It’s the annual Bell Let’s Talk day, which is “designed to break the silence around mental illness and support mental health all across Canada”. I applaud the program for bringing mental illness to the forefront of discussion, and for re-enforcing the efforts to de-stigmatize psychiatric illnesses. Raising funds to support programs, celebrities coming out in support of these efforts….these are all very good things.
But let’s be honest about what the main issues are. Stigma is certainly an issue for some seeking care, but as a physician, I would argue that stigma alone is playing less and less of a role. It is one thing to encourage people to come forward with concerns, but we need to be confident that we can then provide resources to help them. There is nothing more deflating for someone with the courage to come forward than to tell them that our hands are tied with what we can offer them. These are often individuals experiencing hopelessness and despair to begin with, and we need to provide them a stable therapeutic infrastructure. Which doesn’t exist right now in this country.
So shall we talk?
Let’s talk about the fact that our most ill psychiatric patients spend days in ERs across the country waiting to be placed in an inpatient bed. These are patients who often have very little insight into their illness, and leaving them in a foreign, non-therapeutic environment for days is probably one of the worst things we can do to establish their trust in the system. When they are back in the community and have a relapse of symptoms, most are reluctant to seek attention early because of their arduous hospital admission experiences.
Let’s talk about how many inpatients are being discharged before achieving any true improvement in symptoms. Most psychiatrists would tell you that these patients should be in hospital longer, but they have to be cognizant about the constant pressure to admit new, emergent patients to their service. The revolving door swings too fast for these patients, and they return to hospital before long.
Let’s talk about the impossibility of finding community psychiatrists for most patients. Family physicians have filled many of the gaps out of necessity by treating patients who would have normally been followed by psychiatrists. Better access to community psychiatrists will allow them to support family physicians in complex cases with diagnosis and management, with the family physician then taking over care again. (Side note: the recent cuts to physician compensation in Ontario will make attracting new psychiatrists nearly impossible).
Let’s talk about our two-tiered system for psychology services. Those who have benefits through work or whose physicians are in a family health team, and those who are left to pay out of pocket. This disparity is shameful and our provinces should stop playing favourites with these services. Short-term therapy for all who need it, then subsequent discharge from care. Make things equitable.
Let’s talk about the complete void in our system for child and adolescent mental health. Every day in my office I see at least one child or adolescent with a new mental health issue. Generalized anxiety, OCD, suicidality, depression, the list goes on. Older physicians are astonished at the number of individuals presenting with these conditions. As a physician I am legitimately frightened at what the future holds for us given the increased prevalence of these conditions in our youth, and the fact we have no plan to help these children. Not enough child psychiatrists, not enough counsellors in schools, not enough group programs, not enough education, not enough self-management programs, and a lack of coordinated intake for where parents and health care professionals can turn for entry into treatment. Interestingly the Ontario government recently announced a funding infusion into post-secondary mental health care. I would argue that the quality of mental health in colleges and universities is already head and shoulders above the rest of the system in terms of accessibility. Provinces need to recognize the gaps in child and adolescent care, and soon.
Let’s talk about the absurd waiting lists for residential care for children and adolescents with behavioural and substance use disorders. These are young people who, without early and thorough intervention, will be condemned to a life of dysfunction, crime, and substance abuse. Their parents are crying out to us to offer something to help their children, and we are helpless to provide any further options while they toil on these waiting lists. This is one area where government investment would pay off in spades down the road with decreased utilization.
Let’s talk about the potential negative consequences of social media on mental health. It is no secret that the neurobiology of our youth is being significantly altered by their environment, and they are essentially lab rats in an ongoing sociological experiment. This is perhaps an overly simplistic view of a complex topic, but it provides some important basic tenets of the effects social media has on the brain. Most paediatric organizations recommend limiting screen time for reasons linked to obesity, but very rarely do we hear that we should be limiting screen time for mental health reasons. This should be a priority.
Let’s talk about how difficult our mental health system is to navigate for a health professional, let alone for a suffering patient. There are many quality organizations doing good work in our communities, but without a centralized point of reference or entry for programs, most patients will remain unaware of most programs. Even health care professionals who spend significant periods of time to learn about local resources will often be quickly overwhelmed by the disorganization of system resources and contacts.
Let’s have frank discussions with adolescents with the effects of substance use on their developing brains, but doing so without being overly paternalistic or complex. They are often quite engaged when I give them a quick science talk about these substances. They know how the substance makes them feel, and explaining the temporary relief of symptoms with potential long-term consequences does resonant with some of them. We need to reassure adolescents who are experiencing mood disorders that they can experience improvement in their symptoms without resorting to illicit substances.
Let’s talk about how the solution to all of these ills will not simply be through funding. The primary goal has to be better organization within the system, then the funding can follow. Otherwise we’re going to throw our money haphazardly at programs left and right.
So we want to change our mental health care system for the better? Sure, let’s talk. But it has to be more than 140 characters at a time.