HEAL Committee Meeting
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STANDING COMMITTEE ON HEALTH
COMITÉ PERMANENT DE LA SANTÉ
[Recorded by Electronic Apparatus]
Tuesday, May 2, 2000
The Chair (Mr. Lynn Myers (Waterloo—Wellington, Lib.)): Ladies and gentlemen, we'll call this meeting of the Standing Committee on Health to order. It's meeting number 19.
We have, I believe, Mr. Mills, a notice of motion—48 hours is required. Did you want to table that now?
Mr. Bob Mills (Red Deer, Canadian Alliance): Perhaps I could table that now, please.
There are basically three motions that I would like to have voted on in 48 hours. The first one, of course, is that we believe mental health is important, but we think it could be dealt with by a subcommittee. That is not Canadian's number one interest when it comes to health care.
Secondly, we think that the standing committee should be looking at what the major concerns of Canadians are relating to the quality of health care, the problems with education, and the list, which I'm sure everyone here is aware of.
Thirdly, and please don't take this personally, we feel that a chairman needs to be a conciliatory person, someone who is non-partisan in their activities and who would deal on a cooperative basis to get the committee to work together to come up with solutions to what is Canadian's number one concern.
With respect, I do not believe you are that person. I am asking the minister to take action to have you replaced.
The Chair: Thank you very much.
By way of additional comments, on Thursday we will be looking at the Auditor General and after that there will be a tabling of the tobacco regulations. I believe that's coming on the 12th. So this committee will take some additional time to look at those regulations. And then after that, of course, we will resume on the mental health study we're presently dealing with.
On future business, Monsieur Ménard.
Mr. Réal Ménard (Hochelaga—Maisonneuve, BQ): Yes. Mr. Chairman, as you know, some committee members, specifically Mr. Mills, myself and the parliamentary secretary, are planning to attend the meeting of the World Health Organization.
We will be taking part in the assembly proceedings as members of the Canadian delegation. We're scheduled to leave on May 13, which happens to be my birthday, for one week. Do you think it would be appropriate not to hold a regular committee meeting during this week so that we three members do not miss out while in Geneva on any information that may be imparted to the committee?
We'll be away for one week. The parliamentary secretary can correct me if I'm wrong, but I believe we're leaving on the 13th and returning the following Sunday, which means we'll be gone from May 13 to May 19. Perhaps you're also going to part of the delegation. I really don't know.
The Chair: No, I will not, Monsieur Ménard.
Having said that, first of all, let me congratulate you on your birthday. More importantly, perhaps, let me say that is a busy week in a variety of ways. So perhaps we'll take it under advisement not to hold meetings in light of those commitments. We'll get back to you in the next meeting on that.
Mr. Reed Elley (Nanaimo—Cowichan, Canadian Alliance): Mr. Chair, I believe also that next Tuesday there is an opportunity for all health committee members as well as all members of Parliament to take part in a symposium on health and GMOs that is being presented by the Canada-Europe Parliamentary Association, with delegates from the European countries talking to us about GMOs. So we may want to make our people aware of that and make some adjustment too on our schedule for some all-important things.
The Chair: That's a good point, Mr. Elley. We'll take that under advisement and we'll report back on the Thursday meeting. Next week is a busy week as well, and we may find adjustments are required.
We have finally with us the Health Canada people with respect to mental health. I want to welcome each and every one of you.
As you know, this is a very important topic. Health, in general, is important, but we believe mental health, in particular, is of significance and great interest to Canadians. As a result, we want to hear first of all from Health Canada with respect to this all-important issue. So I'd ask whoever is going to lead off to perhaps do that at this point.
If you could introduce yourself and each of the other people testifying today, that would be an appropriate kick-off, at which point we'll hear each and every one of you. After that, we'll take questions, which is the usual and normal way of proceeding.
So who's going to lead off, please? Yes, Madame Brazeau, please.
Ms. Murielle Brazeau (Director General, Strategies and Systems for Health Directorate): Good day. My name is Murielle Brazeau and I'm with the Department of Health. Allow me to introduce to you the experts who are here with me this afternoon. Please welcome Louise Plouffe, who is responsible for seniors' mental health issues; Carl Lakaski, who is involved primarily with mental health issues and the health system; Natacha Joubert, who is responsible for mental health promotion and Louise Boily, who oversees mental health issues for child youth.
Today, I'll be giving you an overview of mental health in Canada. Two documents have been distributed to members and I will cover both of them.
The first document presents an overview of the issue while the second provides some brief details about developments at Health Canada in this field.
First of all, I will start by giving you some definitions.
“Mental health” is the capacity of each and every one of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with challenges. It's a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections, and personal dignity.
“Mental disorder” is different from “mental health”. It's conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that's associated with a present distress or disability, or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
Although mental health and mental disorder refer to two different concepts, they are not mutually exclusive. For example, a person suffering from mental disorder needs to rely on his or her own mental health to overcome the challenges of day-to-day life.
The factors affecting mental health and mental disorder are fairly similar. These include income, social status, social support networks, education, living and working conditions, physical environment, biology and genetic endowment, gender, culture and so forth. The contribution of each of these factors can vary over a person's lifespan.
Over the past fifty years, the federal government has addressed mental health issues, for example, by establishing in 1945 a mental health grant program to assist the provinces in strengthening mental health services.
In addition, between 1953 and 1996, the federal government published a journal entitled Canada's Mental Health.
In 1988, it released a discussion paper which offered guiding principles to help distinguish mental health from mental disorder. Later, in 1989 and again in 1990, a national consultation was held to discuss the implications of the document Striking a Balance.
Health Canada also supported during the 1990s the creation of federal/provincial/territorial working groups on the mental health of children and youth and the reform of the mental health system.
In the mid 1990s, Program Review resulted in major reductions in resources devoted to mental health.
A high sense of coherence, self-esteem, and mastery are important indicators of good mental health. The analysis of the national population health survey data from 1994 and 1995 provides the following information. Some 31% of Canadians had a high sense of coherence, which means that life is seen as comprehensible, manageable, and meaningful. More than half, 52%, of Canadians reported high self-esteem, and 23% showed a high sense of mastery, which is basically having control over your life. Some 74% of Canadians described themselves as being generally happy and interested in life.
The national population health survey data also reported the following: 29% of Canadians reported a high level of distress; 6% of Canadians reported feeling depressed; 16% of Canadians reported that their lives were adversely affected by stress; and 9% reported some cognitive impairment, basically difficulties with thinking and remembering.
In addition to distress and depression, approximately 3% of Canadians suffer chronic mental disorders, such as manic depression and schizophrenia. The prevalence of individuals with psychiatric disorders in primary care has been estimated at 25%, and 1% of Canadians suffer from schizophrenia.
Young Canadians are not doing so well. Canadians aged 15 years to 24 years are now showing the greatest net increase in critical stress, distress, and depression levels among the population. Canada has the third-highest suicide rate overall in the industrialized world for this age group.
It's estimated that the suicide rate for the aboriginal population is two to seven times the Canadian rate. Suicide is the leading cause of death among Canadian males aged 10 years to 49 years. Since the early 1990s, there have been significant increases in suicide rates among youth aged 10 years to 14 years.
Nationally, it's predicted that depression will be the second leading contributor to the burden of disease in the year 2020. The impact of depression on women will be far greater than on men.
The proportion of families headed by a single parent, for the most part women, has been increasing steadily for at least 25 years. Single-parent families now account for 20 per cent of all families with children. This group shows more depression, more distress and is lacking in social support more than any other group.
The relationship of distress to age has changed markedly compared with 20 years ago when seniors were the age group most affected. This trend raises the possibility of lifelong problems for the current cohort of youth.
Unemployment, which was high in the early 1990s, especially among youth, is linked to the increasing number of Canadians experiencing distress. Furthermore, immigrants and refugees display symptoms of adaptational stress that manifests itself in a variety of ways: anxiety, violence, behavioural problems, suicide, etc.
Based on 1995-96 data, mental disorders ranked second highest in total patient-days compared with major causes of hospitalization such as circulatory diseases, nervous system disorders and cancer.
Over the last 20 years, the number of mental health professionals has declined steadily. This change has been most significant for non-medical specialties such as social work and psychology.
In 1993 the total direct and indirect costs for treated mental disorders were estimated to be $7.8 billion, and they were the seventh-highest among all diseases. In a more recent study, the annual direct and indirect economic costs of mental health problems in Canada, both medically treated and not, are now estimated to be a minimum of $12.8 billion. Canadian business is estimated to lose up to $20 billion a year due to psychological distress among employees.
Of all the direct costs associated with mental disorders, treatment with drugs has shown the largest increase since 1986. On average, $65 per person is invested in provincial mental health services, compared to $2,500 per person for general health services. To date, Health Canada's involvement in mental health has focused on the key roles of leadership, research, information, education, and capacity-building.
On the situation at the provincial and territorial levels, as you know, planning and delivery of mental health care services is a provincial jurisdiction, and they have suffered reduced resources in recent years. There are two FPT committees that work with us on mental health issues. I'll talk to you a little more about them in a few minutes.
With regard to non-governmental organizations, there are major national organizations that have assisted and worked with Health Canada on developing resources to provide information for people with mental disorders and their families, and in proposing effective, community-based initiatives to promote mental health and prevent distress. Our partnerships with these organizations are very important.
I'd now like to relate to you some of the work that Health Canada is doing in the field of mental health. I've moved to the second document where at the beginning, you will find a kind of organization chart situating our directorate within the department.
You will see there is a chart. I thought it might be important and interesting for you to see how we are organized in Health Canada. The main objective is to show that mental health is currently being worked on in a number of different places in our branch.
The assistant deputy minister, Ian Potter, is responsible for all health promotion and programs in the department. He's also responsible for regional offices and tobacco.
There are two major directorates that deal with mental health in the branch. I am responsible for the Strategies and Systems for Health Directorate, and there is also the Population Health Directorate. The Population Health Directorate is responsible for aging and children, and we have two experts here. In my directorate we are responsible for the health systems and mental health promotions.
The mental health promotion unit was created in 1995 and has become the focal point of Health Canada's efforts on maintaining and improving positive mental health and well-being for Canadians. The mandate of the unit is to contribute to the development of healthy public policy and facilitate knowledge development and projects that promote and foster good mental health. The resources we dedicate to this issue are $200,000 a year in operational resources and 2.5 person years, or the full-time equivalent.
This unit is involved in a number of activities. For example, in policy and economic analysis we've documented the nature, scope, and importance of mental health issues and the rationale for action. We're assessing the impact of distress and mental ill health on the Canadian economy. We're also looking at the impact of existing programs, policies and interventions, nationally and internationally. We've developed strategies for intersectoral mental health promotion.
In terms of research and knowledge development, we're basically assessing state-of-the-art promotion and prevention activities. We've encouraged and facilitated evidence-based interventions and developed models for applying research findings to particular populations.
In terms of capacity-building, I'll give you just a few examples of the types of resources we've developed in this unit. We prepared a mental health resource directory in 1998; a mental health promotion tool kit called “A Practical Resource for Community Initiatives” in 1999; and an important brochure called “Because Life Goes on—Helping Children and Youth Live with Separation and Divorce”, which has been extremely popular, and we're currently reprinting this booklet for the third time.
YouthQuake! is a national tour we've supported that seeks to promote positive mental health and prevent distress among young Canadians. We've developed Mauve, which is an interactive CD-ROM for suicide prevention of kids, which Natacha is very proud of, and so are we. Mauve has won two awards, one international and one Canadian. Debwengidinook, which is the Ojibway name for voices, is a tool that promotes mental health and prevents distress among aboriginal youth.
Part of the work of the unit is to network with NGOs, professional associations, and international associations. We've listed in the deck a number of those associations we deal with.
In terms of the health system division Carl works in, this division is responsible, in Health Canada, for the renewal of the health care system. Within that work, there is a focus on the mental health system and the reforms in that area.
The resources dedicated for mental health in this unit are one senior analyst and $41,000 of budget per year. Our key activities in this area are mainly working with the Federal/Provincial/Territorial Advisory Network on Mental Health. We basically act as a secretariat, and support and work very closely with the provinces and territories in advancing the work of this committee.
We have also been very much involved in the development of best practices in mental health reform. We have produced and distributed a major report on best practices in mental health reform. We've developed a resource kit for monitoring the performance of mental health services and support.
We're also active in early interventions, and have played a catalyst role in the development of a Canadian Mental Health Association project entitled “Youth and Mental Illness: Early Intervention”. It is basically working on early intervention for young people with the first signs of serious mental illness.
We are also working with the criminal justice system and the mentally ill. We're working with the federal Solicitor General and Justice Canada and their provincial counterparts. We're examining how amendments to the Criminal Code are being interpreted in the criminal justice system. We're working to develop a national protocol model for coordinating the criminal justice and mental health systems, in response to the mental health needs of mentally disordered offenders.
In terms of primary health care and mental health reform, we are working to increase the quality and accessibility of services to the mentally ill within the primary health care. We're doing this by fostering networks between groups of primary care physicians and psychiatrists.
I will now speak to you about the Child and Youth Division.
As everyone knows, some children are born with conditions that affect their mental health development, while others have experiences early in their lives that can potentially have a detrimental impact on their health.
All of our work is based on developmental outcomes of children and the conditions that contribute to optimal health. Good mental health is a key determinant that affects the health of children and youth.
The focus of our work is in policy, research, program and resource development. We do this through building partnerships, supporting NGOs, model development, public and professional education and undertaking research and analysis.
On the subject of partnerships, we work collaboratively with a variety of partners including the federal/provincial/territorial working group on the mental health and well-being of children and youth. The aim is to identify trends and emerging issues and to provide recommendations regarding the priorities and directions of Health Canada's initiatives.
Links are also established with other key activities such as the National Children's Agency, the Advisory Committee on Population Health, and the Centres of Excellence for Children's Well-Being.
Mental health issues are also integrated into the work being done through the community-based children's program.
Key children mental health issues informed by research and addressed by the Division include: resiliency, lifeskills development, learning disabilities, depression and distress.
Here is what we are doing in these areas.
In terms of resiliency, we are in the final stage of seven longitudinal community-based research projects on children, family and community resiliency.
With respect to lifeskills development, we are working in conjunction with the WHO on a project entitled “Guide to Lifeskills”.
On the subject of learning disabilities, we are involved in the project “The Economic Burden of Learning Disabilities and its Impact on Families”.
To address issues such as depression and distress, we have launched a program entitled “Youth Net/Réseau Ado”.
Finally, regarding the funding of and resources assigned to youth mental health, the Division's current operational budget for mental health is approximately $150,000 a year with two FTEs.
Furthermore, $800,000 in Grants and Contributions are also allocated through the Population Health Fund to projects related to mental health.
With regard to the Division of Aging and Seniors, the mandate of this division is basically to be a centre of expertise and a catalyst for change to support healthy aging within a population health approach and to prepare society for the aging of the population. The division provides advice, education, research, and programming in partnership with other sectors. It provides also secretarial support to the National Advisory Council on Aging.
In terms of mental health activities, we do some research and analysis. We are working to get data to identify risk factors for depression in later life, and we're working on the dissemination of an analysis of risk factors and consequences of social isolation.
In terms of resources, we have about $20,000 per year plus half a person-year devoted to this area.
We are working in terms of community demonstration projects. Mental health was a priority for the year 2000-2001, and we are trying to get proposals for this work.
In terms of the National Advisory Council on Aging, it assists and advises the Minister of Health on all matters concerning the well-being of seniors and the aging of the population. Mental health is identified as a challenge in the policy report entitled 1999 and Beyond: Challenges of an Aging Canadian Society.
Before I conclude, I just want to indicate that there are other areas linked to mental health in our branch that are not addressed here. For example, in the branch and in the department in general, we do work in the areas of HIV/AIDS and rural health. So there are links to mental health in other areas of the department. But the core of the mental health activities is done by this group here.
As you can see, mental health resources are rather scarce. However, much has been accomplished in recent years and I believe a lot of this is due to the dedication of experts, including the four individuals here present. They have been tireless promoters of mental health issues.
Thank you for your attention. My associates and I will now be happy to answer your questions, if we can. Thank you.
The Chair: Thank you very much, Ms. Brazeau.
In light of the experts seated at the table, would you please take time to introduce them and indicate what positions they hold.
Ms. Murielle Brazeau: Yes. Louise Plouffe is responsible for the mental health of seniors; Carl Lakaski is responsible for mental illness and the work on the health care system; Natacha Joubert is responsible for mental health promotion; and Louise Boily is responsible for mental health for children and youth.
The Chair: Thank you very much, and thank you for that very good presentation. I think it gives an excellent overview in terms of what the department is doing, and I want to congratulate each and every one of you for the good work you do on behalf of Canadians.
Having said that, we will go to questions now. We'll start off with Mr. Mills, please.
Mr. Bob Mills: I'd also like to thank the witnesses for attending.
I think mental illness is something all of us come across in our ridings, and we deal with it as our constituents bring their many problems to us and ask, what can we do, how can you help, where should we go? I think all of us probably have had that experience.
Several things come to mind, including, first of all, the seriousness of the aging of our population and that increasing. We've all seen figures for 2000 and for 2026, when we double the number of people over 65. Is the number of people having mental problems increasing? What will that demographic do to us 26 years down the road?
Secondly—and I'm not sure whom to address this to—when we look at the overall health care system, we find that there are some real problems in terms of we're behind in technology and in research and development. We lose 50% of our graduates every year. The average age of specialists is 59, and they're not being replaced. Universities have cut their courses and are not training as many specialists. The list goes on.
I wonder if that's the case as well in dealing with mental illness. I am told that in my constituency there's a real shortage when you have a child who has attempted suicide or when you have a senior who would rather die than live and becomes extremely depressed. I'm told that you might wait nine or ten months before you could see a specialist and get treatment. It's not that the system isn't there; it's just that you can't get into the system. I wonder if that's true across Canada. I wonder how you think that should be dealt with and what advice you would give the political people here in terms of fixing that.
Ms. Murielle Brazeau: First, on the seniors question, I'll ask Louise to answer.
Ms. Louise A. Plouffe (Manager, Population Health Directorate, Division of Aging and Seniors, Knowledge Development Section, Health Canada): Thank you for your question.
Depression is the most commonly reported mental health problem among older adults. Even if the prevalence in the community is low, the national population health survey indicates that seniors 65-plus have a prevalence of about 3%, which is much lower than for the younger adult population. Just the sheer numbers of seniors in the coming years will mean that there will be more seniors reporting depression.
Dementia is a serious cause of concern. About 8% of the population 65 and older has dementia. About half of them live in the community. The prevalence of dementia increases with advancing age, so that for the population 85 and older, we're looking at about a third who have dementia. Half of them are living in the community; that is, people with some form of intellectual problem, impaired judgment, impaired memory, impaired language. Many of them have family caregivers, but some of them don't. Of course in institutions the number of persons with dementia is very high.
We don't have results data on depression in institutions for Canada, but in the U.S. it's something like 30% to 40% of older adults living in institutions have depression.
So you're right, we're looking at a serious problem. And even if the numbers don't increase in incidence, more people getting the conditions, just the sheer numbers will mean that this will be a greater problem.
The suicide rate among seniors has gone down over past decades, but still the single group that has the highest suicide rate is men over the age of 85.
The Chair: Certainly those statistics are disturbing and something we need to think hard and fast about in terms of what, if anything, can be done to correct that.
Were you through, Mr. Mills?
Mr. Bob Mills: There was the other question about the specialists and the many other problems we could list. I just named a few of them.
Mr. Carl Lakaski (Senior Analyst, Mental Health, Strategies and Systems for Health Directorate, Health Systems Division, Health Systems Development Section, Health Canada): One of the distinguishing features of the mental health field is that it's not a high-tech field. It's a low-tech field. They don't have the same problem in keeping up with technological advances that perhaps you might have with cancer or other terminal or chronic diseases.
For the most part, clinical interventions in the mental health field rely upon psychotherapy or medications and also psychosocial interventions that target creating greater inclusiveness in the community with regard to the role of the mentally ill; ensuring that citizenship rights of the mentally ill are acknowledged and that in fact they are accorded the same citizenship rights as Canadians without mental disorders; and dealing with the problem of stigma, which is frequently a barrier for people seeking help. It also contributes to considerable suffering and misery on the part of those who have mental illness and their families. Those are the kinds of interventions that we don't fall behind, as I say, in the same way in terms of technological advances.
There has been perhaps a decrease in expertise in the field. That could be related, of course, to the various problems around the cutbacks in the health care system that we suffered across the country. It makes it less appetizing to enter the field, in the same way that there's a problem with nursing shortages.
Mr. Bob Mills: It would seem to me that if you have a mental problem and there's a shortage of specialists to deal with it, that could become very critical, obviously, if suicide and so on are a consideration.
Mr. Carl Lakaski: That's very true. We're seeking to address that through the emphasis on primary care and mental health, trying to make those specialist services available to people through the primary care system.
We're supporting two initiatives right now. One is a collaborative initiative between the College of Family Physicians of Canada and the Canadian Psychiatric Association. They've developed a shared care model whereby teams of local family physicians are connected to a psychiatrist who will respond to their requests for help, in terms of diagnosis and treatment, within a specified period of time, and indeed will visit them once a month or once every two weeks or whatever the contract states so that they can get the expertise of a psychiatrist to help the system in managing their patients.
That increases accessibility. It also diminishes the role of stigma. People are much more comfortable going to see their family physician to talk about depression or anxiety or whatever, rather than going to see a psychiatrist. Still there's a considerable symbolic attachment of high negativity to seeing a psychiatrist.
We're also supporting a World Health Organization physician education package that is particularly suitable for rural areas. Physicians will acquire over a two-day period a binder plus education on six common mental disorders. That binder will include information that could be distributed to the patient to help the patient monitor his symptoms and his treatment. It will also provide treatment protocols for the physician to use. He'll be able to go back to this binder time and again to deal with patients he sees who are exhibiting emotional or psychiatric difficulties.
So there are two separate yet complementary initiatives to make mental health care more accessible and bring it to fall within the primary care system.
The Chair: Mr. Lakaski, you make a number of really strong points. The one that resonates for me is this whole business of stigma. If anything, a goal of this committee in this study, certainly one of a number of goals, should be to help Canadians understand we need to do everything in our power to reduce the stigma attached to mental illness. That's very, very important. I'm hopeful we can flesh that out over the course of time, and I think we will. It's a very good point, and I wanted to interject and make that intervention.
The parliamentary secretary, Monsieur Charbonneau.
Mr. Réal Ménard: I have a point of order.
The Chair: Yes, of course.
Mr. Réal Ménard: Mr. Chairman, that's not the order we agreed upon and that we've always followed. As a rule, we begin with the Canadian Alliance and then the Bloc Québécois, followed by the government. I don't understand why you've decided to proceed differently today. Is it because the member must leave early?
Mr. Yvon Charbonneau (Anjou—Rivière-des-Prairies, Lib.): Yes, as a matter of fact, I have to leave in a few minutes.
Mr. Réal Ménard: Well then, why didn't you say so? We're not mind readers.
Mr. Yvon Charbonneau: I hadn't yet had the chance to get a word in.
Mr. Réal Ménard: I see. Well then, by all means, go ahead.
The Chair: Avec plaisir, did you say?
Mr. Réal Ménard: Yes.
The Chair: Thank you very much.
Mr. Réal Ménard: But you must explain why, because if I don't understand, I cannot guess.
The Chair: Monsieur Ménard, you were too quick off the mark. You see, I was just about to introduce Monsieur Charbonneau and tell you he had to leave, and as a result that's why I was going to him. But your point of order intervened before I could do that.
Mr. Yvon Charbonneau: I'd like to thank Mr. Ménard and the other opposition members for being so understanding. Sometimes, one has to go along with arrangements like this.
We've been listening to a highly informative presentation on mental health and related issues. Several weeks ago, we discussed whether this was a subject that needed to be considered and what our priorities should be. In light of the information that you've shared with us, it's clear that this is a complex issue. Although we may not have given ourselves the necessary resources to deal with this issue, nonetheless, we can't deny that this a major concern. You stated that depression is poised to become the second leading contributor to the burden of disease by the year 2020. That's quite a statement. You also informed us that depression will strike more and more young persons, whereas in years past, it was mainly the elderly who suffered from this illness. Depression in young persons is more likely to be a lifelong problem for this person, for his family and acquaintances and for society. Therefore, we're dealing with a serious problem here.
You also drew our attention to the economic impact of these illnesses, which were the second leading cause of hospitalization in 1995-1996. This statistic is by no means insignificant. In 1993, the costs associated with mental illness totaled $7.8 billion, whereas economic costs, direct as well as indirect, totaled $12.8 billion annually. Meanwhile, businesses losses amounted to $22 billion. As I said, mental illness is the second lead cause of hospitalization.
These statistics illustrate the gravity and scope of the problem and compel us to take action. How should we go about doing that? You were very frank in stating that the planning and delivery of mental health services is primarily a provincial and territorial government responsibility. That's clear, and we don't disagree with you. You noted that the federal government has taken some steps in the past and, among other things, has participated in a federal/provincial/territorial working group. You also referred to a federal/provincial/territorial consultation network on mental health issues. I'd like you to tell us a little more about these last two initiatives. When was the working group set up and when was the consultation network created? Are they still active, or have they suspended their work for the moment? What impact did the work of these two bodies have? What is the nature of the relationship between the federal government, the provinces and the territories? Clearly, some initiatives have been taken. Can you tell us where things stand today, in early 2000?
Ms. Murielle Brazeau: I'll ask Louise to give you an overview of the federal-provincial committee on children and youth for which she has responsibility. Then, I'll have Carl speak to the committee about mental disorders.
Ms. Louise Boily (Mental Health Senior Consultant, Population Health Directorate, Childhood and Youth Division, Child, Youth and Family Health Section, Health Canada): Thank you for your question, Mr. Charbonneau. Let me refer to the documents that were circulated to members.
The Chair: Perhaps while you're doing that, we could have a brief overview, and then you can find the reference.
Ms. Louise Boily: The Federal/Provincial/Territorial Working Group on the Mental Health and Well-Being of Children and Youth is still operating. It last met last year. In view of major initiatives undertaken that target children and youth, we are presently revising the working group's mandate and role. Key activities undertaken include the National Children's Agenda, which was launched in cooperation with the provinces and territories. The Advisory Committee on Population Health has released some papers on children and youth. We also intend to establish centres of excellence for children. The Advisory Committee which is composed of experts working primarily in the field of mental health and children, recommend to us actions and initiatives. It has drafted two working papers for us. The first paper, the first official report to be released by a federal/provincial/territorial committee on the mental health of children, is entitled Foundation for the Future/Base pour l'avenir. The second paper, Building for the Future, is a much more detailed plan of action laying out different steps or initiatives that the federal government can undertake in cooperation with the provinces.
Mr. Yvon Charbonneau: When was the paper released?
Ms. Louise Boily: In 1994. It continues to serve as a framework for action when we develop different projects and initiatives. The Advisory Committee has these documents in hand and reports informally to the Advisory Committee on Population Health. This committee is very active and is an excellent resource when it comes to all child-related issues. Over the course of the next few months, we will find out exactly what its mandate and responsibilities will be.
Mr. Yvon Charbonneau: And what can you tell me about the advisory network?
Ms. Louise Boily: My colleague can tell you more about the network.
Mr. Yvon Charbonneau: Thank you.
The Chair: Just before you do, Madame Boily, could you have those documents given over to the committee, or could we at least get a copy of them?
Ms. Louise Boily: Certainly.
The Chair: That would be useful for staff as well as for all members.
Ms. Louise Boily: I will table the documents that I brought along with me because I intended to leave them with you.
The Chair: Thank you very much.
Mr. Carl Lakaski: The Federal/Provincial/Territorial Advisory Network on Mental Health is the only intergovernmental group that focuses on system-wide mental health policy, programs, and issues. It consists of senior mental health officials from each of the jurisdictions. The advisory network meets twice a year. Most recently, a month ago, in April, it met in Vancouver.
It's been very proactive over the last couple of years. It helped produce a series of documents on best practices in mental health reform, which is assisting the provinces in developing science-based—or evidence-based, as they call it—mental health systems. It also supported two national conferences on best practices and mental health reform. There's a real concern among members of the advisory network that the kinds of developments that occur within the mental health system reflect what science has demonstrated works effectively and efficiently.
Also, a recent project they're about to complete concerns the resource kit on performance indicators for mental health systems. This again feeds into the idea of an evidence-based system, providing information in order to make crucial decisions as to which way program design and policy should go in the mental health system.
They're also very concerned with the alignment of the criminal justice system and the mental health system. The ANMH—that's the acronym for the committee I'm discussing—provided crucial advice to the justice department when they were developing their violent offender legislation a few years ago. They're right now involved as partners in an assessment of the mental disorder amendments to the Criminal Code that the justice department is concerned with. Certain issues in the justice department impact resource-wise quite heavily on the mental health system. The mental disorder amendments in particular do so.
I should say the Advisory Network on Mental Health reports to the Conference of Deputy Ministers of Health through the Federal/Provincial/Territorial Advisory Committee on Health Services. This provides us with an avenue to understand the deputies' concerns with respect to mental health issues and to be able to make our work known at the level of the deputy ministers.
We have scheduled for the next meeting, which will be occurring in October, a work planning session where we hope to scope out a three- to five-year work plan for future initiatives the advisory committee will be pursuing.
The Chair: Thank you very much. I appreciate those comments.
Monsieur Ménard, please.
Mr. Réal Ménard: First of all, I have a general comment. I hope none of you doubts that we are convinced of the importance of mental health. Obviously, the problem we had with the minister's letter setting the mandate was the issue of constitutional jurisdiction, of how the government was planning to go about setting a national policy on mental health. We have some concerns about this. Your brilliant presentation has hammered home the fact that this is an important problem and that the resources you receive to deal with it are truly laughable. A total of $200,000 a year is pretty ridiculous. We also learned that you don't have any direct expertise and that you do not work directly with people with mental health issues. Rather, you work on prevention tools, on mechanisms for action.
Having said this, we mustn't forget that there is a motion on the table to assign this mandate to a body other than this committee. I have four short questions for you. In my view, there is a very real link, or correlation, statistically speaking, between poverty and mental health. You gave us some very telling statistics on mental health in various communities. How do we address the problem of the link between poverty and mental health? Do we need tighter support networks? Could these problems be addressed by bringing in social policies that we haven't yet considered?
I will run though my other questions all at once.
Secondly, another matter is of deep concern to parliamentarians and that is the suicide rate among young persons. What explanation can there be for this rate? What more can you tell us about this phenomenon?
Thirdly, is mental health more connected with physiological problems among the elderly? I'm not talking here about people in their fifties and sixties, but those who are even older than that. If a person doesn't smoke much and pays attention to his health, his chances of living until 80 are pretty good. Imagine, Mr. Chairman, how much fun the two of us will have together if I live until the age of 80! Would you agree with me that the mental health of the elderly is more of a physiological problem?
These are my three questions. I'll reserve the fourth one for later.
Ms. Murielle Brazeau: I think I'll ask Natacha to answer your first and second questions. Louise might want to speak briefly to the second question concerning youth. Finally, Louise Plouffe could also address the committee on this matter.
Mr. Réal Ménard: If I understand correctly, you'll begin by answering my question on poverty.
Dr. Natacha Joubert (Researcher and Manager, Strategies and Systems for Health Directorate, Health Issues Division, Wellbeing Group, Mental Health Promotion Unit, Health Canada): If you don't mind, Mr. Ménard, I'll start by answering your second question first, and then go back to the first one.
Youth suicide is a serious, poignant human problem. To give you some idea of the importance of mental health in our lives and to grasp the scope of the problem, let me share with you the following statistics. The rate of suicide among young persons began to increase dramatically in the 1970s and 1980s and has remained very high in recent years. A number of researchers are looking at the same questions. If you talk to the people who work directly with young persons in the field, you will probably hear somewhat different explanations for the phenomenon. Researchers are trying to identify the risk factors for suicide and are looking closely at neurophysiological, social and family considerations. They are looking at youth suicide from every angle. Those who work in the field realize that a host of factors come into play and they generally have a more comprehensive view of things. Most will tell you that unquestionably, the quality of a person's life, including the lives of young persons, is an important factor. Of course, quality of life is affected by economic conditions. However, it also depends fundamentally on a person's association with the world in which he or she lives. Young persons need their family, just as they need to develop and maintain ties with the community. They have many questions about what the future holds for them. In short, in the case of young persons, suicide issues are tied to life issues.
Mr. Réal Ménard: Issues such as how they will make their way in life or the actual meaning of life? Are there no longer any benchmarks for young persons?
Dr. Natacha Joubert: Both. Young persons no longer have any reference points when it comes to attaching a meaning to their life. Questions about values and meanings are very important. As for economic issues, when the quality of a person's life slips, that person generally does not fare as well as before.
Mr. Réal Ménard: I have a secondary question for you.
Is suicide also prevalent among members of society's more privileged classes?
Dr. Natacha Joubert: Suicide cuts across all socioeconomic lines. Those who imagine that only people living in less than ideal socioeconomic circumstances experience distress and commit suicide are deluding themselves. Distress is a human emotion, one experienced by people of all ages and from all socioeconomic classes.
Another key factor is the support available from family or more generally, from society. Support is a very important risk factor. When things aren't going well and desperation sets in, if support is not available, then already....
Mr. Réal Ménard: To sum up, and I hope we'll have an opportunity to broach this subject again - it is said that a generation spans 25 years. I would bet that we are both products of the same generation. How do you explain the fact that the generation before us didn't have to grapple with this problem?
The family unit has changed, but the role of families in society has not diminished. The makeup of families may have changed. In other words, if the unemployment rate were only 3 per cent, and full employment was commonplace, do you think as many people would be experiencing this level of distress or would the problem be less prevalent?
Dr. Natacha Joubert: In my view, the key factor is social support. I would put this at the top of the list. One phenomenon that has grown steadily in recent years is the breakup of families. Family members have scattered. The family unit has taken on a different appearance. Even life in the community has changed. What explanation can there be for the higher number of suicides today? Generally speaking, I would have to say that young persons do not receive even the minimum amount of support they seem to need to develop and make their way in society. That about sums it up.
Mr. Réal Ménard: Could you now address the poverty issue?
Dr. Natacha Joubert: Let me try and recall your question first.
Mr. Réal Ménard: It concerned the link between poverty and mental health.
Dr. Natacha Joubert: I believe I answered the question in part. I would just like to add one thing, if I could. I think it's very hard to support and justify the existence of disparities in our society. If Canada were a poor nation and everyone was in the same boat, we would probably get by as best we could and get on with our lives, as people elsewhere do. However, when we are faced with a situation of our own making where the gap between various groups or classes in society continues to widen and when we think of people as living on either the right or wrong side of the tracks, this way of thinking can be extremely damaging.
Ms. Louise Boily: I'd like Natacha to focus on the fact that the suicide rate among young persons in a certain age bracket has increased. Perhaps you could talk a little more about that.
Mr. Réal Ménard: For instances, the statistics on page 16 are very disturbing.
Dr. Natacha Joubert: The figures for 1998 are just in. Earlier, we talked about the new trends that have emerged over the past 20 years. There is no question that many more young people are experiencing mental distress. The suicide rate over the past two decades has remained very high. In the past ten years, we have noted an increase in the suicide rate among the very young, that is among children between 10 and 14 years of age. This is a very telling statistic. These children are much closer to us than we think. Sometimes, they experience more of the same things we do than we might expect.
Mr. Réal Ménard: I have final question. Do you think its really possible to cure mental health, that is to say cure people who suffer from mental disorders?
Consider this: for the past three weeks, I've been “seeing” a psychiatrist. I'm allowing him into my life. It's not always simple dealing with psychiatrists. They analyse people and have a way of uncovering people's darkest sides.
Do you think that there is a link between the resources invested in mental health and health care professionals' ability to heal people? Are mental disorders treatable?
Dr. Natacha Joubert: First of all, I would just like to say that we don't cure mental health, we enjoy it. What we want to cure is possibly the suffering, which is heavy burden. There's one thing we need to understand. Too often, people confuse mental illness with suffering. Human suffering has always existed. It is part of our history and ultimately, we have to accept it for what it is.
I'm not convinced that the solution to mental health problems, to distress or to chronic mental illness lies solely in seeking treatment. Obviously, people who suffer from a serious, chronic mental illness need medical treatment. One has to realize that in some respects, the treatment they do receive is somewhat limited. What I mean by that is that we still have a great deal to learn about mental disorders. Theories abound about the etiology of mental illness but the reality is that we still don't know a great deal about it.
Of course persons with mental disorders can seek treatment, but we need to remember that they are still human beings and that they need to live their own lives, to work and to contribute to society. Too often, we tend to relegate these individuals to the fringes of society.
Some people suffer from very serious mental disorders and require some form of treatment. This is not to say, however, that these individuals, along with the 25 to 30 per cent of Canadians who experience psychological distress, which is not a mental disorder per se, will necessarily benefit from a curative approach. What we really need to do is promote mental health. We must focus on personal resources and increase community support resources.
The Chair: Thank you very much. That was a very good explanation.
Ms. Davies, please.
Ms. Libby Davies (Vancouver East, NDP): Thank you very much, chairperson.
I'd like to thank the witnesses for coming. I think the information you've provided us with today is very useful, but I receive this information with a certain level of frustration. In the community I represent, Vancouver East, I feel that on a daily basis.... In fact, everywhere you go there are excellent reports available. There's the national health study that was done, there are provincial reports, there are reports through regional mental health organizations. I feel that the evidence of what we have to deal with and the issues around mental health and mental illness are very much before us. In fact, we could probably pile all the reports up to the ceiling here.
I think what is frustrating, though, is our lack of capacity to be able to respond in a way that's really actually getting to people. Certainly, the people I come in contact with are people who I would say are increasingly falling through the cracks. They're falling through the social safety net. They're people who are often facing a dual diagnosis of mental illness and addiction. The health care system generally becomes less and less accessible to those people.
For example, in one of my neighbourhoods, the downtown east side, the leading cause of death is now drug overdoses. Injection drug users are in many cases also facing mental illness. What's come about is de-institutionalization.
While I really appreciate your info, to me the crux of the matter is why we are failing to provide the resources that get to people at a very primary level. I'm talking about housing. I'm talking about adequate income support. I'm talking about appropriate treatment models that are accessible to drug users, that aren't bureaucratic and so involved that people can never get to them, that deal with young people in a realistic way that isn't judgmental and moralistic. To me these are the frontline issues that are there that we seem to have a lot of difficulty in actually coming to grips with.
I realize that's one big question, but I'm interested in your comments from Health Canada's perspective about this kind of broader environment of social supports and housing supports. I think you're right that mental illness and mental health go across all classes, but I can tell you that if you're poor, you face a double jeopardy and your vulnerability and your risks are far greater.
Mr. Carl Lakaski: I did mention the work of the Federal/Provincial/Territorial Advisory Network on Mental Health. They are concerned with many of these issues of fragmentation and gaps in service delivery. One of the attempts to address those is through the best practices models. The other attempt to address it, of course, is through primary care. It is assumed that many people miss out and fail to access appropriate mental health service precisely because it isn't available to them at the street level or at the level of their family physician. We hope to rectify that.
I wouldn't disagree with you in terms of the double jeopardy connected with poverty, but I also think mental health has to be connected to a larger vision of what constitutes a good society. I think that's a political question. It's a value question and it's a political question.
How should we organize our society and on what basis should it be organized? Whose values should predominate? How should wealth be distributed or what mechanisms should we use for the distribution of wealth and productivity in this country? It's that larger vision of what constitutes a good society that speaks to many of those issues. It's an issue that we as public servants don't address directly, but it's left in the political system.
Ms. Libby Davies: Just to follow that up, if I could, it seems to me that one of the very concrete things that's happened in terms of public policy development is the issue of deinstitutionalization. I think it's really easy for elected people or health care experts to say they want to get people out of institutions. I agree with that. Everybody agrees with that. Certainly the people who are living in those institutions would agree with that. But if we've failed to put into place the necessary supports in the community....
For example, I know from the injection drug users study in Vancouver that one-third of the increase in HIV infection is people with mental illness. It's directly linked to deinstitutionalization.
One question I could ask you is in terms of either federal-provincial relations or the research that Health Canada does independently. Do we track what has happened with deinstitutionalization? As you know, it's a noble goal, but it seems to me that in a real world sense it has been a failure because we've literally dumped people out on the street with no supports. As a result, you begin to see a backlash that develops and you begin to see people who then become criminalized.
This is a very serious phenomenon in Canada. People have become criminalized because they're poor and because they're mentally ill, not because they've really done anything wrong. They end up in the judicial system, they end up being harassed by police, they end up being squeegee kids, whatever. It's a criminalization issue as well. Is there any tracking of that?
Mr. Carl Lakaski: Unfortunately, at the national level we have a very underdeveloped ability to monitor mental health issues. We're hoping to address that and we think we're going to be better placed to do that with the recent restructuring of the department in such a way that we'll be able to develop systems to monitor mental health issues or mental health variables in the provinces and in the territories.
Ms. Libby Davies: I think that would be really important because it's happening across the country and I just don't know that anyone's really paying attention to it. We're all coping with the problems that result from it and no one is looking at actually what happened as a result of these big decisions to deinstitutionalize.
Mr. Carl Lakaski: You're right. During the 1950s and 1960s, when deinstitutionalization first took place, there was this assumption, which later proved to be incorrect, that the community would naturally absorb those who were taken out of institutions and put into their communities. That was not the case.
Since that period of time, there have been a number of adjustments in the mental health system itself: improvements of services, improvements in responsivity. Those have, to some extent, dealt with some of the problems around deinstitutionalization, although the problems still continue because the adequate community services are not in place. I know I'm repeating myself, but that's what the best practice models are meant to do, to address exactly that issue. What services should be in place at what level to address what range of problems?
Ms. Libby Davies: One of the key ones is housing.
Mr. Carl Lakaski: Yes.
Ms. Libby Davies: I come across this every single day. If people don't have safe, adequate, affordable housing, what can you do? Nothing else is going to go right. That is a basic sort of premise of bringing people into the community, for sure.
Mr. Carl Lakaski: Right.
The Chair: Ms. Davies, I'm going to interject at this point. I think those are very good and pointed questions, and there were some very good responses. I've given some latitude, but I'm prepared to do that because of the quality of what was—-
Ms. Libby Davies: That's okay. I've finished.
The Chair: Thank you very much.
Mr. Marcel Proulx (Hull—Aylmer, Lib.): Thank you, Mr. Chair.
Good afternoon, sir.
Let me make a confession right away. Unlike my colleague, I'm not “seeing” a psychiatrist. Therefore, I don't think we will have any kind of conflict of interest.
Mr. Réal Ménard: We could arrange a date for you with someone we know.
Mr. Marcel Proulx: Listen, we can discuss our social lives after the meeting.
I have long recognized that mental health is very delicate and must be treated with great care. Before I get to the main issue, I have two brief questions about the statistics quoted.
Are statistics available in Canada on the number of senior citizens living in private or public residences who require and are not receiving treatment for mental health disorders? Very little is done to treat mental illnesses in private and public nursing homes. That's my first question.
My second question also concerns statistics. Do you have any comparative statistics on first line mental health and physical health services? Today in Quebec, it's extremely difficult to obtain emergency psychiatric services compared to emergency medical services.
If you cross the bridge to Quebec, you will see that in the Outaouais, there are no emergency services available in psychiatric facilities. These types of services are combined with regular medical services. It's only two or three days later, after the patient's needs have been assessed, that he may be transferred to a psychiatric facility. Do you have any statistics on first line psychiatric services? Do you have that kind of information? I see.
Now for my big question,
my loaded question.
According to the figures you quoted....
Ms. Murielle Brazeau: Current statistics are available from the provinces. We don't have them with us right now.
Mr. Marcel Proulx: You don't have access to them.
Ms. Murielle Brazeau: No. We referred to a number of statistics on mental health in our presentation, but that's about all the figures we have. However, I would imagine that we could get a hold of them.
Dr. Natacha Joubert: Basically, since health services are a provincial responsibility, much of this information is in the hands of the provinces.
Mr. Marcel Proulx: Mr. Lakaski was saying earlier that the methodology you use for collecting data is not up to date, but that it is likely to be perfected sometime soon.
It was my understanding that you represent the entire federal team. There must not be many people left at your office this afternoon.
Ms. Murielle Brazeau: There are people who work in other areas.
Mr. Marcel Proulx: I mean your office. Well then, it must be something of an inconvenience, not being able to take a vacation or sick leave for that matter.
The loaded question is what can the federal government do in addition to what you have been so successful at—and I recognize the good work—and what kind of money would the federal government need to invest so that we get better or more results from the federal aspect of health in regard to mental health?
Ms. Murielle Brazeau: First of all, as far as statistics are concerned, Mr. Lakaski has told me that he doesn't think the provinces keep these kind of statistics. Some provinces may, but it is not standard procedure nationwide.
Mr. Marcel Proulx: You're talking about statistics?
Ms. Murielle Brazeau: I'm referring to your first question about general statistics.
Mr. Marcel Proulx: I see.
Ms. Murielle Brazeau: We're saying that some, but not all, provinces, keep these kind of statistics.
Mr. Marcel Proulx: Fine.
Ms. Louise Plouffe: First of all, there are no statistics on seniors in private residences, precisely because these are private, not public, facilities.
Mr. Marcel Proulx: What about the information gleaned from the Statistics Canada census?
Ms. Louise Plouffe: The census provides information as to age, gender and civil status, in short, basic information. However, it provides absolutely no information....
Mr. Marcel Proulx: Nothing about health.
Ms. Louise Plouffe: No information whatsoever. The National Population Health Survey has an institutional component which enables us to collect data on persons in institutions. I'm not aware of any specific analyses that have been done, but one of the initiatives that we mentioned in our presentation involves doing analyses to assess mental health requirements along with the rates of mental illness or mental disorders of persons in institutions in Canada. That is about all I can tell you.
Mr. Marcel Proulx: Thank you.
A voice: Now for the big question.
Dr. Natacha Joubert: Yes, the big question.
I'm tempted to respond that generally speaking, we seem to keep statistics on issues that seem important to us and that we wish to track. People don't seem to think that mental health is important enough to warrant our collecting data systematically from across the country. That's the reality of the situation.
A voice: That answers the bigger question. More services are what we need.
Dr. Natacha Joubert: Partly. That may be the answer to the bigger question which we too have been asking ourselves for quite some time now.
It had become important for us, in recent years, to consider the mental health issue from every possible angle. Between 3 and 5 per cent of Canadians suffer from a serious mental illness. Equally, however, 30 per cent of Canadians of all ages suffer from various kinds of problems. They experience psychological distress, ranging from anxiety to stress, violence and suicide. In short, they suffer from a range of disorders. One important step would be to look at mental health from a very broad perspective. Not only would this help us gain a better understanding of the issue, it would also shed some light on one point that was brought up earlier. It would also be a very effective way of better understanding how people are stigmatized and marginalized. That's possible if we recognize that our mental health is a fragile commodity. All people encounter trials and tribulations during their life and at one time or another, we may be in need of support. When we finally accept that no one is immune, we realize that not only the weakest members of society experience problems.
It's important then for the provinces and the federal government to work together. Although all of the information isn't yet in, we already know that in order to meet the mental health needs of Canadians, promotion, prevention, treatment and rehabilitation initiatives are needed. In fact, the problem must be addressed through various interventions and activities. We already know the costs involved, given that we've just completed a study. We're talking about billions of dollars a year. Obviously, there is a tremendous amount of suffering occurring.
Therefore, I think the different stakeholders should be the ones to debate the figures. Generally speaking, however, non- governmental organizations, communities across Canada and mental health professionals are telling us that concerted action is the best way to prevent distress. We need to mobilize and each stakeholder must assume his share of the responsibility.
I won't go into the details of the figures at this point in time. However, having worked in this field for many years now, my feeling is that a minimum investment would be needed to promote the mental health of Canadians and to prevent distress. We don't need to invest billions in this cause. However, to sit back and simply do nothing costs us billions each year.
The Chair: Thank you, Madam Joubert. That was very enlightening.
Did you have something to add, Madam Boily?
Ms. Louise Boily: To add to what Natacha just said, one promotion and prevention initiative aimed at children and youth which could have a significant impact would be to focus on childhood development through such initiatives as the National Children's Agenda. Activities and initiatives of this nature which target the general public and youth can have the greatest possible impact on the largest number of young people. Very specific initiatives are needed. For instance, there is the whole matter of inquiries.
At present, we have no national data on young persons. I'm not talking about provincial or territorial statistics, but about national data on how our youth are faring. We're talking here about preschool age children. A great deal of information has been collected at the provincial and territorial level in schools and elsewhere, but the data remains quite fragmented. There is no uniformity in the data collected across Canada.
Collecting better data is one thing the federal government could do to get a better understanding of the mental health of our children and youth and of the mental disorders that afflict them.
The Chair: Thank you very much.
Are you satisfied, Monsieur Proulx?
Mr. Marcel Proulx: Thank you.
The Chair: Thank you very much.
Mr. Jackson, please.
Mr. Ovid L. Jackson (Bruce—Grey, Lib.): Thank you very much, Mr. Chairman.
I'd like to welcome our guests.
We do have a body and a soul, but it seems like we haven't come too far. I recall early in the 1960s when I was at university. When a person had a physical break in their leg or something like that, it was great, everybody saw it and so on, but when you had a nervous breakdown, they wanted you to show which nerve had broken down.
From what I'm hearing, there is still a certain amount of taboos. I noticed it in 1993 when we had a study, Economic Burden of Illness in Canada. Obviously the total health of Canadians is important, and mental health is part of the total health. I wonder if maybe we could get an upgrade, or if there has been one, on the economic burden and what component mental illness is of it.
I'm hearing a lot about how somehow there's a taboo about statistics. You have to figure what the federal role is here. Obviously health care is a provincial affair, but information gathering is part of what we have in order to get a picture, in order to deliver these services.
I notice as well that you were saying that the national child care action plan is a good program because it's a holistic approach and doesn't label the person. You take a more holistic approach to people rather than saying this person is a little different from the other person.
First of all, I'd like to know what component of the total health care package is mental health. What chunk of money? Also, what are the effects on our economy of some of the problems we have in mental health? Many of the kids that are street kids or squeegee kids and so on—you alluded to that—are disenfranchised and poor, have sexual orientation problems, and may have been taken out of institutions and things like that.
These factors show up and manifest themselves in a whole different way, and yet we still don't seem to take this holistic approach. I think Libby Davies alluded to some of this stuff. We talk around them, but how do we apply them?
How can we, as a federal government, gather this information, including the statistics, and then make sure all those components are in there so that we take a holistic approach to make our nation better, have less problems with mental health, and have people live better lives?
I know that's a mouthful, so....
The Chair: It's a tall order, but it's a very good question. I'm hoping somebody can begin the response.
Dr. Natacha Joubert: I'm going to start, and then some of my colleagues will probably add a few pieces.
First I will address your question concerning the economic burden. The 1993 study done by LCDC, which is a health protection branch within the department, estimated—and this is in the document you have—that $7.8 billion was the approximate amount for direct and indirect costs related to mental disorders.
It's important to point out that when that study was done, these estimated costs were based on costs of hospitalization and drugs and research and so on. That study, done with 1993 data, did not include the cost of untreated distress or depression.
A more recent study—we just finished it, actually, so it's dated the year 2000—used the data from the national population health survey. We looked at people who reported distress and depression but who had not received treatment from the medical system. We looked at the other kinds of services they may have used—for instance, psychologists or social workers. We also looked at loss of productivity among these people.
We were not able to estimate the cost of non-prescription drugs, which probably would have added to the amount. A lot of people, as you know, will buy and use all kinds of non-prescription drugs or will go for a different kind of alternative treatment to try to reduce their stress or distress level.
Nevertheless, we were able to estimate that, minimally, the cost for mental health problems in Canada would be $13.8 billion annually. Actually, in the deck it said $12.8 billion, but the figure has changed. It's $13.8 billion.
How many billions do we need to have? And we know this is minimum. Our study was made in a very conservative way. Again, because the data on mental health are so fragmented, it's very hard to put the figures together, but at a minimum it would be around $13.8 billion annually.
Maybe Carl would like to address the costs associated with mental illness.
Mr. Carl Lakaski: The costs are elusive at times, and difficult, just because we don't have the data or the research we need in order to answer those questions. I should say, though, that recent research, completed within the last year, has indicated that the chronically or seriously mentally ill constitute 5.4% of the Canadian population. That basically amounts to 1.6 million Canadians, excluding family members, who, if they were included, would bring the amount of Canadians affected by serious mental illness to about 5 million.
The other thing in the mental health field is that there is no scientific evidence or no credibility to the idea that mental disorder is caused by a single factor, whether it's stress, whether it's genetics, or whether it's the economy. Therefore, your call for a holistic approach is very much warranted.
There is strong scientific consensus that biological factors—genetic predisposition, brain chemistry, hormonal activity within the body—interact with psychological factors and social factors, and if you add that into an equation, that's your best bet at getting at a causal model of mental illness and mental disorder.
Again, on the cost question, when you think of five million Canadians being affected in one way or another and you think of the impact on productivity, on lost educational opportunities, the impact of lost resources in terms of a tax base for people who are actively participating in the economy to the extent that they should be or could very well be, the costs can be quite high. Unfortunately we don't have enough research to actually pin that down in a manner that would be satisfactory with respect to the seriously mentally ill.
Mr. Ovid Jackson: I have a couple of other questions.
Is there a chronic shortage of professional people in the psychiatric area?
Mr. Carl Lakaski: It's our understanding that's the case. In fact, I think the Canadian Psychiatric Association would maintain that. That field isn't growing as rapidly as they would like, particularly to meet shortages in the future with respect to the specialisms, for example, geriatric psychiatry.
Mr. Ovid Jackson: Do we have enough information in many of these aspects for us to come up with some document to tell us how to act and where to act, or do we need further information?
Mr. Carl Lakaski: I think what you need is a consultation process that's wide enough to tap into the various professional associations, such as the Canadian Psychiatric Association, the Canadian Psychological Association, and other NGOs, like the Canadian Mental Health Association, the Canadian Alliance For Mental Illness and Mental Health, the Schizophrenia Society of Canada, those kinds of organizations—a broad-based consultation process that would speak to the needs and concerns. They would be able to provide some of the data. Some of these research studies are quite local or specific to a particular profession or discipline. They're not the kinds of databases we keep at the national level. Of course, that process would include also the provincial governments, their ministries of health, and those sections of those ministries that are devoted to mental health issues.
Mr. Ovid Jackson: Thank you.
Dr. Natacha Joubert: To come back to your comment about a holistic approach, I would add that to be effective, any concerted action would have to involve, in a very significant way, communities across Canada, because basically this is where people live, and they're the ones, in collaboration with professionals of all kinds.... I think it would be very important to keep the community people involved to ensure that different interventions, from promotion to treatment, are provided to people.
Mr. Ovid Jackson: I agree with you, and it starts with the family, doesn't it?
The Chair: Thank you very much, Mr. Jackson.
Mr. Szabo, please.
Mr. Paul Szabo (Mississauga South, Lib.): Thank you, Mr. Chair.
Actually, I think I've learned quite a bit here. I tend to agree with Mr. Ménard, though. His first points were on the scope of the work you presented on behalf of the parts of the department you represent. The funding dedicated to it would tend to indicate that this is not a very high priority in Health Canada, and that's a concern.
The discussions that members have had with you have touched on, I would say, pretty well every conceivable social and economic problem a human being could incur in their lifetime, and it sort of prompts my first question, that maybe our starting point ought to be to define what mental illness is—with your help, as you're part of the resources we have—if as a committee we're going to come up with a deliverable.
Maybe you can help us out. As a starting point, let's see if we have a consensus about what we should consider to be mental illness. You might be able to help out also by partitioning that between mental illness that has some physiological foundation to it as opposed to state of mind brought on by other social factors.
Let's start by defining mental illness.
Dr. Natacha Joubert: On the whole issue of trying to define what mental illness is, I don't think there is a definition. There is certainly some agreement around what constitutes within an individual a vulnerability that makes that person non-functional and suffering a lot.
In terms of the factors involved, we have—
Mr. Paul Szabo: Maybe I could stop you there—
Dr. Natacha Joubert: Okay.
Mr. Paul Szabo: —because this is precisely the problem we all have. It's like trying to nail Jell-O to the wall; you just can't.
I understand where you're going here, and I think we could all go on for a great deal of time, but we need to know whether, in all the work and all the studies that have ever been done, anybody has actually written out a definition of mental illness. Is there a definition? I don't want somebody's feelings; I want a definition of mental illness.
Dr. Natacha Joubert: The document that was published in 1998 by the department, Striking a Balance, proposed a definition of mental illness.
If you look into the DSM-IV, the diagnostic and statistical manual used by psychiatrists across North America, you will find a definition of mental illness.
Mr. Paul Szabo: Okay.
Dr. Natacha Joubert: Actually, one of them is provided in your document.
Mr. Paul Szabo: Maybe the committee would be helped by having some sort of authoritative reference to a general definition of mental illness, and maybe because of the complex subject matter, based on all that has gone on today, we need a little help chunking it into its pieces, because some things group better than others, as well as maybe a modest glossary of some of the more prevalent terms so that we don't get lost. Quite frankly, I'm not a doctor, and I didn't understand a few of the diseases or the symptoms you were talking about. That might be helpful, if the researchers or maybe the witnesses could help us on that.
The Chair: Mr. Szabo, if I could interrupt for a minute, that is actually a very helpful suggestion.
It's obvious what Mr. Szabo is asking for. If we can get the definition and how some of the component parts and the context and the framework fit into that, that would be useful, as well as a glossary of terms. Thank you.
Mr. Paul Szabo: One of the other points that has been mentioned a number of times was that we don't have the data. That also concerns to me, because people who suffer from mental illness, as defined, obviously go for services to our health system, to the health care providers, and they do report.
I spent nine years on the board of a hospital. I do know there's a very extensive reporting system. So we probably should have a better handle on the incidence of the various types of mental illness we're looking at.
As Mr. Ménard pointed out, the scope or the dimension of this thing is very important, because it helps to put it in the context of the other health problems that Health Canada as a ministry has to address. We have to put it in a context of how important this is to Canadians. We have to convince them, and I think we as a committee have to be convinced about how important this is.
There are some indicators, and you may be able to help us here. For instance, as you may know, I spent a little bit of time on fetal alcohol syndrome. About 90% of fetal alcohol syndrome victims are clinically mentally retarded. We found out from a response in question period from the Minister of Justice that it's their estimate that about 50% of the people in the jails of Canada suffer from FAS, partial FAS, or other alcohol-related brain damage. This is very significant.
As my last question—and I wish we had more time—I'd like to know from you whether, in the mental health discipline of Health Canada, primary prevention plays a role in terms of addressing mental health issues to an appropriate degree. I'm sensing from your handouts and the discussion that, strategically, Health Canada's role seems to be more skewed to the remedial—after I have the problem, it's the medication, the whatever—as opposed to how to diagnose, how to look at risk factors, and how to target primary prevention strategies, etc., which is, I think, in most cases in the health discipline, a more productive dollar spent than a remedial dollar. So where is prevention? What percent of our work is it, or maybe should be?
Mr. Carl Lakaski: I'd like to speak to the issue you raised about the definition of mental illness. I remember, and I'm sure you do, that back in the 1960s and 1970s there was a very strong anti-psychiatric movement around that claimed that mental illness was in fact a myth. We've come a long way since then. We're much more certain about what constitutes a mental illness and what constitutes, let's say, distress, if you want to differentiate them. I think we need to.
Consequently, we can come up with fairly valid definitions of mental illness. Indeed, the one we came up with in Striking a Balance back in 1988 is being used, I believe, by the Australians as their definition of mental illness. It's not an insurmountable task. It's not overly difficult to come out with a fairly valid definition of mental health that has a broad consensus in the medical and the mental health community. So we can do that for you. That wouldn't be difficult.
Ms. Murielle Brazeau: In terms of your question about prevention and our role in Health Canada, we are very much involved in promotion and prevention. I'll ask Natacha to give you a little bit of explanation on our role in health promotion.
Dr. Natacha Joubert: I think it's important to understand that with better understanding, mental health is a continuum. There is mental health, then you have different kinds of stress and distress, and then you have mental disorders. This changes a lot the way what needs to be done is being defined and the way the responsibility around these interventions is shared among people.
My impression is that the federal government has come to an understanding of the broader picture of mental health more recently; therefore, the importance of promotion and prevention has started to be discussed more recently too.
Now, having said that, you've mentioned primary prevention, and a lot of people still confuse treatment with secondary or tertiary prevention. I think overall the understanding of what mental health is and what needs to be done in terms of different kinds of activities is growing, but we still have to make some progress on that front.
Also, I think it is important to understand that it makes no sense, of course, to be in a continuous way in a crisis situation, where you have all these people out there who need treatment, who need significant support. They are there and they are in need. We need to do something about them. We need to help them. But we also need to elaborate more on our strategy to promote and to prevent.
Having said that, too, I think it's important to say that I don't know what the provinces in this country are doing and how much of their resources go into promotion and prevention. But this is the kind of discussion that has started to take place within our department, trying to define what the federal role would be in promoting mental health so as to prevent distress in this country.
The Chair: Thank you very much. Ms. Joubert, I think you hit the nail on the head, in terms of what you were just saying. It seems to me that Mr. Lakaski talked about, I think, 5.4% who are severely mentally ill. That clearly would be provincial jurisdiction. I think there would be no question about that.
When it comes to promotion and preservation of mental health and the whole notion of wellness, I think that gets to the very nub of what we're looking at here and the kind of federal role that needs to be looked at, in collaboration, of course, with our provincial and territorial partners. But having said that, there is a role, and the question is to what extent and how much?
So that really, I think, is something this committee will be looking at over the course of time. I think it's important. I was interested in hearing your comments on that.
But I did have a question, and that was, when we think of the Canada Health Act, where and how does mental health fit into that? Who can give me that kind of response?
In the last little while, in talking with people who have known about this study, for example, I've heard conflicting views. I want to hear what Health Canada has to say.
Dr. Natacha Joubert: Well, I've asked myself the same question, and I'm sure my colleagues did too.
When I started to work in Health Canada, one of the first things I did was to go to the Canada Health Act to see where mental health was. It's hard to find, to say it in a few words.
This is one of the reasons a lot of our work has been not only to show how important mental health is and all that, but we also understand that as long as mental health is not fully and formally recognized as an integral part of health, we may continue to struggle.
So, I don't know; it's there, but it's not.
Mr. Carl Lakaski: You could recognize it in the preamble of the Canada Health Act. There's a definite reference to issues that could be seen only as mental health. They could not be seen as anything but mental health. It's in the preamble to the act.
With respect to the jurisdictional issue, yes, formally, provincial governments are responsible for the delivery of mental health services for people with serious mental illnesses. But Health Canada has always played a very fundamental role in that area in terms of its relationships with the federal-provincial network on mental health.
With respect to research dollars and targeting certain types of initiatives that we think are good for the country, let me give you one example that speaks to your issue of prevention.
Psychoses and schizophrenia are, as you know, the most costly mental disorders, both in emotional terms and in dollars and cents. Recently, research has indicated that a certain model of intervention, called early psychosis intervention, could be very effective in stopping the progress of this disorder, reducing hospital stays and costs, and providing these people with a much better quality of life.
Previously, it was assumed that once you suffered a number of psychotic episodes or were schizophrenic for a certain period of time, the game was over. You basically spent a great deal of your life in that condition with very little hope of recovery. This new model and the research that supports it indicates that recovery is possible, and in much shorter periods of time than previously thought.
Health Canada is actively involved in trying to support that kind of model and have that kind of model adopted across the country, to the extent that the provincial governments are interested. Indeed there has been some considerable interest shown in that particular model.
Now, we're at the early stages in terms of the research. I mean, we don't have as much research as we'd like to have that would indicate that this would be successful or should be the way to go. But there seems to be a building momentum, in terms of that particular model, for that particular disorder.
Even if you address that disorder, schizophrenia and psychoses—and it also applies to bipolar disease—you'd be making a very important contribution to reducing the burden of suffering on individuals, families, and the economy.
Bipolar is sometimes referred to as manic depression. That's when people experience unreasonable highs and unreasonable lows in their daily lives.
The Chair: Thank you very much.
I'd like to, at this point, ask for two documents. The first is a jurisdictional graph or chart that clearly outlines the provincial jurisdiction versus the federal, and perhaps those areas where there is overlap, or grey areas, if you will. I think useful attachments to that document would be perhaps anything that takes a look at what collaboration is also taking place and how that's being done.
I heard you, Ms. Joubert, talk in terms of how it's there but it's hard to find.
I think we should really have a report on that, on how it fits in.
You, Mr. Lakaski, talked in terms of it being in the preamble. I think we should know that—where and how—so if you could do that, I think that would be most helpful to us as a committee.
I hear the bells now, and of course we have a vote, so unless there's any other pressing business, we'll adjourn this meeting, to meet again at the call of the chair. Thank you very much.