Shadowland: Mental Illness in Dufferin County

Around here, they call it “medicine’s poor cousin.” We’re very proud of our medical system in Headwaters. Yes, there are a few  problems, such as the shortage of family doctors, but by and large, if you’ve had an accident, your kid’s got a fever, you’ve been diagnosed with cancer or your heart is a few beats away from taking a permanent vacation, we’ve got specialists, we’ve got equipment, we’ve got paramedics, we’ve got fundraising. In short, we’ve got you covered.

If, however, you find yourself with health-care needs of a different sort – if depression has seized your life, let’s say, or your kid is anorexic, if you’re dealing with substance abuse or trauma, if you’re hearing voices or have any one of a myriad other psychiatric disorders, well, that’s different.

For many in that position, the word starts with “S” and is followed by “out of luck.”

It’s easy to sweep mental health under the carpet, and as it turns out, in this region we’re exceptionally good at doing just that. It’s a disease that tends to stay hidden behind closed doors. Even those affected may deny or conceal their problems, and the community is generally content to look the other way.

In reality, however, mental health problems are a very pervasive issue.

Based upon national prevalency rates, the 2008 Dufferin Mental Health and Addictions Plan by Jenny Carver and Associates estimates that in Dufferin County alone there are between 1,050 and 1,740 residents with serious mental health issues – those expected to require intensive levels of service over a long period of time. Health Canada estimates that one in five Canadian adults will experience a mental illness within a one-year period. Locally, that translates to more than 8,600 Dufferin adults, a similar number in Caledon, every year.

Then there are kids. The province of Ontario estimates that one in five struggles with their mental health. In Dufferin, that equates to 2,400 to 3,400 children and youths.

Seniors, including those with dementia, are a whole other group. Estimates are that at least one in three of us will experience some form of dementia, if we live to be older than eighty-five. Eighty to ninety per cent of nursing home residents experience depression.

All told, that’s a lot of illness – thousands upon thousands of us, any given day.

Of course, these rates are common across the province, and it’s not news that mental health is a long-neglected issue. In Headwaters, however, the situation is grim even by that standard.

The smallest county in the province, Dufferin has very little mental health infrastructure of its own. Instead, the bulk of adult services have traditionally been delivered by organizations based in other centres. If you arrive in crisis at Headwaters Health Care Centre, you might be transferred to Guelph or Brampton or Penetanguishene.

The majority of patients are in a less critical state, however, and they access the system through community-based services. These have largely been delivered by organizations operating in the Waterloo-Wellington system, as a service stretch, usually with dedicated Dufferin funding and service targets.

While Dufferin has been part of the Waterloo-Wellington system, Caledon has been aligned with the rest of Peel Region, even though, in practice, many north-Caledon residents use services in Orangeville.

In 2006, the province realigned health-care catchment areas. Rather than being tied to Waterloo-Wellington, Dufferin became part of what is known as the Central West Local Health Integration Network, or LHIN, along with the rest of Peel, Malton, Rexdale and Woodbridge. However, while a few Central West LHIN services have now begun to stretch into Dufferin, most are still provided by operations with head offices in Guelph.

Confused yet? The jurisdictional tangle alone is enough to make you, well, crazy.

Possibly because Dufferin has always been the little brother, tagged on to someone else’s system, the county has the lowest per capita mental health spending rate in Ontario. Beyond that, among the services that are available, many providers contribute many tiny parts. Significant service gaps exist. Such a complicated patchwork is difficult for users to access, and once they manage that, they’re likely to encounter lengthy waiting lists, and may have to travel long distances for treatment. So even those services that are technically available often go underutilized. Problems are left to fester until they become a crisis.

It’s little wonder then that the Carver research found, “There was a disproportionately high number of crisis calls from Dufferin (compared to Guelph-Wellington by population).”

nce things do reach a crisis, a good number of people end up entering the system through the back seat of a police cruiser. A recent Canadian study found that one in four police calls involves a person with mental illness.

Scott Davis, community service and media relations officer for the Orangeville Police Service, says that the police view of mental health issues in Orangeville is “concerned.” He explains, “Though we don’t maintain specific statistics, I can say with confidence that we’re seeing an increasing number of calls for service that involve mental health issues. Other times it’s an issue that’s recognized as the officers are dealing with a call for something else.”

Though Davis describes police training in mental health as “very limited,” he says, “We rely on experience. Officers try to identify what the issue is. Some are easy, but a lot are not.”

While the root causes are varied, there are some common themes: “We see depression resulting from the economy,” Davis says. Considering recent statistics showing a significant increase in Dufferin poverty rates, and the poor economic outlook in general, he adds, “With what’s going on there, mental health issues are only going to rise.” He continues: “We also see people with social challenges, like failed relationships. Our most frequent type of call involves a situation where there’s a risk for self harm, and family or friends or sometimes even the individuals themselves call us.”

Unless arrest is required because an offence has been committed, Davis says “We rely heavily on Headwaters Health Care Centre.” Officers accompany individuals while they are assessed by the emergency doctor on duty. Headwaters Health Care Centre has no mental health facilities of its own – not even a separate secure assessment area – so serious patients are transferred to better-equipped centres. Though the hospital now maintains its own security personnel, Davis says, “In years past it was not uncommon for officers to ride in the ambulance to Guelph or Penetanguishene.”

The revolving-door nature of mental health care is a frustration for the police. “We’ll bring someone in for assessment and they’re back on the street right away,” Davis says. “We have several folks who are habitual callers. That’s where the system fails. It’s like these people are told ‘Yes, you have a problem. See you later.’ ”

Davis is also quick to articulate a better solution: “We need a situation where we have both the resources and a clear direction about what to do. Mobile outreach crisis capacity would be a great resource, especially if it was twenty-four-hour. A more streamlined process overall would free up officers for other duties.”

The emergency department at Headwaters Health Care Centre sees over 800 cases a year for which a psychiatric problem is the main diagnosis. Ask Dr. Jeff McKinnon, chief of staff, if there’s a word or term he would use to describe the state of mental health care locally, and he fires off a selection: “Absent. Vacuum. Black hole. Take your pick.”

McKinnon does see some bright spots. For example, the Dufferin Family Health Team has recently funded five mental health counsellors. That funding, he says, has perhaps been “the biggest benefit of the family health team system. So if you’re a rostered patient, you might be okay. But that’s only about half the population. The community mental health clinic [Trellis Mental Health and Development Service] is barely hanging on, which means they can only see the sickest of the sick.”

According to McKinnon, an overwhelmed system combined with the stigma of mental illness means “it’s hard to get people into care and hard to get them to continue. As a result, many end up in crisis.”

About 105 cases a year are what are known as “Form 1” patients. These are people deemed to be a potential risk to harm themselves or others. Cases of this sort are usually transferred to Brampton Civic Hospital.

“So let’s say someone is suicidal,” McKinnon says. “We can hold them for seventy-two hours, and then they’re back out. But as soon as they leave, they’re in a vacuum. Their problem isn’t fixed. There’s a six-month wait to see an [OHIP-funded] psychiatrist. Of course they get in trouble again. Three days later they’re back in the emergency department. We end up dealing with more suicidal patients, because they’re likely to bounce back.”

Quite apart from the pain and suffering going on, there are huge costs associated with the revolving door of mental illness emergencies. By way of comparison, studies estimate that each visit to an emergency room made by someone suffering schizophrenia costs the system between $8,000 and $12,000.

A massive shortage of psychiatrists across the province further exacerbates the problem. The Carver research estimates that a suitable complement for Dufferin would be six full-time psychiatrists. In fact only 0.6 of one full-time equivalent exists, and even that is divided between two different agencies.

Though efforts to recruit psychiatrists have been underway for some time, Cholly Boland, president and CEO at Headwaters Health Care Centre, doesn’t hold out much hope for a quick fix. “Psychiatrists are hard to attract here because there are limited professional advantages. There’s no teaching school, no psychiatric hospital nearby,” he says. As Dr. McKinnon points out, however, at least the situation is better than it was. A recent agreement with William Osler Health Centre in Brampton provides Dufferin patients with access. “Osler has in-patient beds,” McKinnon says. “And they’ve been able to hire a psychiatrist.”

Tim Smith is supervisor of the Orangeville office of Trellis Mental Health and Development Services. With head offices in Guelph, Trellis provides the bulk of community-based mental health services for adults in Dufferin.

Describing the county as “hugely underserviced,” Smith says funding issues are related to population growth. “There is a significant mental health system operating in Dufferin,” he says, but “per capita we’re the lowest funded … We built a new hospital, but we’re not keeping up with funding for mental health.”

Trellis’s operating statistics show how that underfunding plays out: the average wait time for an adult to receive service in 2008 was 175 days – nearly six months. The Canadian Medical Association’s benchmark, meanwhile, is one to two weeks for an urgent situation, and in no case longer than four weeks. Dr. McKinnon says the six-month wait would be even longer, but “people give up and fall off the waiting list – particularly for psychiatry, but also for addiction services. They just feel there’s no access to treatment.”

Of course, for many of us in less dire straits, or with fatter wallets, there are some other options. Those with milder depression may turn to their family doctor, who can prescribe anti-depressants. If that depression is brought on by stress from a bad economic climate, however, there’s a catch 22.

Ajay Gandhi, manager of Fifth Avenue Pharmacy in Orangeville, points out, “We wouldn’t expect to see an increase in anti-depressant prescriptions because of an economic downturn. Anti-depressants tend to be expensive and, of course, if you lose your job, you likely also lose your drug plan. We may see an increase in sleeping aids, which are less expensive, as a quick fix.”

Private therapy is another possibility, but with rates running at $60 to $100 per hour or more, you’ll need either a generous extended health insurance plan from work or deep pockets.

Overall, though the situation is indeed gloomy, it is not totally without hope.

The Central West LHIN has identified mental health as one of its top five priorities for action. And in 2007 Trellis funded a consultant to research and develop the Dufferin Mental Health and Addictions Plan to “address the recognized concerns regarding service capacity and the circumstance in which the Dufferin community finds itself, now being part of the Central West LHIN.”

The plan outlines in detail what it calls an “Integrated Dufferin Solution.” This includes development of a more Dufferin-centred partnership among providers, a stronger delivery model, and significant capacity enhancements across the board, including assessment, counselling, psychiatry, case management and crisis response. The plan would also establish more in the way of self-help initiatives and create a sustainable family-support and education program. A county-wide wellness strategy would also be part of the mix.

So far, Dufferin service providers, attempting to do what they can in the absence of new funding, have taken action to form a network called “Dufferin Connects.” The group published its first newsletter in the spring of 2009.

The estimated cost to implement the Dufferin Mental Health and Addictions Plan is a little over $1.5 million a year. Sadly, Dr. McKinnon says, “We were very positive when the LHIN got behind mental health, but they can’t print money, and they’re at the beck and call of the ministry. I don’t see it moving fast.”

If thousands of people in our community needed a new hip and couldn’t get one, there would be an uprising. And yet, somehow, those with mental illness – perhaps the most vulnerable among us – can be left to suffer. Dr. McKinnon feels he can explain why: “The poorest people have the weakest voice, and they’re the ones who have problems accessing services.”

How are the kids?

Ask Gloria Campbell, program manager for children’s mental health at Dufferin Child and Family Services (DCAFS), if things are as bleak for children’s mental health as they appear to be for adults, and she says, “With kids, there’s always more hope. They’re young and have time. Of course, they also have a family support structure, even if they’re in foster care. That’s missing for many mentally ill adults who often also deal with terrible loneliness, or even homelessness.”

Still, while they may have an advantage or two over adults, children and youth are hardly home free. Recent estimates are that only one in six children with a mental illness in Ontario receives any treatment at all. Trish Grabb, DCAFS crisis response worker and senior clinician, says that it’s more complex than simply a funding issue. “It can be a challenge to identify the kids who have problems.” Beyond that, she says, “Lots of parents don’t recognize they could get help.”

The signs of a developing mental illness may appear differently in young people. “With kids you see more of what we call ‘conduct disorders’,” Grabb says. “Things like theft, aggression, or fire setting.” Those behaviours, in turn, can mean that it’s easy for young people to be labelled “criminal” rather than “mentally ill.”

“Kids with conduct disorders often end up with charges, and then they may never get the support they need,” says Grabb. Campbell adds, “Spend a day over at the court house and you’ll see a lot of young people. We’ve been working to try and get them streamlined out of the criminal justice system and into the mental health system.”

The 2008 Dufferin Mental Health and Addictions Plan identified “considerable youth addictions concerns,” pointing out that there is limited access to withdrawal/detox services. Not only does Grabb agree, but she goes on to illustrate the connection between mental health and addictions in youth by quoting a remarkable statistic: “Thirty-three per cent of kids with a mental health issue also have an addiction, while 99 per cent of kids with addictions also have a mental illness.”

The second leading cause of death for Canadian youth, behind accidents, is suicide. Campbell sees that play out locally too: “There are a couple in this community every year.”

Not surprisingly, money is one of the big stumbling blocks to better care. “Like so many other children’s mental health services, we’re underfunded,” Campbell says. “In addition to more treatment services, we need additional funding for specialized assessments – psychiatric, psychological, and occupational therapy.”

DCAFS currently has fifty-two clients on its waiting list for mental health assessment and treatment, and some non-emergency clients have been waiting up to four months. In the hope of relieving some of the pressure, the agency opened its Talk In Clinic in April 2009. It provides families with single-session, walk-in access to counselling and children’s mental health services. While attendance by the whole family at the session is encouraged, parents or youths over age twelve can also attend alone. The clinic operates on Tuesdays from DCAFS’ offices at 655 Riddell Road in Orangeville, from 1 p.m. to 8 p.m. A second Talk In Clinic is planned for Shelburne this fall.

Imaginary voices stole my friend’s smile

We all have voices in our heads. Most of us, most of the time, recognize the chatter as internal dialogue with ourselves which is either praising our latest triumph or, more commonly, chastising us for some persistent shortcoming.

There are an unfortunate few, however, for whom this internal chatter takes on a much more sinister characteristic. In such cases the “imaginary” voices can induce the listener to undertake bizarre behaviour that is alien to the cultural norms by which the majority of us live.

My neighbour, I’ll call her Norma, is one of those unfortunates. For twenty years, beginning in the mid-seventies, she and I shared a close and supportive relationship. Sensitive, humorous and often wise, she was much more comfortable with the predictable rhythms of country life than the hectic and arbitrary conditions she had experienced in her brief attempt at city living.

About fifteen years ago, she began to exhibit minor quirks of behaviour: a kettle left to boil dry on the stove; uncharacteristic accusations aimed at family members; and once accusing me of tampering with her hydro bill.

Never married, Norma lived with her widowed mother and younger, single sister.

As much as mother and sister wanted to help they were ill-equipped to understand or empathize with the increasingly challenging conduct they were witnessing.

At their request my spouse and I took Norma to her family doctor who quickly prescribed medication. This did help for a few months and she seemed to be returning to her old self until two traumatic events apparently derailed the progress: a close friend hurt her deeply by ending their relationship and she lost her job. She stopped taking her medications.

Shortly thereafter the symptoms returned along with even more troubling behaviour, culminating in a nasty car accident. To those of us who knew her, it seemed like she had made a conscious attempt to end what had become an intolerably painful existence.

She survived the accident and during her brief hospital stay we asked the doctor assigned to her care that she be given a full psychological assessment. For reasons never explained to us he did not feel that was necessary and discharged her a few days later, back to the care of her family.

With the death of their mother a few years later, the relationship between the sisters deteriorated. Norma moved out. With her departure, this bright, gentle woman left behind everyone who knew and loved her just as surely as if she’d embarked on a far-flung journey.

Subsisting on employment insurance and what was left of her meagre savings she lived a spartan life. As time passed we’d come across each other occasionally on the street or in the grocery store. She appeared unkempt and furtive and I’m afraid I found our exchanges unpredictable and unsettling. So unwelcome did they become, I began to take pains to avoid them.

Three years later the conditions of Norma’s life had deteriorated so much that a concerned neighbour, who hadn’t seen her for several days, called the police. They found her in such critical condition that she was hospitalized immediately. This time the severity of the damage required acute attention and she wound up in the mental health facility in Penetanguishene.

She is back home now, and once more on medication with regular monitoring by a local social service agency, but her life is a solitary one (she and her sister communicate only when necessary). She can’t drive and as far as I know she no longer reads. Now she and I have only brief and strained exchanges when we meet on the street. Evidently she doesn’t hear voices anymore. But neither does she smile.

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