Mind the Gap

Tip of the Iceberg

When the mental health system fails Canadians, people die. Just ask bereaved mother and mental health advocate Bonnie Bricker from Winnipeg. She became passionate about mental health reform after her 33-year-old son, Reid, who suffered from several mental health challenges, took his own life in October 2015.

Reid presented himself with suicidal ideations at three different emergency wards and was discharged on his own recognizance every time. On the day of his death, within one 24-hour period, he spent the day at an emergency room for attempted suicide, and was involuntarily brought to a second hospital by the police at his parents’ request. Despite the fact that he presented a danger to himself and had attempted suicide earlier that day, he was discharged alone at 3:20am into a dangerous part of the city and subsequently completed the act.

Bonnie believes that given the circumstances, the doctors’ decision to release Reid was a huge mistake. “Every single person who is involved in mental healthcare, even remotely, knows that the worst scenario for a person who is suffering with mental illness is to be by themselves,” she said.

During that same night, as part of his assessment, Reid was asked a series of competency questions, which he knew how to correctly answer from his previous encounters with the healthcare system. Then, once the hospitals’ usual processes were completed, he was simply let go. Because he hadn’t given his consent for the hospital to phone his family, Bonnie and her husband were not informed of what took place after his admittance. The Manitoba Personal Health Information Act forbade the system from contacting anyone, even though it was obvious Reid’s life was at risk. So they discharged him, alone, on a “huge leap of faith,” in Bonnie’s opinion, and left him to his fate.

What is even sadder about the Brickers’ tragic story is that it represents just the tip of a large iceberg. Stories like this one are constantly repeated across the country, in every province and in all jurisdictions. Though thousands of Canadians take their own lives every year – largely due to gaps in our mental health system – it is because the casualties happen in trickles instead of a flood, that nobody stands up and says “enough.”

And that’s just the suicides. Then there are the people who end up homeless, and those whose mental health challenges become so debilitating that they can no longer get or keep a job. The majority of these people are victims of complex medical conditions, but also of the failings of our mental health system.

The Bottom Line

In terms of dollars and cents, we know that mental illness costs the Canadian economy $51 billion every year[1], and yet, the problem continues to grow. Shouldn’t the combination of death, suffering, and a massive financial burden be enough to make us question what the hell is going on?

Here’s what’s going on: the people who led us to creating the mental health system we have today are the very people now in charge of fixing it. That’s not to assign specific blame for the system’s failings. As organized mental health systems are relatively new, there is very little evidence on which physicians and policy makers can base their ideas and decisions.

Despite the millions of dollars that go into research every year, it seems like we don’t have enough evidence to implement game-changing reforms. The bottom line, however, is that in 2018, everyone who is honest with themselves knows that the mental health system is broken.

And what are we doing to fix it? Mostly just meeting and talking about it. The strategies put forward by organizations like the Mental Health Commission of Canada to combat the problem have no teeth and no legislation behind them to compel people to actually do something.

Rethink Reform

The system needs to turn itself upside down and shake out the cobwebs. Despite mental illness being a leading cause of death and disability in Canada, we keep trying the same old methods and hoping for a different result. Leaders aren’t in charge of reforming the mental health system; psychiatrists, psychologists and social workers are. While I have the utmost respect for their education and ability to treat patients, their clinical skills do not apply to fixing a broken system.

If we make reform a clinical issue rather than a leadership one, we will continue to achieve the status quo.

Clinicians rarely see the bigger picture. They treat patients in offices and hospitals, and help patients manage symptoms, but outside of those places, it is society that is responsible for ensuring that patients don’t fall through the cracks.

Mind the Gap

Yet people do fall through the cracks, because unlike physical ailments, mental health problems are treated in an exclusive, secretive world. There are many good reasons for ensuring doctor-patient confidentiality, but the perverse effect of this is that in the societal realm, important groups like families and workplaces are unable to do much to help patients recover.

Integral to the mental health recovery model, is the support of other people.

This secrecy rarely happens with physical conditions. When my father was in the hospital dying of cancer, there was no veil of secrecy regarding his condition and the doctor readily shared information about his condition with me as I took him home for the last time. Everyone had a very open dialogue about his illness, his medications, and the prognosis. There were no documents that had to be filled out and no confidentiality agreements to get in the way of common sense. When I took him home, I knew exactly what to do and expect. Put simply, I was allowed to play an important part in taking care of him.

Let’s compare that situation to mental illness. As in Reid’s case, if someone attempts suicide and ends up in an emergency ward, the chances are that their family will be given little or no information, nor will they be coached and assisted in providing any sort of care or support on the home front. Why? Doctor-patient confidentiality. Bonnie Bricker believes that hospitals “hide behind” the overly restrictive policies that keep families out of the loop, even during the most critical of times.

Over my 20-year journey in the field of mental health, I cannot count the number of clinicians who, despite dogmatic regulations regarding the sharing of information, have taken it upon themselves to stray and provide information to loved ones. This means risking their career, all the while knowing that they are doing what is best for their patient. Why can’t we adjust the system to react to what is needed, for those suffering as much as for their families and clinicians?

The problem is that the system is geared towards the minority of families who are a problem and ignores the majority who could provide much-needed assistance. By trying to avoid potential harm, the system continues to do actual harm by not sharing anything with the helpful majority. Privacy therefore trumps safety.

I believe this system is antiquated. We need to involve families, and in some cases and possibly even workplaces. People don’t languish and take their own life in their doctor’s office; it happens out here, in society. To exclude families/society/workplaces from the continuum of care is irresponsible and negligent. Safety must trump privacy.

A Seamless Model for Better Continuity of Care

This brings us to Peer Support. The Transitional Discharge Model (TDM), which was tested at several Ontario hospitals between 2013 and 2015, was demonstrated to be beneficial to patients, hospital staff, and the healthcare system itself.

Not only did it result in reduced hospital stays, but it also led to fewer readmissions and provided patients with a “safety net” during their transition from hospital to home.[2] Peer support is a key component in the TDM and the project’s lead investigator, Dr. Cheryl Forchuk, expressed her hope that the TDM would become a standard across the province and the country.

As for Bonnie, she wishes that her son had a peer supporter in the ER the night he was discharged from the hospital; someone with lived experience who could have taken one look at him and known he should not be left alone. She now works tirelessly with Mood Disorders Manitoba to “get the message out there” about Peer Support and reforming our broken system.

While we continue to apply the same old methods, those with mental health problems continue to suffer, and in some cases, die. This is unacceptable, especially when there are solutions on the table and when it’s clear that what we are doing isn’t stemming the tide.

The system is broken in many ways, but some of its key failings could be worked on by focussing on three main areas:

• Realizing that the competencies that make good clinicians are not the competencies required to transform the system. We need experienced leaders who have worked on transformational change initiatives before to do that and these leaders need not be clinicians necessarily. While respecting mental health practitioners in their own right, we need outside-the-box thinkers to get involved.
• Reviewing and modernizing the way mental health professionals communicate with families, loved ones and close friends (if any), to ensure the full continuity of care after discharge and eliminate gaps, all the while protecting privacy.
• Aggressively and systematically scaling up and integrating mental health Peer Support services within the clinical system as a complement to clinical care, to ensure that patients are supported throughout the entire recovery journey and not just during their hospitalization.

Let’s shake things up and ensure that all of society gets involved in treating what is, at its core, a societal issue. Let’s make sure that some day, stories like Bonnie’s never have to be told again.

[1] Centre for Addiction and Mental Health. (2010, September 10). Mental health leaves most costly disability to Canadian employers, study finds. ScienceDaily. Retrieved August 15, 2018 from www.sciencedaily.com/releases/2010/09/100910163327.htm

[2] For more information on this study see: https://www.sjhc.london.on.ca/our-stories/safety-net-between-hospital-and-community-benefits-mental-health-patients