Health Committee on May 28th, 2015

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Since we only have five minutes, my questions will be short.

Ms. Schroeder, I am very interested in the mental health of seniors. The numbers you gave us are very troubling. Many seniors tell me about the obstacles they are facing. You talked at length about shame, which we often hear about. It is not always easy for children to realize that their parents have mental health problems. They wonder how to meet with responders and how to help their parents.

Your approach is much more centred on cooperation. You mentioned a few practical examples. If you know of any model initiatives on awareness, prevention and reducing the stigma, could you tell us about them? What could we do? What are the model initiatives? What is the role of the Mental Health Commission of Canada in sharing these initiatives?

You also talked about housing, which I think is very important. I sometimes receive people at my office who tell me that they have trouble finding housing. This is a challenge first, because they are seniors and, second, because they have mental health problems. It is very difficult for them to find housing. Do you have solutions to suggest to us?

[Bonnie Schroeder]

Merci. I'm going to respond in English.

You raised three points. You asked about family caregivers, collaborative initiatives, and housing. Let's start with caregivers.

We know that, in the recent Mental Health Commission data indicators report, it was reported that 16% of caregivers report distress caring for someone receiving publicly funded home care. We know that number jumps for people caring for someone with depression, end of life, dementia, and aggressive behaviours. It increases exponentially. I do think we need to talk about not only caring for a senior regarding mental health, but we need to also think about the mental health of family caregivers. I think it's very important, and I will get into more of that in the written brief.

That being said, we know there's the emotional toll. We also know working caregivers really are struggling to juggle both work and care, and we're pleased with the federal government, through the Employment and Social Development Canada, for bringing in the employers for caregivers plan and working with businesses to bring this to the forefront, recognizing cost to bottom line, recruitment, turnover, and the like. I think it is a very important population that we need to address.

You talked about collaborative initiatives we've developed. We have our guidelines around stigma, which I think is really key. We developed anti-stigma training for providers, including a video, with the support of the Mental Health Commission of Canada, and the video was recently released. I will highlight two initiatives in our network. The Canadian Mental Health Association in Ontario adapted and piloted and evaluated a community-based mental health promotion program called Living Life to the Full. It found significant clinical improvement in mood, well-being, and quality-of-life indicators for this program, and we think it shows some real promising practice to protect and promote the mental wellness of seniors.

The other one is the Fountain of Health program, in Nova Scotia, which looks at seniors' mental health promotion along five domains: mental health, physical activity, positive thinking, and I forget the other two, but it's a great community-based initiative. So those would be three.

With regard to housing, care in home is critical, I think, and sometimes seniors cannot live independently in their own home. Where do they need to go if they're living with both physical and mental health problems? Long-term care is, again, a struggle to get into, and the statistics that Dr. Cohen mentioned are key. We see a much higher acuity and complexity in long-term care. So what are other options? Assisted living, retirement homes, and home care are options to support seniors living independently in their own homes.

[The Chair, Conservative, Ben Lobb]

Great, thank you.

Go ahead, Mr. Young.

[Terence Young, Conservative, Oakville, ON]

Thank you, Chair.

Thank you, everyone, for your time today.

I'd like to ask Dr. Heisel a question about psychiatric drugs, if I may.

All antidepressants warn right on their labels that, due to risk of akathisia, abnormal behaviour, etc., the patient will be at risk of suicide, and they all say on their labels that the patients should be monitored closely for suicidal ideation, which no doctor has the time to do. It simply doesn't happen.

I personally know two young people who have hung themselves after taking antidepressants, but who were given no safety warnings, one of them after withdrawing from an antidepressant and the other one four days after first being prescribed an antidepressant.

When they're first given an antidepressant, most patients get no warnings that they will become dependent and might have to take the drug for the rest of their life. I've never heard of a patient who's been prescribed an antidepressant and the doctor said, “By the way, you'll probably have to take this for the rest of your life”, or “You're going to go through months of terrible withdrawal symptoms, horrible withdrawal symptoms”. In fact, the drug companies don't even call it withdrawal; they euphemistically refer to as “discontinuation symptoms”.

We know that antidepressants ruin patients' sex lives—many patients are unable to enjoy sexual relations when they're on antidepressants. And we know that one in ten Canadians is on these drugs, such as Paxil, Prozac, Effexor, Wellbutrin, Celexa, Lexapro, Zoloft, Cymbalta, and Luvox, and maybe a couple of others, and most of them, if not all, are being treated for mental health issues.

We've heard evidence in this committee that psychiatric drugs often worsen the mental health of the thousands of patients who are on them, and I think, really, it's no wonder.

What should be done to make sure patients only get psychiatric drugs when they are monitored closely for suicide and other serious adverse effects?

[Dr. Marnin Heisel]

Thank you very much.

I won't be able to answer all of the points you've raised, but I think in many ways you're echoing the comment that my colleagues and I have raised already, which is that, unfortunately as it currently stands, Canadians often don't have access to psychological treatment. As a result, the route that many Canadians will take to get access to mental health service is either to go through a family physician, walk-in clinic, or to present themselves to an emergency department to get referred to, if they're fortunate, a psychiatrist. Then they often have to deal with long waiting lists and then, because of the inordinately long waiting lists, they're restricted in the amount of time and attention they receive from the psychiatrist.

I'm happy to see it when it works well. My colleagues and I have psychiatrists we work with who are extremely knowledgeable, capable, and caring providers with excellent skills.

[Terence Young, Conservative, Oakville, ON]

Excuse me, one second. I'd just like to get another question or comment in.

So we have lots of family physicians prescribing these drugs without safety warnings who don't understand that they should be monitoring the patients closely. Maybe they shouldn't be prescribing these drugs to patients.

[Dr. Marnin Heisel]

That's certainly a thought. I certainly agree that it's important to have a high level of understanding and training and experience, including supervised experience, in providing mental health care. Part of the challenge, as I think I've noted, is that there just aren't enough providers—at least not enough psychiatrists—to go around.

I think to come back to the point that Dr. Cohen and I were raising before that whereas medications can be helpful, many times medications aren't actually cheaper. Many times they don't actually reduce the length or duration of care, and many alternative approaches, including psychotherapy and other psychological interventions, such as group work, etc., can be highly effective. So I agree. I think that we cannot rely exclusively on medication for treatment of mental disorders—

[Terence Young, Conservative, Oakville, ON]

But I'm saying more than that. I'm not saying that we can't just rely on drugs. I'm saying that in many cases, the patient shouldn't be prescribed these drugs because these will worsen their conditions. Would you agree with that?

[Dr. Marnin Heisel]

I do under some circumstances, definitely. I agree that some people should not be on the medications they're provided and that we do need good alternatives—and we have them.

[Terence Young, Conservative, Oakville, ON]

Okay.

You said that there's been a 29% increase—

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Young.

[Terence Young, Conservative, Oakville, ON]

You said there's been a 29% increase in suicide of older people. What percentage of those patients are on psychiatric drugs?

[Dr. Marnin Heisel]

I'm afraid I don't know off the top of my head. What I will say, though, based on a retrospective study done by a colleague in Sweden, is that among older adults who died by suicide, approximately half were receiving some form of mental health care and many of those were receiving antidepressants.

[The Chair, Conservative, Ben Lobb]

Okay, thank you very much.

Ms. St-Denis.

[Lise St-Denis, Liberal, Saint-Maurice—Champlain, QC]

Thank you, Mr. Chair.

Thank you very much to all the witnesses.

I don't usually sit on this committee. I am replacing someone.

When you talk about our seniors, I would like to know whether I am considered one or not. How do you describe a senior? That is my first question.

My second point has to do with the shame related to aging. It might be more appropriate perhaps to talk about “difficulty”. You did not talk about loneliness when you gave the definition of people who are ashamed to grow older, whether by drinking, by taking drugs or in any other way.

Furthermore, what is your main expectation from the federal framework for suicide prevention?

My last question is for the three of you. If you had to choose one priority only in what you are proposing to the government, what would it be? From everything you have said, what is the most important aspect in the prevention of suicide among seniors? Of course, an increase in the budget would be appreciated, but I don't think that's all. I think you might expect something else and I would like to know what it is.

[Bonnie Schroeder]

I'm assuming you're directing a couple of those questions to me?

[Dr. Marnin Heisel]

Is that question—

[Bonnie Schroeder]

I'll throw it to you, Marnin.

Most of the research on seniors looks either at those 55 and older or 65 and older. But we are all aging and know that cohorts are going to move through. Our current cohort of baby boomers going over that 65 threshold is one group, but what do we need to do to prepare for the next wave of seniors at that line, knowing that their life experience and cohort experiences are very different?

So I think we need to look at this from a life course. You might be in that cohort. I'm looking forward to that. That's where we play with those lines.

You talked about the shame and difficulty around the stigma. I know we participated in the National Seniors Council's round tables on social isolation and the impact of social isolation, both in terms of the quality and quantity of the social contact of older adults. We know that fewer contacts and quality of contacts increase the risk for mental health issues. I think we're wanting to take those psychosocial aspects of aging and mental health: hence, the positive thinking, the changing of our internalized stigma, drawing from the Fountain of Health's experience, talking about positive aging.

I'll throw suicide prevention to you, Marnin—the top three.

[Dr. Marnin Heisel]

Okay, thank you.

First I'll say, in talking about seniors, I certainly didn't mean you in particular, so no.

In terms of issues of shame, solitude, etc., I think it comes back to the issue that we as a society, unfortunately, we do not treat older people well. Many times older people feel that there is no place for them in our society. We focus on youth and on productivity, and we mistake and mis-equate the value of a human being with their productivity in the workforce, and that's something we have to change. Quite frankly, if we change that I think it would do a world of good in terms of suicide prevention.

I'll say quickly that in one study of healthy aging, we asked many questions but also one simple question: how old do you feel? What we found is that their actual age wasn't really associated all that much with their felt age. People, however, who felt older tended to do worse. They tended to score significantly higher on measures of depression and loneliness, as you mentioned, and even thoughts of suicide. It really isn't as much how old somebody is, but how old somebody feels, and there is research showing that people tend to feel older if they're not doing well from a health perspective, which again supports the need for prevention, health and mental health, and good care.

Out of the three things I raised, what do I think would be most helpful to prevent suicide among older adults? Clearly, enhancing access to quality care and, yes, including enhanced access to psychotherapy and psychological care.

Briefly, as a follow-up to Mr. Young's question, for our psychotherapy study of older adults at risk for suicide, the majority were recruited from psychiatric services. All were either on antidepressants or mood stabilizer medications and were still struggling with thoughts of suicide.

With the addition of psychotherapy, a sensitive and supportive approach, and an evidence-based psychotherapy, we were able to help effect a significant reduction, if not elimination, of thoughts of suicide; a significant reduction in depressive symptom severity; and a significant improvement in psychological well-being, including a sense of meaning in life. So, again, not to say that one isn't helpful or that both together can't be, but I think we've only been focusing on one approach, the medicinal approach, for financial reasons, large waiting lists, etc., and we have to move beyond that.

Thank you for your thoughtful questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

I'd like to officially invite Ms. St-Denis to the Generation X, if you'd like. If that works for you, we can bring in a Generation X.

Ms. McLeod, wrap it up here.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

I want to make one quick observation and then ask a specific question that I hope the panel can think about.

First of all, I think we've all seen models that are very effective. There are primary care models attached to the family physician. It might be a mental health counsellor. There might be psychiatric shared care. As I understand it, those seem to be a very effective way of dealing with mental health in a family practice setting.

Now, having said that, that is within provincial jurisdiction. I know that provinces are making various strides in that direction. I think it certainly is a model that's been shown to give that care and attention to people who need that focus. It's not necessarily always the family doctor who's doing it in that team-based approach.

As well, as you're aware, the Mental Health Commission of Canada's mandate has been renewed. I've seen some amazing work that they've done with psychological health and safety standards in the workplace and how that's translated into a tool book.

Could you maybe tell me, just within a sentence or two so that I can get all three people in, what you would perceive to be important for perhaps some focus within their expanded mandate?

Dr. Heisel, maybe you could start. Then we'll go to the other two.

[Dr. Marnin Heisel]

Just briefly, yes, the literature certainly supports experienced support in collaborative care, shared care, involving mental health care providers in family health clinics. Part of the challenge is that many people don't have access to that, but when they do, it can work effectively. In fact I was involved in some of those programs 15 or 16 years ago as a trainee.

In terms of the Mental Health Commission, I agree, I think they've done wonderful work. They do wonderful work in connecting up various groups, in disseminating information, and in supporting research, knowledge translation, and care. I think those are some of the key things they need to continue doing. I look forward to continuing to work with them on that, specifically around the issue of suicide prevention but not exclusively.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

Dr. Cohen.

[Dr. Karen R. Cohen]

I think one of the really significant next steps for the Mental Health Commission would be around implementation. They came out with a number of guidelines. You mentioned, of course, the strategy, and the psychological safety in the workplace guidelines. The great challenge that will require a lot of collaboration, horizontally and vertically and across jurisdictions, will be making the change happen.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you.

Ms. Schroeder.