In the first part of this series, I made a point of breaking the fourth wall. It might have seemed like a strange indulgence, but, for this series in particular, I thought it was necessary to explain why some things get into these articles and others don’t. There is almost no natural limit or defined scope to a series discussing mental-health care. It’s too big and too complicated. Triage is necessary.
In Part 1, we established some guidelines and general definitions, and quantified what we could of the challenge. Part 2 was focused on the day-to-day reality of providing mental-health care for Ontarians who are still capable of living independently. In a perfect world, services would be provided as needed and when needed, though, as discussed in Part 2, we often fall far short of that ideal. This concluding part was always intended to take a look at those Ontarians who require in-patient treatment. And, here we are, barely at the start of the piece, and I’m already making tough decisions about what we will not talk about here.
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We will not talk about those who are confined to a facility because of crimes committed for which the individual was ultimately found not criminally responsible on grounds of mental illness, nor the too-frequent collisions between law enforcement, the courts, and the mentally ill. Nor will we deeply engage with the undenied contribution of mental health to homelessness — we’ll touch on that, but that’s an issue that deserves its own close examination.
In the interests of limiting our scope to something manageable, this third and final part will therefore look at a very specific and niche part of the overall system: in-patient mental-health care for those who cannot, at least for a time, live independently. Some patients will require in-patient care for a brief period — days, perhaps weeks, maybe even months. Others will require full-time care indefinitely. And some will require ongoing care that falls somewhere in the middle.
Each group has its own circumstances, of course, and it's important to note that describing them in broad terms is, of necessity, an abstraction for the sake of expediency. That said, it's easier to address the groups on the extremes — those who require short-term in-patient stays and those who'll need permanent, ongoing care. For the latter group, Ontario provides direct funding for beds in facilities where there is care and monitoring 24/7. The care ranges from overall supervision to the medication dispensing to assistance with daily personal tasks. This is for people whose mental illnesses leave them entirely incapable of living independently. Though they make up only a small percentage of the total population of mental-health patients, their care, understandably, consumes considerable resources.
On the other end of the spectrum, of course, are those whose needs are real and urgent but will likely prove relatively brief. I asked Steve Lurie, executive director of the Canadian Mental Health Association Toronto Branch, to describe to me a hypothetical “typical patient” who finds themselves in a crisis requiring in-patient treatment but will who not require long-term housing. Lurie said that such a patient would usually be brought to a hospital and admitted, often but not always involuntarily, while in the grips of either a complicated mental-health crisis or perhaps a severe addiction (opioids are a growing problem, he said, but alcohol remains, by far, the biggest culprit). The patients, of course, may also be suffering from addiction, underlying mental-health issues, and medical problems.
This patient requires stabilization and treatment, which could involve therapy, medication, a detox period, or some combination of those, as well as medical care, as necessary. They can be treated in a primary-care hospital or a psychiatric facility. But their life circumstances, Lurie said, are such that they can recover and heal once the crisis has passed, returning to their lives.
But this brings us to the middle part of the spectrum — patients who don’t require full-time care in an institution but who shouldn’t simply be discharged after the crisis has passed.
Housing, Lurie said, is essential. In the case of the homeless, that means housing, full stop, but, for other patients, it may mean a new housing arrangement, one more conducive to recovery (consider a patient with a severe addiction, for instance, whose normal housing involves living with other people abusing the problematic substance). Other patients may be mostly able to manage their own affairs but require frequent support, either with their illness, medications, or daily tasks. This can be provided in assisted housing or by other programs that bring services to a patient in their own home. This middle part of the spectrum is vast, and care options must respond effectively to the specific needs of that patient.
I asked Lurie how we divide these groups. How does one person find themselves in the group sent home to live with family while continuing with outpatient therapy, while another with a very similar diagnosis ends up in assisted living, while still another must be institutionalized indefinitely? The cases of most extreme need, he said, are the easiest to separate from the rest — many people will experience a mental-health crisis in their lives, but only a small portion of the population will be so afflicted by a severe mental illness that they will require full-time care. A much larger percentage — a majority of the population, eventually — will have an episode, or episodes, that warrants intervention, but most will not need institutional care for prolonged periods. And what divides the group who may require temporary care in assisted living from those who can return home, Lurie said, is often life circumstances.
Again, this is an abstraction. My little phrase there — “life circumstances” — is covering a multitude of extremely complex topics. Life circumstances include, but are certainly not limited to, post-traumatic stress, personal or family financial wealth (or lack thereof), local availability of a variety of health-care services, age, race, religion, gender identity, and sexual preferences, physical disability or chronic illnesses, and professional and educational attainment. Every patient’s experience will differ. But a patient who experiences a mental-health crisis who has a job, has a stable family life, has money, has a supportive, nurturing group of friends and relatives, and, critically, has a stable home to return to, has a good chance to recover. A patient with the exact same mental-health crises who lacks some or all of these things may benefit from a period of living with some level of continuing support beyond routine outpatient therapy or psychiatric medication.
The question is, is such a bed available?
And this brings us full circle. Five months ago, my young son broke a bone. We found ourselves marooned at a hospital struggling to cope with an unexpected surge in patient volume. That led to a series of articles on the state of our emergency rooms, which led to a further series on the province-wide crisis in our health-care system related to the blandly and euphemistically named “alternate level of care,” or ALC. An ALC patient is a patient who does not need to be in a primary-care hospital but remains there, at considerable financial cost to the broader health-care system, because a bed in a more appropriate facility is simply not available.
According to Ontario government figures, on any given day, there are approximately 2,300 patients who are awaiting transfer to a more appropriate bed. If we could wave a magic public-policy wand and get them all out of the system, the problem of “hallway health care” would instantly end. Of these 2,300 patients, 9 per cent, or approximately 200 people, are awaiting transfer to a more appropriate care setting for a mental-health issue.
Creating 200 beds does not sound like an insurmountable goal for a province of some 14 million. But the overall demand in communities isn’t limited to the demand already in the hospitals. While 200 extra beds would solve a small part of the broader ALC problem, it would not begin to address the backlog for mental-health care across the province for people who would benefit from assisted housing or intensive home-based care.
How many beds are needed? That’s difficult to say, as demand would likely grow alongside capacity, but, in 2016, Ontario funded more than 12,000 beds, of varying levels of care: waits for beds were often measured in years — up to seven years, in some areas. A 2016 report by the Ontario Mental Health and Addictions Leadership Advisory Council recommended that Ontario fund an additional 30,000 assisted-housing beds. Lurie suggested that the appropriate number could be perhaps three times higher than that, and little progress has been made.
And it’s not clear we’ll do much better anytime soon. The provincial government has pledged to do more for mental health and to expand the long-term-care system generally. But that will take years and sustained political will. Years, we have. The will? We’ll see.