The public discourse surrounding mental health has progressed by leaps and bounds in the past decade. Whether it’s celebrities opening up about postpartum depression or musicians taking time off of touring due to severe anxiety, more people agree mental health is health, and that’s a good thing.
Unfortunately, those with severe, persistent mental illnesses like schizophrenia, bipolar, and other psychotic disorders are consistently left out of this conversation. People with these disorders generally require more medical care, but they often don’t receive it due to stigma, lack of resources, and barriers to accessing the right care.
That’s a problem, considering how many Canadians are living with these types of mental illnesses. According to the Canadian Mental Health Association, schizophrenia and bipolar disorder each affect approximately 1 percent of the population, which, in Canada, equates to 750,000 people combined. This number doesn’t even take into account the family members and caregivers also impacted by these illnesses.
“These illnesses are actually relatively common and prevalent in the population,” notes Rose Zacharias, president of the Ontario Medical Association and an emergency medicine physician. “Everyone likely knows someone who struggles with a mood disorder or a psychotic illness, and these illnesses are treatable through a combination of medication, talk therapy, and sometimes hospitalization when people are in acute crisis.”
Bridging the Gap
The gap between mental health and mental illness was the topic of a recent roundtable discussion between experts from across Canada, hosted by The Walrus and sponsored by Otsuka Canada Pharmaceutical Inc.
A major theme that emerged was how entrenched the stigma surrounding severe mental illness is at all levels of society but especially within the health care system. That stigma can make it difficult to advocate for more funding and resources, which in turn makes it more difficult for patients to gain access to new and innovative treatments.
“We have to change the way we talk about mental illness in medical schools, because I believe the stigma about mental illness lives in health care, it lives in medicine,” notes Diane McIntosh, a physician and the former chief neuroscience officer at TELUS, who is currently developing a mental illness screening tool for primary care physicians, in a subsequent interview.
Without early diagnosis and proper treatment, psychotic disorders like schizophrenia and bipolar disorder can be neuroprogressive, which may eventually cause cognitive impairment.
Andrea Bardell, who is the medical director for an early psychosis intervention program in the Ottawa-Champlain region, notes that while programs like hers are proven to be effective, there is no standard of care across the country. “When you provide good and early care to people, their outcomes are better,” she explains. “Unfortunately, the very unwell—those with persistent mental illness—struggle because they don’t seek out care.”
The Front Lines of Care
According to the Schizophrenia Society of Canada, misconceptions abound when it comes to psychotic disorders, including the assumption that people who experience psychosis are more likely to be violent and are incapable of being contributing members of society. Much depends, however, on ongoing support—medically, pharmacologically, and also in the greater community.
Family physicians are often the front line in diagnosing and treating mental illness, but the burnout many are experiencing at the moment—whether it’s due to the pandemic, an overburdened practice, or other factors—makes it difficult to give these patients the time they need and deserve. What’s more, according to a 2015 survey, only 23 percent of family doctors feel well prepared to manage severe mental health issues.
“These are complex mental health issues. They deserve respect and time, and our primary care providers are under-equipped to manage that,” notes Zacharias.
On top of everything, the number of practising Canadian psychiatrists was in decline before the pandemic. Considering 24 percent in this profession are over sixty-five years of age, according to a 2019 Canadian Medical Association report, that trend is expected to continue. Those that remain carry massive, lifelong patient loads, leading to burnout, and a shortage of psychiatrists able to take their place.
“People don’t go into the field of psychiatry or family medicine as much anymore because of our fee structure,” Bardell notes. “Our system is set up to reward those who do procedure-based care—surgeries, those kinds of things. Family medicine and psychiatry require time-based care, and you can’t make more time.”
from an Early Age
One of the most important things we can do as a society to ensure people with severe and persistent mental illness don’t fall through the gaps in our health care system is to prevent stigma from ever developing. McIntosh is a strong advocate for teaching children about mental health in an age-appropriate manner in the elementary school system.
“We should be teaching kids that this is what normal worry is, and some worry is good because it gets you out of bed and makes you study for exams,” she explains. “But then, there’s bad worry, and talking about ‘when is sadness a problem?’ and age appropriately learning about emotions.”
Looking at quality of life studies for those with schizophrenia, there is a some consensus that people with better social and family support systems rate their quality of life higher.
“The various studies that come out of countries like Denmark and Sweden rate quality of life far higher than what we have here,” notes Bardell. “[It’s] probably because there is community-based management that doesn’t end after a three-year early psychosis program. There’s more embedded community support. People with schizophrenia are not as stigmatized or isolated in society.”
When time is scarce and case loads are high, family physicians may miss the more subtle cues of serious mental illnesses and misdiagnose their patients. For example, a patient experiencing mania rarely feels like anything is wrong at the time, which means they’re unlikely to see a doctor when the symptoms that would confirm a bipolar diagnosis are present.
“Family doctors see people [with bipolar disorder] when they’re depressed,” explains McIntosh. But if you only have a few minutes with a patient and there are babies crying in the waiting room, doctors may not perform the right screening, which can lead to patients getting the wrong treatment, she adds.
McIntosh is referring, in part, to the “switch phenomenon” some bipolar patients experience when they’re mistakenly prescribed an antidepressant—launching them into mania or hypomania, rather than elevating their mood to a more balanced state. She’s hoping that the screening app she’s developing for family physicians will make it easier for them to identify mood disorders by having all the necessary information in an easily accessible format.
Bridging the gap between mental illness and mental health is a complex challenge, but this conversation reminds us of the importance of fostering innovative research for mental illness in Canada and improving patient access to new medicines. Mental health professionals also need to be recognized and properly compensated for their incredibly challenging and important work.
While a multilayered problem like this requires a multilayered solution, Zacharias says a major priority should be to build bridges between existing mental health supports and family physicians. She wants to see every physician with access to an integrated mental health care team made up of psychotherapists, family therapists, social workers, and community care coordinators.
“We need somebody at the top to take responsibility and ownership of our discoordinated system because there are many willing players who want to be integrated and have their expertise be utilized well inside of a coordinated health care system,” she notes. “So I have hopes for a better day.”
A special supplement from Otsuka Canada Pharmaceutical
For more information, visit otsukacanada.com