxiety disorder.
The criteria for the included disorders were as follows: We needed a prevalence of at least one per cent; it needed to be measurable; it had to be common to Canada; and it had to be amendable to intervention.
On page 13, you will note that we also added what we called ``problems,'' not necessarily mental illnesses per se. Those included eating and behaviour troubles, alcohol use and dependence and problem gambling. The idea was to look for the signs of approaching disorder with some opportunity for treatment and prevention.
Page 14 gives you a list of the other general information that is part of the survey and that can be correlated with the specific mental illness and problem information.
Page 15 indicates the sample design. Again, the idea is that both provincial and national estimates will be available.
Page 16 talks about the survey limitations. It excludes Aboriginal peoples on reserve, the homeless and the institutionalized population. That is unfortunate because these are probably the most vulnerable populations. It only includes those aged 15 or older, and it does not begin to cover all mental illnesses. However, we have a self-reported question that asks if one has ever been diagnosed with schizophrenia or Alzheimer's, for example.
We hope to have first results in July 2003.
Mr. Thomas Stephens, Consultant, As an Individual: I would like to make a few brief remarks about prevalence and costs and then speak to the notes that I provided, which is a three-page handout, distinguishable by its landscape layout.
I will speak to prevalence and, in particular, some of the factors associated with mental health problems and with good mental health. I will also speak to cost, based on some analyses that I have done that rely heavily on data from Statistics Canada, in the first instance from the National Population Health Survey to which Ms. Bailie referred. In this case it was the 1994-95 version, which had a number of questions on not only mental health problems, but also on collected data from a number of indicators of positive mental health. In that sense, it is fairly unique.
You may immediately think that the data is very old because the survey was done nine years ago. Indeed, some of the prevalence levels, such as for depression, measured in that survey may well have changed since that time, as Ms. Bailie showed. However, I think that the associations between mental health status and various determinants are probably more enduring and stable.
I want to say a few words about those. They are shown on the first page of the text, which is an attempt to summarize the rather dense table on the second page. The table is a summary of a great deal of sophisticated statistical analysis that took account of a number of factors simultaneously to try to understand what is associated with good mental health and what is associated with poor mental health. This is important because it does come from a fairly large and representative sample of Canadians across the country living in households.
We consistently see in the analysis that education and social support are positively related to mental health. The more education and the more social support one has, the better it is for mental health. Those are positively related to positive measures such as self-esteem and sense of well-being and are negatively related to negative measures of mental health such as experiencing stress and depression. We can think of education and social support as protective factors, if you like.
I am, of course, focusing here on these so-called determinants because they are extraordinarily useful, not only for identifying populations at risk, but also for identifying strategies that may be effective in mental health promotion and prevention of problems.
I want to stress that this analysis benefited from the Statistics Canada survey because it had four measures of mental health that were positive and four measures of mental health problems. Most of the literature one reads is based on one or two measures only. Those are useful and important, but thanks to this data, we have a broader view and more robust understanding of the associations.
The protective factor of age came across consistently in these analyses. There are a number of different indicators of mental health. There is clear evidence that at least as of the mid-1990s in this country, older people tended to have better mental health. Problems such as depression and stress tended to be concentrated in young people.
Senator Morin: I have been saying this all along.
Mr. Stephens: You are right. This is in striking contrast to the situation 20 years ago.
We had a few measures of mental health in 1978 and 1979 in the Canada Health Survey. There one found a relationship between age and mental health that is so familiar from looking at age and physical health. That is, older people tended to be in frailer health.
That has changed in a generation. It might be interesting for the committee to ask why. What has changed in terms of social conditions between the late 1970s and the mid-1990s to affect the situation of seniors vis-à-vis that of young people, causing this association between age and mental health to completely reverse itself. It is quite astonishing.
Based on these analyses of a population sample, some risks to mental health came across strongly and consistently. They are the four bullets on that first page of text. Not surprisingly, one is the amount of current life stress. Other risks are the number of adverse, difficult life events in the past 12 months and the amount of childhood trauma, which refers to things that may have happened 20 or 30 years earlier, including divorced parents, extended periods of financial hardship or unemployment or alcohol abuse in the home. This continues to be a risk factor for mental health years after the event.
There is also some association between the number of physical health problems and mental health. The more physical health problems people have, the more likely they are to report problems with their mental health as well.
I did not find any particular associations between mental health status, whether positive or negative, and where one lives in Canada or level of income.
There was some difference between males and females — the study was of people age 12 and older, not all adults. On some measures, there was a difference in the incidence of depression. Women seem to fair slightly worse than men. However, that is certainly not true of all measures.
We do not see a part of the country where the population has consistently good mental health, nor is it consistently bad for people with low income. Other factors are taken into account, such as education.
Senator Morin: Any rural/urban differences?
Mr. Stephens: That was not checked because it is difficult to define in a survey. If it could be, it would be an interesting question. I live in Manotick. Is that rural?
The Deputy Chairman: It was, but is no longer.
Mr. Stephens: There are some important associations. We can identify risk factors. We can identify protective factors of a demographic and psycho-social nature in these population surveys. That will be possible again with the new data to come from Statistics Canada.
I would like to say a few words about cost, which you will find on the final page. I want to mention this because you will probably come across different cost estimates as you pursue this topic, and it can get confusing.
You see here a modification of a table that is in your work plan for phase 1 for these hearings. That table came from a study that I published two years ago. In the past few months, Health Canada has updated some of its estimates for the costs of several different health problems and diagnostic categories, including so-called mental disorders.
Their numbers are different from mine. At some point, you will ask what it really costs. Either way, it is a lot of money. Health Canada's estimate currently of the cost of mental disorders is $7.9 billion. The estimate I made several years ago was $14.4 billion, almost double. On the basis of what Health Canada has just published, I would revise my estimate a little, as you can see in table 2, but we are still talking in the neighbourhood of $14 billion, in my view.
The difference is mainly due to the way in which we look at short-term disability, for reasons I can discuss later if you like. The Health Canada approach underestimates the cost of short-term disability. We would colloquially call that ``mental health days,'' people taking time off work for no particular physical reason but for mainly a mental health reason.
That is not captured in the statistics because they do not seek health care. It was not captured in the Health Canada statistics because it did not go with the approach that they were taking, which was consistent across different disease processes. They wanted to compare different physical illnesses.
Any way you look at it, it is a great deal of money. We are looking at an important issue that affects a large proportion of the population. Sometimes the effect is felt in small ways, but in ways that have taken an enormous toll on productivity, in particular.
I would be happy to take your questions.
Dr. Julio Arboleda-Florèz, Professor and Head, Department of Psychiatry, Queen's University: I appreciate the opportunity to talk to you on these matters. My submission is divided into two major sections. The first section appears on page 3 and is entitled ``Historical Overview.''
The second section appears on page 9 and is entitled ``Questions.'' I will give a historical overview of the mental health system in Canada because, from the epidemiological and health services research, we consider that it is impossible to practically differentiate the impacts of the system on the epidemiology of mental conditions.
Briefly then, on the historical overview, we started in Upper Canada in the mid-1800s with a model of institutionalization that had been invented in Europe in the 16th and 17th centuries. The first mental institution in the country was established in 1839 at the York jail in Toronto. Keep that in mind, because it is important with respect to where we are now, 136 years after Confederation.
Because the conditions at the asylum in Toronto were found to be so appalling in a review conducted in 1911, the Government of Ontario introduced in 1913 an Act Relating to Lunatic Asylums and the Custody of the Insane. By that time, there were already 6,900 mental health patients in institutions in the province of Ontario. It was a very similar situation in Quebec.
The solution was to have more mental hospitals. The country went into a frenzy of asylum construction, and by 1957, there were 77 mental hospitals across the country and the number of hospitalized persons was about 45,000. No matter how many hospitals beds were built, more were required, because by about 1956 or so, the utilization of beds in New Brunswick was 110 per cent, and in Saskatchewan it reached 156 per cent. For every 100 beds, there were 156 occupants.
Saskatchewan was the first to say it had had enough with mental hospitals and try a different tack. It closed quite a few, if not all, of the mental hospitals in the province and started what we call a ``system of de-institutionalization,'' which was a last attempt at managing mental patients in their communities.
In 1959, the Canadian Mental Health Association published a major book entitled More for the Mind that was considered a ``Bible.'' It advocated a system of hospitalization only for a few situations, usually in a few psychiatric units in general hospitals, and community care.
All along, mental illness and the care of the mentally ill could not be moved out from under the constitutional framework and the legalities within the system, mostly because, unlike any other physical condition, mental conditions affect rationality. Individuals affected by mental conditions tend to act in ways that sometimes are hurtful to them and harmful to those with whom they deal in their immediate environment.
What was the constitutional framework? The Canadian Charter of Rights and Freedoms has three major clauses that impact on how we care for the mentally ill in our country: sections 9, 10 and 15. Section 9 stipulates that no one can be detained or imprisoned arbitrarily. Keep in mind that commitment or involuntary hospitalization is tantamount to incarceration, only called by a different name. Section 10 requires that at the moment of detention, any person must be advised about the reasons for detention, has a right to counsel and to habeas corpus, if so required. Section 15 is what we call the ``anti-discrimination clause'' because it outlaws discrimination in Canada on the grounds of race, ethnic origin, nationality, colour, religion, sex, age or, most importantly, physical or mental disability. Other issues came out of the Charter of Rights and Freedoms in terms of how and when we can commit people on the basis of their mental health status.
At the same time, there were problems with the application of the criminal law sections that deal with the mentally ill offender. That has been a problem in the mental health system in Canada because, as I said, the first mental hospital in our country was a prison, and many things have been done to try to reform the system.
For example, we had the McRuer commission in 1956. Again, the country was appalled by what was happening in the institutions for mentally ill or criminally insane persons. We had the Ouimet commission to review the situation in 1976. In 1992, we had Bill C-30, which is the regime under which we live.
Bill C-30 has been good in many ways, but there are problems with how it has been applied and the impacts on what is happening in the general mental health system. Around the time Bill C-30 was introduced, there was a change in the test or the onus. Namely, the test one has to meet before one is considered not criminally responsible was reduced to ``on the balance of probabilities'' from the previous ``beyond reasonable doubt.'' With ``beyond reasonable doubt,'' one has to be 95 per cent sure. ``On the balance'' requires only a 51 per cent probability that that person was mentally ill at the time of the commission of the offence. Ergo, it opened the doors to many mental patients to avail themselves of an insanity defence. You may think that was good, but it has actually resulted in a wholesale criminalization of the mentally ill. That situation has placed tremendous demands on the forensic systems because of the issues in the general mental health system. Judges, police, Crown attorneys, et cetera, find the forensic route the easier way to gain access to psychiatric treatments.
What is the present configuration of the system? Most mental patients avail themselves of the Mental Health Act in their particular provinces. They are all covered under the five principles of the Canada Health Act, so there should not be a problem.
However, as we closed the mental hospital beds, more and more patients found themselves in the community without adequate services. If you wish to put it differently, it is like diagnosing people with cancer, irradiating or operating on them, and sending them home without any further treatment whatsoever. That is what we actually do many times to mental patients in our country.
Those are the issues of the contemporary situation. How we are dealing with them is a tragedy, because our mental patients suffer from the ill effects of good policies badly implemented, that is, de-institutionalization. Most of our patients remain homeless. They are over-criminalized, remain in prison, victimized, suffer from poverty and unemployment and the stigma attached not only to the mental illness, but also to the effects of criminalization. That is where we are at this time.
The first question is: Where and why have we gone wrong? The second question is: What can we do to solve the problems?
On the first question, we must look at three levels: the epidemiological level, the cost, and availability of the service. With all respect to my colleagues from Statistics Canada, we have problems because the epidemiological studies that have been done in our country have dealt only with the prevalence of mental conditions. They are very recent, and not all of them deal with the incidence of the mental conditions. They are brand new cases.
If we do not deal with the incidence we cannot plan, because we do not know what the burden of mental conditions will be five or ten years from now.
Second, mental conditions are very common in our country. Any epidemiologist will tell you that between 20 and 25 per cent of the population suffers from some mental problem at some time in the year. About 10 per cent require specialized professional services. About two to three per cent require a psychiatric bed.
The Deputy Chairman: What was the first figure?
Dr. Arboleda-Florèz: That was 20 to 25 per cent.
That causes problems. If you then look at some of the actual epidemiological conditions, the standard anywhere in the world is about one per cent. We are then talking about 300,000 people who suffer from schizophrenia in our country. You would then look at the epidemiology of other conditions — about six to eight per cent of depression. We already know of the relationship between depression and suicide. We know that depression does not affect everyone according to socio-economic status or ethnic group. We know, for instance, there is much more depression and suicide among impoverished groups and in Aboriginal groups.
We look at the issue of, for example, dementia. With respect, my data will not be exactly the same as those of the previous witnesses because it indicates that getting old causes problems. It causes problems because dementia is growing faster than the number of people over 65 anywhere in the world where it has been measured.
In our country right now, about 8 per cent of Canadians over 65 suffer from dementia. That is a grand total of 252,600. By 2021 it is calculated that 592,000 Canadians over 65 will suffer from dementia.
The Deputy Chairman: Could that be related to the fact that people are living much longer?
Dr. Arboleda-Florèz: That is a possibility. The fact is, the number of dementia cases is growing faster than the number of people crossing the age barrier of 65.
Senator Morin: It is growing faster than the aging.
Dr. Arboleda-Florèz: Apart from that, there are other factors associated with the increase in these mental conditions. My own data analysing the NPHS version of 1996 indicates, for example, that victimization during childhood increases the risk of depression in adulthood. How much is the increase? If a person has been exposed to one event of victimization, it already increases by 2.17 their risk of being depressed over a person who has not been victimized. If there are two events, it increases the risk to 4.03. If there are three or more events, it increases the rate of depression in later adulthood to 4.69.
As we know, women suffer more from depression than men. For women who have been victimized by violence, et cetera, risk of depression over those not victimized is 3.54 per cent higher. The issue here is that from the data of the 1996 NPHS version, those who are younger than 50 have a much lower level of at least one measurement of mental conditions, that is, depression.
This is not only for adults. We are also seeing impacts of mental illness among children. The study measuring mental conditions in children was done in Ontario. This is a study of four major psychiatric disorders in childhood, including conduct disorder, hyperactivity disorder, emotional disorders of any kind and somatization. It indicates that of those 4 to 16 years of age, over a six-month period, 18 per cent suffer from any one of these disorders or a combination thereof.
That is not the end of the story. There are other mental conditions that are not included in the things that we have spoken about, and those are stress conditions associated with labour practices. We already know that they produce major disability. It is considered that these conditions impact on the economy of countries worldwide. Losses in productivity due to stressful reactions have been calculated at a median of about 25 days in any given year in the United States. In that country, these losses in productivity due to mental conditions usually amount to about $200 billion a year. In Japan there is even a word for this, ``karoshi,'' which means death due to excess work, stress at the work site.
How do we do in Canada? In Ontario between 1992 and 1998, while the percentage of all users of the medical system rose by 4 per cent, the percentage of users for mental health services rose by 13 per cent. You already see more persons falling into mental health problems. The cost of all billings to the Ontario Health Insurance Plan rose by 11 per cent in the same period because there was an increase in users of 4 per cent. However, the cost of mental health services increased by 28 per cent. The cost of mental health conditions is growing.
In Ontario between 1992 and 1998, most of the care was provided by general practitioners. There are not enough psychologists and psychiatrists to do the job. In fact, general practitioners imparted psychiatric care to between 76 and 84 per cent of users with mental conditions. They also participated with psychiatrists in about eight to nine per cent more. Most of the care for mental conditions falls on the backs of the general practitioners in Ontario.
This may all sound like gobbledegook. There are issues with epidemiology in our country. Those issues are, first, on page 10, the country does not have a national program for mental health and provinces do not have a system for mapping mental illness by geographic regions, monitoring presentations or carrying out epidemiological surveillance.
Second, mental illness responds differentially to demographic characteristics and socio-economic conditions. Therefore, regions are not the same. The mental illness considerations in Toronto are not the same as in other regions. Populations are completely different.
Last but not least, research funding for mental illness in Canada, let alone for epidemiological studies, prevalence and incidence, and health care research into these conditions is extremely inadequate relative to the burden of disease.
I say that we are users of the research funding of others when it comes to epidemiology of mental illness. Most of the research funding comes from the U.S.A.
I would also say that although we are now benefiting from the work done by Statistics Canada, we already heard that it does not study our Aboriginal or homeless population. Most of the mental health populations are homeless. That is a major drawback to the data that has been presented here.
That is the first point, epidemiology. Let us look at costs.
The issue of costs pertains to the disability-adjusted life years. When we only are concerned about the mortality ratios of any kind, obviously most people die of heart attacks or cardiovascular conditions, et cetera. That is not the situation with mental illness. Although depressive, schizophrenic and alcoholic persons may comprise 15 to 20 per cent, still mortality is not as high as mortality for other reasons.
When we look at disability, that is where the cause of mental illness comes about. At present, out of the 10 leading conditions that cause disability, 5 of them have to do with mental conditions or behaviour and medication conditions. It is calculated that by the year 2020, the most important leading condition causing disability will be depression.
What is the cause? Goeree, one of the researchers in Canada, has estimated that the cost of schizophrenia to yearly productivity in our country is $105 million.
Goeree and collaborators calculate that in 1996, the cost of this condition in terms of disability was $2.35 billion, which is equivalent to 0.3 per cent of the gross domestic product. Further studies have calculated that the estimated economic burden of all mental illness in the country is $14.4 billion per year.
Former Finance Minister Michael Wilson calculated that the cost of mental conditions is 3 per cent of total national product, which is about 13 per cent of the net annual profits of all Canadian companies. This is not a cheap proposition.
There is more. The problem we are dealing with here is a measurement called the PYLL — potential years of life lost. To determine that, we look at the reasons people die — from mental conditions, suicide, homicide, motor vehicle accidents and behavioural medical conditions such as obesity, smoking, drug and alcohol abuse, et cetera. These reasons account for almost 60 per cent of the potential years of life lost in our country. Potential years of life lost simply means that, since a male in our country lives to an average of age 78, if one dies at age 20, the country has lost 58 years of potential productivity of that person to our economy and to the benefit of our nation.
The issue of services has already been described. We think that the immense needs of mental health patients, the staggering costs and the inadequate services all contribute to the poor fate of our mental patients and to the emotional and financial burden attributed to mental disease in our country.
As to what can be done, I will not belabour the issue. Many things can be done. At the bottom of page 12 you will find in summary form the things that we should consider.
First, there is a need for a national program or agenda for mental health at the federal level. Second, there is need for better intergovernmental cooperation and integration between the provincial systems, the federal system and the NGOs. Third, we need better-coordinated systems of community care. Fourth, we need industry programs for the early detection and management of mental conditions in the workplace. Rather than being thrown out of work upon becoming mentally ill, people should being given protections and help to get back into the workforce. Fifth, we need more research on the etiology and genetics of mental conditions. Sixth, we need more epidemiological research and research on determinants and risk factors for mental conditions. Seventh, we need more health care research to determine what are the best treatments, best practices and best interventions. Eighth, we need development of regional epidemiological research rather than only a centralized federal system, as is the case now with the work of Statistics Canada. I do not wish to minimize the good effects of their work in the country, but mental problems are local problems, not national problems as such. As was already said, we know the prevalence but we do not know the incidence. That must be measured at the local level. Ninth, we need better information technology. We have already heard that one of the major problems is that this is treated prevalence data — those who go to the hospitals and not those who come to outpatient centres or community services, or those who never come because they do not have access to the services required. Finally, we need increased accountability of governments and providers alike.
Senator Morin: The presentations have been extremely interesting. We have learned a lot this morning and this is very important information for us.
I would like to direct my first questions to Dr. Millar and Ms. Pullen. I am very much interested in indicators of quality of care. I realize that we need so many things, but would it not be preferable for CIHI to identify a number of specific indicators that we know could help in the quality of care? I looked quickly at the indicators that were agreed on at the last first ministers' accord and I did not see anything specific for mental health.
Would the first step not be to identify some indicators? That would at least give us some idea of how our provincial systems are managing health care. Of course, we need all sorts of information, but perhaps we could start with that.
My second question deals with the flat curve of which Dr. Millar spoke. It worries me that we should talk about that in the context of mental health care. I am sure intuitively that we have not reached that level in mental health. This is a very important issue and Dr. Millar knows that we have talked about that. The first thing that CIHI should do is apply this to Canada. These are all American figures and it would be interesting to see if this applies to Canada, because we know that there is regional variability in the country with regard to health care resources.
I am somewhat worried to see this brought up in the context of mental health, where I feel intuitively that it does not apply, because the resources are unique compared to other sectors.
My third point deals with confidentiality and the information system. One area where we will have problems in our health information system will be in the matters of health, illness and consent. Many of these patients are in no position to give informed consent. I hope that those who are involved in our information system will deal with these two issues, which are very important.
Finally, I am somewhat surprised at Dr. Millar's comments concerning the budget. I think the government has been extremely generous over the last two budgets. For example, Canada Health Infoway had a first budget of $500 million and in the last budget it was awarded another $300 million. We are approaching $1 billion for Canada Health Infoway. Of course we can always use more, but how can these organizations absorb additional resources? Here again, the flat curve applies to the organizations as well. There is a point of diminishing return. I have the impression that the recent budgets have been extremely generous to our health information system, but perhaps I am wrong.
Ms. Bailie, I was interested to hear that you concluded from your survey that stigma exists, and I am wondering how you arrived at that conclusion. I know it exists, but I am wondering how you gathered that from your questionnaire. Were the questionnaires identified as to the person or was it completely anonymous?
Mr. Stephens, unfortunately these are 1998 figures, but your last table deals with direct costs of mental health conditions, which are in the range of $5 billion. We need more recent figures. We know that the total health cost in the country is $100 billion.
We know that approximately 10 per cent of those consulting the health care system suffer from mental illness. In theory, approximately 10 per cent of resources should be allocated to mental health. I have the impression that if these figures are correct, then we are only allocating 5 per cent. In fact there is a shortfall of 50 per cent.
These total numbers are important because they give us an idea of the resources allocated to mental health in Canada. If there are not sufficient resources allocated to those conditions, then it is an important issue.
Dr. Millar: On the question of indicators, we totally agree that the first important step would be to agree on a set of indicators, which was done by the expert group that we brought together. That was the framework for the indicators. I think seven indicators were actually spun out of that. That work is underway. We generally find that you can take that first step, which is relatively easy, but going beyond that to obtain the data to support the indicators is difficult because it requires resources.
Speaking of resources and the flat-curve diagram, you are quite right: I did not mean for a minute to include mental health. My point is that for the outcomes that we can track — such things as cancer and heart disease, where we have reasonable, comparable data — we can speak to the Canadian situation. This data is not all American. The preliminary data that we have for Canada does indicate that we probably are getting to the flat of the curve for some of those diagnoses that have received sufficient attention in the past. Mental health, I quite agree, is not included. We have zero information about what the health care system actually routinely produces in the way of outcomes — for people to be able to stay with their families or return to work, et cetera.
The point of the flat-of-the-curve diagram is that there is Canadian-U.S. data, and in several countries, that indicate that we are over-treating for some of those common clinical diagnoses. We are in a situation such that we are providing more services and actually obtaining, according to the American data, worse outcomes.
If we could identify those, the resources could then be freed up and brought to bear on mental health. That was the point I was trying to make.
With respect to the budget — and I would ask Ms. Joan Roch to respond to the other issue because she is here to speak to confidentiality — there is one slide in the material that speaks to what some jurisdictions have spent. At the moment, though, you are quite right: The Canadian Health Infoway has almost $1 billion to put toward an electronic health record. Kaiser Permanente in California spent $3 billion on an electronic health record system for a client base of 9 million. For a population of 1 billion, $30 million does not even begin to come close. The estimates are that we should be spending in the order of 6 per cent to 8 per cent of our total expenditures, which would take us up into the $9-billion range, instead of the current $1 billion to $2 billion.
Whether the system can absorb those costs is difficult to predict. I agree that it does not seem to have absorbed them so far. However, it is interesting that sectors such as Kaiser Permanente have been able to absorb 20 per cent of their operating budget into information systems. It may be a question of will rather than of capability. I cannot comment on that. I will ask Ms. Roch to speak to the confidentiality issues.
Ms. Joan Roch, Chief Privacy Officer and Manager, Privacy Secretariat, Canadian Institute for Health Information: I am pleased that you mentioned the issue of confidentiality. One of the first things that we all look at, when CIHI is entertaining new data systems and new data holdings, is the implications for privacy and confidentiality. We are able to handle confidentiality quite well because we can apply some interesting techniques to ensure that data are properly protected and that the confidentiality is maintained. Here, we are talking about the fact that much more information is required and you are expanding the spectrum. Privacy is important, and the whole cornerstone of privacy is consent, which you mentioned. Much more debate and discussion is needed on what consent is required for this kind of data holding.
Presuming that it is the most sensitive kind of data, you would want to apply the highest standard, which is informed consent.
However, we are also cognizant of the fact that we are dealing with a population that may have difficulty giving that consent. With all respect to Ms. Bailie, I know that they addressed consent when they conducted the survey, but we do expect, particularly when we move into the homeless population, that it could be a tricky concept with which to work. Presuming that you are expecting to receive consent for this data holding implies that the participant can say, ``No, I do not want to be included in that database.'' Then you have to wonder about the impact on epidemiological studies. What will that do to the quality of the database and to the robustness and reliability of the conclusions that you can draw from that data. That is a long answer, but much discussion would be required in respect of those elements, not only amongst the research and information-holding community, but also in the public. I do not think that has been addressed particularly well yet.
The Deputy Chairman: We had a witness at our first meeting who suffers from bipolar disorder. I know we are talking about two different things in respect of the database, but on the whole question of confidentiality, this particular person had to re-tell her story every time that she went for help. There seemed to be no link. I know that the confidentiality and privacy requirements enter into it, but accessing treatment was a major problem for her. How do you deal with that angle of the privacy and confidentiality issue? For her, it was a major deterrent to seeking proper treatment.
Ms. Roch: That is the treatment component and now we are talking about information. You are approaching this individual and asking if she wants her information shared in this way. Probably, she will not respond.
The Deputy Chairman: It would be difficult.
Ms. Roch: It is very challenging.
The Deputy Chairman: What is the solution? You need this information in your database. What methods are there to bridge that divide?
Ms. Roch: Is this a rhetorical question?
The Deputy Chairman: More or less.
Ms. Roch: We have debated, amongst ourselves, a number of approaches or strategies that need to be addressed to deal with this issue. We need more public debate and discussion on what ``consent'' means in the health setting. We understand it in terms of care and treatment; however, what does that mean in the information world? We need someone to come forward and take charge of that debate.
Dr. Millar: I would emphasize that. There really has not been a public dialogue in Canada on the issues of privacy and health information. It is a missing dialogue and there has been no leadership on this. Building on Ms. Roch's point, you may want to consider that.
Senator Morin: Everyone hopes that this subject will go away as time goes by, but you are right: We have never worked on this and it is extremely important.
The Deputy Chairman: It is certainly important for that particular witness. That was a major point of frustration.
Ms. Bailie: The questions were: How do we know the stigma exists? Was it a random selection? In testing the waters to see if we could ask the public some of these questions, we conducted qualitative testing. We did one-on-one interviews and focus groups. We asked people how they would generally feel about answering these kinds of questions and divulging that kind of information. They had some concerns about the information landing in the wrong hands. Obviously, people who have suffered from mental illness do not want their employers to know about it. People feel that it could be detrimental to their employment opportunities.
I am speaking about qualitative testing results. I have no science to back this up.
We asked specifically, ``Would you respond to these Statistics Canada questions?'' For the most part, they were comfortable responding to Statistics Canada. This sort of non-partisan organization is fine. We have a good reputation for maintaining the confidentiality of the data, but they did not want to share information like this with friends or employers.
In the development of our strategies for data collection, it was an enormous challenge to make our interviewers comfortable in an interviewing situation. They had concerns about negative repercussions or sparking negative reactions by asking these questions. In the entire development of the survey, we kept coming across different barriers that we do not normally encounter in developing general health surveys.
We used a random sample of households. We go to the household, ask for a list of people in the household and select an identified respondent based on age or gender. It was totally random and absolutely anonymous. It was collected under the authority of the Statistics Act.
Mr. Stephens: The senator asked about some of the cost estimates in my table on the third page. In particular, all but one of the components of treatment costs come from Health Canada. As I understand their methods, they essentially started with the total of health care costs and then allocated proportions of that to a large number of diagnostic categories to add up to 100 per cent.
I was not involved in that calculation, but the practical problem is how to allocate a cost when the patient takes more than one problem to the health care system. They have apparently allocated the cost according to the primary diagnosis, which does seem to lead to an underestimate based on the total proportion that is due to mental health issues.
That leads to another question. If mental health and physical health problems are presented together, is there a stigma or an economic issue? There may be a fee for service consideration here that encourages physicians to attribute a consultation or prescription to the physical health problem and not the mental health problem. I do not know. However, the numbers came from the primary diagnosis.
Senator Fairbairn: I, too, would like to thank the witnesses for being part of this discussion. Each of you touched on a certain matter in some way, but Dr. Arboleda-Florèz got my attention on page 10 of his report.
You note that less-recognized conditions are more insidious in their impacts. You mention stress-associated problems and the labour market. You address demands for higher levels of knowledge to remain competitive and dependence on mental skills and knowledge. You also talk about the measurement of education.
We have some alarming statistics in this country, not just in terms of institutional learning. It is reasonably easy to create benchmarks to figure that out, but we have alarming statistics in Canada on the entire question of functional literacy. We see some 40 per cent of our adult population at risk every day, due to varying degrees of difficulty in reading, writing and numeracy, in routine tasks that we around this table simply take for granted. I am glad to see your comments, because many people do not understand the kinds of pressures that this puts on individuals. In your comments, doctor, are you talking about the people who are having difficulty responding to changes in our knowledge- based society? They have been able to function at a certain level, happily doing very good jobs. All of a sudden, they may face the pressure of having to move to a different level.
Do you also include people who come forward with functional literacy problems that are very difficult to identify as the particular issue? They may find the foundation of their problems on your chart more easily. Am I making myself clear?
Dr. Arboleda-Florèz: Yes, it is clear. I am including both. Quite often, we give as a rule of thumb that most Canadians read at only a grade 8 level of education, which, given the advances in technology, is practically illiterate. This is for reading only.
As for numeracy, most people can only add and subtract. Something is wrong with the educational system, but that is a different story.
The levels of literacy and numeracy are very low. Jobs demand much more than the basics because we have become a high-technology society.
Many more people now fall now by the wayside in the labour markets. Those who by virtue of their personality and resiliency usually keep pushing also get to a point where they fall off, usually due to stress when the demands of the job require more knowledge and capability than they possess.
Senator Fairbairn: Is there lack of esteem?
Dr. Arboleda-Florèz: That is the basic issue, and it is compounded. Often, these people cannot go to someone within the organization and say, ``I am having problems.'' They would lose their jobs. Such persons end up seriously depressed.
Usually, it begins to cause problems in performance. The person then gets thrown out of the job. That is just a long road on an issue that could have been identified much earlier. We do not have that system to identify and support people. It is a very cutthroat market in many institutions.
Senator Fairbairn: The literacy movement in Canada has difficulties because of the hidden nature of the problem. People struggle, try to do their best, and in many cases survive, until technological issues arise. They do a remarkable and very clever job of working around it.
However, because of the nature of the problem, they are greatly reluctant to come forward and say what is troubling them so that the literacy movement can help them to deal with it. Not on the scale that you are talking about, but on the practical scale of learning to read. The stigma is not as bad as it used to be; however, in addition to their stress, it prevents them from accessing facilities to help them correct the situation.
Dr. Arboleda-Florèz: That is correct. We consider that the outcomes for mental conditions is much better in, let us say, Third World countries, where the pressures are not as many and where most livelihoods are rural-based. There is a better outcome for mental conditions in Third World countries than in advanced countries. One of the reasons given is that there are too many demands on populations that are not prepared for them. There is a tie-in between the issues of confidentiality and stigma. Dr. Millar has said that we as Canadians have to talk openly about these issues, because the stigma comes from our wish to hide from each other. In response to the senator's question about how a person can access services and protect privacy and confidentiality, the Ontario Mental Health Act, section 14, simply states that clinicians in mental hospitals cannot send information to the family doctor if a patient does not agree. Many times, patients do not agree because they are afraid that if the family doctor knows there will be problems. This is bad and risky medicine, because many psychiatric medications have interactions with other medications, and quite a lot of psychiatric conditions are related to physical conditions. It is about 33 per cent comparable.
If the family doctor does not know this person has been in a psychiatric unit and what medication has been prescribed, mistakes can happen. That is because we are afraid to say to each other that mental illness affects all of us. We have to enter into a major national dialogue on that.
Senator Fairbairn: Do any of the other witnesses want to comment? What you are saying today and having it on the record is enormously important in trying to deal with what is a huge and largely hidden issue in our country.
Dr. Millar: I will emphasize my point that if we continue to inappropriately spend money on health care services and do not address the problems of literacy and education, we will fail to make progress in mental health. We cannot just treat people after they become ill; we must also think about prevention. That is one of the things outside the health care system that we have to think about.
Senator Cordy: Dr. Arboleda-Florèz, I enjoyed your historical overview. While some of us have some of the information, it is nice to have it compiled. One can realize how things have changed, from situations where people suffering from mental problems were put in jails, to indefinite or lifelong hospitalization, to what we have now, where patients go in for short periods of time. De-hospitalization is certainly becoming the trend.
I liked your statement about good policies badly implemented. That is certainly what I see happening in this area. How do we, within the community, help mental patients who are de-hospitalized to recover and reintegrate into society? We seem to be depending very much on family members to do that, which is fine if the individuals have a very supportive family. However, if they do not, it seems to me they are falling between the cracks and are often hospitalized again. It becomes the swinging-door policy.
Dr. Arboleda-Florèz: That is the sad story of the poor implementation of a good decision. We could not have continued building more mental hospitals and providing more beds, so the way to go was community treatment, integrating psychiatric services with general medicine. The acute psychiatric units in general hospitals, by virtue of their very high cost per diem, could not hold the mental patient for long. In fact, the benchmark of the federal government is 10.6 days for average length of a stay. The average length of stay in my unit in Kingston is 12.6 days. We get people's symptoms under control quickly. They are discharged into the community and to outpatient systems. Sometimes the systems are not there, or if they are, they not integrated in a cohesive manner, and a person who suffers from mental illness does not even know how to navigate the system. We have to provide help to the person to go from A to B. The government funds these agencies, but they do not do the job, unfortunately. There is tremendous accountability in hospitals because they have a tradition of counting everything to receive the funds.
However, you say you would like to have the mental agencies here, but often there is no accountability. Government provides the funds because the agency is supposed to look after certain types of patients. Just wait for two or three years; they will be doing something completely different from what they were funded for and there is no accountability to government. That is the problem. These mental patients fall between the cracks very easily. Ergo, the eventual revolving-door phenomenon. Because it is difficult to access another bed after readmission, the person ends up committing some minor crime and lands in prison. That is my major concern about the epidemiological studies. Our mental patients are on the streets or in the prisons. We started there before Confederation and we are still there, and we do not count them. The problem is that without engaging the family, creating a community system that is wholly integrated and seamless, we will not succeed. Mental patients do have problems navigating those thousands of agencies.
Senator Cordy: My second question deals with the information you provided on page 11, about the costs to businesses and to productivity of stress-related illnesses. You mentioned Michael Wilson, who is doing a great job, and I know there is a doctor from Nova Scotia who is doing a tremendous job in bringing those types of things to our attention, as you did today.
Where do we start? We can certainly educate business in one way, by providing the statistics that you provided in your document and that Michael Wilson has provided. When you are talking business dollars, the statistics speak loudly.
It is also a matter of looking at the individuals. We spoke earlier about the stigma attached to mental illness. People also fear that if they tell their employer that they are suffering from a stress-related disorder, they may not receive promotions within the firm. They tend to keep it to themselves. Rather than take a week or two weeks, which may be all they need to deal with an immediate crisis, they end up being off for a year or two years, and some may not return to the workplace for a substantial period of time. Where do we start? There is both the business aspect and the individual aspect.
Dr. Arboleda-Florèz: The issue is that there are systematic barriers in this regard.
Take, for example, a mental patient on welfare. He has some social security money for an apartment and for this and that. That patient has a relapse and spends 15 days in an acute psychiatric unit. He then loses not only the social security funds for that period of time, but also the apartment provided by the housing system. We have a major problem because he ends up staying longer than the 15 days that the government pays the system to keep that person waiting for a bed somewhere in the community. Social security systems must be more proactive and made more capable of dealing with the situation.
Social services are government operations. What about private labour?
There is tremendous discrimination, not only from the boss who may not think of this person for promotion because he has depression, but also from the insurance industry. The insurance industry is excellent at getting our money. However, when we need them, they are not there. They have hundreds of reasons why the small type provides that your case does not apply.
What is intermediate disability, long-term disability or total disability? Only a lawyer can understand that, but individuals sign a health policy with an insurance company.
Therefore, discrimination exists, but it is different from a stigma. A stigma concerns our attitude toward particular groups. Discrimination is a denial of legal entitlements that we all ought to be able access.
Many insurance companies, and even the government, discriminate against the mentally ill. Those are systemic issues that we must look at. They are easier to look into than how we feel as a society about the stigma. Let's deal with discrimination first, and then we can start chipping away at the stigma.
Senator Léger: Ms. Pullen, you said that the statistics are only the tip of the iceberg. That is frightening. How big is that iceberg?
Ms. Pullen: We do not know. We have some sense from epidemiological studies, practices and history. We have a good sense of what the need for mental health services is in the general population.
We do know that where we can measure those services at a national level, we are only touching on hospital services. We cannot capture information from all those other services that people are currently accessing, such as consumer groups, Alcoholics Anonymous, Weight Watchers, depression or eating disorder groups or the family doctor, which is where most services are probably delivered.
Senator Léger: What is the value of knowing only about the tip?
Ms. Pullen: That is a very good question. There is no value. We are striving to look at ways in which we can capture the information in all the other areas, but it is quite an onerous task. We must develop national standards and implement electronic systems that would be used in a standard way at the front line by an entire range of service providers. There are huge costs and training issues. Consensus building must take place to achieve that.
We work away at it. As the framework shows, we have identified the areas where we know that we need to do the work. However, it is not an overnight process to achieve that.
Senator Léger: I am not at all a specialist in statistics, but I feel it is a lot of energy and money to put into describing the tip of a problem. One can ask, is it absolutely necessary? It certainly is necessary, or you would not be there.
Dr. Millar, did I understand correctly that you said that increased dollars do not necessarily mean better outcomes?
Dr. Millar: You did.
Senator Léger: We need smarter dollars rather than more dollars?
Dr. Millar: In some areas that is true.
Senator Léger: This question is a difficult one for me. Ms. Bailie, why are the Aboriginals and the homeless not included? Is it because the way in which the questions are written would never be understood? Is it a question of culture?
That is quite serious. Do we understand the questions that you ask us? Do the questions conform to your way of thinking rather than our way? Is that a problem?
Ms. Bailie: There are a number of reasons why we are not addressing those populations. The demand and the gap have been clearly identified. If we could cover them, we would.
I will talk about the Aboriginal peoples on reserve first. Historically, we have had difficulty getting cooperation even with our census of population to go on reserve to conduct the surveys. That is issue number one. The budget allocations and so forth are another component.
We do not have a frame for the homeless population. It is difficult to count people if you do not have some kind of frame or context in which to put them. I did find, though, when we were developing this survey, that there seems to be some quite interesting and valuable information being collected at the community level through observation. People are going into soup kitchens and asking the staff to evaluate the homeless population and make some assessment of the situation. Did it look as if they had an alcohol problem? They are asked to make an assessment through observation.
You can assess average age, sex and a little about their situation. Therefore, I did find, even in the Ottawa-Hull area, some interesting information that was gleaned from that.
You are correct. This onerous set of questions in a 60-minute interview would not work for this population. They could not respond to that.
Senator Léger: Are you beginning to have the Aboriginals or the homeless work for you and gather information in their respective communities? Perhaps 30 years ago that was impossible, but it must come from them, not from us.
Ms. Bailie: That is the approach we have taken with the census this time, with some success. Perhaps we can move forward on that.
Senator Léger: The other items for discussion, such as education, social support and all the positive aspects, are not in your line of work. The mental issues all start with the social conditions?
Dr. Millar: It is not directly part of our measurement and statistical system. However, certainly within CIHI we have the Canadian Population Health Initiative. I specifically mentioned some of the results regarding Aboriginal youth suicide. We do have information showing that the social aspects of the way in which their cultures are organized are having a huge impact on mental health and the likelihood of suicide.
We certainly are thinking about those broader determinants of health, particularly the importance of education and early childhood development. They have emerged as having a huge impact on subsequent mental health. We are concerned about these things.
We do have good measures for some of these things. They can be brought down to a local level to assist in thinking through how to prevent mental illness and support mental well-being.
Senator Léger: I also wanted to mention that there have been no studies to provide statistics, rural and urban, on Newfoundland.
It is strange, given that your job is to be precise, that there are no statistics on Newfoundland.
Ms. Bailie: I think that with this new survey, we should be able to say something about urban/rural, and certainly about the provincial differences. It will happen.
The Deputy Chairman: We will make sure that we have you back in August when you are finished.
Dr. Millar, when you spoke about health information and other countries, is there a country that we could look to as an example of health information data gathering?
Dr. Millar: I do not think there is any one country that is ahead of us. The international comparisons that we have been making show that, for outcome measures in health care, if that is what we are talking about, Canada does as well as any other country. However, there are better examples within other countries. One I talked about was Kaiser Permanente in the U.S., which has invested a great deal in the system. The Veterans Administration in the U.S. has done a much better job. There are other examples like that, but no nation as a whole has exceeded Canada. As bad as it is, it is as good as it gets.
The Deputy Chairman: I thank our witnesses, who have been most informative.
Honourable senators, we have two budgets for consideration. The first is the budget allocation ending March 31, 2004, for legislation, which totals $3,000. I would entertain a motion to approve this budget.
Senator Fairbairn: I so move.
The Deputy Chairman: Is there any discussion? All those in favour?
Hon. Senators: Agreed.
The Deputy Chairman: Motion agreed to.
The next budget item is for the special study that we are doing now on mental health. This budget is in the amount of $142,000. We were planning to be in Toronto this week or next, and therefore add that amount to this fiscal year. We are now unable to go, so we will move it to the next fiscal year. That then puts our budget amount at $142,000.
May I have a motion to approve this budget?
Senator Cordy: I so move.
The Deputy Chairman: Is there any discussion? All in favour?
Hon. Senators: Agreed.
The Deputy Chairman: Motion agreed to and the budget is approved.
On March 26, we will meet for preliminary discussions on Bill C-13, the human reproductive technology bill. We wanted to have Senator Morin arrange some special briefings for us.
On Bill S-13, Mr. Radwanski is not available until early April. That is a much better date than the original date in late May.
The committee adjourned.