August 2002 Mental Health Today and Tomorrow
If Canada has produced one hero for our particular times, it is Romeo Dallaire, who in 1994 headed the United Nations peace-keeping mission in Rwanda. Now retired, General Dallaire was one of the new breed of Canadian soldiers who spent much of their careers containing post-colonial wars. Military commanders are essentially managers, and the UN commander faced a predicament familiar to any manager in this age of tight budgets. The resources allocated to his task proved unequal to carrying it out.
Denied reinforcements, he and his small band of troops had to stand by in horror as an estimated 800,000 men, women and children were bloodily massacred. He came away from the carnage severely wounded - not in the body, but in the mind. What makes him a peculiarly modern hero is his willingness to defy military tradition and talk frankly in public about his mental ailment, called post-traumatic stress disorder. He has come to the aid of fellow PTSD victims in the armed forces by appearing in a video urging them to seek treatment rather than trying to tough it out in the old stiff-upper-lip manner. Today he continues to confront his psychological demons by acting as special adviser to the Canadian government on war-affected children.
By showing that even a rugged veteran officer can break down after living through extreme stress, Dallaire brought home the point that mental illness can happen to anyone. His case came into the public eye at a time when health care had climbed to the top of the list of Canadians' public policy concerns. It drew attention to the basic fact that health is more than just a physical matter. To that extent, at least, the agony of Romeo Dallaire has not been in vain.
Still, our society has a long way to go before mental health gets the attention it deserves on the policy agenda. In public discussions of the health care crisis, the mental component is seldom mentioned at all. Like so many mentally ill people themselves, it is out of sight, out of mind, and largely out of money. According to ex-federal Finance Minister Michael Wilson, honorary chair of the Business and Economic Roundtable on Addiction and Mental Health, the mental side of health care attracts only three per cent of total national spending on medical research.
One consequence of this near-invisibility is that few Canadians have any idea of the extent of our current mental health problems. How many know, for instance, that schizophrenia is more common in North America than Alzheimer's disease, diabetes, or multiple sclerosis? Or that mental illness constitutes the second leading category (after accidents) of hospital use among Canadians aged 20 to 44?
To gain some idea of how prevalent mental illness is, imagine the population of your neighbourhood standing in the local park, divided into groups of eight persons. Then imagine that the men in the white coats appear and lead one person away from each group. That illustrates how many among us are hospitalized for a mental disease or disorder at least once in our lives.
But, because fewer and fewer sufferers are now being hospitalized, not even this sorry picture can convey the full magnitude of the problem. So now imagine that your neighbourhood is split up into groups of five, and one man, woman or child is led away from each cluster. That is proportionate to the number of Canadians who suffer from a mental ailment of some sort in any given year.
And the situation is likely to get worse before it gets better. "Projecting to the future by examining related trends, it is likely that the number of persons in [mental] distress in Canada will increase alongside upward trends in child poverty, income disparities, single parenting, youth unemployment, and declining expenditures on health, welfare and education," the Canadian Mental Health Association declared in its recent brief to the Romanow Commission on Health Care.
The association projects that depressive illnesses will become the leading cause of "disease burden" by 2020. Some experts expect that over the next five years, mentally-related disability and care claims will amount to fully half the number of claims in employee health plans. Ominously enough, the incidence of mental distress is growing among young people. In a recent survey, more than 30 per cent of under-30s reported suffering anxiety attacks. These statistics make it all the more alarming to learn of a serious shortage in Canada of psychiatric services for children and youths.
When in 1935 T.S. Eliot observed that "human kind/Cannot bear very much reality," he might well have been referring to the people who would be caught up in the stress-ridden lifestyle of two or three generations later. Tuned in as we are to instant and sometimes excessive information, we are all being exposed to at least as much depressing reality as we can handle; consider September 11, 2001.
Addictions positively thrive on the stress, anxiety and personal upsets of modern living. Alcohol and drug abuse can lead to dementia and hallucinosis, while on the other hand, disturbed and distressed individuals may seek relief in addictive anodynes. In either case, many people wind up in "double trouble," living in a nightmarish world of both addiction and mental disease; or "triple trouble" if they are homeless as well.
Addictions - notably to gambling - account for a rising number of suicides, more than half of which can be traced to mental health problems. The number of Canadians who take their own lives every year would populate a fair-sized town: more than 3,500 tormented souls. Much of the increase in suicide in recent years has been among young people, males especially. It has become the second most common cause of death, after accidents, among people under 35.
Suicide can happen in any family, but it is more likely to happen in poor families than in rich ones. The same goes for mental problems in general; the less money people have, the more they are likely to discover that, in the title of Morris West's 1984 novel, their psychological "World is Made of Glass." Not only does mental illness tend to strike the economically weak, it actually creates economic weakness. Many the affluent well-educated person whose mental health has failed has been plunged into poverty. No matter how they started out, the majority of people with mental illnesses "have significant income and housing needs," according to the CMHA.
One reason for these deficiencies is that society continues to shun mentally ill persons as pariahs -- or worse, as wrongdoers who bear some mystical culpability for their condition. In fact, mental unsoundness is caused by shattering experiences, genetics, and even viruses. Yet the discrimination against the victims of these phenomena lingers on at a time when Canadians as a whole have long since stopped discriminating against other groups.
Among the myths that nourish the discrimination is the idea that mental afflictions are permanent. There is a popular misperception that patients not only can never get well again, but that their condition can only worsen. In fact, advances in medication and therapy have now made recovery quite common. It is entirely reasonable to expect victims of mental illness to bounce back and lead full, productive lives.
Lead full, productive lives, that is, if they are given a chance to do so by the so-called normal population. Unfortunately, many otherwise charitable citizens don't want "nut cases" (or pick your own pejorative) anywhere near their back yards. Mentally ill persons are literally avoided like the plague, as if their insanity - an outmoded term now reserved for legal use - were contagious. This superstitious feeling harks back to the dark ages, when "mad" men and women were seen as carriers of evil, and banished to the deserts and woods.
In later centuries, mentally unstable or simply eccentric folk were consigned to jails alongside common criminals who tormented and exploited them. In time specialized "lunatic asylums" were founded, like the one in 19th century Toronto described in Margaret Atwood's novel Alias Grace. The ill-clothed inmates lived in dark, dank cells; their skimpy diet rarely included meat because it was thought to excite their bestial instincts. At its most charitable, the society around them regarded their quasi-punishment as their hard luck. "[T]he insane, like idiots and cripples, owe their state to Almighty Providence," one character in the novel writes.
While Canadian attitudes grew more enlightened in other respects over most of the 20th century, mental patients were mostly excluded from the progress. They continued to be kept in highly unpleasant custody. The advent of anti-psychotic and other drugs in the 1960s and '70s allowed large numbers of seriously ill patients to depart from mental institutions on the expectation that the drugs would enable them to manage their own treatment and so adopt a normal lifestyle. Instead, former patients were left wandering the streets or placed in large psychiatric boarding homes. Or they were returned "to a family who suddenly had to cope with an enormous burden of care but [with] very little support," as the CMHA notes.
Why did the outside world give them such a chilly reception? Partly, at least, out of fear. People have been exposed from childhood to movies, television shows and best-selling books which spread the impression that mental illness and violence are inextricably mixed. This year's Academy Award winner, A Beautiful Mind, made a welcome switch, with its sympathetic depiction of John Nash, a Nobel Prize-winning mathematician afflicted with schizophrenia. But for every presentation like this, there are a dozen others featuring psychotic stalkers, kidnappers and "homicidal maniacs."
The news media stands ever ready to encourage the notion that disturbed people are walking deadly hazards. A story like that of Andrea Yates, the former mental patient who drowned her five children, automatically rates top play in newspapers and newscasts. The publicity helps to perpetuate a frightening image of an essentially harmless portion of the population. The truth is that mentally ill persons are much more likely to be victims of violence than perpetrators of it.
In a recent British survey, 60 per cent of mental health services consumers attributed the discrimination they experienced to negative media coverage. The British Department of Health has included awareness training for journalists in an ambitious program called "Mind Out for Mental Health." It brings together volunteer organizations, companies and student organizations in a campaign against this type of discrimination. "Our aim is to raise awareness, challenge people's assumptions, and provide practical advice to help people make positive changes in their attitudes and behaviour," a Mind Out news release explained.
The Ontario government has launched a similar public education campaign to be carried out by nine regional Mental Health Implementation Task Forces. The MHITFs also deal with vocational training, housing, and the formation of drop-in centres and self-help groups. The latter two items reflect a growing realization that informal support groups contribute just as much to rehabilitation as formal facilities, and should be integrated into the public health system. Along with concerned citizens and representatives of the relevant provincial agencies, mental health care consumers and their families have been appointed to the Ontario Task Forces - an idea whose time has come.
It is generally agreed that the business community should be central to any such attitude-changing efforts; it is, after all, mainly through business that poor mental health exerts its drain on our national prosperity. As Canadian entrepreneur Dan Tapscott explains, brainpower and human interaction have become the most important factors of production in the new economy. It has therefore become crucial to ensure that the millions of brains that drive production are healthy, just as in former times it was important to ensure that manual workers were physically healthy in order to do their jobs.
Mr. Tapscott says that mental problems in the workplace are drastically on the rise, and yet "we tolerate societal and corporate attitudes of disdain and stigma that penalize employees for stepping forward and saying they need help coping with a mental illness." Workers in a corporate climate that discourages them from coming forward with their mental ills will only get sicker and less productive, he adds.
These people need access to treatment, and when they return to work, they should be greeted with "the same support and acceptance as if they had won a battle with cancer or recovered from a heart attack." Even taking the first steps toward treatment may be difficult, however. As the CMHA points out, mental illness victims are often ineligible for benefits under current disability plans.
But an ounce of prevention is worth a pound of cure, or its metric equivalent. Speaking on the same theme, Mr. Wilson of the Business and Economic Roundtable urged pre-emptive measures by top management such as "reducing stress at work, distributing work fairly, investing in working conditions which promote mental health, reforming management practices which can contribute to mental distress - all this for sound and measurable business reasons and nothing less."
The Roundtable estimates that poor mental health costs Canadian business about $16 billion a year, roughly equivalent to all the money earned by all the people in one of the smaller provinces like Nova Scotia. Clearly it is time for action to bring down these enormous costs, which in the final analysis will have to be met, through prices and taxes, by Canadians as whole.
But the need for a resolution to the apprehended crisis is more than a question of economics. It is a question of justice: justice long delayed and thus long denied. The continuing discrimination against the mentally ill is a standing reproach to a society that claims to offer a fair deal to all its members. According to the CMHA, funding for mental health is "sparse in relation to the prevalence and burden." At the same time, prejudiced public and even official attitudes "affect how people are treated, criminalized, and deprived of choice and control."
It has often been said that the true test of a civilized society lies in how it treats its weakest members. When it comes to the mentally ill, Canada has not done well by this test. We have shunned and ridiculed a class of people who are in no way responsible for their misfortune. We have treated them unequally, compared to sufferers from physical ills, in the spending of public money on the care and treatment of their plight. We have failed to provide them with equitable opportunities in employment, education, or housing. By "criminalizing" some of their actions and "depriving them of choice and control," we have even failed to provide them with the full rights of citizenship.
The economic cost of failing to keep our population mentally fit for the challenges ahead is sufficient in itself to warrant an out-and-out crusade to improve the state of mental health in Canadian society. But that is not the best reason to embark on a campaign to conquer the primitive prejudice that continues to mete out injustice to some of the weakest people among us.
The best reason is to rid ourselves of a national disgrace.
This issue was written by Robert Stewart.
As a valued reader of Royal Bank Letter, we would like to inform you of an important decision we have made to produce a more environmentally friendly and useful product. With the increasing popularity and accessibility of the Internet, we believe it is time to replace printed copies of the Letter with an electronic version posted on our website.
On the website, you will still have access to the same thought-provoking, well-written essays you have come to expect. Internet technology will also allow us to provide you with a complete, searchable archive of all Royal Bank Letters published since the first non-economic analysis issue in 1944.
For those without Internet access, copies can be obtained upon request at your RBC branch or at most public libraries with Internet access. Please look for the RBC Letter at www.rbc.com/community/letter. We hope you continue to enjoy the Letter in its new, electronic format, and are able to spend some time revisiting classic Letters on our website.