Illustration by James Lee Chiahan
David Gratzer is a physician and an attending psychiatrist at the Centre for Addiction and Mental Health, where he serves as co-chief of General Adult Psychiatry and Health Systems. He is an associate professor at the University of Toronto.
When the days are long, I try to get some fresh air. I’ll walk across the campus of Canada’s largest research mental hospital, where I work, and then up Ossington Avenue to grab a coffee at a neighbourhood café.
I didn’t see him coming. I’d never met him before, but he looked like the sort of person I might meet in the emergency department: dirty clothes, the smell of sweat and a hardness to his face. He walked close to me. He grew angry, and he clenched his fist. And then, the unexpected: he took a swing. In a split second, I jumped out of the way and ran down the street. I’ve lived in Toronto for almost 25 years, but it’s the first time I’ve felt afraid for my safety. What if I was just a bit slower? Or he swung a bit faster?
Many people feel unsafe these days. At my dentist’s office, a person tells me how she saw a man attacked on the subway. A friend remembers how his subway train skipped a station because police had been called when a TTC employee was assaulted. Another friend talks about a verbal altercation on a streetcar, in broad daylight, with a stranger who accused him of being part of a conspiracy.
Violence on the TTC. Syringes in back alleys. Homeless people sleeping in our subway stations and in our parks. Canada’s largest city – like many other cities across Canada – struggles. It’s not surprising that some are calling for more police. And others are going further, arguing that we should fundamentally reassess the rights of those with severe mental illness: In Alberta and British Columbia, the premiers discuss forcing people with substance problems into treatment against their will; the mayor of New York proposes involuntary hospitalizations for those with severe mental disorders even if they aren’t a threat to anyone; some even wonder if our whole approach is flawed, and we need to go back to the days of the asylum.
It’s a complex issue that involves society’s most vulnerable, our public safety, and basic questions about rights; it’s also an issue where we can do better.
Let’s start here: People with severe, persistent mental illness are much more likely to be victims of violent crime than perpetrators. A JAMA Psychiatry paper noted that one in four U.S. psychiatric patients are subjected to crime in any given year; Danish data also show a clear pattern of victimization.
And while the headlines are troubling, it’s important for us to recognize that violence is exceedingly rare (thank goodness). Perspective: Last year, 1.8 million people rode the TTC every weekday, the vast majority without incident. I’m not trying to minimize or excuse – the loss of life is always tragic and the threat of violence is terrifying, I know. But it’s important for us to keep perspective.
The situation on Toronto’s public transit is the tip of a much larger iceberg, a mountain of policy and institutional inadequacies that have exacerbated stresses on people living with mental illness. They may be attempting to self-medicate using illegal drugs, may be looking for shelter when homes are almost impossible to procure, may be unable to see medical professionals when they need it most.
What we have isn’t simply a perceived crisis of violence, but a crisis of neglect, wherein decades of failed public policy, combined with recent developments (the pandemic, potent street drugs), have left society’s most vulnerable languishing in our subway stations, on our streets, in our parks. Quick fixes such as deploying more police or forced treatment are unlikely to resolve anything. There is hard work to be done, but there is a way forward.
Let’s start by exploring how we got here, with a focus on deinstitutionalization, the pandemic, the drugs and access to care.
Deinstitutionalization
After my psychiatry training, for a brief period of time in 2005, I covered my colleague’s jail-based practice. In truth, I was completely unqualified for the work – I had never set foot in a correctional facility. Starting work at prison on my first day, I half-expected to make the acquaintance of a character out of Silence of the Lambs. Instead, I talked to one patient after another who had similar stories: time spent in and out of different systems – the jail system, the hospital system, the shelter system. The patients weren’t all strangers; I knew several from my community hospital practice.
Today’s problems are rooted in a major public policy decision made decades ago.
Sixty years ago, a few things came together that resulted in a radical shift in patient care.
The abuses and deplorable conditions of asylums became well publicized. Add in the civil libertarianism of the era, with demands for dignity and self-determination for those with mental-health problems. And, of course, there was the enthusiasm (perhaps overenthusiasm) for antipsychotic medications, cutting-edge treatment at that time. The change was dramatic. Deinstitutionalization – moving mental-health services out of asylums and psychiatric hospitals – was meant to modernize mental-health care. In a relatively short period of time, starting in the 1960s, beds were closed with a vision of robust community care (which was never fully realized). At the old Queen Street Mental Health Centre, one of the founding hospitals of what is now the Centre for Addiction and Mental Health, the number of beds dropped by 75 per cent over a 20-year period. Nationally, the trend was similar: Health and Welfare Canada data show that the number of in-patient beds in psychiatric hospitals decreased from four beds per 1,000 population in 1964 to under one in 1979 (this decrease was initially partly offset by general hospital beds, but their number also fell over time).
The statistics may seem impressive, but deinstitutionalization, initially seen as a good, has proven to be a disaster. Dr. E. Fuller Torrey, a psychiatrist and a renowned researcher, writes critically in his classic 1996 book, Out of the Shadows. “For a substantial minority, deinstitutionalization has been a psychiatric Titanic. Their lives are virtually devoid of ‘dignity’ … ‘Self-determination’ often means merely that the person has a choice of soup kitchens.”
Where did many patients end up? For some, prisons replaced hospitals; this was the experience of many of the patients I saw back in 2005, and was common across North America.
Consider: The three largest mental-health centres in the United States are jails – LA County, Cook County and Rikers Island. Deinstitutionalization did not get people out of institutions. It merely moved them into different ones.
The pandemic
The predictions of the impact of the pandemic on mental-health were dire. There would be a sharp rise of suicides. A mental-health tsunami would accompany the physical problems – “a pandemic after the pandemic” was a phrase used by some experts. For most people, however, the pandemic reality turned out to be different. A recent paper published in the prestigious journal BMJ, drawing on 137 studies, finds that anxiety and depression symptoms “were close to zero” in terms of change from the start of COVID-19. And the sharp rise in suicides? Statistics Canada reports a drop during the first year of the pandemic – something seen in many other countries. From a mental-health perspective, the catastrophic predictions didn’t pan out.
For most. But, of course, some had great difficulties. I work with a patient who stumbled badly. Prior to the pandemic, he completed university (the first one in his family) and landed a big job in a company. He was laid off along with half of his co-workers. He turned to alcohol and his anxiety problems – well-controlled for years – consumed him. When we first met, he could barely get out of his apartment.
It was a long pandemic. For those with major mental illness, there have been many stresses. Not surprisingly, then, some have done poorly. A recent Canadian Journal of Psychiatry paper notes the rise of those with psychosis among admitted psychiatric patients – something that started early in the pandemic. They also observe that involuntary admissions (when patients are so ill that their most basic rights are taken away) went up as well, by 7 per cent.
In other words, these individuals seem to be sicker.
The drugs
It’s 3 a.m., and I’m clustered up with several young physicians by a handful of computers in the nursing station of the CAMH emergency room. We’ve been working non-stop, seeing patient after patient. I’ve just spoken to a man who was reportedly doing well, diagnosed with schizophrenia but taking his meds and considered stable. But then he used crystal methamphetamine. Now, he is so disorganized in his thoughts that I can barely understand what he’s trying to say, except that everything “is a dream,” which he repeats over and over again. One of the resident psychiatrists reviews with me a person she saw who, intoxicated and agitated, pushed someone on a city bus in an unprovoked attack. The residents openly muse about the safety of the TTC (for the record, they are divided).
These are conversations that we didn’t have with such regularity a short time ago. That those individuals with mental illness gravitated toward substance use isn’t new, of course. But the drugs have changed.
Crystal methamphetamine is highly addictive and known for its long intoxication state. It’s also linked to periods of incredible agitation and impulsivity, which can outlast the highs. A recent Canadian Journal of Psychiatry paper finds that amphetamine-related emergency department visits rose from just 1.5 per cent to over 9.9 per cent in seven years at CAMH (from 2014 to 2021). At the same time, as has been well documented, opioids have been transformed, with Percocet and heroin giving way to fentanyl, leaving a wake of destruction and death, claiming the lives of 30,000 people in the past seven years in this country.
Crystal meth and fentanyl are cheap and – since they are made in a lab and not extracted from a plant – available year-round, unconstrained by growing seasons. Dealers now mix in inexpensive fentanyl with other drugs, creating ultra-addictive cocktails.
But even more traditional drugs such as cannabis have changed. Until the 1980s, cannabis had only between 1 per cent and 4 per cent THC (the principal psychoactive constituent) in a joint. In the past two decades, THC concentration has soared, to more than 19 per cent on average. For those who are vulnerable, cannabis is linked to psychosis and poorer patient outcomes – and the rise of high-concentration THC is a problem.
Why are our streets different? In part, it’s because the street drugs are different.
Access to care
A few years ago, a patient walked into my office and burst into tears. I hadn’t met him before and he knew nothing about me – except that I was a psychiatrist. He was so relieved to finally meet a specialist who could help him.
Mental-health-care services are stretched very thin.
Until relatively recently, mental health was heavily stigmatized. The lingering effects are palpable. Start here: For every dollar spent on health care in Canada, mental-health care gets just 7 cents. Contrast that with countries such as Britain or New Zealand, where spending is 12 cents on every dollar, or with some OECD nations, where spending approaches 19 cents.
Complicated patients do well with Assertive Community Treatment Teams (ACTT), which means that patients are offered support from a psychiatrist, as well as a full multidisciplinary team, aiming to address needs beyond just medication management. The paper describing this model of care was first published in a major journal more than three decades ago – hardly cutting-edge. Where I work, I can refer people to such services but the wait time may be a year if everything works out – or double that if it doesn’t. Substance problems? Publicly funded programs tend to be thoughtful and well organized. Residential treatment programs have been shown to be effective for reducing substance misuse (even cravings) – but the wait time is at least 10 weeks, if not significantly longer.
Think it’s different for those who break the law? Forensic patients struggle to get access to care. A new paper for The Canadian Journal of Psychiatry notes that “despite a high risk of poor outcomes including recidivism and acute [mental-health care and addiction services] utilization post-release,” researchers found there was low access to outpatient care in prison and postrelease.
Access to care is a major problem.
Illustration by James Lee Chiahan
Solutions, solutions, solutions
With so many problems, is it surprising that government officials offer proposals? Earlier this year, Toronto tasked dozens of police officers to monitor public transit. The move may have helped people feel better, but it’s unlikely to make a meaningful difference. As doctors Vicky Stergiopoulos and Stephen Hwang noted in the Toronto Star: “with 75 subway stations, 192 bus routes, over 8,000 bus and streetcar stops … the odds are long that a police officer will be on the scene at the moment they are needed.” A city official commented to me that buses are particularly tough to police by their very design.
Others question whether we need to push people into care. The Alberta government drafted (but didn’t release) legislation that would allow involuntary treatment for those with substance problems, the Compassionate Intervention Act. British Columbia Premier David Eby (a former executive director of the British Columbia Civil Liberties Association, no less) favours such a step. For those with severe mental illness, New York Mayor Eric Adams champions involuntary care based on illness severity, not the potential of harm to others, and California proposes “care courts” to do as much. To quote writer Anna Mehler Paperny: “Coercive care is having a moment.”
The debate over involuntary treatment tends to be heated. Mr. Adams insists that we have a “moral obligation” to help those with mental illness, including those who don’t want help. “The very nature of their illnesses keeps them from realizing they need intervention and support. Without that intervention, they remain lost and isolated from society, tormented by delusions and disordered thinking.” The proposal picks up on the fact that we can hospitalize those with serious mental illness who are at risk to themselves or others, but not those who are “only” seriously ill.
Critics argue that we would violate the rights of the most vulnerable among us. The tension is understandable: On the one hand, we can see these individuals as sick and needing help; on the other hand, there is something inherently unsettling about forcing care against someone’s will. The issue is complicated and nuanced. Of course, countries such as Canada feature mental-health legislation that allows fundamental civil freedoms to be temporarily constrained – freedoms of movement, freedom of choice – when mental illness poses a threat to the person experiencing it or to others. There is a series of checks and balances to limit the use of this power.
But could we do more? Families have long advocated for that. Some of the toughest conversations of my career involved telling concerned parents that their son or daughter is leaving hospital and may well use again – but that I can’t force them into rehab. I remember the hate in the eyes of one father during our conversation. He told me that his son – just 24 years of age and trained as a nurse – would soon be back to drinking rubbing alcohol. “I’ll call you from the funeral home,” he said to me with a withering glare. The risk of death weighs on family members. In The New York Times, author David Sheff writes about his son being given the choice between rehab and jail. He chose the former. “There was a time I didn’t think he would make it to 21. He turned 40 this year.” Mr. Sheff favours more involuntary treatment.
But how would that work? Would people be forced to sit in residential care against their will for weeks, even months? Would they be required to take methadone or other medications?
What does the literature show? Involuntary care for substance problems isn’t exactly backed by solid evidence. In the Sheff essay, he notes some evidence and cites a paper – but it’s almost 20 years old. A more recent review in the International Journal of Drug Policy finds mixed evidence at best, in part, because of different definitions of involuntary care, but also because of the unevenness of quality of such care. We can all agree that a brief involuntary admission for a person so sick with his substance problems that he can’t eat or drink makes sense (and the law already allows for that). But how many will respond to weeks of mandated residential programs? And there is a more practical concern: Patients interested in working on their substance problems can’t presently get access. Shouldn’t they be the priority?
And what about the New York proposal? While we can hospitalize those people with mental illness who are at risk to themselves or others, what about the person with psychosis calmly seated on a sidewalk, vividly hearing and talking with voices in his head?
Again, though, practical considerations come to mind. Writing in JAMA Psychiatry, former New York State commissioner of mental health Michael F. Hogan argues against the proposal: “[A] limitation of the proposal is the fact that access to ‘aftercare,’ principally stable housing and flexible treatment and support, is not ensured in the mayor’s plan. Without these, any value achieved through hospitalization is temporary, providing only time-limited clinical benefit.” As with forced substance care, I find this argument persuasive.
A return to the asylum? In a widely debated paper, a few academics make the case. They note that: “During the past half century, the supply of in-patient psychiatric beds in the United States has largely vanished.” They forward various ideas, including that for some, we should return to the asylum. “These individuals cannot help themselves or live independently, and they deserve a safe place to live with proper supports – not cycling between the streets, emergency departments, and prisons.” To be clear: We aren’t talking about an ill-conceived blog or a social-media rant. The paper was published in one of the most prestigious medical journals and the authors include a vice provost of an Ivy League university. Writing in May for Newsweek, Christopher J. Ferguson agrees: “Protecting their autonomy is a virtuous impulse, but leaving them with the autonomy to die on the streets is not something a compassionate society should be striving for.”
Our current approach is a failure, but looking back to asylums seems nostalgic at best and backward at worst. Should we address traffic congestion by embracing the horse and carriage?
But their central point remains: we need to do better.
More coercive care makes for a good sound bite but not necessarily a meaningful way out of this problem. Here is the less media-savvy alternative: we need to do some hard work.
Address the drugs
For the past decades, there have been two dominant approaches to addiction. First, there was the “war on drugs” – an American term, yes, but a reality on this side of the border, too, with aggressive policing and harsh sentences. More recently, we have become more tolerant, no longer viewing substance use as a moral failing, and allowing for cannabis legalization and a move away from prosecuting for small possession. Both approaches are problematic. The war on drugs came with a significant cost, and landed too many (particularly those who are racialized) in correctional facilities. Tolerance is good, but increasingly we seem permissive about street drugs; indeed, in some public-health circles, there is rejection of the idea that drugs are even bad. Complicating a complicated situation: an increasingly partisan and polarized discussion of how we move forward.
Let’s start here. Our aspirational goal is providing evidence-based care for anyone interested in achieving sobriety.
We need to build up substance treatment. Rapid Access Addiction Medicine Clinics are impressive, providing access and treatment for people when they walk through the door, not in six weeks or six months. These clinics already exist in many Canadian cities, but they tend to be poorly staffed and have limited funding, often offering a couple of hours for drop-ins for only a few days a week. Here’s a bold goal: clinics running 24 hours a day, seven days a week. Imagine a person addicted to, say, crystal meth being able to get care right away. And we need to greatly expand treatment options for those in correctional facilities, perhaps drawing a page from Kenton County Detention Center in Kentucky (previously a state that embraced the war on drugs) that has dedicated social workers and substance treatment beds.
But we also know that there are limits to our current approach. While most people can achieve sobriety (a U.S. study drawing on data from more than tens of thousands of people finds that 75 per cent people with substance-use disorders are in remission), some need more help. The political rhetoric is heated, but our approach should be cool and focused: We should meaningfully study new approaches. Not every experiment needs to be a randomized controlled trial, but some type of data collection and evaluation must be baked in. The availability of treatment options should be governed by what works, not what makes a good sound bite.
Provide care
As mentioned above, ACTT workers directly help people with severe mental illness in the community. The original work was published in JAMA Psychiatry showing higher patient satisfaction and greater employability over the usual care (with its many hospitalizations). ACTT workers typically help those who have had disorders for years. On the other end of the spectrum, first episode psychosis programs focus on young patients with psychotic illnesses, providing them with care. A study in The American Journal of Psychiatry, drawing on Canadian data, shows that such programs reduce mortality fourfold over the usual care.
As noted above, a patient could wait a year or more for ACTT. First episode programs are stretched. We need to build up such services – in Toronto and across the country. That will require a substantial investment, one that has been overdue for mental-health services.
Offer homes
In 2008, the late Jim Flaherty, then the federal minister of finance, offered a substantial grant to the Mental Health Commission of Canada (MHCC) to study Housing First, the concept of offering housing immediately to people with mental-health illnesses who are homeless (as opposed to making them wait until they are sober and engaged in treatment). The late Dr. Paula Goering of CAMH and others helped design it.
While Housing First has been debated in policy circles since the 1980s, this Canadian study shows sparkling and conclusive results: For the most ill, providing housing and support was far cheaper than not providing them (for every $10 spent, there was an average saving of $21.72).
But many years later, so many people with mental illness continue to be homeless.
Let’s build up housing options with the goal of eliminating homelessness among those who have mental illness and are precariously housed. Across the country, municipalities experiment, with some of the most interesting projects involving not-for-profits (some created by and for Indigenous peoples). All levels of government need to work together.
And help them recover
Is there more to be done?
Dr. Thomas Insel, a psychiatrist, led the U.S. National Institute for Mental Health (NIMH), the largest funder of mental-health research in the world, for 13 years. He’s advised American presidents and overseen US$20-billion of funding. He marvels at the incredible advancement in scientific knowledge when it comes to mental disorders. But he also sees deep problems. In a recent conversation, he explains: “In the years I was at NIMH, the suicide rate in the United States went up 30 per cent, and overdose death went up 300 per cent. The numbers of people with serious mental illness who were working, who were housed, who were not incarcerated, all those numbers went down, not up.”
How to address our current problems? He talks about the advice he received from a psychiatrist who works with the homeless. “‘If you really want to make a difference, stop thinking about diagnosis and symptoms, start thinking about recovery.” He said, ‘it’s simple. It’s just the three P’s.’ And I thought: Prozac, Paxil or psychotherapy. He said, ‘No, it’s people, place, and purpose. Social support, a decent environment with housing and food and things that help people to prosper, and people will have to have something to live for.’”
I think about that man who took a swing at me. I don’t know his story, but after working in psychiatry for 23 years, I can speculate. I suspect that his life has been touched by illness and substance use, that he has been in and out of shelters and hospitals and perhaps even correctional facilities. And I suspect that he had difficulty getting mental-health services.
Imagine how things could be different. He would get help with his crystal meth problem from a team that would even provide him with vouchers for sandwiches when he attends meetings. For psychiatric care, he would regularly meet with his ACTT worker in a coffee shop, not a clinic, and be provided with medications to quiet the voices from his schizophrenia. Of course, he would need somewhere to sleep at night – besides a tent in a park or stairwell in a subway station. He would have a place to call his own, and not just for a few weeks.
But let’s also remember that he needs more: purpose. Through his local community centre, he would be doing some paid employment to supplement his public assistance. He would be actively helped by others with lived experience through a peer-support group. He would spend time with a faith-based group.
He wouldn’t be swinging at strangers in an intoxicated state. He would be living his life.
Today, that vision seems far-fetched. But we live in one of the most prosperous countries in human history. Surely, we can help the most vulnerable in our society.