For too many Canadians, fixing the mental-health system is a matter of life and death.
A lot is made of the economic benefits of preventing and effectively treating mental illness, and for obvious reasons: Reducing disability payments and unnecessary medical costs and keeping employees on the job and productive should provide a persuasive argument for governments and businesses.
A well-run mental-health system saves the public purse and the corporate dollar. But it also saves lives. And, ultimately, is there a more critical bottom line than that?
In the past 10 years, the rates of suicide for youth, the middle aged and seniors have hardly budged – sorry progress identified in a report released Thursday by the Mental Health Commission of Canada.
Suicide is still devastatingly common in certain pockets of the population, such as aboriginal Canadians. Men are more than three times as likely to kill themselves as women, with rates especially high for men in their 40s and 50s.
Compared with other Western countries, Canada falls in the upper middle – marginally better than the United States, on par with Britain, worse than Spain and Italy.
But for all the energy put into anti-stigma campaigns, reports on how to fix mental-health care and grassroots movements to address suicide, Canadians continue to take their lives at rates that experts argue should be considered a public-health crisis.
The suicide rate for youth is 9 per 100,000 15-to-19-year-olds; for seniors, it's 10.4. In the commission's latest mental-health indicators, the persistence of these statistics raises "significant concerns," and was identified as an urgent issue spanning generations.
Canada appears to be getting better at diagnosing mental illness, and Canadians' overall sense of well-being is pretty high. But mental illness, mostly depression, is linked to roughly 90 per cent of suicides, and too many people still go without comprehensive clinical care, particularly therapy, an effective treatment preferred over medication, in patient surveys, by a majority of both women and men.
"The best suicide-prevention program is a good mental-health care system," says Alain Lesage, director of research at the Douglas Mental Health University Institute in Montreal, and associate director of the Quebec Suicide Research Network.
Suicide is top of mind for advocates such as Michael Kirby, former chair of the Mental Health Commission, who is making the case for government to ensure that there is universal access to psychotherapy for youth so that those from poor families do not linger on wait lists.
Crisis intervention is essential to deal with suicide, yet fast access to psychiatrists, for consultation and treatment plans, is sorely lacking, making an enterprising program by the Mood Disorders Association of British Columbia worthy of national consideration.
The Vancouver-based program has four full-time psychiatrists who offer one-off individual consultations to patients referred by their general practitioners. Their wait times are four weeks, compared with an average of eight months in the city, according to executive director Martin Addison.
To expand access to rapid care, after the initial consult, psychiatrists treat patients in follow-up groups of eight, which can booked as needed and usually on the same day. The focus is on medication management and symptom monitoring, and the appointments are not structured psychotherapy, which would still be most cost-effectively delivered by trained psychologists, social workers and psychotherapists.
By using this medical model, Mr. Addison says, the program hopes to treat 4,000 patients a year. Doctors find it efficient, he says, and patients often learn from other questions posed at the appointments. A 2014 study in the Canadian Journal of Psychiatry found that even those who had previously received individual care preferred or had no issue with the group sessions.
Similar approaches are now being adopted by psychiatrists in Kitchener-Waterloo and Toronto.
"This is where I believe we are getting in front of suicide," Addison says.
Mental-health care also has to be seen as larger than crisis intervention; prevention and education are essential, particularly to target suicide and to prompt more men, for instance, to seek help.
Once in the system, most men prefer therapy, which empowers them to fix the problem, over the quick fix of drugs, says John Ogrodniczuk, a researcher at the University of British Columbia who is about to launch a new mental-health website directed specifically at men. "We make a lot of assumptions about what men want," he says – stereotypes that can make men reluctant to come forward.
Elliot Goldner, a psychiatrist at Simon Fraser University who worked on the commission's report, says an effective suicide-prevention strategy probably needs to target specific populations differently, since the reasons behind suicide can vary across age groups.
So, school-based mental-health literacy can target teens. Public-awareness campaigns and universal access to therapy as good follow-up care could support men contemplating suicide, who often wait too long to get help and are more likely to first turn up in emergency departments. Teaching physicians about the link between depression and disease would help seniors.
Marnin Heisel, a psychiatry professor at the University of Western Ontario, points to new "zero-suicide initiatives" in the United States meant to change the mindset that every society will lose some people and, instead, strive to catch everyone. After all, we don't give up on other preventable deaths so easily.
"It's about prizing the individual sitting across from us," Heisel says, "and making sure we do everything we can to provide the best care, that we are doing everything we can to make sure that person doesn't die."
Canadians need to ask themselves: What is the suicide rate we are willing to accept?
Editor's Note An earlier version of this article incorrectly said the suicide rate for youth is 9 per cent for every 100,000 15-to-19-year-olds; for seniors, it's 10 per cent. In fact, the suicide rate for youth is 9 per 100,000 15-to-19-year-olds; for seniors, it's 10.4.