Improving mental health care by fighting poverty

This was the first of a five-part series in The Globe and Mail on modernizing medicare considering lessons from home and abroad.

Historically, Canadians embraced medicare as part of an effort to separate personal wealth from individual health. But, in defending our rights to enter hospitals without risking financial ruin, did we swallow a bitter pill?

Mental-health care continues to stymie health-care providers and policy-makers with relatively few clinical advances and growing numbers of sufferers; especially alarming are the high rates of suicide among Indigenous people. Canada’s Mental Health Commission maintains that the system is sorely underfunded, resulting in annual losses of $50-billion in productivity. Individuals with mental disorders are more likely to live on the margins, compounding conditions of illness and disability, creating a vicious cycle of poverty and mental distress. For a growing contingent of ex-patients, families and clients of the mental-health-care system, the solution is not medical: It is political.

We know that smoking is linked to illness, and we have anti-smoking campaigns. We know that poverty aggravates our mental health, but we are not investing in anti-poverty strategies. Why is that?

Since the 19th century, our Western approach to caring for madness relied on segregating patients in separate mental hospitals. We increasingly treated madness as a medical problem, rather than a personal, behavioural or criminal issue. Treating people as medical subjects had its advantages in that people were humanized and viewed with a degree of sympathy. But there were also drawbacks.

By the mid-20th century, mental hospitals across the country downsized dramatically and emptied their residents into our communities. For the most part, we celebrated this move as an overdue recognition that people could live independently or semi-independently with supports provided by a now expansive health, education and welfare system. At the same time, medicare seemed to ensure that Canadians had access to medically necessary services, including mental health care.

But, this shift away from mental hospitals and into doctors’ offices, psychiatric wards or emergency rooms did not coincide with a decline in the numbers of individuals and families seeking assistance. Quite the opposite occurred. Where the standalone mental hospital had ostensibly provided a set of services under one roof, problematic though they may have been, decentralized care in the community involved a complicated matrix of fragmented services. Clinical care, housing and employment needs, along with financial and family support services, required skillful maneuvering through bureaucratic red tape, which was challenging enough for civil servants to navigate, let alone for patients and families. The transition in service delivery was often slow and piecemeal, exposing gaps between programs and needs, creating new levels of health-care professionals and stimulating ex-patient activism.

People seeking attention for mental-health issues were left with few choices but to resort to the hospital as the first port of entry, regardless of whether the underlying concerns stemmed from inadequate housing, employment or emotional support. Ex-patient Jayne Melville Whyte received less in a month from social services in the 1980s than the $1,000 it cost taxpayers for one day of hospitalization. Ms. Whyte has suggested that redirecting patients away from general hospitals established a new set of “hotlines” or crisis-prevention services aimed at addressing clinical care, but what many people needed were “warm lines”: a friend to talk with, an advocate to help fill out a complicated application, a companion to share meals with after relocating to a lonely apartment in a new community. Peer supports and self-help groups are beginning to emerge, but remain sorely lacking and unevenly distributed across the country.

Medicare helped to centralize and destigmatize mental illness in ways that have offered some genuine benefits, but it has also contributed to the growing medicalization of problems that are often more political than medical. Prime Minister Justin Trudeau’s recent promise to provide $70-million to target mental-health care will fund more services and expand the number of professionals, but those dollars will not reach the people who need it most. Until we recognize the value of investing in peer-supports and client-led governance, our investments in mental-health care will continue to exacerbate the problem. Can we boldly admit that investing in anti-poverty strategies is a medically necessary intervention?