Health Committee on May 26th, 2015

[Wayne Easter, Liberal, Malpeque, PE]

If you were a member of this committee, then, what would you recommend at the end of the day? What kind of recommendation, what wording would you use to ensure that the federal government, number one, has the data, and two, makes the information that you need in order to deal with the issues available to you?

[Dr. Janet Smylie]

We need to have some national standards around indigenous health data collection. Statistics Canada was moving in that direction. I sit on the National Statistics Council, though, of course, I'm here as an individual today. When I first joined the council five to ten years ago they were meeting with our national aboriginal organizations and working on those kinds of partnerships, and there still is some good partnership work, but we need to have national standards.

I became a co-chair of a national committee on birth outcomes and we liaised with all five national aboriginal organizations. It can be done...the pieces to invest in the partnerships. In order to do that, the national aboriginal organizations have to be supported, and then to simply have proper data quality. That's the first course I took at Johns Hopkins in public health, if you take health informatics 101. As a physician, it's like I'm in the emergency room and I see people in incredible distress. I'm talking of hundreds of thousands of people with these urgent symptoms, but I don't have any diagnostic equipment to treat them with.

It's a sorry state of affairs for an affluent country like Canada.

[Wayne Easter, Liberal, Malpeque, PE]

You say Statistics Canada was moving in that direction. Why did they stop, and how do we get them back on track so that they do keep that data?

The second question I have, which is for Ms. Hopkins, is what needs to be done? The $25,000 investment for your addictions management information system, to me, seems to be a small number. What needs to be done to implement that system?

[Dr. Janet Smylie]

You would have to reinstate the health directorates for our national aboriginal organizations. The funding for the health portfolio was cut for the Native Women's Association of Canada. It was significantly cut for Inuit Tapiriit Kanatami and the Métis National Council. I believe there were significant cuts to the Assembly of First Nations and the Congress of Aboriginal Peoples as well.

When I started, there were actually people in a portfolio who would have that expertise. Now, even at the provincial and territorial level, I'll go to meetings...because this urban data that I was talking about, that is owned by the communities. We negotiated that, so it can be done.

If you look at New Zealand, they have seven ways of identifying Maori in their health system, and the Maori feel empowered. There are actually protocols to ask people in a respectful manner.

[The Chair, Conservative, Ben Lobb]

Okay.

[Dr. Janet Smylie]

So the first thing is to actually reinvest in our national aboriginal organizations so they can sit at the table, then recognize that there need to be some national standards, because the other thing that has happened is that FNIHB and PHAC decided that all of this should happen at the regional level. But to my mind, we need to have some national standards.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you.

We're right at the end of this round.

Ms. Hopkins, do you have a final thought on what Mr. Easter asked, or was it all covered?

[Carol Hopkins]

I'm in for training.

[The Chair, Conservative, Ben Lobb]

Okay, that's brief. I like that.

We're going to conclude this round. We are going to bring in our new panel, two of them by video conference. So we're going to suspend for a couple of minutes, bring them up, and be right back.

[The Chair, Conservative, Ben Lobb]

We're back in session. We have another three guests to present.

We'll have Janet Currie, coordinator and founder of the Psychiatric Awareness Medication Group.

Because you are the farthest away, we'll have you present first. Go right ahead.

[Janet Currie, Coordinator and Founder, Psychiatric Awareness Medication Group]

Thank you very much for asking me to submit to you today. As the chair said, I'm presenting for the Psychiatric Medication Awareness Group, which is a web-based information support group for people on psychiatric drugs. I'm also the co-chair of the Canadian Women's Health Network, and have contributed to many Health Canada regulatory hearings, and was a member of the expert advisory panel on the vigilance of health products for five years.

I'm going to bring to the session today my background in working with families, parents, and children in tapering them safely off psychiatric drugs. These are people who have faced a myriad of side effects related to psychiatric drugs, which have increased their mental health and emotional problems. I'll be discussing gaps and barriers in the mental health strategy and proposing some best practices.

I want to talk first about the context in which our mental health services are delivered, and this is really a unique and unprecedented context.

First of all, we have very high stated prevalence rates of mental illness and high diagnostics in many areas of mental health, and these rates are continuing to rise. I think in Canada now we consider that 20% of Canadians may be exposed to a mental illness, and in some cases the rates are much higher. The World Health Organization is now saying that depression will be the major cause of disability globally by 2020. Thirty years ago, depression was considered to affect a very small number of people and to be self limiting.

So in terms of statistics, what does this manifest itself in? We have 6% of boys from 6 to 14 taking psycho-stimulants. We have a quarter of our seniors in our care homes taking antipsychotics, even though they do not have a diagnosis of schizophrenia. We have 20% to 25% of women in middle age and older taking antidepressants. We have a tenfold increase in the number of children who are being prescribed antipsychotics, which are very potent drugs not approved for this group. And we have large numbers of people taking benzodiazepines—15% to 25% in some cases. I was very disturbed to learn that Canada is the third-largest user of antidepressants among 22 comparable OECD countries.

So what does this mean in terms of the individual and their mental health? All psychoactive drugs have side effects. They are very potent drugs that affect the structure of the brain and the neurotransmitters that are the chemical in the brain. All of the drugs can either exacerbate or create new mental health problems or new kinds of emotional problems for the user.

For example, someone taking a tranquillizer like Ativan, which is a very commonly prescribed drug, will eventually become depressed if they take it long enough, and then they will go back to their doctor and say they are depressed, and their doctor will either increase the dosage of benzodiazepines or prescribe an antidepressant to deal with the depression, which is a side effect of the tranquillizer. This kind of pattern is called the prescription cascade, and anyone who's on a psychoactive drug for long enough is going to be taking other drugs to deal with the side effects of the drug they are already taking.

It's the same for antidepressants. Someone on antidepressants may become agitated and develop akathisia, which is a form of restlessness. They may have agitated depression, and so they may be put on a tranquillizer, or they might be put on an antipsychotic to deal with those symptoms.

The point I am making is that we need to take adverse drug reactions from psychiatric drugs very seriously. These drugs not only cause impacts on the sense of mental well-being of patients, but they also cause physical effects. For example, tranquillizers cause dizziness and falls that lead to hip fractures. Antidepressants can lead to suicide or suicide ideation and sexual dysfunction. Antipsychotics can lead to cognitive impairments, memory loss, and issues like that, as well as a predisposition to diabetes and stroke. So we really need to take these things seriously.

I think the other thing that we need to recognize is that if a person stays on a psychoactive or psychiatric drug for a long period of time, their brain is going to adapt to it and they're going to become addicted. I know that's a strong word that we don't like to use in relation to the drugs we prescribe. But it actually is the same mechanism as addiction. When a person tries to reduce their dose or change their dose, they may be affected by an upsurge of symptoms that can be really very unpleasant, including increased anxiety and increased agitation, to the point of hallucinations and irrational violent behaviour. I think in the media we're seeing stories of people engaging in very frightening homicidal or suicidal acts that are associated with prescription drugs. We feel that prescription drugs are definitely a contributor in these cases.

So what do we need to do about it? We need to reassess the degree to which we're prescribing psychiatric drugs. A recent study in the United States is showing that the rate of prescription of psychiatric drugs to children has grown by about 31% in the last decade, yet the children who are prescribed these drugs are ones who are considered to have really moderate issues, whereas children with very severe issues are falling through the cracks. So I think we really need to reassess the degree to which we are prescribing psychiatric drugs. In order to do that we need to provide more supports in the community to families, to women who are pregnant and who are having post-partum difficulties, to young people, to teenagers, to seniors, so that they can address their sense of isolation and find cognitive help that's accessible and reasonable in terms of access. I think a central place to provide these services for families is in the schools, where in the past there were school counsellors and groups that would help parents deal with their family issues and their children.

I also think that we need to really assess people's use of drugs and the impacts these may be having on mental health. We talk about dealing with polypharmacy, but I think anyone who comes in to a health provider with a mental health symptom needs to be assessed in terms of the drugs they are taking. It is not only psychiatric drugs that cause mental health symptoms. There are also common cardiac drugs, antibiotics, the corticosteroids, smoking cessation drugs, and acne treatments. All of these can be associated with mental health issues that the person or physician don't associate with the drug. I would say, too, that we really need physicians and health care providers who are skilled not only in assessing the side effects or the adverse drug reactions caused by psychiatric drugs, but also physicians who understand how to taper the use of these drugs, how to design tapers, how to support people, how to understand what a person is going through on a taper. I've done tapers for dozens of people. It's an arduous job, but it's really miraculous the degree to which people can recover their health. However, it needs skilled health care providers to provide that kind of service.

Finally, I would say that when we consider mental health in general, we need to consider it as a gender issue. Two-thirds of the people who are diagnosed with mental health issues and who receive prescription drugs are women. Women are subject to many stressors related to their role in society and the expectations placed on them. I think we really need to build that back into our assessment of the most effective mental health treatment.

Thank you.

[The Chair, Conservative, Ben Lobb]

Okay, thank you very much.

Next up by video conference in Toronto from the Centre for Addiction and Mental Health we have the director, Jurgen Rehm.

Go ahead, sir.

[Dr. Jürgen Rehm, Director, Social and Epidemiological Research Department, Centre for Addiction and Mental Health]

Thanks a lot for allowing me to present the point of view of the Centre for Addiction and Mental Health, the largest hospital for psychiatric illnesses.

I would like to start with a definition of “addiction” since we were asked to talk about addiction. Usually this term comprises substance use disorders, but also more recently it has been expanded to gambling and gaming disorders. For example, the DSM-5 and the current proceedings of the ICD-11 will also include something to that degree.

If you look into those addictions, and we take the full spectrum of addictions, we have to say that alcohol use disorders are the most prevalent of the addictions. There is a question mark here with tobacco use disorders, because they're usually not assessed in general population surveys like the CCHS. If you go into how many people are actually concerned with addictions, alcohol again is also the highest. About 1 in 20 men in Canada—and that's of all age groups—would have alcohol use disorders, and it's 1.7% for females.

The second most important addiction would be cannabis use disorders, and all other drug addictions would be about half of cannabis, at about 0.7%. Again, the usual prevalence is higher for men compared to women by a factor of 2:1 for most of those addictions.

In terms of harm, we do have a lot of disorders resulting from the legal substances that are associated with far more [Inaudible—Editor] in terms of mortality and morbidity, but also disability, than the illegal substances, and all of those addictions have a pattern of high comorbidity with other mental disorders. This means we usually have comorbidities with mood disorders. About one in five people with addictions would also have a concurrent mood disorder, and if you go into generalized anxiety disorders, it's about one in ten. Mood disorders, of course, would be what we would normally call depression, and they include a whole number of psychiatrically defined depressions.

Now to your questions with regard to the mental health strategy and how addictions are treated, addictions overall are covered by the mental health strategy, and there are a lot of very important things to be said about them. But if you look into the practice and if you look into the national policies and the strategic approaches, we see that a lot has been regulated by the national anti-drug strategy of the Government of Canada, and that leads to a conflict of objectives and a conflict of different overarching approaches.

When we look at the national anti-drug strategy we welcome the recent addition of non-medical use of prescription opioids and non-medical use of other drugs as a good step. Part of that, as you heard in the first submission, of course is a result of addictions having been caused in part by the medical system.

The two most costly substances from both a health and economic standpoint, however, are tobacco and alcohol, and these remain completely outside the strategy. I would just mention again that gambling and gaming, although lesser in scope and money, are also outside of and not covered by the national anti-drug strategy.

Overall we would like stress that all addictions and substance use disorders should be a health issue, and substance use should be dealt with by a public health approach. That means we should have a four-pillar approach for illicit drugs, prevention, harm reduction, treatment, and enforcement. The same is true for legal drugs.

We also have to state that the current approach to illegal drugs in Canada is overly enforcement focused. That means that if we look into the balance between a four-pillar approach and the current Canadian approach, we have an emphasis on enforcement, both in terms of money spent and the overall efforts of society. We would like to add to this a harm reduction approach, which is currently missing altogether. The more Canada can shift its overall approach into the public health sphere, the better our chances are for reducing the overall harm.

For the first point, I would like to summarize that addictions in Canada should be addressed through a public health approach, more or less in the way we have seen it in the mental health strategy. If we go into this public health approach, we would have to change some of the things in the national anti-drug strategy, but it would be rewarded by better strategies for tackling addictions and reducing the harm related to addictions.

For the second part of my submission, I would like to look at the stigmatization issue. You've asked specifically about stigmatization for addictions, and unfortunately addictions are very stigmatized in our society. We are not alone in the world. Addiction issues are the most stigmatized mental disorders in all high-income countries, in North America, Europe, and Japan.

From surveys, we know that while the overall stigma associated with mental health has been reduced over the past decades, for addictions this is unfortunately not the case. People with addictions are seen as unpredictable and dangerous. The overall causal attributions that are made see them as not being morally intact and as responsible for their own addictions. This, of course, makes a problem not only for the people afflicted with addictions, but also for the health care system in total because it is leading to the lowest treatment rates of all mental disorders.

While the treatment rates of mental disorders are still below the treatment rates of somatic disorders, among the mental disorders, addictions stand out. For example, in people with alcohol use disorders, only one out of ten in Ontario would get adequate treatment, and would be treated.

Contributing to that is our tendency to see the world in black and white, usually as dichotomous people with having or not having a disease, and not as a continuum. The problem of this dichotomous approach, of not seeing addictions as heavy use over time, as one end of a continuum—which we all share—is leading to these people being more stigmatized and more outside of our society. As a result, they do not seek treatment because they do not want to open themselves up to admitting that they're addicted. That leads to problems in the whole health care system, both in primary health care and in specialist health care.

Stigma interferes with a seamless continuum of treatment, and this is part of what is currently plaguing addictions.

I will remain here. I have 10 minutes, and I have used the 10 minutes, and I would like to just summarize.

All addictions should be seen as a public health problem and should be dealt with from a public health perspective. Stigmatization is one of the major barriers not only for mental health in general but also for addiction specifically.

Thanks a lot.

[The Chair, Conservative, Ben Lobb]

Okay, thank you.

Next up, from the Royal Ottawa Health Care Group, we have Mr. George Weber, president and CEO.

Go ahead, sir.

[George Weber, President and Chief Executive Officer, Royal Ottawa Health Care Group]

Thank you very much, Mr. Chairman.

Ladies and gentlemen, good afternoon. Bonjour.

I am pleased to appear before you, as the chair has noted, as the president and CEO of the Royal Ottawa Health Care Group, to share our views on the mental health strategy for Canada.

Thank you for inviting me to take part in this important forum.

I also applaud your efforts focusing on a critical issue in health care today, the mental health care of our families and communities. For us at the Royal Ottawa, you can't talk about health unless you support mental health. Understanding the link between mental and physical health is paramount to understanding the complexities of the brain.

Along with my senior management team, I'm responsible for leading and managing the operations of an academic health science centre specializing in the treatment of mental health and mental illness and addictions. We serve a large spectrum of clients receiving services through more than 15 specialized programs at the Royal. Our mandate is to treat patients as young as 16 years of age with complex mental health needs to geriatric patients with age-related issues, including dementia, behavioural problems, and chronic medical issues. We run a 222-bed treatment centre in Ottawa, which has served more than 1,600 in-patients and 14,000 out-patients in the past year.

We also hold over 1,000 telehealth consultations every year.

We have also used technology, through the creation of apps for mental health awareness, early identification of mental health problems, and a self-management tool. In Brockville, we operate a 630-bed forensic treatment facility, including two beds for the Correctional Service of Canada.

This year, we also started looking after female prison inmates, who increasingly need mental health services.

We also provide mental health treatment and clinical services to 100 male offenders serving provincial sentences at the St. Lawrence Valley Correctional and Treatment Centre for the Government of Ontario.

We are very proud of the work we do in our operational stress injury clinic, as the only academic health science centre in the network of OSI clinics for Veterans Affairs Canada. We offer specialized mental health care treatment and research to veterans, soldiers, and RCMP officers. These are men and women who perform a great service for our nation and for the peace and security of the world. Whether they were deployed in combat duty, on peacekeeping missions, or domestic operations many of our veterans and Canadian Forces members are experiencing psychological consequences as a result of their courageous service. The number of soldiers seeking help is on the rise. Last year we saw a 238% increase in referrals compared to five years ago. We are doing our best to provide the necessary treatment and help them to regain a quality of life.

Today, I would like to comment on three critical barriers to mental health and where a national strategy, advocacy, and funding could change the lives of people and their clinical outcomes.

The first is access to care. It's not a new word, not a new concept, but something we just can’t guarantee in our current mental health system. There is no question that our anti-stigma campaigns are reaching Canadians, breaking down social barriers, and encouraging people to seek help. The problem is that awareness campaigns are not tied to treatment options. Realizing that you need help is the first step. Trying to get the right treatment at the right time is the real challenge. With no increase in our global operating budgets in the last six years, we have streamlined operations to make them more efficient in order to get more people into our care; however, a growing number of people are trying to get in. We know, according to the latest statistics from the Public Health Agency of Canada, that one in three Canadian will be affected by a mental illness during their lifetime. We had always thought that the figure was one in five. Those are the latest statistics. The numbers of those seeking treatment are rising, not decreasing.

Every day, I look at the schedule of our wait lists and the number of people looking for treatment. Funding is available to help people navigate a fragmented mental health system in Ontario, but not for specialized treatment that will give people their lives back.

We are doing our communities an injustice when we focus on working around holes in the system rather than building the services that will bring about recovery. How we approach access to care has an impact far beyond the individual patient. Mental illness touches the entire family in every way possible. It also impacts friends, colleagues, and employers.

Mental health affects all of us. It is a social problem that demands our attention.

I talked to a mother last week who urged me to have her 20-year-old son Andy admitted to the Royal, as he continues to harm himself. I had to tell her that the first available appointment in our concurrent disorders, an addiction program, is in three months' time. What will Andy do during that time? Will he be able to stay with his parents? He has already threatened them several times, and police have been called. Ending up in jail is a real possibility for him. What is the chance that he will be able to wait at home, holding on to some hope about getting help? It's more likely that, without the benefit of a specialized team who know how to treat his complex disorders, he will grow anxious and frustrated trying to manage his disorders and addictions.

There is a long list of people like Andy. As a matter of fact, as of yesterday we had 1,858 patients in the greater Ottawa area on our waiting list, with 500 still to be triaged, and this story isn't unique to our organization. In talking to some of my colleagues across our country, the situation is basically the same from one province to another and in the territories.

The Government of Canada succeeded in the past with their wait-list national policy for certain medical procedures, which was introduced in 2004. Many Canadian lives benefited from this much-needed government action. The reports from the Canadian Institute for Health Information clearly showed how a $1 billion investment significantly reduced wait times across the country and enhanced quality care. Can we not do the same for mental health?

As reported by the Mental Health Commission of Canada, Canada spends about 7% of every public health dollar on mental health. Countries like New Zealand and the U.K. have devoted up to 10% or 11% of public health spending to mental health in order to bring in addressing the needs of their citizens.

We support the commission’s recommendation to increase mental health-related expenditures to 9% over a 10-year period.

The question we need to ask ourselves today is what is preventing us from reaching this realistic objective?

We know that more than 75% of mental illnesses will manifest during adolescence. Can we not show our youth that they really do matter, and that services and treatments are available for them in real time should they develop a mental illness? Those who suffer from mental illness need a national voice and funding for specialized treatments in addition to much-needed awareness campaigns.

We must make the mental health of Canadians a priority.

Morally and socially, increasing support for mental health care is the right thing to do, but it also makes economic sense. A 2011 report prepared for the Mental Health Commission of Canada reported that mental health problems and illnesses cost the Canadian economy, in both direct and indirect costs, over $48.5 billion every year. This means that the right thing to do is also the smart thing to do.

Another significant issue is our aging population, as you've heard many times before. It is a factor driving significant demographic change. As we know, the proportion of seniors with dementia will more than double by 2031 in Canada; by 2028 more than 310,000 seniors in Ontario alone will have dementia.

We are seeing a significant increase in the age groups between 65 and 90. We need to go in a new direction with this issue.

We know that we can change the outlook with a targeted course of action. Research in the last decade in Canada, the United States, and Europe has clearly shown that late onset of depression is a prodrome, an early symptom for dementia. If we are concerned about the lives of our seniors and the futures of our younger generations, we need to invest in earlier treatments that will address the significant risk factor for dementia and reduce those alarming statistics. We have the opportunity to stem the tide before it turns into a tsunami.

You heard from Dr. Merali last week about the important depression research being conducted at the Royal's research institute and his perspective on the need for national collaboration, as co-founder of the Canadian depression research and intervention network. We need to invest more in mental health research to improve the clinical outcomes for depression. Let’s get more people treated better and faster.

My third and final point is about the minimal amount of research funding in mental health and, in particular, suicide prevention research. Understanding the brain is the last frontier of discovery that will enable personalized treatments for mental illness. Suicide prevention research funding and national coordination are needed to advance best practices across the country.

As co-chair of the Community Suicide Prevention Network in Ottawa for the last four years, I know too well what suicide does to families. We have made the Ottawa region a suicide-safer community and have brought together the key community agencies, hospitals, police, government agencies, United Way, schools, colleges, universities, clients, advocates, and youth to help us identify the gaps, break down the silos, and better coordinate our efforts in order to save lives.

We have been inspired by the Nuremberg community model of reducing suicides in Germany and have learned from their experience. In Ottawa, we have set an objective of reducing suicides by 20% by 2020. We have championed new initiatives that train and empower our youth to reach out and help each other. We’ve also generated awareness among youth about who they can turn to for support and have created community gatekeepers in order to build a climate of trust and safety for all our youth.

The Royal, with the support of DIFD, a youth-led initiative, and the Mach-Gaenslenn Foundation, has established a Canadian chair in suicide prevention research. There are many initiatives across the country on suicide prevention, but do we really know what is evidence-based or more effective in reducing suicides? We want to find the answers and we hope we can lead a collaborative and supportive effort across the country. We owe it to our clients—

[The Chair, Conservative, Ben Lobb]

Mr. Weber, we're quite a bit over time here. I'm sorry to interrupt you. Would you be able to wrap up?

[George Weber]

Yes, I'm wrapping up now.

Thank you for inviting me to share my thoughts as a mental health leader. Our minds are critical assets in this global knowledge-based economy, and I encourage you in your deliberations to see the value of investing in treatment and mental health research to change the pathways of mental illness.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you, sir.

Ms. Moore is next. She's going to ask her questions in French, so we'll do a little test for our video conference people to make sure they're getting the interpretation.

Go ahead, Ms. Moore.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Thank you, Mr. Chair.

I just want to check whether Ms. Currie can hear me clearly in English.

[Janet Currie]

I can. Oh no, I can't.

[The Chair, Conservative, Ben Lobb]

Try it again.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Are you hearing me clearly in English?

[Janet Currie]

Yes, fine.

Yes, now.

[Christine Moore, NDP, Abitibi—Témiscamingue, QC]

Okay.

My questions go to Ms. Currie.

I talk with a lot of parents. They are concerned about the whole issue of attention deficit hyperactivity disorder. We routinely see children taking medication at a young age. Sometimes, they start in daycare. A lot of parents are worried since it is a new phenomenon. When I was in school, practically no children were taking medication to go to class. They were just considered children who were more naturally inclined to move around. It seems that very few alternatives to medication are being provided in these cases. In your view, are there any alternatives? Is research being done to find some?

I recently read about stationary bikes being installed under desks so that children can move while they are in class. Are you familiar with that initiative to reduce the use of medication, especially for children?

[Janet Currie]

I think your question is a very good one, and I think that parents are very frustrated because it falls upon the family to make these decisions. I think there are a number of options.

Can you hear me okay?