Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 14 - Evidence for May 6, 2003 - Morning
MONTREAL, Tuesday, May 6, 2003
The Standing Senate committee on Social Affairs, Science and Technology, met this day at 8:35 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. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the Chair.
[English]
Chairman: Welcome to the first of our hearings in Montreal. I thank our witnesses for coming on a rainy Montreal morning.
I will ask each of the witnesses to make a brief opening statement and then we will ask questions following the last presentation.
Our first witness is Dr. Michel Maziade, the Head of the Department of Psychiatry, Faculty of Medicine, from Laval University.
[Translation]
Dr. Michel Maziade, Head, Department of Psychiatry, Faculty of Medicine, Laval University: Thank you honourable senators for listening to me this morning. I will summarize my brief in seven or eight minutes. Besides being a psychiatrist and head of the department, as you mentioned, Mr. Chairman, I am also a researcher on the identification of sick genes in schizophrenia and manic-depressive psychosis, two very widespread illnesses in Canada as well as in other western countries.
I also hold a Canada research chair in genetic psychiatry. I am a board member of our Institute of Neurosciences, Mental Health and Addiction, which is headed by my colleague, Dr. Rémi Quirion.
I think that Canada and other western countries have trouble with the concept of mental health and mental illnesses. It is important for the committee to recognize that mental health and mental illness are two different things; they are two important concepts, but two very different ones.
For example, if I read the document you sent me, it clearly illustrates the point I am trying to make. The text reads as follows:
Mental health is each person's ability to feel things, to think and to act in a way that enables them to better enjoy life and better meet challenges.
However, your objective is accountability. I will come back to that a little later. The document also contains a chart on costs. Obviously, the costs you mention pertain to neuropsychiatric illnesses and serious mental illnesses, which, in my humble opinion represent at least 70 to 80 per cent of the costs.
Schizophrenia alone affects one per cent of our citizens, who take up 4 to 7 per cent of Canada's hospital beds. A vague and fleeting concept such as mental health cannot lead us to the desired goal, either from a research standpoint or in terms of providing care.
Mental health does not call neuropsychiatric illnesses by their name, of which there are seven or eight, which are very widespread among children, adults and seniors.
It is now clearly established that neuropsychiatric illnesses such as schizophrenia, manic-depressive psychosis, recurring major depressions and autism are diseases of the brain that have clear indicators. Those indicators exist in this country. They can be compared to figures from other countries. It is far too difficult for the mental health problems, which range from anxiety as a trigger for an infarctus to the quality of life of AIDS sufferers.
The concept of mental health is an important one, but it is different from that of mental illness. Either the two concepts must be dealt with separately or we will have a decision to make to determine which of the two concepts should be adopted, given the available funds.
As a psychiatrist working both in practice and in research in an interdisciplinary context, I would like to underscore the fact that known neuropsychiatric illnesses are diseases of the brain, but with serious biopsychosocial consequences. I certainly do not object to an applied interdisciplinary approach to research or to the treatment of neuropsychiatric illnesses.
In fact, those who want to turn a blind eye to the scientific proof that widespread neuropsychiatric illnesses are diseases of the brain have missed the entire point.
[English]
The Chairman: Thank you very much. Our second speaker is Dr. Rémi Quirion, the Scientific Director at the Institute of Neurosciences, Mental Health and Addiction with the CIHR, the Canadian Institutes of Health Research.
[Translation]
Dr Rémi Quirion, Scientific Director of the Institute of Neurosciences, Mental Health and Addiction: It is a pleasure to be here with you this morning to give you some statistics and to express my views on the state of research on mental illnesses and mental health in Canada.
I would also like to thank the committee for holding these hearings. I think that they are very important. It is high time that we give greater priority and visibility to mental illness research in Canada.
We would like to commend the recommendations made by Senator Kirby's Senate Committee on Social Affairs to give Canadian institutes a certain percentage of the health budget for research purposes. This is very important and we are very pleased with this recommendation.
[English]
I want to make it very clear that the research in mental health and mental illnesses is underfunded in Canada compared with the costs to society. In 1998, the estimate was 14 billion dollars per year. It is likely to be higher today post-September 11, following the stress of the recent war and all of these things.
What about investment and research related to mental health and mental illnesses? It is hard to get complete data so I will talk here about the Canadian Institutes of Health Research, CIHR. I do not have all the data for Health Canada and other governing councils.
Even at CIHR, it is not easy to dissect the relevance of mental illnesses compared with other aspects of brain research. However, the figure I have, which is partial at the moment, is in the range of about 40 million dollars per year for mental health, mental illnesses and addiction.
We need to increase funding in this critical area. I will argue that the model at CIHR, the Institute of Neurosciences, Mental Health and Addiction is the right one. It is a unique model. This is the first time we have put these elements together under one umbrella to try to stimulate collaboration among scientists interested in brain research.
Before I go in more detail about the Institute of Neurosciences, Mental Health and Addiction in CIHR, I would like to emphasize that an important question to ask is: Why is research in mental health and mental illness underfunded compared with other areas?
[Translation]
Even with all the progress that has been achieved in medical research, it is still much more difficult to diagnose major depression than high-blood pressure or a cardiac problem, despite the knowledge of the two cardiologists, Senator Morin and Senator Keon. The brain is truly the last frontier. It is difficult to make an accurate diagnosis of brain-related illnesses.
Consequently, there tends to be some discrimination and stigmatization pertaining to mental illnesses and addictions. People with these afflictions still hide, people still are embarrassed about suffering from a mental illness. As a result, the family is not there to support the patient. The general public is not as knowledgeable as it should be. We are not exerting enough pressure on the various government levels, including the federal government, to provide adequate funding for research on mental health and mental illnesses.
The federal government and the Institute of Neurosciences, Mental Health and Addiction must play a significant role in finding ways to reduce the discrimination against people suffering from mental illness and addiction in Canada.
My objective is that it should be as easy to talk about mental illness as it is about cancer and heart disease, without judging the individual suffering from the mental illness.
Because of this discrimination, there are not many strong charitable organizations that can really form an effective lobby at the government level.
The Canadian Institute of Mental Illness and Mental Health does play a role, but a very small one. We do not have the funds available to the National Cancer Institute, for example, in order to establish some kind of lobby. That, therefore, is another problem.
Another important point that has already been raised by my colleague, Michel Maziade, pertains to the dichotomy that exists between mental health and mental illness. Nobody can be against mental health, everybody is in favour of health, obviously. Nevertheless, we must not forget about the people who suffer from mental illness.
We, as the specialists in the field, must agree amongst ourselves, but also with you and the government leaders, that mental illnesses are indeed brain diseases. These are truly physical illnesses, brain diseases.
I mentioned that the Canadian Institutes of Health Research provide approximately $40 million per year for mental illnesses and addictions.
Approximately $50 million per year is spent on neuroscience research, research into the way that the brain and the neurons operate. This is not an insignificant hand out of money, but it needs to be increased, we have to go farther. We are in an excellent position to do so.
Canada is one of the world leaders in the area of neuroscience research. In terms of the impact of our discoveries in neuroscience, we rank second or third. We therefore have excellent capacity. We are quite strong in the area of mental health. We need to do some rebuilding on the addiction side: we lost many of our significant researchers in the 90s.
[English]
By putting all these specialists together at the Institute of Neurosciences, Mental Health and Addiction, we have a unique opportunity to have a great impact — not only in terms of discovery of the cause of mental illnesses but also to better treatment for Canadians that suffer from these diseases.
For example, there is a substance in our brain called dopamine. A person with too much can develop schizophrenia; a person with too little can develop Parkinson's disease. Dopamine is also important in addiction. Therefore, rather than having the neurologists, the psychiatrists and the addiction specialists working in their own corners, we try to put them together. At the end of the day, I think, the impact of their research will be much greater.
To give you a sense of what we do, I have provided information on our strategic plan and a summary of what we have been doing over the past few years. I would like to describe some of the more recent initiatives at the institute. We have supported a training ground to train the next generation of scientists: One on suicide here at the Université du Québec in Montreal; two on autism, one at McGill and one at Queen's University; two on tobacco abuse; one on mental health in First Nation; and two in health services research on or how to improve treatment. A grant of $15 million covers these projects.
We also have a new emerging teams program, which promotes the development of multidisciplinary research teams. We have also undertaken programs addressing Fetal Alcohol Syndrome, FAS, and Post-Traumatic Stress Disorder, and a national placebo initiative. We also have a program on discrimination. We are now sponsoring a team at the University of Victoria in on trying to find better ways to reduce stigma against people suffering from mental disorders. We need your support on that one; it is a key program at the institute.
The question of ethics is closely related and very important to mental health issues and mental illnesses. I have submitted a copy of our call for applications for a neuroethics program to provide you with a little more detail on what is different in terms of ethics when you think about mental illnesses compared with some other disorders.
Knowledge translation is another important area. It is important to ensure that the work of scientists such as Michel Maziade and Laurent Mottron is translated into practice — that it is not left on the shelf.
Finally, where do we go from here? We will be undertaking national strategies on tobacco abuse and nicotine addiction, suicide, neurogenetics, gambling and addiction. We have our work set out over the coming years.
We have two recommendations: First, increase funding for neurosciences, mental health and addiction research in Canada, and second, a national action plan for research in the field for this country. Of course, the Institute of Neurosciences, Mental Health and Addiction will be very pleased to play a key role on that one.
[Translation]
Dr. Laurent Mottron, Researcher, Department of Psychiatry, Faculty of Medicine, University of Montreal: Thank you for giving me the opportunity to present opinions which come from 15 years of clinical research in the field of neurosciences and developmental disorders.
I am a research physician responsible for a specialized clinic working in the area of autism, which is a field that combines development neurology and psychiatry.
My remarks will emphasize two points that are mainly organizational and legislative and that seem to me to have the possibility of significantly improving the quality of psychiatric research in Canada.
My first point deals with clinical research in the hospital setting. I will take a simple example. To fund my scientific research, I obtain a grant of some $130,000 a year from the Canadian Institutes of Health Research, which is not really very much money.
Moreover, in order to have subjects for my research and a specialized clinic, it costs about $300,000 a year at the hospital. That means that the costs of clinical research are paid mainly by the hospital and do not count as research costs.
What makes the situation much worse is that it is generally the hospitals that decide on their own whether to invest in a specialized clinic that will be used for research or whether to allow clinicians to concentrate on their practices. Some physicians in clinical practice have no interest in research.
So my point is that two things seem to be changing where clinical research in hospitals is concerned. It seems to me that clinicians have too much leeway with respect to research requirements.
They can decide not to do research and, even though they have a scientific background, they can decide to practice without any involvement in research.
On the other hand, hospitals do not have the funding needed to enable some of their clinical physicians to carry out research. It is still very difficult for physicians and non-physicians to spend part of their time on research without having the status of full-time or half-time clinical researcher.
Another aspect of this suggestion relates to the status of Ph.D.s in hospitals. Although their careers are entirely devoted to research, these people are at a lower level in the hierarchy than physicians. It is very difficult, for example, for a non-physician Ph.D. to head up a specialty in a hospital. It seems to me that that should be changed.
My second point is quite different. We are talking today about mental health research. There are a certain number of brain disorders that, traditionally or because of the efforts of lobby groups, come under the heading of mental illness: I talked about mental retardation and autism.
Many lobby groups insisted that autism be ``removed'' from psychiatry. This has had a lot of beneficial effects. It had resulted in autism — in part as to integrate those affected and help them lead normal lives — has been shifted completely to regular schools and rehabilitation centres.
Now we need to look at the negative and troubling side of this development. ``Removing'' autism and development disorders in general, such as mental retardation, from psychiatry has led, in my opinion, to a huge drop in the expertise brought to bear in working with these people.
When an autistic child is in a regular school, the teacher applying a rehabilitation method is under no constraint to take a scientific approach. The method can be completely unscientific.
I am highlighting the perverse effect of what is basically a very good idea, that is, to help people with development problems lead normal lives and integrate them into a regular system.
Senator Pépin: When you say that people are less aware when it comes to mental illnesses, there is also the fact that they are afraid, since this is definitely a medical area that is not well-known but that people would like to know more about. There is still a lot of fear about mental illness.
Although I worked as a nurse in a psychiatric hospital for a couple of months, that was a very long time ago. I am certainly not an expert in that field.
But it is important to be out there and to get the message out. But when people realize just how much research you do, it is easy to understand why it is very difficult to get things done.
I read that by the year 2020, many more young people will have mental health problems. I therefore think it is high time to tackle the problem and demand the necessary funding for research.
I will probably make some wrong assumptions, since you reeled off so many names of associations, but please feel comfortable, because we have with us two illustrious doctors who know everything, whereas we have everything to learn.
Is there a national mental health research program or a program dealing with the different kinds of mental illnesses? Does Canada have an umbrella organization today? Who would manage and fund such an organization?
Do we have a national organization which is on top of the latest developments in the field?
Dr. Quirion: We do have a new organization, which was created three years ago, and which is called the Canadian Institutes of Health Research. I am in charge of one of these institutes, the Institute of Neurosciences, Mental Health and Addiction. It is a kind of umbrella organization. Dr. Michel Maziade sits on the board of directors.
However, we do not really have an integrated national research network on depression, for instance, along with a Canada-wide network. There are only a handful of embryonic organizations.
Usually a researcher and some of his or her colleagues work in close cooperation, but not usually on a national scale. I do not think we necessarily need a national network dedicated to mental illnesses, because researchers must work together when they share the same views and not just because they may share an interest in a particular area. However, team work should be promoted and Michel Maziade heads a fairly important team.
Senator Pépin: In other medical area, there is a certain interaction. I understand that your organization collects data from many sources.
Is there interaction? Do you have the necessary funding to bring people together?
Dr. Quirion: Yes, there is a fair amount of collaboration. Another advantage we Canadians have over our American colleagues is that there is a lot of collaboration amongst Canadian teams. It is easier to work together. So if we have the means to fulfil our intentions, I think our research will have a much greater impact.
Dr. Maziade: I would like to add, senator, that another reason why we are lagging, apart from the reasons mentioned by Dr. Quirion, namely ostracism and guilt, is the fact that families affected by neuropsychiatric illnesses stay hidden. Rich families who may have a member with a neuropsychiatric illness...
Senator Pépin: Do not want to get involved.
Dr. Maziade: You will see them make donations for cancer research. Corporations compete with one another. At the beginning of the 1970s, there was an anti-medical movement in the West. In Canada, the movement appeared in Quebec. This, of course, hindered networking.
But it also hinders, which leads me back to my point, the development of concepts. We have to talk about these illnesses. I realize that your objectives include setting priorities, finding the right indicators and comparing them to other countries.
But to reach these objectives, there is no getting around talking about mental illnesses. You have to talk about schizophrenia and manic-depressive psychosis, which alone affect over a million Canadians, as you probably know. Some people are hit with these illnesses by the age of 20. Ten per cent commit suicide when they are still young and others are affected for the rest of their lives.
Another 2 per cent of the population suffers from recurring major depression and 8 per cent suffer from major depression their entire life. And if you consider that eight or nine neuropsychiatric illnesses for which we now have clear scientific data, in my humble opinion, it will be easier for you to set priorities and to look at Canada as a whole.
Right now, if you look at Canada's mental health policy and Quebec's, it is difficult to find the word ``schizophrenia.'' You find the expressions ``severe and persistent problems,'' which are catch-all phrases, that have a non-medical, anti-psychiatric origine. You find that the term ``psychiatrised.'' In cardiology, you never say ``a cardiologized patient.'' You say a person, a patient suffering from infarctus or ischemic heart failure.
In the Canadian government policy, you do not say cellular health, you say cancer. And you talk about every type of cancer. So I think that in our field, one must talk about schizophrenia. There are clear, international indicators of manic-depressive psychosis, severe hyperactivity, et cetera. The syndromes exist.
It took several years for the WHO to say something very simple. The WHO worked for several decades before realizing it was important to have a good medical diagnostic tool in the health sector to establish and assess the care, distribution of care and research.
In our field — and I am sure you will notice this during your study — the concepts are vague. And it will be difficult to find people who will talk about neuropsychiatric illnesses and diseases of the brain, who talk about the concept of mental illnesses rather than the concept of mental health.
Senator Pépin: It is because people are very scared to speak out. People want to know more, to work on the problem, but they feel they are venturing into the unknown. This is the first time I have opened a document and when reading it, I realize I do not understand it very well.
Dr. Maziade: Senator Pépin, we must bear in mind that 750,000 Canadians who suffer from schizophrenia and manic-depressive psychosis are between the ages of 16 and 75. And you will ask yourself the following question: Where are they, since they are no longer in institutions?
Where are the new patients? Twenty per cent of schizophrenic patients still do not respond to drugs and are readmitted to hospital.
In other words, if you talk about illness and think in terms of illness, I think that some of your concerns will disappear. I think we must stop waffling and call a spade a spade. That is a basic concept that Canada has not yet grasped.
Dr. Quirion: Perhaps we could draw an analogy with cancer research. At the end of the 1950s and the beginning of the 1960s, everyone was very scared of cancer. Breast cancer, for example, meant a quick death.
Heart problems were viewed very much the same way. Now, in terms of our understanding, we may be late in the field of brain research. It is a little more complicated.
The time is now. There is a great deal of expertise in Canada because of the national health care system. That allows us to collect data and to have data banks that are much more impressive than in the United States. Take the new genome research, for example.
I think we could have a major impact and we should not be afraid to forge ahead. If we forge ahead with the expertise we currently have, we will succeed in finding the causes of brain diseases and of mental illnesses.
[English]
The Chairman: I have one supplementary question. I always use Alzheimer's as the example of something; it used to be that older people were ``senile'' or they were just ``old'' Now the public uses the word Alzheimer's.
All three of you made comments that deal with what I would call really obvious illnesses. You talked about bipolar; you talked about schizophrenia; you talked about autism. Where does the notion of ``common depression'' fit in the research agenda? Does it have a place or is it essentially like the common cold in that it is sufficiently uninteresting from a research standpoint and most people can live with it — sometimes with medication — so it never gets to the research agenda.
I ask this because Dr. Quirion said, for example, there is no national focus on depression or stress-related diseases. However, the data indicates that the percentage of Canadians who suffer at least some element of mild depression — I do not know if the term is mental illness — is growing very rapidly. There is an increased demand for services — not only from psychiatrists, but also from psychologists, social workers. Many family practitioners are now spending one third or half of their time acting as counsellors, because it is the only way they can get it covered under medicare.
Does that whole area fit in the research agenda, or is it at a sufficiently low level that nobody pays any attention?
Dr. Quirion: No, to the contrary. Although in terms of genetic studies such as Dr. Maziade's group is doing, there is more focus on bipolar, there is a lot of research activity on depression and on what is commonly called ``burn-out,'' which can be politically correct in a sense — a man will suffer ``burn-out'' and a woman will suffer ``depression.'' Again, there is a stigma associated with these terms. One ``owns'' a burnout as a result of hard work. ``Depression'' connotes weakness. This is the reality.
The Chairman: He is right.
Senator Pépin: That is true. It is a reality.
Dr. Quirion: There is a lot of basic neuroscience research on the processes that relate to what you call a kind of common depression and burn out. At the institute, we are starting to look at mental health in the workplace. Mental well-being and depression are major issues in the work place. Stress-related illnesses are big issues as well. Therefore, these are part of our research agenda.
Senator Keon: Thank you. All three presentations have been very interesting. I have been sitting here thinking — to quote Yogi Bera — ``It is déjà vu all over again.''
Some 30 years ago when there was a bit of money and so much to be done, we used to sit around the Medical Research Council table and debate where we should go. Should we invest our money in good basic research and stop wasting our money on anecdotal research or anecdotal cataloguing and some of the clinical research we were doing?
As that universe unfolded, we have reached a point through CIHR where we are investing in good basic research and the clinical research in which we investing is funded on the base knowledge that is coming out of the basic research. The drug trials are classical examples. You have to discover the drug before you can do the trials.
Here we are talking about research into and the management of mental illness. On the one hand, we seem to be getting to a point where we are beginning to understand the psychopharmacology of mental illness. Dr. Quirion used a good example, with dopamine in the brain and whether there is too much or too little. Tweak the dopamine and you get rid of two problems, one of each side of the equation — if you know how to tweak it.
Dr. Quirion raised the question of an action plan, but I would like the two other speakers to comment as well. We cannot cover everything because there are not enough resources, there is not enough money and there are not enough people. Therefore, an action plan must have a flagship. It must have a strong direction. Should that strong direction be in the area of the understanding of psychopharmacology or should we continue to smatter the money out into all of the dimensions of mental illness that we know?
I would like all three of you to comment on that.
Dr. Maziade: I would say that when we look at research and practice, disease by disease, we already have data that can help us to improve our situation in Canada. For instance, with respect to Senator Kirby's comment on depression, it is now established scientifically that when you focus on depression, with established international criteria to define depression, the most efficient treatment is the combination of appropriate pharmacotherapy medication plus psychotherapy of specific type — called cognitive therapy, working on self-esteem, et cetera — combined. It has been well established that the combination is better than the medication alone and better than psychotherapy alone. However, when you talk about mental health problems in general, you cannot derive this from the literature or from the people to whom you are speaking.
For schizophrenia, it is established that for those who respond well to the new antipsychotic drugs, alleviating symptoms is again the combination of pharmacotherapy and familial support and what we call ``social support therapy'' is most efficient than medication alone or psychotherapy alone. This is a trend that has been established for 10 years, yet we never see that in Health Canada documents, in the policies of the provincial governments. It is the same situation for autism, although there has been less research there than in schizophrenia or depression.
In terms of the clinical practice, we need both sides — the psychotherapy or psychosocial, and action direct on brain physiology. Research also shows that psychotherapy can affect connectivity and the neurobiology of the brain.
It is also affecting research. We also need research on both sides — to improve psychotherapy and the efficiency of psychosocial support and to learn more about neurobiological forms of treatment such as pharmacology.
I am talking about disorders. I am talking about specific diseases. I am not talking about helping Canadians to be happy in life. We must focus on disorders and categories on a disease-by-disease basis. For the past 20 to 30 years, there has been a bias against our field. In my view, that was a social movement that was anti-medical, anti-psychiatry and so on. That is over now. It is clear that there are specific disorders and environmental factors triggering a genetic vulnerability in most of our patients — schizophrenia, for example, which has a very strong genetic basis — but we know that those are susceptibility genes and that environmental factors trigger or help the brain to develop a disorder. It is the same for most depressions, hyperactivity, for obsessive-compulsive disorder, and for Tourette's Syndrome, which is a prevalent disorder of ticks and other brain symptoms.
[Translation]
Dr. Mottron: I would like to answer the question as to whether we should put the onus on fundamental research or clinical or applied research?
I would like to get back to organizational issues. The objective of this meeting was to deal with issues pertaining to research funding. What I am talking about is how to get more bang for our buck from the two current systems, whose primary raison d'être is not research, while limiting their freedom to remain isolated from research. The two systems to which I refer are, on the one hand, medical clinics and, on the other hand, education and rehabilitation.
As things stand, a doctor working in a hospital is in no way bound to be involved in a research project. A teacher using a rehabilitation technique when working with a mentally retarded or autistic child is, at the moment, by no means bound to transparency regarding the scientific methods he applies.
In terms of budgets, the amount of money allocated to rehabilitation and health in general far exceeds the amount allocated to research.
I wish to underscore that, in the case of a clinic specialized in clinical research, the money spent on fundamental research constitutes perhaps 20 per cent of the total research costs, by which I mean access to patients and evaluating patients using standardized methods, as well as the costs associated with the outcome of this fundamental research on diagnosis and care provided.
I, therefore, suggest that organizational issues pertaining both to the link between medicine and research and to that between special education and research, be studied.
The autonomy in terms of research which is currently enjoyed by both the medical and teaching professions is in some ways very positive but can, in some cases, lead to a lack of openness towards research.
Let it be understood that I am not an anti-medicine apologist. I am not really bothered whether those who carry out research are doctors or not. The question is not relevant to our discussion.
[English]
Dr. Quirion: I would like to add a couple of comments. What Dr. Mottron has described is critical. It is always difficult in this country because there are federal and provincial jurisdictions. With respect to provision of services at the hospital level, it falls under the provincial mandate. However, we need to work with the provincial organization, the various ministers, as well as research organizations such as the FRSQ here in Quebec to try to promote research in clinical 'milieu'.
It is true they have a lot of demands, they are overworked, and that some of them do not have the training to be able to be involved in a research project. However, at least in institutions that have a university affiliation, it should be understood that for a clinician to be there part of the job is associated with research, that there is a goal to try to advance knowledge. It is not just providing services. That is true of all kinds of clinicians — not just medical doctors — but also nursing staff, psychologists, and social workers.
We need a national plan. It is a big mandate and of course, some provinces would support it more than others, but that is politics. I think we need to move in that direction.
I am always very optimistic and that is probably why I took the job that I have now. One of the beauties of CIHR is that we are trying to have an integrated approach. We are not there yet, but we are trying to do more and more in the strategic initiative of the institute is an integrated approach. The health services specialist talks with the basic scientist and the clinician. They information and eventually they will start to share or exchange language. When I started in that field a few years ago, it was as though one professional was speaking French and the other one was speaking Chinese. The culture was so different.
Yet, increasingly, in some of the more integrated programs, I think each side has started to see the benefits of working together. That has occurred in the suicide training ground program that we are just beginning to fund here in Montreal. Previously, the focus was social. I never talked to someone interested in brain neurochemistry. Now, it is part of the team. Likewise, with autism research — it now covers the whole spectrum.
Rather than having different fields compete with one another, we are trying to work together. It will take some time; it will not happen overnight. There are some who resist change. However, it is my hope that the next generation of scientists that will have been through these kinds of more multidisciplinary programs will be more open to it.
For example, let us say that tomorrow we find a gene associated with depression or autism. What does the team or the person do with that gene? I would thing they would need to then talk to an epidemiologist and to a population health specialist to study what the impact might be on the developed population.
This integrated approach is a bit of a paradigm shift, but that it what we are trying to achieve at CIHR. It is still very young — it started only three years ago and we need to give the system a chance to succeed. Of course, we need a bit more money, but I think we have a potential for partners. There are possible partners in both the provincial and federal governments.
[Translation]
Senator Pépin: If I understand you correctly, you are saying that you would agree that medical personnel working in a university centre or teaching hospital carry out research. You also said that not all clinicians are involved in research.
So, doctors at teaching hospitals should be doing research. Is that what you think? You said that many doctors, or clinicians, do not carry out research.
Dr. Mottron: What I am saying is that there is a marked conflict between the autonomy of certain professions and their involvement in research.
For example, a doctor who has a clinic is perfectly free to enter his data into a data base which is compatible with research but, on the other hand, he is also free to use a language which would be used by no one but him.
If we try to limit this freedom we are normally met by a general outcry. In the field of rehabilitation, to give a parallel example, a mentally retarded child will perhaps spend only two days in his entire life with a specialized team.
However, he will spend several years with teachers. This means that the teachers who are the ones using special education techniques are, it could be argued, 200 times more important than the specialized speech language pathologist who only spent three hours contact with the child.
This means that using research findings in a way which is beneficial to those involved in the health care and education systems is essential, because research, as an activity in its own right, will never receive enough funding.
For example, when somebody needs research subjects, he or she cannot, with the funds available from the ICRS, finance a clinic to get these subjects. He would have to ask a clinician.
I made a different choice because, given that I am also a clinician, I was able to find subjects myself. This, however, is a luxury which I can allow myself because I have a foot in both camps. In the majority of cases, where a doctor of something other than medicine, I would be completely at the mercy of a doctor being kind enough to fill in the files in the way in which they could be used for research.
However, in the medical profession, as in any profession, there is the good and the bad in terms of civic engagement. There are those who work solely in their own interests and then there are those who work a little or a lot for others.
I think that this conflict between professional freedom and civic engagement in terms of research must be addressed openly and frankly. This is particularly true when we ask teachers to be transparent regarding the rehabilitation methods that they use. We have to ask questions. Why are you doing that? What evidence are you basing yourselves on?
People say to us: ``Why are you sticking your nose in? What do hospitals and researchers have to do with school? We do not want you here.''
It is a bit like a stock reaction, and it probably is understandable. However, in terms of applying research findings to daily life, it is not a good thing. I think that we have to dare to encroach a little on the autonomy of the medical and teaching professions in this field.
Currently, the College of Physicians tells doctors that they are duty bond to promote and carry out research. It does not go any further than that.
Senator Morin: I am going to put three short questions to each of you. Dr. Maziade, I would like to read you a text which was published in one of this country finest newspapers on Saturday, in other words, three days ago. Allow me to read an extract:
According to basic medical principles, we cannot prevent a disease if we do not know its causes. Consequently, when dealing with mental illness, if we focus most of our efforts on prevention or the promotion of a healthy lifestyle, we are simply diverting attention from those diseases which cost Canadians the most money. Mental health problems are hard to define concepts and, rather than facilitating accountability to the population and the government, they simply muddy the waters.
First, I would like to ask Dr. Maziade what he thinks of the author who wrote this article.
Second, I would like to know what he thinks about this seemingly fairly radical article. I will pass it around.
Dr. Maziade: In fact, senator, it is not a radical article. I think that it is very clear. It is clear in the sense that, currently, we are moving towards a laudable approach which entails preventing disease rather than waiting for it to affect all sectors of society. This brings me back to your comments and to those made by Senator Kirby regarding depression. I approve of such a medical philosophy. What I wrote was that we cannot prevent any disease without understanding its causes.
To prevent an atmospheric phenomenon, to prevent an earthquake or to prevent a disease, we have to understand the causes and target the causes before the disease raises its head.
In various specialties, we can, to a certain extent, prevent certain diseases. But for schizophrenia, manic-depressive psychosis and major recurring depression, we do not understand what makes the brain more vulnerable. We do not know the causes, in a specific environment, which trigger these diseases.
As I wrote in my text, concentrating funds on prevention will be to the detriment of ``[...] the three or four diseases which affect more than a million Canadians because we have to move towards what is termed secondary prevention,'' in other words, we have to act early, as soon as the disease raises its head.
All of the new drugs for schizophrenia, manic-depressive psychosis and several other syndromes such as autism have improved recently, but they only relieve the symptoms, none of them provide a cure.
There is no cure for major neuropsychiatric syndromes. There is no biological diagnostic test, as there is for diabetes. As Dr. Qurion mentioned, it is still difficult to diagnose those illnesses. It takes us a few years before being sure of the diagnosis.
A certain percentage of major depressions, however, are the exception because the new antidepressants combined with specific psychotherapy treatments have proven very effective for some of those major depressions.
We all know that major depression is heterogeneous and is therefore caused by several illnesses that have varying environmental and biological causes, as is the case with anemia.
So this is not a radical article, senator. I think you have just quoted a rather clear statement.
Senator Morin: You agree with the author?
Dr. Maziade: I agree with the author.
Senator Morin: I think a basic principle could be that research is surely one of the fundamental solutions to the problem of mental illnesses at the current time in Canada and that adequate resources should be earmarked for that purpose.
I see three problems here, which you in fact referred to. The absence of volunteer groups who fund mental health research in Canada is a serious problem.
Research funding by volunteer organizations in Canada is a Canadian success story. In the United States, the American Heart Association does not fund heart research. That concept is very Canadian. Our Canadians are generous. It is a Canadian tradition to be generous towards health research.
Volunteer groups provide funding for research on cancer, Parkinson's disease and a whole list of illnesses. I think that is something you should consider.
I do not see why Canadians would not voluntarily fund schizophrenia or autism. Nowadays, people are much more aware of those illnesses and I am sure they would get involved if an organization was willing to help financially and, of course, in another way.
My second question also shows a gap, I think. I asked your assistant to read me the total amount allocated to research in the field of mental illnesses and drug addiction in Canada as compared with other countries. I wanted the exact figures and the percentages that go to research, in absolute terms and by population. We could see whether Canada gives less money to mental illnesses than other countries. If Canada gives more, great. If it gives less, that must be mentioned.
This is a very hot issue for politicians. Politicians are very sensitive to Canada's position compared to other OECD countries, for example.
As for medical equipment, for example, it was shown that Canada spent less than other countries. Quickly money became available because of Canada's position within the OECD in terms of investment in medical equipment.
I think we should use that argument. You should use that same argument with us so that we can help you get funding for research on mental illnesses. I realize those figures are not easy to obtain, but I think you should make the effort to get them for us so that we can help you.
My last question is on your share of funding among the health research institutes in Canada. This maybe a difficult question to answer, as a director, but do you feel that your institute gets sufficient funding, within the overall budget for institutes, especially the sums allocated for mental illness and drug addiction?
Or are you disadvantaged for various reasons? Do you think we could help?
Dr. Quirion: Those are three very good questions. On the first — working very closely with volunteer organizations — it is true that there are not many right now who raise a lot of money from the Canadian public, compared to the National Cancer Institute or the Heart and Stroke Foundation, where my colleagues, both directors of these institutes, can form partnerships with those two organizations. And both contribute between 40 and $50 million annually to research in Canada.
We are the Institute with the largest number of non-governmental associations associated with it. There are some 60 nationally, but they are all very small, and many have no money for research.
It comes down to stigma and discrimination. True, it is now a little bit easier to raise funds for mental illnesses, but it is still a bit complicated.
When the Institute was created, we organized two national workshops with these organizations. We invited them. There were about 30 of them at each workshop. They participated in the drafting of the Institute's strategic plan. There are two members of the general public on our Institute's board of directors, and we invite them to our annual meeting. I want them to play a growing role in helping us to develop a strategy for greater funding.
I think you can help us here too. We need to decrease the stigma associated with mental illnesses and find champions. We need champions who will promote this cause. Former Minister Michael Wilson did a truly admirable job of that.
I would also like to be able to count on a few senators as our champions, and a few members of the House of Commons, a bit like they do in the United States, where some senators and congressmen are involved. They are visible, and they advocate for mental illnesses and research on mental illnesses in that country.
I think that would be one way to increase donations from Canadian taxpayers, donations for mental illness research. Canadians are indeed willing to give. The stigma has to be reduced somewhat.
For mental illnesses, I think that we are nearly there. For addiction, it is still complicated. To fight alcoholism, cocaine addiction and so on, people are not willing to give. But if we were to start with mental illness, that would be a good start.
As for the overall amount of funding for mental illnesses and mental health research in Canada, it is true that we should have this very important data.
The figures I gave you this morning are probably relatively accurate for the Canadian institutes. Now we need the figures for the provinces and some non-governmental organizations. It would also be very helpful for me to have this information. My assistant at the Institute, Richard Brière, is going to focus on that in the coming months.
Very often, the same grant is counted four or five times, under neurosciences, mental health, and addiction, so all of that has to be dissected. It takes a specialist who understands the research project summary in order to see where things are okay and where they are not, et cetera. I hope that we will have the information within a few months to help out with your deliberations.
Turning to the last question, all 13 of the Canadian institutes have the same budget for their strategic initiatives. When I was interviewed for the position of Director of the Institute, my future boss at the time, Dr. Alan Bernstein, President of the Institutes, asked me the following question: ``If all of the institutes had the same budget, do you think that would be fair?'' I said no. I still say no today.
Once again, the model we have is unique. I think it is the right model for neurosciences, mental health and addiction. I worked very hard to promote and make sure we had an institute that brought together all of these subject areas.
On the other hand, had there been three separate institutes, there would surely have been three separate budgets. I am talking about strategic initiatives, not individual grants that researchers get.
So to start up the Canadian institutes, the fact that each institute had the same budget was probably the right formula and it encourages us to cooperate with our fellow scientific directors. We have a high level of cooperation with all of the other institutes.
I forgot to mention that the Institute has an Aboriginal health training program. There is a real need to train people as specialists in first nations mental health.
So, we got off to a very good start. In the medium term, if we are truly to develop the vision and mission of the Institute, I think that the allocation of strategic initiative portfolios among the various institutes will have to be re- examined. And my boss, Alan Bernstein, is aware of that. I discussed it with him yesterday.
Senator Morin: I would like to ask Dr. Mottron one last question. You referred to the organizational aspects of research. I understood you, and we are surely going to take an interest in that.
I would like you to tell us a bit about your field, autism. As you know, it is a unique field, not only in terms of mental illness, but also in the field of health in Canada.
That seems to be the area where the most parents sue the government to get care. We have seen that in British Columbia, in Quebec and elsewhere.
Surely there is a problem when parents are suing their own government to get care, and we may not always get to hear from experts like yourself in this field.
I would like you to provide us with some insight. I must tell you that at our first meeting, we heard from the father of an autistic child, who described in detail the difficulty he had had in getting treatment for his child and all of the problems he had had in taking care of his child. It was really very moving and very touching, and it made a strong and lasting impression on us.
I would like you to tell us about the research side of things, but also about care. We might not have another opportunity to hear from a clinician. How do you see the future of autism in terms of the lawsuits we are seeing and the cost of treatment?
What do you expect? Is the future bleak or is there reason for optimism?
Dr. Mottron: Like you say, it is a field where there are a lot of lawsuits, and I myself am very afraid to say anything about that.
Senator Morin: You are protected here. You are completely protected here, in other words you cannot be sued for what you say here.
Dr. Mottron: Oh, well in that case! First of all, I may have to saw off the limb that I am sitting on. There is absolutely nothing special about autism as compared to other neurodevelopmental disorders.
The fact that the media give it special attention is a stroke of luck, because that is an excellent way to expose the problems and further the research. But it is quite unfair to attach greater importance to this neurodevelopmental disorder than to others, like Rett syndrome, Williams syndrome, Prader-Willi syndrome, foetal alcohol syndrome, fragile X syndrome and in fact all kinds of neurodevelopmental cognitive or mental impairment. So my position is a little bit ambivalent, because I work in the area of autism, and therefore I benefit, as a researcher, from this incredible media favour. At the same time, I do a lot of work with lobby groups to get them to include other rare illnesses.
By the way, I suggest that the committee look into what is being done in the European Union on rare neurodevelopmental illnesses. There is an excellent initiative there.
If you were a parent who belonged to one of the 60 associations Rémi referred to earlier, and 300 people in Canada had the same illness as your son, you would have no lobbying clout. You would obviously have no specialized training and no special knowledge about how to educate your child.
If you were the parent of an autistic child, then in a way, you would be the luckiest of the unlucky in terms of services, because at least autism is a known and recognized illness.
That means that what is true of autism is generally true of the other neurodevelopmental disorders. But if there is autism combined with cognitive impairment, that no longer holds true.
Autism is one of a handful of neurological causes of cerebral sclerosis, or neurodevelopmental disorders, but in terms of the number of actual cases, autism is no more common than fragile X syndrome and probably less common than foetal alcohol syndrome. Neurodevelopmental disorders must therefore be taken as a whole, and autism's special place in the media must be used for the benefit of all the other disorders.
Second, the issue of lawsuits is an extremely thorny one. What are these parents doing? I was saying earlier that an autistic child, especially if there is an associated impairment, has to be placed in a special school.
At what age does school start? At age 5 or 6. What happens between the time when the child is diagnosed at age 2 and the time when school starts? Currently, in Quebec, rehabilitation services take care of that and do what is called early intervention.
All of the lawsuits in Canada were filed by parents seeking a certain number of hours of early intervention for their child between diagnosis at around age 2 and the point at which, at age 5, the same early intervention will be provided free of charge by the school.
I should tell you that I am acting as an expert in a class action, so I cannot say I am against class actions. It is only natural that children should get the same type of free services between ages 2 and 5 as they will get between age 5 and adulthood.
Currently, because of a legal oddity, the parents of an autistic child are entitled to services for the child from age 5 to 18. After 18, the child is considered an adult.
By the way, there is a little gem in your document: ``Autism, a Chilhoold Illness?'' But they do not all die at 18. After 18, they are still autistic. And before 5, they were also autistic.
The main point of class actions is obviously to seek services for this period from age 2 to 5, which is extremely important for neuroplasticity, because things that can be acquired between ages 2 and 5 can no longer be acquired later.
Clearly, they have to have the same quality of services before school and after school. That is the main point in these class actions.
Class actions are extremely litigious. And they have taken the worst page from the book of American experience: A Capacity to Distort Information for Trial Purposes. In order to win a class action, some go too far. They say, for example, that if autistic children are treated between age 2 and 5, they will be completely healed.
I regularly protest against that in La Presse. And Rémi has set up a committee of the greatest experts in diagnosis in the world, which produced an extraordinary report on the value of these rehabilitation therapy methods, saying that were conducive to improvement. But, first, these improvements are not, in general, correctly quantified by the research. Second, the patients are not cured, contrary to what some have been saying.
That is of no importance. Are we going to stop providing palliative care because it does not cure people? Unfortunately, class actions have tended to overstate the impact or rather to overstate our scientific knowledge of the impact of early rehabilitation methods to make their point. I fully support these methods, but there is no need to lie to justify them.
[English]
Senator Robertson: I am impressed. Thank you very much for your presentations this morning. You have separated mental health and mental illness very nicely. Some of you have spoken about prevention in certain areas — a topic about which some of us feel strongly.
Usually, in Canada, the first door that a patient goes through is the family practitioner's door. I suppose it depends on the province in which you live, but often the family practitioner knows very little about psychiatric problems.
Generally speaking, how much time medical students who are going into general practice spend on problems related to mental illness?
We had a similar situation with geriatrics about 20 years ago. Family practitioners were seeing senior patients, yet they had no training in geriatrics; they did not know what kinds of strengths of medications to prescribe. It was really quite sad.
I should like to know your appraisal of what is going on in mental health, please?
Dr. Maziade: There is a problem at both ends of the continuum. There is certainly a problem at the training stage. There has been a great development of knowledge in medicine in general. Then there are the increasingly complex specialties. For example, today in psychiatry, there are 10 or 15 sub-specialties — several in child psychiatry, several in adult psychiatry, and several in geriatric psychiatry.
However, it is difficult for a medical doctor to get everything or most of the basic knowledge at the medical school level. That is why we are trying to get continuing education in medicine operating in all provinces in Canada. There is training, but it is not necessarily sufficient as a result of the continuing increase in knowledge.
The problem at the other end of the continuum is for the medical doctor to have access to the specialists. The average age of medical specialists in the Province of Quebec is between 52 and 54 — largely as a result of government policies. I would expect the statistics would be similar throughout the rest of Canada. We need these specialists to provide continuing education. Family doctors know they will have a problem getting a fast consultation from a specialist because there is a lack of specialists in psychiatry.
There are problems at both ends of the continuum.
Dr. Quirion: It is true that we need to work to ensure that the curriculum is adequate with respect to mental health and mental illness at the medical school level — we need to cover the spectrum from basic science to population health. We also need to work closely with groups that promote continuing medical education.
At this institute, we have met with the Canadian Medical Association and the Canadian Psychiatric Association to see how we can work together to try to provide access or better access to these kinds of refresher courses. We know that the physicians in primary care will see a lot of mental health patients — particularly those suffering from depression.
We also need to work with other groups at the federal level. The federal government now deals with telehealth. There is an opportunity for us there. Last week I visited the University of Moncton. There is no real hope that we will be able to have 15 psychiatrists providing services to the French community in New Brunswick and the Maritimes. We need to find a way to link them with Dalhousie, Sherbrooke, Laval, and Montreal by using telehealth-type systems to provide continuing medical education at that level.
Finally, we need to decrease stigma not only at the level of the public, but also in the medical profession. Psychiatrists are still stigmatized compared with the other types of doctors. It is still often seen more as an art than a science. This needs to change. We need to make sure that the young students will be stimulated to go into psychiatry.
Senator Robertson: At some point, our committee will have to recommend to the federal government increases in funding for mental health research. If we are able to do that and get a positive response — which we would expect to get — would the research agencies be able to come up with an agreed agenda that we could recommend to the federal government?
As you respond, please think about where we have to start with the public so that we can eliminate stigmatization or discrimination.
I am thinking about an awareness campaign. If you think back many years ago when smoking was considered ``cool'' and cigarette companies financed sporting events, dance events and all sorts of glamorous things. With the proper type of advertising, that soon turned around. Perhaps we should not overlook the power of advertising to get the public on our side.
However, I should like to know what you think would be a practical list. Where would we start in recommending to the government?
Dr. Quirion: We are rather fortunate because we have a national organization called CIHR. The Institute of Neurosciences, Mental Health and Addiction is under one umbrella so we do not have to discuss such topics with 15 scientific directors as they do at the National Institutes of Health in the United States.
What we will have to do — and we can do it relatively quickly — is to meet with potential partners at the federal level. For example, we should meet with Mr. Marc Renaud at the Social Sciences and Humanities Research Council of Canada, SSHRCC, because there is a social component. We should also work with Health Canada to ensure that mental health and mental illnesses are placed high on the agenda in that department. It is not there now. They talk about physical health and mental health should be part of that. You cannot cut it off there.
We could create a national research agenda that would include advertising and an anti-discrimination campaign. We could do that fairly rapidly and provide it to you to help you in your deliberations.
Senator LeBreton: Those were all excellent and compelling pieces information and testimony.
Dr. Quirion, you talked about the whole, of being the ``final frontier.'' I think those are very important operative words. In response to a question, you said, ``the time is now.'' Then we had the discussion of stigma.
In your presentation, you used the term ``neuroethics.'' Would you expand a little on what that term means for a layperson such as myself?
Dr. Quirion: That is a good question.
There are aspects of ethics related to mental illnesses that are a bit different from those related too other disorders such as cardiovascular disease or cancer. For example, there is the issue of informed consent to participate in drug trials. If a patient is in a depressed state, there is always discussion as to whether he or she understands everything about the consent form. There are other ethical issues related to privacy and to the placebo effect that may be quite different from those related to other kinds of illness.
The term ``neuroethics'' is rather new and not necessarily accepted by everyone. However, it is a way for us to highlight the fact that there is something special about mental health, mental illness and other brain diseases. We need to pay special attention to these issues and invest in research that addresses issues related to mental health and mental illness.
There is also the moral aspect. We know more and more about the brain function. For example, now using brain imaging, you can provide evidence that a person could be, perhaps, more sensitive and more responsive under high stress. There are concerns that such information could be used to prevent people from working in professions of their choice because of a particular weakness in a particular part of their brains.
As we learn more about brain function, we have to make sure that society will not use the information to practice discrimination. Last fall I gave a lecture at UNESCO on ethics. I have provided copies of my related slides in the handout.
Senator LeBreton: Incidentally, I loved your example of a double standard on the stigma, men/burn-out versus women/depression.
The Chairman: I think you can guarantee that will end up in our final report in some form.
Senator LeBreton: You also talked about losing researchers in the 1990s. To whom did we lose them and has the situation improved since that time?
Dr. Quirion: Yes. The situation has improved quite a lot. It is still very competitive. Research has no boundaries; it is international. The best researchers always have offers to move elsewhere. However, programs such as the Canadian Fund for Innovation have helped to recruit some of these young scientists back into the country. It is a very competitive area.
Addiction research was quite strong in Canada in the '70s, '80s, and early '90s. However, as a result of a crisis in funding, the already small addiction research community was cut drastically. We lost key people to the National Institute on Drug Abuse in the United States.
Now, we have to find ways to attract people into the country. The University of Toronto recently recruited a first- class addiction specialist from Germany and he got a Canada Research Chair position. There are opportunities. We will always lose some; and we will gain others.
Most of my students are not working in Canada; they are working in the United States and Europe. I hope to be able to recruit them back to the country. The best ones will always have a lot of opportunities, so we have to offer them good conditions in our centre at the university to make sure they will stay in the country.
Senator LeBreton: You face the same situation as many of the other areas in keeping them here.
Is there anything that deals with the stigma within your own profession? Is it difficult to get people to practice in this particular field? There was a time when everybody used to call psychiatric doctors ``Shrinks.'' My sense is that this is a highly specialized field and if I were one of you, I would not to be seen by the general public as odd or different because of the profession I have chosen.
How do you deal with that in your own profession?
Dr. Maziade: I think that discrimination from our colleagues in other specialties is more prevalent in the older section of the profession. It is understandable. However, we do not see it so much in the younger ranks because the new image of psychiatry is both brain and environment; it is pharmacotherapy and psychotherapy. It is now recognized at the medical school and by the residents in other specialities.
We have been, and still are, discriminated against as psychiatrists and it is our own fault. Our patients are not to blame; it is our own history. In the 1950s and up until the late 1960s, psychoanalysis was very prevalent and everything was environmental. It is as if the brain did not exist at all. If you look at papers published at the time, all those disorders — schizophrenia, autism, and manic-depressive depression — were the fault of the mother. It was always because the mother was lacking in education. Do you remember all those education trends and books?
Senator LeBreton: Yes, unfortunately.
Dr. Maziade: There is still some of that in French psychiatry from France. Just a few years ago, a respected French journal published an article that stated that autism was still a disorder caused by a lack of relationship between the infant and the mother. There is still some residue of today.
In those days, we accused people. I am a practising child and adolescent psychiatrist and I did that myself as a resident in the early 1970s. I was giving the parents the diagnoses for this terrible disorder and instead of providing support to them, as one would if their child had a cardiac disorder, I was accusing them because I was suggesting that they go to psychotherapy to help the child, because something was missing in the relation.
That was terrible.
The Chairman: This was as recently as 30 years ago?
Dr. Maziade: Yes. That was the practice in 1972.
The Chairman: Your story sounds to me like the 1800s.
Dr. Maziade: As both Dr. Quirion and Dr. Mottron both said, that is why there has been a tremendous change in the field. We certainly need your committee to transmit that image of the field in terms of research and practice. It is changing. However, my colleagues who are over 55 years of age knew psychiatry in the same way; many believe we still practise that way. However, our practice now is balanced.
There is still what I call ``anti-medical pressure.'' I am very multidisciplinary, however, it is very difficult in Canada and in the province of Quebec for a medical doctor to have pro-medical thoughts. The sense is that if a doctor says, ``I am a doctor. I am putting ahead medical concepts,'' he or she risks accusations of being unidisciplinary. I have felt more discrimination from other health professionals for being a medical doctor than for being a psychiatrist.
[Translation]
Dr. Mottron: I would like to reply as regards the indications of discrimination with respect to psychiatry that I see in my practice. The discrimination I see most often does not target psychiatry directly, but rather the psychiatric hospital as an entity.
I think that governments, particularly provincial governments, pay too close attention to lobby groups which have lumped the whole hospital together and said that hospitals must be rejected. I heard the heads of lobby groups say that certain hospitals should not be changed, but rather destroyed.
It goes without saying that this is an extremely dangerous stalinist position. We see what was done at the Douglas Hospital, a psychiatric hospital which has had its share of lawsuits, like all hospitals, but it is now a research centre. It is a hospital, but it is also a research centre.
I think discrimination toward psychiatric hospitals would be really changed if we were to improve hospitals to make them into very well maintained places that could be used as the basis for research centres.
At the moment, and this is unfortunately very true in Quebec, there is a movement that maintains, in a non- discriminating way, that patients must be taken out of hospitals, full stop. And often, we get patients in through the back door, because extremely violent, dangerous patients who are not hospitalized would be placed in hospital prisons.
Moreover, some proponents of early intervention say that it cures these patients, which is false. There is another group that holds that violence is eliminated and there is no need to send a patient to the hospital if rehabilitation methods are used.
I would say that these are half-truths. There is something very intelligent and profound in these methods. However, unfortunately, this position is not true 100 p. 100 of the time, and we will always need hospital beds for extremely difficult patients.
In Quebec, there was an extraordinary situation in which groups of parents took violent action to try to get patients out of hospitals. Another group of parents, who are in hospitals, is fighting a little less forcefully — because there are fewer of them — to have patients kept in hospitals. This means that I have some protection against lawsuits, because they are fighting against each other.
Psychiatric hospitals must not be stigmatized. We must help eliminate reactionary practices, and heaven knows there were many. Psychiatric hospitals must be improved so that they can be used for research purposes, and this vocation must be maintained.
I am very pleased with the work being done at the Douglas and also at the University of Montreal. Research must remain within the hospital setting, because the only way of reforming a psychiatric hospital is from the inside out. If we remove the people who work there, it will remain as it was.
[English]
Senator Cook: I come from Newfoundland. I have been listening to what is a very complex challenge in this particular field. From the perspective of where I live, I think it is imperative that there be a national action plan. I do not know how we can function without it. I am making the comparisons about how mental illness and wellness is treated in my own province.
We have to have dedicated research and an integrated approach, because I agree with Senator Robertson's comment that the family doctor is at the first gate. In my province, the waiting list for specialists is between 12 and 18 months. In the meantime, the patients who require care go back and forth to the family doctor and get prescriptions for something to keep them quiet. Depending on where you live, there might be a nurse practitioner or perhaps an NGO. You have to wait and manage the problem and therein lies the problem.
I think we need a national action plan that is dedicated to best practices that can go out to the provinces — given that health is delivered provincially and funded federally. If you have an alternative, however, I would welcome it.
You talk about not having enough money. That is a perennial problem. If we manage what is available within CIHI and SSHRCC, are you getting your share? Can something be done here? Can you cut the pie differently to ensure that you get this national action plan with all those pieces in?
Mr. Chairman, in my province, if you had a mental disease you were ``simple.'' If you had Alzheimer's you were ``low-minded.'' There is a lot of meaning in those words. If you had epilepsy, you had ``the fits,'' and I will leave it at that.
With respect to stigmatism, I think you have to look back at your own profession and how you dealt with it. Treatments included the lock-ward, shock therapy, and institutionalization. Now we are at the other end trying to do the opposite. I think the stigma is not with the public, I think the profession has to shoulder the responsibility.
Dr. Quirion: You have made a very good point.
In terms of an action plan, we all agree that the federal government needs to be involved, as it is in other aspects of health. Mental health and mental illness are critical and we should have a national type of agenda that includes cutting- end research.
In terms of access to services in various provinces, as I said, I am always optimistic. I know that is hard, there are long waiting lists. There are long waiting lists in Montreal as well.
I was very impressed when I visited Newfoundland. I have been to P.E.I. and New Brunswick. If we can capture the energy of the community in these provinces, it could be fabulous. Perhaps it will not happen overnight. However, we should be working to provide proper telehealth services to the communities. It seems easier to convince the communities in small villages that they need to be on board. What they have done in New Brunswick on suicide is fabulous; all cases are now referred to Montreal. There is a national policy, voted in the legislature, that every case will go.
When I visited P.E.I. in relation with Alzheimer's-type dementia, it was amazing in these small villages that everyone seemed to be involved in trying to help de-stigmatize the illness and provide better services such as halfway houses and so forth. The rural aspects present a challenge. CIHR now has a research strategy for rural health. That has been a good development.
In terms of research money, of course I think I need more. We always need more. In addition, it is not just a matter of more, it is a matter of doing things a little differently so that we can integrate the entire spectrum. That is what we are trying to promote at the institute. If we can work together on that, there will be a greater overall impact at the end of the day.
Senator Cordy: This has been an informative morning for me. I was particularly was pleased with the differentiation that you showed between the concepts of mental illness and mental health. I was also interested in your comment that the public tends to refer to illnesses such as childhood mental illness, autism and fetal alcohol syndrome as ``childhood'' illnesses, when indeed they are not ``childhood'' illnesses; they may suffer as children, but they do indeed grow up.
I would like to return to Senator LeBreton's comment about neuroethics. Does this also include balancing the rights of the patient with what the medical profession feels is right for the patient? You made reference earlier to people suffering from schizophrenia as a group with a high incidence of non-compliance with medication. You also made reference earlier to lobby groups who are saying that patients should not be hospitalized and family groups who are saying they should be hospitalized.
In balancing the two issues, is that part of what you refer to as neuroethics?
Dr. Quirion: Yes, it is. Phil Upshall is a lay representative on the board. He is in Montreal this week because he is working on a group studying the use of placebo for treatment of mental illnesses and also privacy. Mr. Upshall is working to ensure that the patient is involved in decision making at every step. It is not appropriate for a psychiatrist to dictate what the patient should or should not have; the patient must be involved. Mr. Upshall would be a good person to talk to about neuroethics.
Senator Morin: I think that Senator Cordy is referring to an issue that is currently before the Supreme Court of Canada that concerns the rights of the patient. In this case, a patient is refusing treatment despite the fact that his physician and his entire family — including his own mother — think that he should be treated. That is a very important issue right now, I am sure, for your profession.
Dr. Maziade: This is an extreme case and there will always be extreme cases. In terms of ethics, there is a new profession evolving in Canada and other countries. Universities are developing new curriculum. In several instances, ``true bioethics'' is balancing the risks of research against the benefits. We cannot just make a list of the risks, because that could result in a decrease, rather than an increase, in research. We must properly supervise research.
This is a concept that must be addressed. Research is evolving in the uncertainty area. We do not have research in the status quo. There are risks in the area of uncertainty. The real research in bioethics — what we need — is to balance the risks against the benefits for all psychiatric patients.
I should also like to remind you that the lack of psychiatrists in several provinces is not a result of young medical doctors opting not to study psychiatry. There are government policies that limit the number of specialists in psychiatry.
Finally, I would like to reiterate a point that Dr. Mottron made earlier. In several provinces in Canada, for reasons we mentioned, there is a very strong lobby from other professionals and groups of parents against the psychiatric institute. In most North American university cities, they are developing, excellent innovative treatments and enhancing research in neuropsychiatric institutes. In Canada, we need to maintain strong, modern neuropsychiatric institutes that foster research and innovative treatments. Our institutes must emphasize openness and networking with the communities rather than just fight the forces that try to destroy them.
Senator Cordy: Dr. Mottron, you talked about autistic children entering the school system. Since the early 1980s in Nova Scotia, there has been a big movement to include children with autism into regular classrooms, which may have thirty-odd children. I would like some clarification. Do you think that these children should be included in classes with high numbers?
[Translation]
Dr. Mottron: I really think I am going to reach a record number of lawsuits. In the Handbook of Autism and Developmental Disorders on which there is scientific consensus, as far as possible on these issues, the article on integration is very lukewarm and moderate, to say the least.
Many adults with autism say that the worst time of their life was when they were being persecuted by other children at regular schools. There are two ways of viewing integration as well: first of all, the politically correct way, in which all individuals are given the same rights — obviously this is a desirable approach — and second, the practical implications of carrying out this good idea. What happens when someone with serious neurogenetic problems that interfere with understanding social mechanisms is placed with normal 13-year-olds is that he or she quickly becomes a victim. Integration may produce exactly the opposite result from that desired.
In the case of very young children, lobby groups are completely justified in asking for one assistant for each child or for every two children in a class or group. That is the final opinion contained in the report prepared by the committee I was referring to earlier: one assistant for two individuals. That was not exactly a regular school.
We cannot put these children into regular schools and have one assistant for two children. In Quebec, some children are integrated into regular schools, and they have a full-time assistant with them. That does not make much sense.
I think that on this point, I really agree with what Dr. Maziade said: Let us start with the diseases, that is let us try to discern properly and apply intelligently the broad, anti-discriminatory principles, and so on, and also the very technical matters linked to a particular disease.
People with autism do not use the part of the brain that we use to recognize faces and emotions. You can integrate them as long as you like into regular schools, and they will not benefit from that at all. They need specialized care.
We can retain the major principles of integration, such as access to work and housing, while sparing these people full integration.
The ridiculous situation we have at the moment stems from the fact that most lobby groups have insisted on early integration, which means putting children into regular schools. That means that all the money goes to early intervention, and there is almost nothing left to assist profoundly autistic adults with housing or work problems.
I know someone with autism who is redoing the Web site of a former minister of the Quebec government. This guy does just as good a job as a person who does not have this handicap. We had to organize that ourselves. There was no assistance for this person.
In other words, integration as such must become a technical aspect. We must start by considering the limitations imposed by the disease and integrate the ideological constraints intelligently. But we should not be placing autistic children into a sort of immersion setting without thinking about the consequences.
[English]
Senator Cordy: Just because they are physically in a classroom does not mean they are integrated.
[Translation]
Dr. Mottron: Of course, no, it is artificial.
[English]
The Chairman: I should tell you that Senator Cordy was for many years a primary school teacher, so she has had more than a little experience with that problem.
I thank all of you for coming. I realize we went overtime, but your comments were extremely useful to us and we thank you for taking the time.
Our next speaker this morning is from the University of Montreal, Dr. Richard Tremblay, the Canada Research Chair in Child Development and the Professor of Pediatrics, Psychiatry, and Psychology and the Director of the Centre of Excellence for Early Childhood Development — All of which is the longest single title I have ever heard in introducing anybody.
Thank you very much for coming, Professor Tremblay.
[Translation]
Dr. Richard Tremblay, Canada Research Chair in Child Development, Professor of Pediatrics, Psychiatry and Psychology, Director of the Centre of Excellence for Early Childhood Development, University of Montreal: First of all, I would like to thank you for inviting me to be here today. I do research on the development of children. I began my career as a researcher and a clinician and worked with adults in psychiatric hospitals and prisons.
I realized how difficult it was to have a significant impact on the development of adults. I therefore decided, after a few years, to work with adolescents, particularly young offenders, to try to do something about the fact that most of these young offenders end up either in prison or in psychiatric care.
After working a few years with young offenders, I realized how little impact our actions had. I decided to work with nursery school children, because I decided I had to start at the beginning if I was going to do anything in the way of prevention.
After working a number of years with nursery school-aged children, I am now working with pregnant women. In my current work, I realize that some of these adults with whom I work are very similar to the adults with whom I worked in psychiatric hospitals and prisons.
So I am back to where I started. It certainly seems that if we are to prevent mental health problems from developing, we have to start early, but we must also target both children and their parents.
I have been doing longitudinal studies for more than 20 years now. We follow individuals from pregnancy to adulthood, and we try to understand how mental health problems develop, while taking certain action, to see to what extent taking action very early in life can prevent the development of mental health problems.
I specialize in problems of violence. We hear a great deal about violence in society: violence by adults and adolescents, but we often forget — and this is what our work made us realize — that problems of violence, particularly physical violence, begin very early in life.
Human beings are most frequently violent at the age of 24 months. Physical aggression is used most often by infants in this age group. It seems that we do not learn to become aggressive, we learn how not to become aggressive.
The philosopher Jean-Jacques Rousseau, said: ``Children are born good and society makes them bad,'' but it does seem that the opposite is true. Children are born with all these tendencies that are ultimately considered anti-social, and society teaches children to control their behaviour, which may be useful, at some times, but which is often harmful to social relations.
Mr. Henri Dorvil, Professor, School of Social Work, University of Quebec in Montreal: Thank you very much for your invitation. I have been in Quebec for 38 years. I arrived here at the time of the Quiet Revolution and the time of the revolution in psychiatry.
At that time, the Bédard report had just come out. It favoured deinstitutionalization, community psychiatric services, in other words, the social integration of psychiatric patients. I had not even studied social work, I was a social worker without a degree, so I was just beginning in the profession.
We started by meeting with priests and community leaders to tell them that psychiatric patients are not dangerous, at least not any more dangerous than other people, and that they should be given a chance.
We could not take patients out of psychiatric hospitals and integrate them into the community until they had acquired certain social skills. That is when social workers, psychological educators, started teaching psychiatric patients the skills they would require to function in society.
I subsequently completed my social work program. I worked for about 10 years and then I went back to university to do a Ph.D. in sociology, but I still had the same obsession about people's attitudes toward psychiatric patients.
Social workers who work in hospitals are called ``placers,'' that is, people who place psychiatric patients in the community.
It is thus quite natural that my current area of research is housing as a factor of social integration for individuals who are considered to have a mental illness.
What is being done in this field? Psychiatric patients receive a diagnosis. And according to the information in the scientific literature, psychiatric patients go through a number of stages in their recovery.
We think, and this is consistent with the findings of the scientific literature, that some types of housing are more suitable to the initial recovery phase of psychiatric patients.
During this initial phase of recovery, psychiatric patients feel somewhat lethargic. They wonder what is happening to them. From our studies, we think that at this stage, psychiatric patients would be better served in what is known as a group home or residence.
After some time, psychiatric patients begin to regain their strength and to connect with the healthy aspects of their personality, and so on. At this point, they can go further afield and live in a supervised apartment, for example, because they have made some progress.
In the third phase of recovery, psychiatric patients start to feel stronger. They start to think about their quality of life. They have learned a number of social skills in the earlier phases, in the housing experiences they have had. When they start to talk about quality of life, they can think about what is known as independent living.
In psychiatry and in mental health services, there are many ideological trends. Some even advocate that mental illness is an ideology, and that as soon as patients get out of the hospital, they can go into an independent living situation. That is an extreme opinion.
Others say that it is out of the question for psychiatric patients to go a little further in society. They must stay within what is known as the ``daycare model.'' They cannot go any further, they cannot be rehabilitated. So these are two diametrically opposed extremes.
After doing three or four studies on housing as a factor in social reintegration, and after doing a typology, a classification of the daycare model, that is housing with professional support — support from the psychiatric hospital — and then independent housing, rooming houses, and so on, we realized that there is no perfect housing situation. For example, group residences, which follow the daycare model, provide security, but do not foster independence.
At the other extreme, independent housing provides a great deal of freedom and independence. And some psychiatric patients wonder what to do with all this independence. Often, psychiatric patients feel isolated when they are on their own, whereas in the group residence, there were people around.
Finally, I would say that we study society's prejudice regarding access to housing. When individuals with physical handicaps or members of ethnic minority groups look for housing, they may encounter some resistance from society. The same is true for psychiatric patients. Sometimes, they are qualified to take possession of some type of housing in a building, and quite often, because of their psychiatric diagnosis, which follows them throughout their whole lives, they have trouble being seen as citizens, like any other citizen of Quebec or Canada.
So that is what we are looking at at the moment, because psychiatric patients are more or less imprisoned in the housing provided by the health care network. We want to get out of this health care network.
We want to work with the Quebec Housing Corporation and with the Canada Mortgage and Housing Corporation. We say that psychiatric patients are citizens, and that this must be taken at face value. Quality housing makes so-called normal people happy. This is even more crucial for people whose health has been compromised by mental health problems.
Mr. Michel Tousignant, Professor and Researcher, Centre de recherche et intervention sur le suicide et l'euthanasie: Thank you for allowing me to speak to your committee this morning. Let me introduce myself briefly. My main area of research is social science. I have a background in psychology and anthropology, and I do research mainly on the history of life from the time a human being is a foetus until the time of his or her death by suicide. I work mainly with adults, but I am also involved in projects on adolescents and even seniors.
My presentation will deal with the day-to-day problems confronting researchers in social sciences and mental health. I will discuss some of the topics listed in the letter sent to me by Mr. Charbonneau last weekend. My first point is about the level of funding and the balance between various research sectors.
In Canada, there has been a net improvement in the past three years following the creation of the Canadian Institutes of Health Research, as well as an improvement in the research funding, particularly for mental health. However, there is still a great deal of room for improvement in the area of research and especially in research on mental health and social sciences.
First of all, whether in terms of public government funding, the university chair program or private foundation funding for health care, mental health is often not sufficiently funded in relation to the costs and burden these types of illnesses represent for society.
With regard to suicide, which is the principal cause of death for men under 40 in Canada, there is a lack of funding compared to other causes of death such as heart disease or cancer.
Suicide attempts also represent a very heavy cost in terms of hospital care. There are 500,000 hospitalized cases in the United States and there must be 50,000 in Canada. That represents $10,000 per person.
There is a handful of researchers in this field in Canada. Fortunately, they are mainly concentrated in Quebec. There may be about fifty in all. There is a great deal of research to be done concerning certain mental health problems.
With regard to mental health research, a large part of our budgets are allocated to psychopharmacology, genetic factors and neurotransmitters, which are important factors in etiology and cure rates. At the same time, the study of the social aspects of mental health are underfunded, even though they are just as important and perhaps even more so in the case of many psychiatric disorders.
Our society's fascination with technology and the whole aura of the medical world, with solutions that are quick and cheap in terms of human effort, the masking of social and political factors in many problems that have increased very rapidly in the past decades, all these factors have meant that social sciences have taken a back seat in mental health research.
To give you just one example, enormous amounts of money are invested in research for new psychotropic drugs, which is good, but there is very little examination of the personal and social factors involved in taking the medication.
What factors lead to a patient taking the drugs or not? This is a problem that was raised by Dr. Rémi Quirion at the end of the last session.
You could have a very effective drug, but if patients do not take it or if doctors do not prescribe the correct dosage, how effective will that drug end up being?
My second topic is the area of communications and the application of results. We know that the last step of the research project is that of communicating results, not only in scientific journals but also in media aimed at the general public.
This stage is often obviated, for many different reasons. The popularization of results is not sanctioned by universities and research organizations. It plays a negligible part in one's curriculum vitae.
Research budgets should have an amount earmarked for scientific popularization. In addition, researchers have little training in the dissemination of their results to the general public.
Although this is one of the new objectives of the Institutes of Health, the fact remains that people will have to be trained if these objectives are to be achieved. There is therefore a need to create a public relations infrastructure to support researchers' efforts.
Perhaps we also need to encourage academic career models that focus more on the utilization and communication of results rather than the production of original results. Similarly, certain research programs should have communications as their exclusive mission.
Last, my third point is about ethics, which has become an extremely important issue in medical research following abuses that occurred among certain populations.
That being said, there are sometimes very heavy restrictions and major obstacles that prejudice the validity and quality of research while taking up a lot of the time of those in charge of research. For better or for worse, this has become a huge bureaucratic structure whose main purpose is often to protect hospitals and universities against lawsuits rather than protecting the patients themselves.
Researchers must now spend more and more time, sometimes months and up to a year, satisfying all the criteria before starting a research project. First, there are university ethics committees, then those of research centres affiliated with hospitals, and then those of each individual hospital. There can also be a protocol that must be submitted to the Access to Information Commission in order to obtain lists of individuals. In the latter case, delays can vary from three months to a year. This represents an extremely heavy bureaucratic burden for researchers.
Over the years, I found that the steps that need to be undertaken are more and more onerous and the results are more and more restricted. For example, in order to gain access to the families of those who have committed suicide, we can no longer contact these families directly. We have to send a letter via the chief coroner of Quebec. If the families respond to this letter, we can conduct the research. That means we often get a 30 or 40 p. 100 response rate, which to some extent calls into question or invalidates the representative nature of these populations.
We did some research with Eric Latimer to gain access to the list of people who receive welfare. A hospital ethics board turned down our request for these lists. But it is impossible to conduct research on poverty without access to such lists. We must therefore rethink all these issues with an eye to protecting not only the institutions, but also the general well-being of the populations affected by mental health problems, if we are to determine what should be done.
Ethics committees have become watchdogs to protect everyone's interests. Very little time is allocated to consultation with researchers. Often, highly complex ethical problems arise during a research project and that is when people who are involved in ethics should help researchers with day-to-day concerns.
[English]
The Chairman: Thank you.
I would like to welcome our fourth speaker, Mr. Eric Latimer, the Health Economist from the Douglas Hospital.
Mr. Eric Latimer, Health Economist, Douglas Hospital: The Douglas Hospital is the psychiatric hospital for patients who are more comfortable in English and who need long-term care. It is also the institution that provides psychiatric services to a sector of Montreal that comprises St. Henri, Verdun, Lasalle, and Lachine, about 260,000 individuals.
The Chairman: Has the Verdun Institution, as I knew it, been closed?
Mr. Latimer: The Verdun Hospital that was founded in 19th century is still the same. There are some additional buildings, and there are far fewer beds.
The Chairman: It is still a mental institution?
Mr. Latimer: It is still a mental institution, yes.
The Chairman: Sorry, go ahead. That was for my own edification.
Mr. Latimer: Not at all.
Thank you for giving me the opportunity to speak to you this morning. I am especially pleased to see that, following your report on general health reform, this subcommittee is turning to the specific issue of mental health and mental illness. As no doubt you have heard already, the area of mental health and mental illnesses is perceived as an ``orphan child'' by us in that community in the context of health research generally.
I was very happy to listen to my colleague Michel Tousignant's responses to the questions that were posed to us. I agree entirely with him.
It may be helpful to the committee to know a little bit about my background. I have a Ph.D. in Economics and I have specialized as a mental health economist, which is a rare specialization. I am the Director of the Services, Policies and Population Health Research Program at the Douglas Hospital Research Centre, the research centre of which Dr. Quirion, is a scientific director.
My core research interests have been in the area of services to severely mentally ill adults. I have also been actively involved in dissemination activities related to one evidence-based practice called assertive community treatment, ACT, by means of writing, organizing and speaking at provincial conferences.
Honourable senators, your recent report on health care reform emphasized the need for the federal government to strengthen its commitment to health research in general — well beyond the substantial increases already granted since the establishment of the CIHR. More specifically, your report also recommended greater federal commitment to health technology assessment and evaluating health care system performance. In my view, if those conclusions are valid for health and the health care system in general, they are equally valid — perhaps even more so — for mental health research.
There are many burdens of disease posed by mental illness. The stigma that has tended to push it under the carpet, the effectiveness of many existing treatments for common mental illnesses that are under-used, and the need to seek more effective treatments for devastating illnesses such as schizophrenia and Alzheimer's disease have all been well documented. I will not go over that ground again. These various factors combined call for greater investment in biomedical, clinical, health services and population health research, as well as greater investment in knowledge transfer activities.
I would like to focus my remaining comments on health services and to a lesser extent population health research, which I know relatively well. I would also like to further focus my comments on services to the severely mentally ill — people who represent approximately 2 per cent to 3 per cent of the population and who are the most severely disabled. In many case, this population also consumes the most services. This is the area of research in which whatever expertise I possess lies.
Close acquaintance with the area of services to the severely mentally ill reveals one striking fact: Over the past two decades, experimental studies — conducted mostly in the United States — have revealed about a half dozen organizational delivery models and approaches that are markedly more effective than traditional approaches in helping people with severe mental illness integrate successfully into the community. These include assertive community treatment, supported employment, integrated treatment for concurrent mental illness and substance abuse disorders, family psycho-education, early intervention for psychosis, and a few others.
However, these are not widely used. This is regrettable, not only because it means individuals with severe mental illness are not being helped as they could be, but also because resources are squandered on costly ineffective services such as unnecessary or unnecessarily long hospitalizations, a variety of hospital-based rehabilitation services and in- patient substance abuse programs.
We could be getting more ``bang for our buck.''
At the same time, health services research in general — and certainly mental health services research — tends to be contextualized. It this respect, it defers from biomedical and clinical research.
Let us look at supported employment as an example. Among people with severe mental illness, we find unemployment rates typically in the order of 75 per cent to 90 per cent. However, when we survey these individuals, we find that most would like to work and, in fact, they would like to work in regular competitive settings. Traditional approaches have typically involved transitional methods that try to bring them to the point where they can work. However, what usually happens is that these individuals end up staying in these sheltered environments indefinitely, or they are maintained deliberately in these sheltered settings if it is accepted at the outset that they will never have the ability to work in regular settings.
An approach called ``supported employment'' developed in the field of developmental disabilities during the 1980s. This, in a nutshell, replaced the paradigm, ``train, then place'' with the paradigm ``place, then train.''
In subsequent years, health services researchers in the area of mental health services examined the question as to whether this approach could be adapted to people with severe mental illness. There emerged from that a model called individual placement and support, IPS. Now, more commonly called ``evidence-based supported employment.'' In a nutshell, this involves helping an individual who has a severe mental illness to identify the kind of work that he or she would like to and has the ability to do, helping them find such a job and support them once they have that job.
I can give you a specific example as we are currently studying one of the first evidence-based supported employment programs in Canada right here at the Douglas Hospital. A woman was interested in working in elementary schools, supervising at lunchtime. She wanted to do this in her neighbourhood in Verdun. Her employment specialist — an employee of the Douglas Hospital — helped her to find such a job by knocking on the doors of the different elementary schools in Verdun. They eventually found one that was willing to try her out and this has worked out just well. She could not have done this on her own.
There have been a number of experimental studies in the United States that have indicated that this is an effective approach. We have been trying to see whether it is equally effective here. We have that the effectiveness of the model seems to be somewhat dampened by a number of institutional differences between our setting here and that in the United States. Incentives for work are not as great and there are a number of alternative opportunities for employment offered to people with mental illnesses here that are not offered in the United States. There are a number of other factors. All these differences raise questions that we must to address in order to optimize this kind of program for our setting.
These observations lead to the conclusion that we need more health services researchers in the field. More health services researchers make possible greater knowledge transfer as well as more research on local adaptations and enhancements. Furthermore, they foster the development of a culture of innovation, of continuous quality improvement.
Pleases note that I said, ``More health services researchers,'' not ``more money for health services research.'' There is a broad sense in our community that what we most need at this point is greater capacity, not necessarily more grant money. People who are currently engaged in mental health services research are very busy.
How much more capacity do we need? That is very difficult to say. We do not have the data to be able to answer that question. However, based on my observation of the opportunities for useful evaluative research and the number of us out there doing it, I would suggest that doubling our capacity would be a minimal target. There are some initiatives under way in this direction, which in the interest of time I will not detail, but more would be even better.
At the same time, we need to increase the receptivity of the health services sector to innovation. This requires nothing short of a cultural shift. Some individual hospitals such as the Douglas Hospital are trying to do this, for example by means of monthly meetings that group together clinicians and researchers. However, such hospitals are exceptional.
Finally, in terms of ethics, I am in entire agreement with the views expressed in your committee's previous report on health. I would like to confirm to this committee my personal experience that standards set by research ethics boards at different teaching hospitals are extremely variable and some oversight is needed. Yet, I would like to make the further suggestion that a centralized process to further clarify the ethical standards to apply in a wide range of specific situations would be helpful. The Tri-Council guidelines in practice leave much room for interpretation. This is an obstacle to research.
In addition to the points that my colleague just raised, I have found that ethics committees spend inordinate amounts of time deliberating over protocols and may ultimately be unduly influenced by specific individuals, judging by the variety in the decisions that they render on the same ethical question. Researchers also can spend inordinate amounts of time obtaining approval of their protocols from multiple institutions. I have often had the impression that ethics committees will give an enormous amount of attention to what appear to be relatively minor points, whereas decisions with very great ethical significance involving the care of patients that are made by clinical administrators or decision-makers are themselves not scrutinized at all to the same degree.
The Chairman: That is a very provocative ending. I am sure we will come back to that.
Senator LeBreton: Mr. Tousignant, two areas struck me in your presentation: One was the whole area of public awareness and the allocation of funds and the other was on access to data.
On the public awareness side, when you are working with limited research funds, how will you decide and what do you propose in terms of public awareness and how you involve the public in the severity of this particular illness?
Mr. Tousignant: There needs to be a lot of creativity in that field because that researchers do the research and then they have to apply for more money and get to the next point.
We are increasingly asking the researchers to disseminate the results that they have painfully obtained. However, they are not necessarily competent to do so. Three must be some structure. If, for example, a research institute required them to do more in terms of applying the results, they would need assistance because they have not necessarily been trained to do that. Some people have more natural talents to do so. However, others have been trained to live a monk's life in their laboratories and they have not necessarily good communicators. Sometimes they have chosen their jobs to shy away from the public. There should be a little more weight given to career. If your curriculum vitae indicates that you have published in public-oriented journals, that is not a good point. They feel that you have wasted your time. While things are changing, if you applied for research grants, these things were not considered. Therefore, I think that we have to change a little bit the way we see the traditional academic career.
Furthermore, although we produce of lot of knowledge nowadays, there is nobody to integrate the results. This would be research in itself. We need someone who can take in everything we have and try to make sense of it all. Even we do not know; we do not have time to read what our neighbours are doing — even within the same institution. There is a need for people to synthesize the results of research and better communicate the results.
Senator LeBreton: In other words, on the public awareness, it is actually internal and external. It is within the community of researchers and you want to increase awareness to that body at large. Is that what you are saying?
Mr. Tousignant: Yes.
Senator LeBreton: You mentioned having difficulty access to data to people living on welfare. I am just wondering what you are doing to overcome this? Is there a solution? How are you approaching this important data? Is there any chance or any hope that you are going to have success in getting it?
Mr. Tousignant: Yes. We did find a solution. I will not go into the details. Sometimes one has to tinker or cheat a little to get around obstacles.
Senator LeBreton: Since this is a Parliamentary committee, as Dr. Morin pointed out, you will not be penalized for your answer. Can you give us an example of like how to do get at this data? What can this committee do in its recommendations to help you get access to full data? Perhaps someone else wants to take a crack at this?
Mr. Latimer: I would like to reiterate a point that I made towards the end of my presentation. It seems that there are certain types of situations that we can anticipate would be presented fairly regularly before ethics committees. These could be studied ahead of time and there could be a kind of deliberative process to figure out what is an appropriate way to deal with this particular kind of ethical situation.
In other words, I am suggesting that the Tri-Council guidelines be greatly amplified to spell out what should be done in a number of situations. I think that would help in the types of situation to which you referred, where in fact, different ethical bodies that we had to deal with had different interpretations of what was ethical in this particular circumstance.
Senator LeBreton: Professor Dorvil, you talked about the issue of community integration and social integration. You spoke to the whole mess — and it is a sorry mess across the country — concerning access to housing and you specifically mentioned the biases as you try to access public housing. Perhaps the better term would be barriers.
In your specific case, can you explain the process that you follow in order to try and access this? What is your success rate? What is the severity of the shortages in this area? That information could perhaps be of use to us as we go across the country?
[Translation]
Mr. Dorvil: Yes, in the area of housing, and you are perfectly right to point that out, we must talk about obstacles that prevent certain psychiatric patients from gaining access to subsidized housing or affordable housing, etc.
If the authorities do not spend a bit of money to build subsidized housing, we are going to see deinstitutionalization leading to ghettos of housing inhabited by psychiatric patients. To prevent this ghetto phenomenon, to prevent the effects of its stigmatization caused by a psychiatric diagnosis, North American society must broaden its range of housing options.
I am in communication with colleagues in Ontario, for instance, who work at the Clarke Institute and who have observed the same thing, namely that when a psychiatric patient is qualified to live in so-called normal housing, the waiting list is four or five times longer than that for group homes and other residential facilities administered by psychiatric hospitals.
On the whole, the number of subsidized housing units must be increased to give qualified psychiatric patients a chance to obtain normal housing.
[English]
Senator LeBreton: What happens to them in the interim? There are these people and there are access problems. Where do they live? Are they kept in institutions, are they on the streets, or are there families trying to deal with it? Where are all these people in this holding pattern waiting for public housing?
[Translation]
Mr. Dorvil: Yes. You are perfectly right to point that out. For example, 57 per cent of psychiatric patients in the community live with their natural family. In the United States, in the State of New York for instance, that figure rises to 69 per cent, so that was true.
Some families can no longer house a loved one who is ill simply because the parents have become too old. That is why it is virtually a necessity to have other types of subsidized housing so as not to increase the number of homeless people.
You are quite right to draw attention to the contribution of families. Families provide far more housing for psychiatric patients than the State. And that is their role, it is their duty.
We must not forget that society has changed. Women now work outside the home so the State cannot order families and therefore women to stay home to look after these patients themselves.
The State has some responsibility and it must also provide what we call respite care, emergency help and support for families who still have a psychiatric patient living at home, with all of the extreme ups and downs that can represent.
[English]
The Chairman: It would certainly be very helpful — even if you do not know the answer today — if we could have your conjectures down the road as to why it is in Canada you have the 57 per cent staying with their families and right next door in New York state you have 69 per cent? That 12 per cent increase is a huge difference and would clearly be beneficial to the patients.
Why is there a difference? Is there some public policy change — it may even be a tax change for all I know — that would enable us to move from 57 per cent up towards 70 per cent?
[Translation]
Mr. Dorvil: Yes, it is possible to improve the situation. I believe that while the figure is 57 per cent in east-end Montreal, in the Laurentians for example, it climbs to 66, 67 or 68 per cent. There are even some regions in Quebec where it surpasses the American rate. This is true in the Saguenay/Lac Saint-Jean region for example.
In Ontario, in the area around Kitchener, there are far more families who keep psychiatric patients at home than in the London region. Why? We do not know. Perhaps because the psychiatric hospital makes more alternate housing units available to families. People therefore turn to the easiest solution.
In the Kitchener region, where there are no psychiatric hospitals, people have become accustomed to fending for themselves. That is why the families there do a bit more.
Those are some of the things we discuss with our colleagues from Ontario, John Trainor and John Sylvestre, and these are hypotheses that we will continue to examine.
[English]
The Chairman: Thank you. Can I urge you and your colleagues to conduct some research that will answer the question? If you have a case in Ontario where the numbers are different between London and Kitchener, there must be a reason why. It would help us to know the answer.
Mr. Latimer: It does not seem to me to be at all obvious that increasing the percentage is in itself necessarily a good thing. It depends. The real answer is we want families who have someone who has a severe mental illness to have a range of options available to them so that what is best for the family and for the patient is possible.
The Chairman: I agree with you completely. However, it does strike me as curious that in a relatively small geographic area, there are significantly different results. Forget for the moment whether it is better or worse for the patient; we want to understand what the underlying societal motivators are that lead to that difference. In particular, it would be helpful to understand the motivators if you were to design a program to encourage those patients who are ideally suited to being at home, to be at home.
Senator Robertson: I should like to quickly tell you about a program with which I am personally involved.
Last year a small group of us started a program called ``Alternative Residences and Rehabilitation for the Mentally Ill.'' Dr. Gilbert Finn —who was one of the past Lieutenant Governors of the province — has been on the French radio stations all year. Your humble civil servant here has been on the English stations all year, talking about the necessity of supporting alternative residences.
We have not raised a lot of money, but we have raised $750,000.00 so far; not a dollar of which has come from governments.
Each residence has four apartments. We keep them small so that we will not ghettoize. The program is extremely helpful. It has shown that if you get into the media and start talking about these problems, the public will respond. We have had a great response from the public.
The Chairman: Thank you. I should just say to our witnesses, Senator Robertson is a former Minister of Health and from the province of New Brunswick.
Senator Robertson: Our community is small.
[Translation]
Mr. Dorvil: Yes. But I would add that it is a very complicated situation. We encourage families, to keep the patient with them. And with approaches such as respite care and emergency care, the more support we can provide these families the more they will continue to do so.
But even taking that into account, we feel that the State must still contribute to subsidizing other types of housing. The ideal type of housing for psychiatric patients has not yet been found. So we want to discover other types of housing.
Senator Morin: Doctor Dorvil, I would like to continue on this issue of housing, because it seems to me there is some ambiguity here.
I think that we have to put the focus back on the patients and not on the family or the State. If we look at this from the patient's point of view, are there not patients for whom it would be better to be housed independently, away from their families?
A 50-year-old person cannot stay indefinitely with his 80-year-old parents. I am not talking about the parents. I am thinking of the patients. I think there comes a point in life where you want to leave your family and have your own home, whether you are sick or not.
I think that the high percentage of patients who live with their families, as Mr. Latimer pointed out, is not necessarily a good thing. I think there are advantages to these people having their own homes.
You have not discussed this, but to pick up on Senator LeBreton's question, are there in fact patients who are on the streets because there is no housing available?
Mr. Dorvil: I would like to answer the last part of your question first. It is true that there are psychiatric patients who live in facilities or in supervised apartments in group homes. At 9 or 10 in the morning, the person in charge of the home may say ``You have to get some air. Go for a walk.''
There are also psychiatric patients who have trouble adapting to a residential facility. No matter how many different types of housing we try out for them, they prefer to wander the streets. I am not saying that this is part of their pathology, but one can say that there are a certain number of homeless people wandering the streets who have been diagnosed with psychiatric illness. One cannot get away from that.
To get back to what you said earlier, I think that all human beings dream of a certain level of autonomy. It all depends on their means. Everyone knows that at 20, 22 or 25 years old, the first time we sign a lease we are quite proud of ourselves.
A psychiatric patient of 40 or 50 years of age also wants to have that feeling of pride. He wants to free himself from the guardianship of his parents. I think that is perfectly normal.
Many patients encounter obstacles or anomalies within the housing or sheltering system. In the course of my research, I met with psychiatric patients who lived in residential facilities who could have lived in autonomous housing. And I met some in autonomous housing who would have been better to learn social skills in residential facilities.
We sometimes end up faced with two groups: one under the auspices of a hospital and the other under the auspices of community groups or non-profit organizations and so forth. These two groups do not talk to each other. There is really a brick wall there. We need some intervention to make these two groups speak to one another for the well-being of the patients, as Senator Morin just said. We must always take the psychiatric patient into account. Depending on what stage the patient is in in the healing process, certain types of housing are more suitable for psychiatric patients in the first phase of healing, others for those in the second phase and yet others for those in the third phase.
Senator Morin: Doctor Tremblay, you raised the issue of violence, which seems to me to be very important. A lot of the discrimination and stigmatization faced by psychiatric patients stems from the fear that many normal citizens feel; they are afraid that the patient will suddenly become violent.
You stated that an individual starts to become violent as early as 24 months of age. Of course, this is a matter of degree. Is this a sign of underlying mental illness?
Can anything be done to provide early treatment of mental illness, or is this a situation that has no bearing on these different mental disorders?
I would also like to talk about the environment and I would especially like to talk about television.
Recently, a team that examined violence on television submitted quite an exhaustive report to the CRTC asking it to limit the broadcasting of television violence and expressing the opinion that there was a close relationship between the violence among young people and in society and what was viewed on television. I would like to hear your views on that.
Mr. Tremblay: You are correct in saying that part of the psychiatric population produces a significant proportion of the incidence of violence. Studies conducted on the development of violent behaviour show that indeed, the frequency of physical aggression, since we are talking of physical violence, reaches its peak in early life, around the age of 24 months.
The older children get, the less they resort to physical aggression. What we see is that children learn to control their violent behaviour when they are very young. Virtually all children display this physically aggressive behaviour very early. But there are significant differences in terms of frequency.
Very early, we see this gap between children who will occasionally hit or bite others and children who frequently use these modes of interaction with others.
In recent research, we discovered that part of this component is genetic and the other is environmental. The frequency in the use of violence at age 17 months seems partly determined by genetic effects. The fact that this diminishes over time seems strongly related to the environment.
A child whom we might describe as ``turbocharged'', who is born with the need to have everything and grab everything and who ends up in a disorganized environment will never learn to apply the brakes. At age 2, he will not hurt too many people except other small children, but as he gets older, he becomes more and more of a threat for his environment.
What I say to people who work with 2-year-olds is: imagine that that child goes to bed tonight, and when he gets up tomorrow morning, he is six-foot-three and weighs 250 pounds. Do you want to continue living with him? A 2-year-old who cries, screams, has temper tantrums, is not a person you want to have around when he is six-foot-three and weighs 250 pounds.
It is quite obvious that these children have to be helped at a very early age. Problems related to physical aggression, hyperactivity, depression, in short just about all mental health problems, manifest themselves early.
The signs appear early, but they get worse, and once that aggressive person is in society, he becomes a threat. We tend to wait too long. Some children get to kindergarten and we can see clearly that they have problems, but we wait because they are not considered dangerous.
Instead, we focus on adolescents. Our resources become available at adolescence and adulthood. We wait for children to grow up and of course if we have not done what we were supposed to do, we end up with adults and adolescents who are very difficult to control and then they are placed somewhere.
Some children are placed at the end of elementary school, at adolescence. In fact, even in supervised facilities, overly aggressive children are removed from their environment.
At the early age of 2, 3 or 4 years, those who will later be called mentally ill are already marginalized. They are marginalized very early. The approach that we feel is adequate in terms of investment in our children is a preventive approach, one that must take place as early as possible.
One thing that mental health and neuroscience research has taught us is that the human brain is like a pension fund: the earlier you invest, the bigger the long term dividends. The human brain shows its greatest capacity to learn early in life. If you want someone to learn French or English, teach it early. If you wait till later, it will be much more difficult.
This is true for aggression, for hyperactivity, for anxiety and all other mental health problems. We can intervene early. And we can do some screening. Longitudinal studies show that we are able to identify children who will become mentally ill later in life. So there are advantages to very early intervention.
Senator Morin: And television?
Mr. Tremblay: Oh, television! Given what I have just said, you understand that physical aggression is at its peak in terms of frequency at age two and that it diminishes with age. Even among the most serious cases, the frequency of aggression diminishes with age, but not the gravity of it.
People confuse frequency and seriousness. Of course as they get older, patients become more aggressive, but the frequency of these aggressive outbursts goes down with age. It is hard to understand that as they age, people become less aggressive even though they are exposed to more aggressive television content.
From what we know, we cannot state that television is one of the factors that contribute to people becoming more aggressive.
However, it would seem that television has a greater influence on people who already are aggressive. If people who already are aggressive are shown all kinds of ways of being aggressive to others, they are not going to learn how to be aggressive, but they will learn new means of aggressing others.
It is a fact that the majority of North Americans are exposed to violent television content. But it is not true that television makes everyone aggressive. Just like alcohol does not make us all alcoholics, television does not make us all violent.
[English]
Senator Cordy: Thank you to all of you for your presentations this morning.
Dr. Tremblay, you talked about early intervention and that you are now working with pregnant women. A number of years ago, there was a very high-profile case in Canada of a pregnant woman who was abusing drugs and alcohol. What can we do legally, in 2003, if we see a pregnant woman who is abusing her body and thus abusing the unborn child?
Dr. Tremblay: Well, I am not a lawyer, However, it is obvious. I have provided a package that explains the work that the Centre of Excellence for Early Childhood Development is doing. Last fall we dealt with the topic of the use of alcohol and tobacco during pregnancy. It is very clear that smoking or abusing alcohol during pregnancy have a tremendous impact on the brains of babies. That impact has an effect on the capacity to control your behaviour after birth.
Twenty-five per cent of pregnant women in Canada smoke throughout their pregnancies. In my view, smoking during pregnancy is the thing we could act on to prevent a lot of mental health problems. We know that smoking produces low birth weight; it also produces brains that are, in fact, addicted. It produces hypertension. We say, ``They are smoking. What can we do?''
If a mother gave a cigarette to her baby after birth, we would intervene. If a mother gave alcohol to her baby after birth, we would intervene. Nicotine gets through the milk of breast-feeding mothers. Alcohol gets through the mother's milk. We encourage these women to breast-feed, yet babies are starting to smoke and drink during pregnancy. These are huge mental health problem issues.
Senator Cordy: What can we do? I mean, we can educate and advertise — this has worked to a great extent with smoking and with drinking and driving. These have been successful programs.
However, what can we do with people who refuse to listen?
Dr. Tremblay: I think we need to do much more. The knowledge has not been that clear for long. We must ensure a transfer of knowledge and it must be done in a very intensive and systematic way. Most nurses who do home visitations for pregnant women tell us that we are crazy; that we will not get them to stop smoking because it is their only means of coping with stress.
The focus is on the well being of the adult. We have been talking about mental illness mainly for adults. We need to think about the next generation. Therefore, whenever we are making a mental illness intervention, we should prioritize the next generation.
In most mental illness facilities in North America, the people who do the intervention with adults who have mental illnesses do not really care about the next generation. At one of the biggest hospitals in North America — the Hôpital Louis Hippolyte-Lafontaine, here in Montreal — I asked for information on the patients' children and their ages. I was told they did not keep such records.
That occurred five years ago and I think the attitude persists in most facilities. Even though we know that mental illness is largely an inter-generational phenomenon, we do not do must about the next generation.
[Translation]
Senator Morin: Doctor Tremblay, you have raised an important issue. Could you perhaps send us some references about the link between smoking while pregnant and children's health?
Mr. Tremblay: Certainly. There is a Web site where you can find an encyclopaedia and I will send you the reference.
[English]
Senator Keon: Smoking behaviour can be modified. It is just a matter of the investment. In my other life, we have an enormously successful anti-smoking program.
The Chairman: In his other life Senator Keon is the CEO of the Ottawa Heart Institute.
Senator Cordy: With respect to early intervention, your comment ``the earlier you invest, the greater your return'' is an excellent one. I will have to remember that.
Last week we heard from some witnesses who said that there is reluctance on the part of many people to admit that children indeed can have a mental illness and that this creates a problem in early identification and intervention. If you do see a child who is showing signs of a mental illness — you talked about a high degree of aggressiveness than an average child would have — how do you get parents to develop better parenting skills?
I used to teach elementary school. I have seen parents who thought that their children were being cute or precocious or, a term that I hated, ``all boy.'' How do you get parents to recognize that perhaps they are lacking in substantial parenting skills?
Dr. Tremblay: There are a number of ``parent training'' programs have been developed. We experimented with such a program with a sample of kindergarten level children who were showing these problems. They were from low socio- economic areas and their parents had low education. That program has shown long-term effects. Those children are now in their early 20s and we have been able to reduce their dropout rate by half and we have reduced substantially delinquency, drug use and alcohol abuse. One of the reasons for our success is that we went to their homes. We did not ask them to come to a clinic or to come to school.
The majority of the programs are organized in such a way that those who need it most cannot access them easily. Most services are like that. It is much easier for the professional to say, ``Come and see me between 9:00 and 5:00,'' than to go to their homes on Saturdays or on Sundays, or at night. We need to try to find professionals who will work at the time when these people are available.
It does not make sense for the professionals to try to make the patient fit their schedules. However, it can work if one invests a lot in reaching out to provide the services. While some people say it will not work, we have found that those who need the services the most were most welcoming in their homes. They realize that they have these problems and once they realize that you are helping them, they catch on.
Senator Cordy: If a child has a problem at the age of 5, he or she will most definitely have a problem at the age of 15 — compounded many times.
Dr. Tremblay: Oh, yes. The studies have shown that. Kindergarten teachers are very good at identifying those who will have big problems in the long run.
However, the resources are not there. The head of the school will direct resources towards children aged 11 and 12 because they have bigger problems. However, the problems are bigger simply because they have not been dealt with earlier.
Senator Morin: Also because they are bigger children.
Senator Cordy: Dr. Tousignant, I am just looking at the statistics you provided on the high percentage of people who attempt suicide and the number of deaths by suicide. I wonder whether or not this actually registers with the public. I know that the information is out there; we have certainly heard it as a committee and anybody involved with children certainly is aware of it.
Is the public not willing to talk about and accept that the percentage is that high, or is the information just not reaching the public?
Mr. Tousignant: It is difficult to say how much the public knows. I think they are increasingly informed, at least in Quebec, where the rates tend to be a bit higher than in the other provinces. Perhaps they are not aware of the figures for suicide attempts because most of the statistics reported in the press are about suicide. There is much less information on suicide attempts. For each suicide, there are 10 suicide attempts hospitalized. There are many more attempts that do not come under professional supervision. The numbers are high.
We also need to increase sensitivity — not only with the public, but also with hospital teams. Not that many years ago, people who were admitted following suicide attempts were sort of stigmatized by health care professionals. Doctors would say, ``Well, we have so much work to do, why are you giving us more work?''
What the public does not see is the extent of moral suffering. This is not evident to doctors, let alone the general public. If someone bleeds, he receives care within 10 minutes. If a person is bleeding from the soul, he can spend two days in the hospital. Moral sufferance can be as life threatening as bleeding from an accident, but it is always given second priority.
In terms of prevention, we need the general public, because we do not have enough psychiatric and psychological help — particularly with psychiatry. There are very few psychiatrists for all the people who are suffering from all kinds of mental illnesses. People who can give help are people who are there — the neighbours, the members of family.
People need to recognize the extent of the mental suffering, because those who are suffering tend to hide it out of fear of being stigmatized. They have to learn to show it and so other people can support them. In fact, in Third World countries, there is much more sensitization; much more support is given to people who are suffering from mental illnesses than we find in our Western societies.
I do not know if I answered your question fully or not.
Senator Cordy: Yes, you have. Thank you.
[Translation]
Senator Pépin: How do you explain the higher rate of suicide among young men, as opposed to young women?
Mr. Tousignant: Let us not forget that in males in general, the suicide rate is four times higher than in women. As for suicide attempts, the rate is more or less the same.
It is peculiar. It is also true for homicides. We often forget that suicide is in the homicide category. For all types of violent deaths, such as in reckless driving or in traffic accidents, men are over-represented, at least in western culture, but especially when it comes to suicide.
However, there are variants. In China or India there are as many women as men who commit suicide. We know that half of suicides among women happen in China.
That means that there is a particular problem. I have not looked in depth at the situation in China, but in India when there is a problem in the family, it is the woman who is excluded. She finds herself alone and stigmatized. In western societies, in 90 per cent of cases the man is stigmatized and finds himself alone.
That does not mean that women have no problems, but women have more continuity and anchoring within the family. Since the rate of separation and divorce have gone up in our society, it is men who have found themselves more isolated. It is more difficult for them to find a new anchor, to have access to the children, and so forth. This is one hypothesis that could explain the marked differences between western and eastern societies.
Mr. Tremblay: The number of suicide attempts is the same among men and women, but because of the means that men use, they do not fail as often. Women tend to swallow pills whereas men tend to use a firearm.
[English]
Senator Cook: The more compelling evidence I hear, the more convinced I am that there is a need for a national action plan for mental illness and wellness. I think that if we could achieve an integrated approach to it with good evidence-based information and best practices, we would reach the person that we really care about: the consumer of mental health services. The more I listen, the more I am convinced that would be the best way to go.
I would like to hear your comments on the people of the subculture: people in poverty who have access only to foods banks, shelters and a social assistance cheque that is not adequate — and even if it were the ability to spend it is impaired. That fringe relates to your affordable housing. It comes into nutrition and appropriate medication the ability to use it. It also brings in the authorities — the police who pick someone up and the process of automatically being carried into the psychiatric unit. The individual waits with the police officer for two or three hours, and then bang, he or she is put into the psychiatric hospital for 30 days, when perhaps the only offence was that the individual was drunk or had taken an overdose. The police are not trained to recognize symptoms of mental illness; they do not have the processes to deal with it. There is also the whole issue of literacy.
Given all these other stresses, I would like to hear your opinion on a national action plan with an integrated approach. There is a federal government, but the provincial governments deliver the programs or the care, as the case may be. I come from Newfoundland, and we are pretty stretched, you know, for specialized care for people who are consumers of mental health.
I wish I had the time to tell you about the wonderful affordable housing projects that are partnerships between the provincial and federal governments and NGOs, who really give the people that they meet at their doors a good quality of life.
I am concerned when I hear you say that the data are not really available. There are barriers in the system that I think a national action plan could help.
Dr. Tremblay: I think the key phrase here is ``evidence-based interventions.'' It would not be a good idea to have an action plan whereby we continue to pour a lot of money into things that we are not certain are working. There has not been enough learning about what works and what does not work. As lot of money has been invested, but in many cases — and I have experience of this on the prevention side in terms of childhood and adolescence — most of what people are doing is not based on evidence-based information.
Therefore, I would include in an action plan, the requirement to evaluate what people are doing, so that we can learn from experience what is effective. Most of the research in mental health is focused on either learning the mechanisms or on drugs. However, with respect to the interventions that are ``psycho-social'' — that is, they are not drug based — are not based on evidence.
We need to put together the resources we are putting into services and, at the same time, conduct evaluation research, so that we will learn what are the best practices and what are the most cost-effective practices.
Senator Cook: At the top of my notes here, I wrote ``dedicated research'' before I wrote the words ``national action plan.''
Dr. Tremblay: Yes.
Senator Cook: It would also have to be broadly based across the spectrum called ``curriculum'' — a whole learning process right through the entire system. This would include doctors, nurses, social workers, teachers, educators, and so forth.
In my experience as a volunteer, I have noticed that those who work at the NGO — the organizations who see the individual on a regular basis in a shelter or in a social setting, has very little, if any, training. It is basically hands-on.
The same situation exists in affordable housing. We have an affordable housing program that comes out of a three- month life skills' learning environment. There is a board of consumers who live in the house — it is fairly large with 30 or 40 people. These people are connected to a governance board and it works very well. There is empowerment of these people there. If someone slips in that loop, they go back into the first piece.
I think that NGOs do a lot empowerment with assisting-living practices to help people with mental illnesses. A lot of them have no family. The only family they have, they meet in that place.
Therefore, I am very supportive of a curriculum-based approach with all of this information. We have CIHI, we have SSHRCC, and we have many things. WE could probably do things differently and we do not need a lot of money to achieve it.
The Chairman: I noticed Professor Dorvil was also shaking his head. I do not know if that meant he agreed or disagreed, but he may want to comment. I know Mr. Latimer wants to comment.
[Translation]
Mr. Dorvil: Yes. Just a comment on the sharing of all this data. We have one advantage in that our research team works in both Ontario and Quebec.
Other groups do research throughout the whole country, which is even better. I believe that we now have enough quantitative and qualitative data to develop an action plan. That is my belief.
[English]
Mr. Latimer: The question that you raised runs into the whole of issue of federal versus provincial jurisdictions.
The Chairman: Yes. This committee has a tendency to simply ignore that distinction and if you read our first report, we had a number of recommendations, by the way, that were strictly in the area of provincial jurisdiction. Interestingly, none of the provincial governments ever criticized us for doing so.
As well, a number of our recommendations such as the Care Guarantee are now part of the government's health platform — which is strictly provincial jurisdiction. It is part of the government's platform in Quebec, it is in the Throne Speech in Ontario, it is coming in Alberta.
Therefore, our tendency is to try to tell it right and not get hung up on jurisdictional questions. I just thought I should give you that as background. I was not being critical.
Mr. Latimer: That is very helpful. One area in which it would be helpful to invest more money is in public education. To the extent that mental health is a bit of an orphan child, it is as a result of the stigma and lack of information about what can be and what should be. The pressure to ensure that the money is spent in accordance with these priorities, ultimately comes from the public. Therefore, we need more education at that level. We see a lot of ads against smoking; I do not understand why we could not see more ads educating the public about mental illness. That is one element.
Another element is in terms of describing and making clear what best practices are and facilitating their dissemination. In the United States, the Robert Wood Johnson Foundation has funded the development of modules on evidence-based practices in mental health. There is one on assertive community treatment; there is one on supported employment, and so on.
These modules are designed to facilitate the adoption of these practices by clinicians and by state governments. They are divided into three components. The first component is for environments where the practice is not yet adopted. People are simply considering it. There is a video, there are materials are targeted at decision-makers, materials for parents, materials for consumers, and so on. The second component provides information on implementation — how one goes about setting up a program. The materials are targeted at the relevant audiences. Finally, once the program has been established, the third component provides material on how to ensure that the practice remains evidence-based because there is often a drift away from evidence-based standards.
I would think that the federal government could get involved in adapting such materials, making sure they are translated, and perhaps, in funding training programs, so that clinicians become more familiar with these types of practices.
Senator Cook: I just want to say thank you for reinforcing my idea this morning. I speak as a layperson, but I can see that there must be national standards in this country because of the way the governance is set up. Of course, evaluation is part of it. I would never be so bold as to try and write the criteria for a national action plan. Thank you.
Senator Keon: Well, following on Senator Cook's hypothesis, I think that either by design or serendipity there will be a national action plan. In fact, our document, when it comes out, will probably be the beginning.
All of you cut across and extremely interesting theme this morning. Dr. Tremblay emphasized that human beings are born non-conformists and they are trained to become conformists. Then Dr. Dorvil talked about the ethics of imposing lodging on the homeless when they do not want lodging, and where you end with their freedom. Dr. Tousignant touched on the terrible problem with the ethics committee that scientists face. I must say the ethics problem is being handled quite well, I think, because there is a lot of good direction out of CIHR and MRC about ethical conduct in research. However, there is virtually no good material on ethical conduct in patient-care management and Mr. Latimer touched on that when he spoke.
So the truly interesting thing that arises here — particularly in mental illness — is how far does society have the right to go in couching and defining the life of an individual? This is a very penetrating ethical dilemma that must be addressed in whole and in parts as the evolution of this whole thing unfolds.
Mr. Dorvil, perhaps you could start. I find the relationship between homeless people and mental illness tremendously interesting. Many homeless people just do not want to be put someplace. They want to stay out on the street. Mercifully, someone usually goes around and picks them up so they do not freeze to death. I would like to hear your thoughts about the ethics of how far you go on the total management of this. Perhaps Mr. Tousignant and Mr. Latimer would also expand on that.
[Translation]
Mr. Dorvil: You raised an important point, the respect of human dignity. I worked as a social worker in the east end of Montreal, and I sometimes would tell homeless persons that they were entitled to a government cheque.
They would tell me ``I don't want a cheque, I want my freedom. Just give me a couple of quarters.''. I would then tell them that they were entitled to $600, but they did not want to take part in government research. They did not want to be in the government files as social welfare recipients. They did not want to be social welfare recipients. It was a question of dignity. They preferred to ask me for fifty cents or a dollar rather than receive the $600 they were entitled to at that time.
Afterwards we came to an agreement with the government so that homeless persons who, by definition, do not have an address, could pick up their cheque at a psychiatric clinic, at a mental health clinic, at La Maison du Pare, et cetera. But even then some of them did not want it.
How far should we go to preserve the freedom so important to human beings? For example there are psychiatric patients living in transition homes who would like to live independently, but they cannot because they still have behaviours, sometimes violent behaviours, that are not acceptable in society. So we tell them that we will first teach them social skills because to live independently, they must behave normally according to society's standards.
That is what we do at Douglas Hospital. We sometimes have to tell patients that they cannot live independently because they still do not have the skills. By doing so, we are limiting their freedom.
But society has rules that we must abide by. The responsibility lies not only on the individual but also for society. We must therefore try to find the right balance between society's need for order and security, and the respect for human dignity.
The ethics issue is important in all our research and our interventions with psychiatric patients who are vulnerable because they have a diagnosed mental illness, there is no doubt about it.
But at the same time we must respect the patient's freedom. We have to explain to them that they will have to learn the necessary social skills before going to the next step. They must go through the next phase in their recovery before they can live independently as they so dearly wish.
[English]
Mr. Tousignant: If you see a traffic accident on the road and someone is bleeding, I think you are obliged by law to come to the help of the individual. However, if the person is depressed and planning to commit suicide, you say well, you should respect their freedom. We have two very different ways of behaving towards people who are in need of medical assistance and those who suffer from mental illness. Very often people shy away because they become aggressive, because they are afraid to be stigmatized and they refuse help. They want to be autonomous.
That is a big challenge. However, a lot of people are in danger of dying if we do not help them. There are a lot of issues involved. Sometimes we have to be a bit more assertive in bringing help or at least offering real help to people you are in need of it. Certainly, there is a lack of assertiveness right now and we need to be much more affirmative in ensuring that assistance is available to people who have a lot of moral sufferance. However, because of the culture has evolved, these people try to hide themselves. They live marginal lives, because they know they will be stigmatized if they come to the fore.
It is a big problem and there are no easy solutions. However, we should not justify leaving these people on the street with the argument of individual freedom. There should be creative ways of bringing solutions to their daily problems.
Mr. Latimer: I would like to add to what I said earlier in response to Senator Cook's question. Having identified evidence-based programs such as the Assertive Community Treatment program that is fairly widespread in Ontario as a result of the Ontario government's initiative, I do see why the federal government could not say ``We would like to see practices X, Y, and Z developed and we are going to fund the development of these specific programs.''
In respect of the question raised by Senator Keon related to bringing people into treatment, I have a story that will illustrate the principles beautifully. I heard the following story from a psychiatrist. A female patient was pregnant and had a delusion that led her to not want to eat. This was, of course, threatening her baby. The clinical staff had a debate among themselves as to whether to force-feed her. This psychiatrist was brought in on the case and he had a different idea. He pretended that he was talking to the baby. He constructed a tube and put it to the mother's abdomen, started talking to the baby and pretended that he heard the baby responding to him and saying that it was hungry. It needed food. In this way, he was able to help the woman disassociate her own desire to avoid eating from the baby's need. She started eating and the baby was delivered successfully.
This is a beautiful story that illustrates how, in clinical situations, greater clinical skills, greater creativity and imagination can often lead to better solutions. In my view, we need to think about increasing the quality of training of clinical personnel.
[Translation]
Senator Pépin: Who decides when a patient can live in a special-needs apartment, a transition home, or independently? Is it the doctor? I assume it is the doctor who decides when the patient is ready to go on to the next step. What criteria does the physician use to decide if the patient is ready to go from a transition home to special-needs housing or to an apartment? Do you follow up on the patient?
Also, I would like to know if the community living approach that was put in place in the 70s for people with a mental illness is a success.
Mr. Latimer, I presume that Douglas Hospital still cares for people with severe mental illnesses. You talk about getting these persons back in the workplace, and I agree. But if they are severely ill, at what stage will they be able to go back to work? How do you go about it? At what stage is that possible?
Mr. Dorvil: Psychiatric patients who live, say, in a transition home or in an apartment under supervision still show certain forms of behaviour that are not acceptable in society.
Those who want to live independently must learn how to cook. They must learn how to shop for groceries. There are psychological re-education workers who help them acquire those skills.
Sometimes, they exhibit unpleasant behaviour traits. The action plan given to the person in charge of the group home would then specify that those traits would have to disappear within, let's say, 18 months, or 3 years, and so on.
Psychiatrists usually work as part of a therapy team. Within that team, there will be a social worker or a nurse in charge of the patient, and the psychiatrist can check with him or her to see how far the patient has progressed in acquiring social skills.
If the response is that the patient is ready, that progress is well underway, although it may not be complete, the patient can then go on to the next step. The individual is then allowed to leave the home in order to live in a supervised apartment, or even in what we call an independent living unit.
All of this is done progressively, until such time as the person is ready to move into an independent living unit. The situation is then discussed with the group in charge of independent living units so that the patient can go to the next step. Generally speaking, as far as the psychiatric hospital is concerned, everything goes quite smoothly.
As for deinstitutionalization, I would say that any group holding some kind of power in our society will not readily relinquish it to another. People working in hospitals, hospital managers, psychiatrists, social workers, they all tend to stick together. It is perfectly normal that they have a lot of control over psychiatric institutions, as well as a large say in deinstitutionalization. Let's not kid ourselves.
I do not see why power would have changed hands since, for the time being, as you know, there are no miracle treatments for psychiatric illnesses. Despite all the work that is being done by psychiatrists and psychiatric nurses, we have not yet managed to eradicate those illnesses.
We can eliminate the most acute symptoms, but some patients are not able to communicate, they do not have the required skills. At the same time as we were making almost miraculous progress in the area of medication, we should have been investing in treatments designed to improve the communication and social skills of patients.
However, that is now a matter of history, and history cannot be rewritten. Despite all the budgetary constraints our governments have had to deal with, despite society's reluctance to have psychiatric patients integrated not only into their family, but in their community, in shopping centres, and everywhere else, I feel that the trend has been quite positive. People have finally understood that they need to show empathy and lend a helping hand.
People in charge of group homes are doing more than what they are required to do. I know some women who are in charge of homes who have set up baseball teams and soccer teams for their patients, when they did not know the first thing about baseball or soccer.
The first attempts at deinstitutionalization were disastrous. Indeed, Dr. Murphy, a psychiatrist at the Douglas Hospital, had this to say: ``We have taken patients out of the hospital setting, but we haven't given them much. There has been no follow-up by professionals.''
Follow-up by professionals has now been added to the system, because Dr. Murphy condemned the fact that patients were living in a vegetative state. What had those patients gained? Where they had been rocking themselves back and forth in the psychiatric hospitals, they were now rocking themselves in homes.
What was the point of having taken them out of the hospital setting when the result was the same? Society reacted by improving the system. And we are continuing to improve it. My colleague, Dr. Latimer, talked about psychiatric patients being reintegrated through work. There are indeed a lot of psychiatric patients who are working. They are working in the computer industry, on farms, in factories. And they are contributing to what we call the gross domestic product.
As far as housing goes, a number of psychiatric patients now sit on the boards of subsidized housing developments run by NPOs, whereas in the past, they would have been put away in an asylum. Now, they can look after their own homes, they can sit on the board, they can vote, and so on.
This, to me, is a sign that we have made some progress in our society. People with mental disorders also have qualities. If you look at what has happened over the last 45 years, the situation for psychiatric patients has significantly improved, with progress being made at the institutional level, in psychiatric medicine, and at the community group level.
Both groups would have to agree to work together. Each group has a tendency to want to protect its turf, but I am nevertheless very optimistic.
[English]
Mr. Latimer: In response to your question regarding the overall assessment and whether the transfer into the community has been good for the patients, I would say yes, over all. However, we need to provide more supports in the community.
Putting on my economist's hat, I would like to present an efficiency argument for delivering services more in the community. I am thinking of a particular kind of the model of assertive community treatment, which involves a multidisciplinary team that supports people with severe mental illness in the community.
Let us compare what happens when a patient is hospitalized versus what happens when they receive community support services. From an economic perspective, we can see that when one is hospitalized, a whole set of resources is automatically deployed hour after hour and day after day to provide support no matter how the patient's state is evolving. Often times, we observe that people remain in the hospital longer than necessary because there is no place for them to stay outside of the hospital. Therefore, we are wasting a lot of resources.
If, instead, you had a multidisciplinary team that meets every day to review the list of clients and set up a plan for each individual, the resources that are deployed for each client can be adjusted in a more flexible manner — in a real- time sort of way and practically on a daily basis. Therefore, you are doing a much better job of putting resources where they are needed, when they are needed. Such a method is far more cost effective.
Having said that, we are absolutely not doing enough in terms of providing access to evidence-based rehabilitation services for people with severe mental illnesses. Which brings me to the latter part of your question about supported employment and integration into the work force.
There has been a long-standing perception among clinicians that many people with severe mental illness cannot work and that if you push them toward work, you are likely going to precipitate psychotic episodes. They will need to be re-hospitalized and so on, because it is just going to be too stressful and they cannot take it.
Experience shows that the situation is rather more complex than that. People who have been involved in setting up supported employment programs in the United States report that clinicians cannot tell ahead of time whether a particular individual is going to turn out to become a good worker or not. There are individuals who look initially like they are never going to be able to hold even a part time job successfully and whom, with proper support, turn out to be able to do it and to enjoy it.
I am currently conducting a study at the Douglas Hospital that excludes people who have anything less than schizophrenia, bipolar disorder with psychotic episodes, or depression so severe that they are classified as kind of disabled and get kind of the maximum welfare cheque. We only work with those people. Many of them do find work successfully.
Finally, there is the whole issue of how these people are socialized and that is, in many ways, the big battle. There is the traditional approach in which these people are viewed as patients and they are socialized to be patients. They are encouraged to spend time together and to live in their own little world apart from the rest of society.
The movement right now is towards empowerment, towards recovery. Those are some of the key buzzwords that you have undoubtedly heard. Part of empowerment means socializing people away from the patient role into a citizen role. Experience has shown that if you can help these people and gradually bring them to a point where they are functioning at work and meeting demands that are appropriate to their capabilities, and if they have to push themselves to meet the demands and not too many allowances are made for their illness, they end up the better for it. They are more satisfied because they view themselves as citizens, and that is what we are aiming for.
The Chairman: I thank all of you for coming. I know we have indulged your time well beyond what we said we would, but we found your comments really helpful.
The committee adjourned.