Report for the Senate Committee Study on Mental Health
Norman Hoffman, M.D., F.R.C.P.C.
Over the past twenty years, university mental health and counselling across North America have experienced a dramatic rise in the need for services. At McGill University, the number of students we treat has doubled every four years. The severity of mental health problems also appears to be increasing. Of the 1920 students treated this past year 50% had serious longstanding psychological difficulties. In a recent survey of university counselling services across Canada, 75% of service directors reported an increase in the severity of problems seen. There has been some suggestion in the U.S. that the increase in demand is due to better, earlier treatment that is allowing students with mental health problems to attend university. From our experience this appears to be totally erroneous. The service has seen little increase in specific major mental illnesses. The increase is mostly due to increased long-term psychological distress. Our major concern, though, is not primarily for the university population. Certainly, this is a population that holds great promise for our society. Fortunately, universities have the ability to provide proper mental health resources for their population, though at the present time in Canada, only McGill and University of Toronto provide full services. While psychiatric services across Canada have become increasingly system centred over the past twenty years, McGill Student Mental Health has remained strongly patient centred. Each patient has a primary therapist who works with the individual to ensure personalized care. We are working to keep up with the increased demand to be able to maintain a full service model. In surveying university services across North America, it is apparent that one mental health provider per every thousand students is the minimum number necessary to have adequate patient centred care. Universities in Canada fortunately do have the ability to provide this level of service. The same is unlikely to be true for the rest of Canada.
I do have two major concerns for the mental health of our country. The first concerns the roots of our mental health situation. It appears that the mental health of our society is deteriorating. Reports from educational institutions across the country indicate increased behaviour problems and emotional difficulties in students at all ages. Mental health systems are unable to keep pace with growing demands. Secondly, I am concerned about the responses of our society and mental health systems. As demands have been increasing, we have moved towards a system centred, symptom based approach, that often provides only minimal care.
A disturbing and evolving social condition over the past twenty years has been the weakening of relationships between parental figures, authorities and children. The solid presence of families, extended families, teachers and other mentoring figures in the lives of our young has been dramatically eroded in recent times. At the same time, the power of the media, and of peer groups has been heightened. In order to have a positive impact on the mental health of our whole society, it is imperative that we strengthen the role all adult figures in the lives of our youth. We need to provide increased support for all families, and we need to improve our education systems so that every teacher can be an aware and involved mentor for our children. Programs such as therapeutic day care and after-school care for high-risk kids and could have a major impact on our children’s development. Strong counselling services in schools are essential.
The manner in which our youths’ emotional problems are presently being addressed is also a major concern. There has been a trend over the past ten years towards hasty diagnosis and simplistic treatments. The DSM is a manual of descriptive diagnoses that is meant to be used as a guide, and does not, for the most part, indicate actual disease entities. In its introduction the DSM states “The specific diagnostic criteria included are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion”. Unfortunately, in most medical schools across Canada, psychiatry is presently being taught by a predominantly biological approach that assumes DSM diagnoses to be actual biological disease entities. The misuse by the DSM is leading to a medical disaster for our youth. At McGill 15% of first year students are on psychiatric medication. In many universities in the United States, up to 30% of students are on psychiatric drugs. 90% of the students that we see from the U.S. who are on medication have been inappropriately diagnosed and treated. This trend is now moving into Canada. It is imperative that, especially for our young people, we move away from a simplistic diagnosis based model to a problem based model. While it may be fine to increase awareness of mental illness, programs such as depression screening using inexact tools tend to lead to misinformation rather than the addressing of problems. The most widely used depression screening tool is a commercial product, highly financed by the pharmaceutical industry, that has been poorly validated in a general population, and not validated in a young population. Screening programs in mental health are contrary to the patient centred approach this committee is recommending, as these programs tend to categorize individuals according to system needs. If we do not have adequate assessment and treatment facilities in place, screening programs, while appealing for their optics, can do more harm than good. Twenty years ago, students would come in to see us, saying “I feel down”. Now they are far more likely to say “I think I have depression”. The concept of depression as a singular biological entity is being highly promoted by the pharmaceutical industry, but has no support either in research or in clinical practice. We need to stop labelling, and to start addressing the real issues. Across our nation, people are becoming increasingly out of touch with their emotional lives. Relationships are becoming more superficial with significant attachments waning.
One concern about this committee’s interim report is that it focuses too strongly on mental illness rather than on mental health. With the growing needs in our country, there is no way we would ever have the resources to properly attend to the emotional problems of our nation. Placing our resources mostly in aiding those who we have labelled as mentally ill is not going to stem the tide of increasing psychological distress. More emphasis should be placed on prevention by addressing the issues that lead to the development of psychological difficulties. We need to strengthen institutions from families to education to care providers that will help children grow up to be emotionally healthy adults. Helping disadvantaged youth should be a priority. I would recommend setting up a countrywide, government-sponsored system of “Outward Bound” type summer programs for young people, with continuing after school mentoring programs throughout the year. Let every child in our nation grow up with positive feelings and memories of a strong mentoring figure. We cannot afford to wait for troubled children in our society to turn into mentally ill adult.
The impact of marketing by the pharmaceutical industry is also a major concern. It is in the pharmaceutical industry’s interest to have the maximum number of people on medication for the greatest amount of time. The industry has been highly promoting the idea that medication should be prescribed to all people with depressive symptoms, as well as constantly coming up with new indications for medication usage. A ban on direct marketing by the pharmaceutical industry to doctors would encourage proper prescribing habits. Drug companies presently spend more on marketing than on research. Over the past five years, the two classes of drugs that the pharmaceutical industry has spent the most marketing have been modern anti-depressants and Cox-2 inhibitors. This marketing has led to an over-prescription of these medications. These medications, while useful, often are no superior in the majority of patients than older, better established and less costly drugs. Especially as the government is looking at universal drug care, the cost of pharmaceuticals is going to be a major factor in the spending of our health care dollars. I would recommend the establishment of an industry financed government board to review drug literature and provide appropriate recommendations to the medical profession. This could lower drug costs, and put the emphasis on the pharmaceutical industry to produce more effective drugs rather than more marketable drugs.
Ultimately, the value of this commission will be determined by how its recommendations are implemented. Most frequently, administrations will often pick out aspects of recommendations that have high media visibility, and will tend to ignore those aspects, that may be more difficult to implement but will have higher impact. It is likely that the majority of suggested actions of this commission will be shelved, while a few simplistic actions may be taken. This would be just a further example of the “disease” of superficiality that we are facing in our families and our country. A national strategy on Mental Health sounds good, but will be empty words without proper resources and determination. The Mental Health systems in Canada are partially driven by research coming out of the United States that highly promotes symptom based treatments. These treatment modalities frequently fail to address the most crucial issues affecting a real life patient population. It will take more than rhetoric or policies to change the way medical students and psychiatric residents are taught, and the way hospitals are run. A national suicide strategy is good politics, but may have no impact. In Quebec, we do have a provincial suicide strategy, but the most important element in suicide prevention; access to services is absent. It is imperative that your final report contains practical and feasible direction and does not simply promote empty jargon.