Children’s Mental Health and the Need for a National Mental Health Movement

May 8, 2008



Children’s Mental Health and the Need for a National Mental Health Movement



THE HON. MICHAEL KIRBY

Chair, Mental Health Commission of Canada



Chairman: Catherine S. Swift

President, The Empire Club of Canada



Head Table Guests:



Charles S. Coffey: Chair, Canadian Centre for Diversity, and Director, The Empire Club of Canada

Rachael Myra Pettapiece-Phillips: Second Year Honour Student, University of Western Ontario

Reverend Canon Douglas Graydon: Coordinator of Chaplaincy Services, Anglican Diocese of Toronto

Dr. Debra Pepler: Research Professor of Psychology, LaMarsh Centre for Research on Violence and Conflict Resolution, York University

Brigid Murphy: Chair, The George Hull Centre for Children and Families, and Senior Vice-President, The Dominion of Canada General Insurance Company

Michael Howlett: President and CEO, Mental Health Commission of Canada

Georgina Steinsky-Schwartz: President and CEO, Imagine Canada

Dr. Jean Victor Wittenberg: Head, Infant Psychiatry, Hospital for Sick Children, and President, Canadian Alliance for Children’s Healthcare

Sylvia Morawetz: Treasurer, Canadian Alliance for Children’s Healthcare, Honorary Patron, Regent Park School of Music, and Director, The Empire Club of Canada

Dr. Simon Davidson: Chair, Child and Youth Committee, Mental Health Commission of Canada, and Chief of Psychiatry, Children’s Hospital of Eastern Ontario Department of Psychiatry C14

Dr. David Goldbloom: Board Member, Mental Health Commission of Canada, and Senior Medical Advisor, Centre for Addiction and Mental Health

Gordon Floyd: Executive Director and CEO, Children’s Mental Health, Ontario

George L. Cooke: President and CEO, The Dominion of Canada General Insurance Company, and Past

President, The Empire Club of Canada.



Introduction by Catherine Swift:



May is Mental Health Month and this week is Children’s Mental Health Week. Although much has been done over the past number of years to bring issues surrounding mental health out of the shadows, the stigma still remains in the minds of many people. In fact, a recent public opinion poll on this issue found that 38 per cent of Canadians would be embarrassed to admit that their children suffer from anxiety or depression. And of course if parents cannot even admit the possibility, their children will likely not receive the treatment they need to become well.



Recent statistics show that about 20 per cent of young people struggle with mental-health issues. Not surprisingly, youth with mental-health disorders are much more likely to drop out of school, end up in jail and not become fully functioning members of society. Depression also seems to be affecting younger and younger people as time goes on. The good news is that prevention programs and treatments work, as long as problems are identified and acted upon. To further inform us on this important issue, we are joined today by Senator Michael Kirby. Michael’s academic background includes degrees in Science and Mathematics, and he received a PhD in Applied Mathematics from Northwestern University in 1965. He was Principal Assistant to the Premier of Nova Scotia from 1970 to 1973, and Assistant Principal Secretary to the Prime Minister from 1974 to 1976. He was President of the Institute for Research on Public Policy from 1977 to 1980.



After two years as Secretary to the Cabinet for Federal-Provincial Relations and Deputy Clerk of the Privy Council, he served as Chairman of the Task Force on Atlantic Fisheries. He became Senior Corporate Vice-President of Canadian National in 1983. He was a Senator from 1984 to 2006, during which he chaired the Standing Senate Committee on Banking, Trade and Commerce and the Standing Senate Committee on Social Affairs, Science and Technology, the latter of which focused on Canada’s health-care system. After completing a study of mental health in 2006, he was appointed Chair of the Mental Health Commission of Canada in March 2007.



Please join me in welcoming Senator Michael Kirby.



MICHAEL KIRBY:



It is always an honour to be asked to speak to the Empire Club of Canada.



I am especially grateful to be asked to speak to you today, as it marks the third time I have had the privilege of standing behind this podium.



In fact, two of these appearances have come within the last year. It is during this past year that I have taken on a new set of responsibilities and challenges as the Chair of the Mental Health Commission of Canada.



My appearance here today is a testament to two things: first, to the commitment of the Empire Club to using its distinguished platform to explore the most important, and often controversial, issues of the day, as well as its tenacity in seeking out speakers who will bring these issues to light.



But it also speaks to the growing recognition that mental-health issues must now be counted amongst the most pressing matters for us to address as a country, as a people and as individual Canadians. More particularly, it is a testament to the urgency of addressing issues relating to child and youth mental health and illness in this country. This is the theme of my remarks today.



The seriousness of the situation with respect to child and youth mental health must not be underestimated. But there is also hope. There’s growing attention being paid to mental-health issues by governments across the country, as well as in the media and amongst the general public. We now have what is perhaps a once-in-a-generation opportunity to make real progress.



Despite the efforts of thousands of dedicated professionals struggling under very demanding circumstances, with often limited resources, to provide the best possible care they can, our progress over the past decade hasn’t even come close to what is needed.



In preparing my remarks for you today, I came across a speech I gave in Vancouver six years ago on the plight of children and youth in Canada who are living with mental-health problems and illnesses.



I was struck by how little the situation has changed. The facts tell the same story in 2008 as they did in 2002.



Then—and now—between 15 per cent and 25 per cent of our children and youth suffer at least one mental-health problem or illness. These range from depression and anxiety to eating disorders and substance abuse.



Then—and now—once a child or youth is faced with a single mental-health disorder, chances are they will also be challenged by a second one.



Then—and now—only one in six children and youth with a mental-health problem or illness will be adequately diagnosed, often not until long after the onset of symptoms.



Then—and now—suicide is the second leading cause of death among Canadian adolescents. This makes Canada the third-worst amongst OECD countries.



What does this say to you?



To me, it says that there is a crisis. It says there has been a crisis for many years and that, if anything, the situation is getting worse. Our world is a complex and often confusing one. It constantly places new and exacting pressures on our children. There is a very real danger that this crisis will become a permanent state of affairs.



I’m here to say to you today that this must not be allowed to happen. But in order to stop it from happening, it is critical that we each look at what we—every single one of us—can and indeed must do.



Let me be clear. I am not saying to you simply “action must be taken” and that some distant body or governmental agency or even the Mental Health Commission can accomplish what is required to adequately address the problem of child and youth mental health. What I am saying to you is that “we—all of us—must take action.”



We can no longer wring our hands. We must roll up our sleeves and get down to work. You cannot do both at once. Hand wringing and problem solving are mutually exclusive activities.



So today, after giving you an idea of the extent of the problem, I want to point to some actions we can take to improve the situation with respect to child and youth mental health in Canada. And by “we” I mean the commission, to be sure, but also you and Canada’s business community.



In the past, I have described the mental-health system in Canada as being the orphan of our nation’s health-care system. For years—forever really—mental-health care has been marginalized, often forgotten, always under-funded.



But the orphan itself has an orphan. That orphan is the child and youth mental-health system, making children living with a mental illness in Canada the orphans of the orphan.



The challenges in child and youth mental health are formidable. There is a vast range of problems and illnesses, and many of these are difficult to diagnose and treat—often more so than physical illnesses.



The stakes are high. For 80 per cent of adults living with mental illness, onset occurred when they were younger than 18. In fact, psychiatric disorders are the single most common illness that begins in adolescence. But, unlike many physical illnesses, the effects of mental-health problems and illnesses on our youngest and most vulnerable citizens can last a lifetime.



Yet, despite the obvious importance of addressing child and youth mental health, many experts in the field say that Canada does not have a coherent system of care. And it is hard to argue against that view.



Among 29 OECD nations, Canada ranks 21st in child-well being, including mental health.

Twenty-first!



This is all the more shocking given our potential. Listen to the words of Canada’s Advisor on Healthy Children and Youth, Dr. Kellie Leitch.



“Canada has the potential and the ability to be the Number One place in the world for a child to grow up from a health perspective. We have the resources and the capabilities to reach this goal.”



So what is the problem?



One of the reasons for what I call the permanent crisis in children’s mental health is the issue of stigma. Stigma refers to the negative and prejudicial ways in which people living with mental illness are labelled. This labelling is so pernicious that people living with mental illness are often seen as nothing more than the disease label itself. No longer a person, merely a label.



Of course, the phenomenon of stigmatizing mental illness is not new. Half a century ago, a report on psychiatric services in Canada described the presence of stigma in these words:



“In no other field, except perhaps leprosy, has there been as much confusion, misdirection and discrimination against the patient as in mental illness…. Down through the ages they have been estranged by society and cast out to wander in the wilderness. Mental illness, even today, is all too often considered a crime to be punished, a sin to be expiated, a possessing demon to be exorcized, a disgrace to be hushed-up, a personality weakness to be deplored or a welfare problem to be handled as cheaply as possible.”



In some ways, the age-old stigma against mental illness reflected in these words is starting to fade slowly, but in many ways these words still ring true today.



It is true that today, more Canadians are aware of the realities of mental illness. For example, four out of five Canadians believe depression is a life-threatening illness.



But does this mean that depression is treated as any physical illness would be, that people are actively encouraged by their family and friends to seek the help they need? No it does not! Forty-five per cent of Canadians believe that someone who missed work as a result of depression would be likely to get into trouble and may even be fired.



The effects of stigma are felt as much in acts of omission as in acts of commission. Frankly, I will celebrate when the day arrives that there are as many corporate titans putting their names on the psychiatric wings of hospitals as on cancer research facilities or heart institutes.



If anything, prejudice and stigma affect children more than adults. Think back to your own days as a child or a teenager. Would you have gone to your Mom and Dad and said: “I’m feeling depressed. I think I need to see a doctor?” Not very likely.



But if you’d broken your arm or got a rash or a bad case of the flu, you would have had no problem asking for help.



The situation hasn’t changed much since you were a child. Today, two-thirds of youth say that fear, embarrassment, peer pressure and stigma are major barriers to them getting help for a mental illness. And three-quarters of our young people list either “no one” or “friends” when asked who they’re likely to speak to about mental-health concerns. Not family, and certainly not health-care professionals.



Many of these issues have surfaced in recent weeks following the tragic death of Nadia Kajouji, the young Carleton University student whose apparent suicide has been the subject of front page news. My thoughts go out to her family and friends at this time of profound loss.



We all need to look inside ourselves and ask the hard questions. Would we be as open with friends and family about our children’s mental-health problems as we would about a physical illness? How many of us would have no problem admitting our child suffered from, for example, anxiety or depression?



Unfortunately, not enough of us. In a recent survey, only 62 per cent of Canadian parents said that they wouldn’t be embarrassed talking about their children’s mental-health issues. That leaves many ashamed Canadian parents out there, not to mention kids who feel distanced from their families at a time when they need them most.



Stigma—albeit often unintended—also persists within the health-care system itself. All too often kids and adults who show up at the emergency rooms of general hospitals get pushed to the back of the queue. Physical ailments take precedence because they are seen to be more urgent. And then there are children and youth who face the double challenge of a mental illness and a substance-use problem. I often hear of kids being shunted between mental health and addiction treatment. Each system tells them to deal with the other problem first. The result is that they never get the help they need.



Co-occurring disorders must almost always be treated at the same time. People are people; kids are kids, and you can’t carve them up into separate compartments. Yet we have an extreme shortage of care providers who have expertise in both mental-health and substance-use problems.



So in a country that has an embarrassment of riches, when it comes to managing our most precious natural resource—our children and their minds—we are faced with an embarrassment of shortages.



Shortages of people are compounded by shortages of time and limitations in education and knowledge. For example, family physicians, who are often the first port of call in the health-care system for young people with a mental illness, are under pressure to see as many patients as possible. Because caring for patients with mental-health problems is time-consuming, most family physicians cannot find that precious time.



Training in mental health remains neglected in medical schools across the country. This can leave family physicians insufficiently trained to deal with the array of mental-health problems and illnesses they encounter.



And it isn’t easy for family physicians to find the specialized resources and backup to assist them in meeting their patient’s needs. We do not even know the exact number of child psychiatrists in Canada. There is no Canadian agency or organization that monitors the actual numbers of psychiatrists who practice with children and adolescents, the percentage of their time devoted to child-related practice, or their level of expertise in the field of child psychiatry.



Our system also has great difficulty in putting the right services in the right place, at the right time, and also linking them into an organized system of care. For example, schools are where kids spend the better part of their days and where they build their peer and social networks. It is also where they may confront the onset of mental-health problems.



School counsellors, therapists and psychologists have all been cut back in the last few years, so lots of kids just fall through the cracks. Schools must become a place where mental-health services are provided, not by teachers, but by trained mental-health professionals.



Elsewhere in the world, including New York and London, schools have become a preferred location to deliver children’s mental-health services, precisely because it is where children and their parents feel most comfortable seeking help.



There are other troubling dimensions as well.



While the number of children diagnosed with mental illness has risen in the past decade, funding to look after them has not kept pace. This can have only one result. The one in six mentally ill children, who currently get the help they need, will have to wait longer to get it. The other five in six will not be treated at all.



Moreover, while everyone else in the health-care system is concerned about reducing average wait times for certain procedures, there is no such concern when it comes to children’s mental health, for the simple reason that wait times are not calculated. So no one really knows what they are. How can you improve something if you don’t measure it?



Now some would call this situation a national disgrace. And, of course it is!



But it is also a wake-up call to look carefully at the big picture and finally come up with a strategy that will deliver what Canada has never had—a cohesive system that provides excellent continuity of care. A system that always places the best interests of our children and youth with mental-health problems and illnesses at its centre.



We need a national strategy for child and youth mental health. This will be a major part of the national mental-health strategy that the commission will develop over the next three or four years.



This national strategy will provide a comprehensive framework that takes into account our unique and often frustrating jurisdictional realities. The national strategy will also be useful and practical. I like to say that the commission’s national strategy must be “just inside the outer edge of political feasibility.” There is no sense in producing a strategy, which is theoretically perfect but politically impossible to implement.



But even if the strategy is a practical one, there is a further ingredient that is required. No matter how good the child and youth mental-health strategy is, no matter how good the overall national mental-health strategy is, they will be useless without the political will to implement them. Given the magnitude of the changes that are required, this political will must exist across multiple jurisdictions and over a sufficiently long period of time to allow us to get the job done.



What can the commission do to help create that kind of political will?



A good place to start in understanding what is needed—and also for seeing what can be done—is to look at the experience of people who are concerned with other health conditions and diseases. Those that have succeeded in establishing a strong presence on the political agenda, and keeping their cause—their disease—in the public eye, have at least two key factors in common.



First, a national organization of volunteers was created. These volunteers do many different things. They raise money; they volunteer in the health institutions that serve the people battling the disease; they mount campaigns designed to persuade government to increase funding for treatment and research; and they do everything they can to ensure that the public never loses sight of their concerns.



Very little of this happens in mental health. Although many dedicated volunteers across the country have worked hard over the years, they have not been able to build the profile for mental-health issues that is needed, or to establish the framework that would allow mental health to be brought out of the shadows forever.



Therefore, a major task of the commission in the coming months will be to duplicate for mental health the kind of volunteer organization that exists for breast cancer, diabetes, heart disease and stroke, to name but some of the most familiar. We must build on past efforts of mental-health organizations, but move everything to the next level.



Such an initiative will reinforce the efforts of the commission to address the stigma attached to mental illness. Stigma has been the biggest single obstacle to the development of a national social movement targeted at improving services for people living with mental-health problems and illnesses. Many people are still reluctant to talk to their friends and neighbours, let alone the general public, about their own mental illness or about mental illness in their family.



Yet, in order for us to build a vibrant volunteer movement, we will need to overcome the hesitancy many people will have to becoming openly involved in mental-health advocacy. In other words, stigma must be fought so that the tens of thousands of Canadians who are affected directly or indirectly by mental-health problems and illnesses can become fully engaged in improving mental-health services and supports.



At the same time, the very fact of building a national volunteer organization will greatly contribute to the work of the Mental Health Commission as it pursues its goal to dramatically reduce stigma. A well-organized and funded grass-roots organization—one that undertakes a series of community-based activities every year—will help to ensure that mental health will be the subject of ongoing publicity and public discussion. It is only by making it completely acceptable to discuss issues relating to mental health and mental illness in public, that we can ever hope to fully eradicate the scourge that is stigma.



Given how intractable stigma has been to date, why do I think it is possible for the Mental Health Commission to be the catalyst for the creation of such a movement? I believe that two factors will make this possible.



First, in the two years since the release of the Senate report, “Out of the Shadows at Last,” the amount of media coverage and public discussion of mental-health issues has dramatically increased. The issue is, at least temporarily, out of the shadows.



Second, the Mental Health Commission as a national, non-governmental organization is ideally suited to spearhead this effort. We have excellent relationships with national, provincial, regional and local mental-health organizations across the country. We are capable of building the infrastructure required to support a national network of community-based volunteers.



Most importantly, since the commission was established, many, many Canadians have asked us what they can do to help. Thousands of Canadians want to help us succeed in our objective of keeping mental health out of the shadows forever.



In addition, the commission has a new President and CEO to give us the leadership and to build the management team that will make our vision a reality. Michael Howlett brings a solid business background and commitment to fiscal responsibility to our cause. He also brings an unprecedented and successful history with mental-health causes ranging from the prevention of child abuse to the treatment and rehabilitation of substance abuse. His recent experience leading the Canadian Diabetes Association includes the development and management of national volunteer networks.



Therefore, I believe that the commission has an excellent chance to be successful in creating a national social movement around issues of mental health and mental illness. The board of the commission has already given commission management the go ahead to embark on this journey. I hope that we will be in a position to launch the movement before the end of the year.



In concluding my remarks on the national mental-health movement, let me emphasize one point. The Mental Health Commission will never—let me repeat never—be involved in directly lobbying governments. That is not our role. That is not part of our mandate.



But by creating a national movement of community-based volunteer organizations, and by providing fertilizer and water in the form of infrastructure support, we will enable a grass-roots movement to grow and flourish.



It is this community-based movement, which will be free to lobby governments for improved services for people in their community who are living with mental illness. That is as it should be. Service improvement must be community-based and what is done must reflect the unique characteristics of each community.



A lobbying effort run from the centre by a national organization such as the commission makes no sense. The country is too varied, and the issues surrounding mental-health service and delivery are too specific to each region, for a centralized national lobbying effort to be effective.



You will recall that I said a few minutes ago that all effective national disease specific organizations have two things in common. One is the national organization of volunteers that I have just discussed. The other is a not-for-profit charitable organization that enables individuals and corporations to contribute money, and be able to receive a charitable tax receipt.



Indeed, for existing disease-based organizations, a great deal of their activity—including much of the work of the volunteers as well as efforts to gain positive media coverage about the disease—is related to fundraising activities.



It will therefore also be necessary to incorporate a national not-for-profit charitable organization as part of the infrastructure of the national mental-health movement. We have already begun the legal work required to create such a body, including the submission of an application to Revenue Canada for a charitable registration number. I hope that this process will be completed by this summer.



This mention of governmental procedures leads me to a more general point about the relationship between mental health and politics. The Mental Health Commission is the child of government. It is funded by the Government of Canada and benefits from the participation of representatives of five provincial and territorial governments on its Board of Directors.



But mental health and mental illness must never be seen as partisan issues and the commission must never become a politically partisan organization. All political parties must come together to improve mental-health services. After all, mental-health problems and illnesses do not distinguish amongst the members of one political party or another.



In this spirit, let me say that, although I am a former Liberal Senator, I want to congratulate Prime Minister Harper, Finance Minister Jim Flaherty and Health Minister Tony Clement for their unswerving support of the Mental Health Commission. They have made a commitment to fight mental illness that no other federal government has. And the non-partisan spirit of their commitment has been complemented by the co-operation the commission has received from provincial and territorial governments of all parties, and from mental-health stakeholders across the country.



But, as I noted earlier, governments can’t do everything. We can’t look to Ottawa or Queen’s Park or City Hall to adequately address the scale and scope of the issues and problems we confront in the mental-health sector. As I conclude my remarks today, let me say to you as directly as I can that all Canadians need to get involved.



Business, in particular, needs to step up to the plate. Nearly all of you here today are in business, and as we get the national mental-health movement underway, we will be coming to you and seeking your help to turn our vision into a reality.



But employers also need to look in their own backyards. Much can be done to improve the way in which mental-health problems and illnesses are handled in the workplace—things that will benefit not only individual employees who are confronting mental-health challenges, but also the corporate bottom line. Sometimes, doing the right thing is to everyone’s advantage.



Let me illustrate. Studies done by the Mental Health Commission and the Global Business and Economic Roundtable on Mental Health and Addiction have shown that improved case management for employees on short-term disability leave for stress or mood disorders can lead to that employee returning to work much quicker—15 days earlier on average.



The savings this yields in foregone disability insurance and other costs are between two and four times greater than what it costs to implement the improved case management. These are savings that accrue directly to the bottom line.



It is thus in the business interest of the employer to improve the way mental-health issues are addressed in the workplace, in addition to being in the obvious interest of the affected employees themselves.



However, we are not only seeking a corporate commitment. Each of you in this room can individually help us implement our vision, and contribute to enhancing mental-health services for all Canadians, particularly children and youth.



The first thing you can do is to tell your friends and neighbours how important it is that children’s mental-health services be improved. Tell them about the state of crisis I described to you this afternoon, educate them about the issues involved and ask them to get involved.



The second thing you can do is to join our national mental-health movement when it is launched. Use the movement as a way to become an active supporter of mental health.



The commission can be a catalyst. But only you can make our efforts successful.



With the help of each and every one of you in this room I believe—truly believe—that we can turn the words of Roy Muise into a reality. Roy is a person living with a mental illness who testified before the Senate Committee at its hearings in Halifax. He challenged all Canadians in these words:



“To the people of Canada, I say welcome us into society as full partners. We are not to be feared or pitied. Remember, we are your mothers and fathers, sisters and brothers, your friends, co-workers and children. Join hands with us and travel together with us on our road to recovery.”



All of us associated with the commission—all members of the board, advisory committees and staff—have taken up this challenge. I ask each of you to do the same.



The appreciation of the meeting was expressed by George L. Cooke, President and CEO, The Dominion of Canada General Insurance Company, and Past President, The Empire Club of Canada.