Evidence of meeting #65 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was prevention.
A recording is available from Parliament.
3:30 p.m.
Conservative
The Chair Conservative Ben Lobb
Good afternoon, ladies and gentlemen. Welcome back to our committee study.
We have three guests in the first hour. First up we have Dr. Marnin Heisel.
Mr. Heisel, can you hear us all right?
3:30 p.m.
Dr. Marnin Heisel Research Director and Associate Professor, Department of Phychiatry, University of Western Ontario, As an Individual
Yes, I can, thank you.
3:30 p.m.
Conservative
The Chair Conservative Ben Lobb
Since you are coming to committee by video conference, we're going to have you go first. Go ahead—
Mr. Young has a point of order.
3:30 p.m.
Conservative
Terence Young Conservative Oakville, ON
Chair, there was a witness I hoped could appear by teleconference from Europe, Dr. Peter Gøtzsche. The explanation that the clerk, Mr. Chaplin, gave me was that he had attempted to communicate with him and there was some reason he wasn't available. It was with regard to translation or something to do with the teleconference.
Was that it?
Can I get a description?
3:30 p.m.
Conservative
3:30 p.m.
The Clerk of the Committee Mr. Andrew Bartholomew Chaplin
Sir, we didn't have time to set up a video conference, and in the second hour, when we were to ask him to appear, we already had a witness appearing by teleconference in French, and we don't have the capacity to do English and French at the same time.
3:30 p.m.
Conservative
Terence Young Conservative Oakville, ON
Is there no other date that he could appear? Is this the last day?
3:30 p.m.
The Clerk
Today is the last day, sir.
3:30 p.m.
Research Director and Associate Professor, Department of Phychiatry, University of Western Ontario, As an Individual
Thank you very much.
Honourable chairman, vice-chairs, and members of the House of Commons Standing Committee on Health, I'm very pleased to join you this afternoon to discuss mental health care and suicide prevention in Canada. I commend you for seeking input on these issues of critical importance to the health of Canadians, and I applaud the government's decision to continue supporting the Mental Health Commission of Canada over the coming decade and beyond.
My name is Marnin Heisel. I'm a clinical psychologist, and associate professor and director of research in the Department of Psychiatry at Western University, and a research scientist with the Lawson Health Research Institute in London. My area of research expertise is the study of suicide and its prevention, with specific focus on older adults and other at-risk populations.
In the field of suicide prevention we say that suicide prevention is everyone's business. Globally, over 800,000 lives are lost to suicide every year. In Canada, approximately 4,000 people die by suicide annually, exceeding 10 deaths every day.
Suicide affects all sex, age, and socio-demographic groups, but does so inequitably. Men account for the vast majority of Canadians lost to suicide, with rates highest for those in their middle and older years, and especially for those of European-American background. Between the years 2000-2011, there was a 29% increase in the number of older men and women who died by suicide in Canada. This increase at least partly represents a shifting population demographic; however, we need to work at decreasing the number and rate of suicide, and can't allow them to continue increasing among our most vulnerable groups.
Suicide risk is also high for Canadians living with mental disorders, addictions, a history of trauma, and other factors. We've known these facts to be true for decades, and we have a good understanding of various psychological, social, and biological risk factors for suicide. However, we have much less information on evidence-supported models of suicide risk, of how best to intervene to prevent suicide, and perhaps even less still about how to effectively promote mental health, well-being, and psychological resilience.
Thankfully, this is changing. There's a growing movement among clinical and public health researchers to conduct innovative suicide prevention and intervention research. For instance, my colleagues and I have adapted a psychotherapeutic intervention for older adults at risk for suicide. We've conducted a knowledge translation study, training front line providers who work with at-risk older adults. We're conducting an upstream preventive intervention study of meaning-centred groups for community-residing men concerned with their transition to retirement. I'm facilitating one of these groups this evening, which is unfortunately what prevents me from joining you in person today. These are just a few examples.
There's a growing focus on electronically enhanced therapy for at-risk individuals, interventions with veterans in the military, individuals who self-harm, individuals with a history of trauma, and the list goes on. This is necessary and highly promising work that needs to continue, and to incorporate strong elements of knowledge translation and dissemination to health care administrators and providers, and to incorporate collaborative input from individuals with lived experience.
Learning how best to prevent suicide necessitates expenditure of resources in the form of people, ideas, finances, and political will. I'm very pleased that the Federal Framework for Suicide Prevention Act officially recognizes suicide as a Canadian mental health and public health priority, and outlines the need to raise public awareness, share information, and disseminate statistics about suicide to enhance collaboration and knowledge translation, define best practices, and promote evidence-based approaches for suicide prevention.
With these aims in mind, in 2012 a suicide prevention think tank was convened in Ottawa, serving as an inaugural meeting of the National Collaborative for Suicide Prevention, with representation from researchers, clinicians, government agencies, non-government organizations, and Canadians with lived experience. I had the honour of presenting this research on our knowledge translation study with colleagues at the Canadian Coalition for Seniors' Mental Health. For the last two years I've represented the Canadian Psychological Association on the steering committee of the National Collaborative for Suicide Prevention.
Canada does not currently have a coherent focus for suicide prevention research or intervention. Health care providers and administrators are thus left with a paucity of resources to help them decide how best to respond to the growing need for approaches to detect, monitor, and reduce risk for suicide among their clientele. Hospitals are now required to have processes and procedures in place for suicide risk detection and intervention. Sadly, many lack the expertise or resources to implement these procedures in a sensitive and effective fashion. Although we have the benefit of a strong and dedicated mental health care workforce in Canada, we nevertheless lack clear evidence for proven approaches for translating existing knowledge on suicide prevention into effective service delivery.
All too often I hear the stories of people who present themselves to their health care providers, clinics, and emergency departments but find themselves unable to access timely care and are transferred from service to service, being given recommendations for seeking out mental health services that do not exist in their communities, or being discharged without a clear treatment plan or sensitive follow-up.
Families frequently entrust their suicidal loved ones to our health care facilities for protection. Yet Canadians die by suicide in our hospitals and other facilities, sometimes even when under close observation. Others do so soon after leaving hospital. Some say this is unavoidable. I hope you'll join me in saying that it is unacceptable and that together we will do something to change it.
Given the need for enhanced development and implementation of rigorous evidence-supported approaches to suicide prevention, I propose creating a Canada-wide suicide prevention research network. The primary aim of this innovative network would be to bring together Canada's research scientists, clinicians, policy experts, advocates, and those with lived experience to integrate and quickly disseminate knowledge on suicide and its prevention across diverse content areas, methods, populations, and approaches; to facilitate implementation of large multi-centre and population studies; to respond quickly and effectively to the needs of individuals, communities, families, and government agencies; to train future generations of Canadian suicidologists; to inform sensitive and safe health care practices; and ultimately to help meet our vision for a Canada without suicide. Such a network could thus help ensure successful implementation of the Federal Framework for Suicide Prevention Act and advance collaborative scientific discovery and action to prevent suicide in Canada and ultimately help enhance our nation's health and well-being.
Together with my colleagues at the Mental Health Commission of Canada, the Public Health Agency of Canada, and CIHR's Institute of Neurosciences, Mental Health and Addiction, we will be holding a full-day meeting of more than 40 leading Canadian experts on suicide and its prevention next month in Montreal to begin the process of establishing a new set of Canadian strategic research priorities for suicide prevention. This meeting builds on the successes of a meeting in 2003, with support from the federal government, and aims to benefit from what we've learned over the past decade and focus on where we need to go in coming years. I'm very optimistic about this meeting and aware that, in order to succeed, we need to move beyond setting priorities to implementing them.
In closing, I thank you for your attention and respectfully request your support for three initiatives that can help enhance suicide prevention in Canada.
Briefly, the first is dedicated research funding for suicide prevention. There's great potential value in creating a national suicide prevention research portfolio with dedicated funds for operating and knowledge translation grants, career support for trainees, postdoctoral fellows, new investigators through mid- and senior-career individuals, CIHR or Canada research chairs in suicide prevention, and a national centre of excellence in suicide prevention. Funds could be shared among various government agencies and other funders.
The second is the Canadian suicide prevention research network. For our network to develop and succeed, it too requires dedicated support. We're making great progress in beginning the process of setting strategic research priorities, but this could not have been achieved without the invaluable assistance and support of government agencies; and we have farther to go.
Third is access to psychological services for all Canadians. This week The Globe and Mail published a series of articles calling for increased access to mental health services, including psychological services. I find the movement towards personalized medicine compelling in arguing for the need to tailor medical interventions to individual characteristics. Yet it's nothing new, in that mental health providers have been doing this for years. Psychologists engage in truly personalized health care, providing in-depth individual assessment, treatment planning, implementation, and evaluation; taking into consideration clients' personal and family histories, development, and functioning.
Ideally, all three initiatives would work in concert, establishing a network of researchers, identifying key research priorities, and providing the necessary support to conduct and disseminate innovative and effective research with strong health implications to be implemented in health care services. For instance, research is promising regarding the role of psychotherapy in reducing suicide thoughts and behaviour. Psychotherapy, I feel, is necessary for many if not most individuals at risk for suicide, yet many Canadians cannot afford it.
I thank you very much for your attention.
3:40 p.m.
Conservative
The Chair Conservative Ben Lobb
Thank you very much.
Next up, from the Canadian Coalition for Seniors' Mental Health, we have the director, Bonnie Schroeder.
Go ahead, please.
3:40 p.m.
Bonnie Schroeder Director, Canadian Coalition for Seniors' Mental Health
Thank you for inviting the coalition to take part in this consultation on mental health in Canada. I'm very pleased and honoured to represent the coalition.
As a brief introduction, the CCSMH, as we are known, is a national coalition sponsored by the Canadian Academy of Geriatric Psychiatry, with approximately 2,000 members across this country representing older adults, caregivers, and family members, as well as health professionals and decision-makers across multiple sectors and levels of government. Our mission is to promote mental health of seniors by connecting people, ideas, and resources. Our primary strategic goal is to ensure that seniors' mental health is recognized as a key Canadian health and wellness issue.
As you know, Canada is in the midst of a significant and permanent demographic shift to an aging population that will have profound impacts on our physical, mental, social, and economic well-being. From a public health perspective, we see older adults who are living well into retirement and more engaged in their health. On the flip side, more Canadians are living longer with chronic conditions, frailty, cognitive impairment, and mental illness.
This demographic shift will continue to have a significant impact on Canada's health care system, with mental health care systems particularly vulnerable. While there is a growing need for an appropriate range of physical and mental health services for seniors at home, in the community, and in long-term care settings, our current health care system is limited in its capacity to meet the needs of our aging population.
Mental health concerns in later life are a growing concern given the impact on older adults and their families, as well as society as a whole. We assert that mental illness in later life is not a normal part of aging, yet we know that the prevalence rate of mental illness increases as we age. The Mental Health Commission report, “Making the Case for Investing in Mental Health in Canada”, noted that 65% of men and 70% of women who reach 90 years of age or more have experienced or will experience a mental illness in their lifetime. Approximately 1.6 million older adults are living with mental illness today. By 2041, the number will jump to over 2.8 million of Canadians over the age of 60.
Based on these costly tolls on seniors' families and governments, it's the combination of seniors' physical and mental health that needs to be addressed. Interventions targeted and tailored to identify, connect, and support older adults and their families who are experiencing physical and mental health challenges can play a role in preventing depression, reducing anxiety, reducing substance use and harm, preventing suicide, and reducing stigma and the negative consequences associated with these mental health challenges.
We will be presenting a written brief, but for the purposes of this presentation, I'll be focusing on addictions and stigma in later life and will defer to Dr. Marnin Heisel in regard to suicide.
For older adults, alcohol and psychotropic prescription medication for anxiety, sleep, and pain are more of a concern. Findings from the “Canadian Addiction Survey” of 2004 indicated that 16% of adults aged 65 and older report heavy drinking: more than 14 drinks per week for men, and nine for women. Almost half of these heavy drinkers report consuming more than five drinks on one occasion at least once a month. Alcohol overuse in older adults is associated with poor mental health functioning and increased suicide risk. Other studies have found that seniors using alcohol and taking psychotropic drugs are at increased risk for hip fractures and injuries due to falls and motor vehicle collisions.
In preparing for this presentation, I consulted with board members of the Canadian Academy of Geriatric Psychiatry about what they see in their day-to-day practice. One board member and doctor noted the following:
Addictions, treatment, and housing are particularly poorly resourced for the elderly. Those with persistent addictions often lead to cognitive sequelae secondary to traumatic brain injury, nutritional deficiencies, and multiple medical illnesses. This triply damned group—old, addicted, and demented—is not a very sexy group to provide services for, yet merits a more focused intervention.
He noted that in his community this group of older adults often ended up homeless or in nursing homes without any service providers seeing the complexity of their situation.
Therefore, older adults often present with multiple medical conditions, exacerbated by alcohol, that may not fit the expected profile of the chronic drinker. Drinking can increase later in life as well, for a variety of reasons—loneliness, grief, or a way of self-medicating emotional pain. While substance use is known to decrease with aging, men report much higher rates of alcohol than women in all age categories. However, given the physical changes associated with aging, older adults may be more vulnerable to the negative effects of even low-use drinking on cognitive, emotional, and physical health. The economic and social costs of substance abuse in Canada is estimated at $39.8 billion. It's not clear what the costs are associated with older adults.
Despite this research, access to current data on the prevalence of alcohol and other drug use in later life is pretty slim. From the 2013 results of the Canadian tobacco, alcohol, and drugs survey, data is only provided for under 25 or over 25, missing an opportunity to inform decisions about alcohol use and misuse in later life. That said, we are encouraged by the Canadian longitudinal study on aging dataset that will likely provide us with some of this information moving forward.
As a growing demographic, older adults uniquely experience the phenomenon of a double-whammy stigma due to the combination of mental health and aging. We know that ageism and stigma can create barriers to accessing care, to proper detection and assessment, and to good public discourse. This phenomenon was recognized in “Out of the Shadows at Last”. The final report emphasized that symptoms of mental illness in later life are often attributed to growing older. In fact, recognition of ageism as a form of stigma was a pervasive theme throughout the standing committee report on aging.
I would also say that there is another level of stigma: sexism. Men are often diagnosed with alcohol and drug dependency and are at a higher risk of suicide. Depression and anxiety are also common comorbid diagnoses, yet, as noted by the Chief Public Health Officer's report, “Influencing Health—The Importance of Sex and Gender”, mental illness among men is often underdiagnosed and under-reported. This is thought to be associated with a multitude of hypothesis factors—social, cultural, and biological—as well as stigma associated with a perceived weakness in men with mental illness.
This intersection of age, mental illness, and gender creates an opportunity to explore how we can improve mental health for all older Canadians, especially older men, and those who support them. Delayed and untreated mental illness in older men can impact the health system. In a recent Australian study of older men with depressive symptoms, they were at a higher risk of hospital admissions unrelated to their mental health condition, and were more likely to have long hospital stays and worse outcomes, than non-depressed patients. In Canada, hospital stays for mental illness are much longer for this age group than any other. The average stay is 29 days for older adults over the age of 60, compared with 16 days for adults 45 to 60 years of age.
How does this stigma play out in real life? To give you a brief example, we would argue that in the strong focus on youth suicide, we talk about the lost potential of a young person who dies by suicide, but our response to older adult suicide is deafening in its silence. We don't talk about the lost legacy of older adults.
You asked for a focus on coordinating efforts of stakeholders at the national level. I'll focus on best practices. With the funding from the Public Health Agency of Canada, the coalition led the development of the first national interdisciplinary guidelines on depression, delirium, suicide risk and prevention, and mental health in long-term care. These guidelines were authored by a team of researchers and health providers from across disciplines, who reviewed international and national literature and synthesized the evidence.
Since the release in 2006, thousands of copies have been disseminated both electronically and in print across Canada and in over 60 countries. To support the knowledge translation and implementation of the guideline recommendations, again with the support of the Public Health Agency of Canada, we were able to create a variety of companion tools, including clinical pocket cards, resource guides for seniors and their families, and educational modules and tool kits for health care providers. We currently have updated the delirium and mental health and long-term care guidelines and are working on the update of the suicide and depression guideline.
We also co-authored with the Mental Health Commission of Canada the 2011 guidelines for comprehensive mental health services for older adults in Canada. The guidelines recommended a model—
3:50 p.m.
Conservative
3:50 p.m.
Director, Canadian Coalition for Seniors' Mental Health
I'll leave that there.
For recommendations, based on this evidence and the guidelines for mental health services that look at a comprehensive package, we focus on strategy. We urge the federal government to ensure that seniors' mental health issues remain a priority in the national mental health strategy. In addition, we recommend the federal government establish a national seniors strategy with a strong emphasis on protecting and promoting the physical and mental health of Canadians.
From a system capacity standpoint, the coalition recommends reorienting the system from a disease management perspective to more promotion of mental health and prevention of mental disorders, chronic conditions, and disabilities, with adequate allocation of resources across all settings.
The coalition is committed to ensuring that older adults have access to mental health care services, including mental health promotion, with a strong focus on supporting older adults living with chronic health conditions, family caregivers, and prevention in later life.
Thank you.
3:55 p.m.
Conservative
The Chair Conservative Ben Lobb
Great. Thank you very much.
Next up is the Canadian Psychological Association.
Dr. Karen Cohen, go ahead.
3:55 p.m.
Dr. Karen R. Cohen Chief Executive Officer, Canadian Psychological Association
Thank you.
Good afternoon, Mr. Chair and committee members. My name is Dr. Karen Cohen. I'm the chief executive officer of the Canadian Psychological Association or CPA.
CPA is the national association of Canada's scientists and practitioners of psychology. Approximately 18,000 psychologists are registered to practise in Canada. This makes psychologists the largest regulated, specialized mental health care providers in the country.
Psychologists are employed by publicly funded institutions inclusive of hospitals, family health teams, and primary care practices, schools, universities, and correctional facilities. However, with cuts to human resources in the public sector, psychologists increasingly work in private practice.
Their scope of practice includes the assessment and diagnosis of mental disorders and cognitive functioning, the development and evaluation of treatment protocols and programs, the delivery and supervision of treatment, and research.
We are pleased that in the 2015 federal budget the Government of Canada indicated its intention to renew the Mental Health Commission's mandate for 10 years. CPA has a long history of involvement with the commission from providing support for its creation, sitting on advisory committees, and providing input on past and current projects. This new investment will hopefully give the commission a mandate to implement the recommendations of the mental health strategy. The strategy scoped out the changes that Canada needs to make to enhance the mental health and well-being of its citizens. It's now time to make change happen.
The strategy called for increased access to evidence-based psychotherapies by service providers qualified to deliver them. We hope that the commission will work with governments and other stakeholders to move this important recommendation forward.
Research has demonstrated that psychological treatments are effective for a wide range of mental health disorders such as depression, anxiety, eating disorders, and substance abuse. They are less expensive than, and at least as effective as, medication for a number of common mental health conditions. They work better than medication for some kinds of anxiety. They lead to less relapse of depression when compared to treatment with medication alone. They lead to patients who better follow through on treatment, feel less burdened by their illness, and have lower suicide rates when used with medication for bipolar disorder. They help to prevent relapse when included in the services and supports for persons living with schizophrenia. And, finally, they reduce depression and anxiety in people with heart disease, which when combined with medical treatment, leads to lower rates of heart-related deaths.
Despite this evidence, there are significant gaps in service and care when it comes to mental health. Canada has no parity in its public funding of mental and physical health care. Canada's mental health strategy tells us that spending on mental health in Canada has been measured at only 7% of total health spending. Psychological services are not covered by our public health insurance plans. Canadians either pay out of pocket or rely on the private health insurance plans provided by employers. Coverage through private plans is almost always too little for a clinically meaningful amount of service.
Erin Anderssen from The Globe and Mail hit the nail on the head this week when she wrote about this health crisis. She stated, “We have the evidence...Why aren't we providing evidence-based care?”
Access to treatment should not depend on your employment benefits or your income level. Those who cannot afford to pay for treatment end up on long wait lists, they have to depend on prescription medications, or they simply do not get help at all. If we want a health care system that will deliver cost and clinically effective care, then we must re-vision policies, programs, and funding structures through which health care is provided.
CPA commissioned a report by a group of health economists that proposed several models of delivering enhanced access to psychological services for Canadians. The report provides a business case for improved access to psychological services based on demonstrating positive return on investment and proposed service that yields desired outcomes. It looked at countries like the United Kingdom, Australia, the Netherlands, and Finland that have programs that make psychological services accessible through public health systems.
A 2012 report on the U.K.'s improving access to psychological therapies program says it has treated over 1.1 million people, with a recovery rate in excess of 45%. Some 45,000 people have moved off sick pay and benefits. Savings from the program in 2015 are estimated at £272 million for the National Health Service and £700 million for the entire public sector. By the end of 2016-17, the net financial benefit of the program is pegged at £4.6 billion and judged attributable to prevention, early intervention, and a reduction in absenteeism.
Mental disorders that are addressed promptly and effectively will yield a cost offset from their treatments. That can include fewer medical visits and interventions, and decreases in short- or long-term disability. On the other hand, untreated or undertreated disorders cost the workplace tens of billions of dollars annually.
Accessing needed psychological care affects people across their lifespan.
The May 2015 report from the Canadian Institute for Health Information showed that emergency room visits and hospitalization rates for children and youth with mental disorders have increased since 2006, particularly for those between the ages of 10 and 17 with mood and anxiety disorders. Use of psychotropic medications has increased as well. A 2011 report from the Canadian Policy Network and CIHI shows that the strongest evidence for return on investment in mental health involves services and supports that are geared to children and youth and that reduce conduct disorders and depression, deliver parenting skills, provide anti-bullying and anti-stigma education, promote health in schools, and provide screening in primary health care settings for depression and alcohol misuse.
Canada's population is aging and seniors will also face barriers to accessing necessary psychological care. While many of us will age in relatively good health, others will face a wide range of cognitive, emotional, and physical challenges that include dementia, depression, anxiety, chronic disease management, and end-of-life care. As many as 20% of seniors are living with a mental illness. Depression occurs in about 40% of patients who have had a stroke. Up to 44% of residents in long-term care homes have been diagnosed with depression and 80% to 90% have a mental illness or cognitive impairment.
Canada has taken some very important steps to improve the mental health of Canadians. Campaigns and public conversations deliver the message that Canadians can and should seek help for their mental health problems. Collectively, we are reducing the stigma of mental health and substance use disorders. However, only about one-third of Canadians seek and receive such help. While stigma may be one barrier, access to care is another.
It is time Canada walked the talk and made needed treatments and supports available. We need a health care system that is nimble enough to respond to the health needs of our citizens, deliver evidence-based care, and hold us accountable for care delivered. To accomplish these goals, innovation is needed.
The federal government has an important role to play in Canada's mental health. This role includes delivering care in jurisdictions under its authority, increasing or targeting mental health transfers to provinces and territories, and collaborating with provinces and territories in delivering effective innovations in health promotion, illness prevention, and health care delivery.
To ensure that innovations in mental health care delivery happen, the federal government can set up an innovation fund to assist provinces and territories in developing sustainable mental health infrastructure across Canada that will bring psychological care to Canadians who need it. The fund could, for example, be used by the provinces and territories to adapt the United Kingdom's improved access to psychological therapy programs here in Canada and to expand the role of primary health care in meeting mental health needs.
Finally, investment in research and training for students is also critical to the success of Canada's health system, the success of which will depend on its ability to effectively respond to the changing health needs of Canadians. While research into the biomedical causes and treatments of mental disorders is important, research into the psychosocial determinants and treatments is equally important. Like many more long-standing health conditions, mental disorders involve a complex interplay of biological, social, and psychological determinants and depend on a team of providers, services, and factors for their treatment and management.
Canada is poised to do better by the mental health of Canadians. The Canadian Psychological Association is very pleased to participate in this work.
Thank you for the opportunity to present to this committee
4 p.m.
Conservative
Cathy McLeod Conservative Kamloops—Thompson—Cariboo, BC
Mr. Chair, I wonder if we would have consent for both of these rounds to be five minutes just to ensure that we not only get around in here but also have time, because, as I understand it, we have committee business to deal with.
4 p.m.
Some hon. members
Agreed.
4 p.m.
Conservative
The Chair Conservative Ben Lobb
Okay, seeing unanimous consent, we'll carry on.
Ms. Morin, la parole c'est à vous pour cinq minutes.
