From the Editor

How to free the mentally ill from their chains?

This week, I’ve selected three Readings. We open with a moving essay about a man who works to free the mentally ill from their chains – literally – in Africa. In an op ed, Mental Health Commission of Canada’s Michael Wilson argues that the federal budget must make suicide prevention a priority. Finally, we look at a new study considering an old problem: access to mental health services.


Making a Difference in Africa

“Gregoire Ahongbonon: Freeing people chained for being ill”

Laeila Adjovi, BBC News, 17 February 2016


Aime has just come out of his room. He is taking tiny steps – his ankles held in leg irons.

The scene takes place in a small house in the city of Calavi, on the outskirts of Cotonou, the capital of Benin. Aime, 24, has a mental illness and his elder brother and sister have been looking after him to the best of their abilities.

‘We’ve had to lock him up because he disturbs people and they come to our house to complain,’ says his brother, Rosinos.’

Laeila Adjovi

So opens an essay written by the BBC’s Laeila Adjovi describing the work of Gregoire Ahongbonon, a former mechanic, who has spent three decades helping those with mental illness. The article focuses on the West African country of Benin, where health care is relatively expensive, and families of those with mental illness often turn to traditional healers and churches. For the mentally ill, life may be spent in chains.

Ahongbonon takes a different approach. With limited resources, he offers patients care and low-cost medications. Volunteer psychiatrists from Europe visit the clinic; the staff includes former patients.

Adjovi writes:

“Ahongbonon and his staff find homeless people, thrown out on to the street by their families, and give them a home. They also travel across West Africa on alert for reports of mentally ill people shackled or mistreated in remote villages. When they find such people they offer to take them in.”

The essay follows the journey of Aime, a young man with a psychotic disorder. With care, his sleep is restored and he seems better. It’s a compelling if haunting story.

Making a Difference in Canada

“Aid for suicide prevention must be part of federal budget”

Michael Wilson, The Globe and Mail, 24 February 2016

We can no longer ignore the alarming evidence: Every day, at least 10 Canadians die by suicide. Do we have the courage to face down stigma and get help into the hands of those who need it?

As a former finance minister, I understand the tough challenges Prime Minister Justin Trudeau and Finance Minister Bill Morneau face in preparing the 2016 budget and allocating spending. The Mental Health Commission of Canada (MHCC) is asking the government to commit funds for a far-reaching national suicide prevention project, based on a plan that accounts for fiscal reality and maximizes the use of existing community resources to help those at risk of suicide.

As a father, the rate of suicide in Canada isn’t just an alarming statistic, it’s a deeply personal matter. We lost our son, Cameron, to suicide in 1995. I know the devastation it leaves in its wake.

Hon. Michael Wilson

So begins Michael Wilson’s op ed. Wilson has had a storied career – a former Minister of Finance and U.S. ambassador, and now chair of the Mental Health Commission of Canada. Wilson advocates making suicide prevention a budgetary priority – he both draws on statistics, and also movingly from his own personal loss.

Though Wilson champions work done in the field, he is particularly keen on the “gatekeeper” model – “key people who regularly interact with members of the public and are well positioned to recognize suicide signs and therefore intervene. The gatekeeper model is already in place and achieving results in Quebec and abroad…” Wilson suggests that a demonstration project should be done, focused on at risk populations.

There is urgency about this problem. Consider that the suicide rate has remained basically unchanged in Canada in recent years, and that suicide is the second leading cause of death for children and youth aged 10 to 24. And certain populations are particularly affected. As the CMAJ recently noted: “In some First Nations and Inuit communities, suicide rates are 4 – 10 times the national average. In Nunavut, the suicide rate for young men aged 15 – 19 climbs to a staggering 40 times the national rate for that age range.” (!)

But, fortunately, suicide prevention is an area that has been transformed by good research and solid thinking over the past decade or two. Yes, there have been thoughtful studies. Better still: there have been thoughtful experiments, like the work done in Nuremberg, Germany, built on the “gatekeeper” model that Wilson touts. It showed a reduction of almost a quarter of suicides in its first years. Is that an endorsement of Wilson’s proposal? It’s an endorsement of more experimentation – and a demonstration project seems the right way to do just this.

Seeking Care in Canada

“Mental Health Service Use Among Children and Youth in Ontario: Population-Based Trends Over Time”

Sima Gandhi et al., The Canadian Journal of Psychiatry, February 2016

Most mental health conditions have an onset between childhood and early adulthood, highlighting the importance of access and early intervention after first presentation of illness. In Canada and elsewhere, numerous sources have documented significant issues regarding access to mental health care and coordination between community-based and physician services. Despite the attention to these issues, only 1 in 6 children and youth receive the mental health services they need, resulting in a significant proportion of youth and families relying on acute care resources during crises.

US studies have shown that mental health accounts for a significant portion of acute care use among children and youth ages 3 to 20 years. Less is known about the proportion of health care use attributable to mental health care use among children and youth in Canada.

Sima Gandhi

So opens a paper by Sima Gandhi et al. from The Canadian Journal of Psychiatry that asks the basic question: are children and youths accessing more mental health services?

This paper is relatively straight-forward: it draws data from several databases (National Ambulatory Care Reporting System, CIHI, Canadian Institute for Health Information Discharge Abstract Database, and OHIP physician billing) to figure out different types of health care service use: ED visits for mental health and addiction, psychiatric hospitalizations, and outpatient psychiatric visits. The data: from Ontario, covering the years 2006 to 2011, and for children and youths, ages 10 to 24.

Here’s what Gandhi et al. found:

· “[T]he rate of ED visits increased from 14.6 to 19.3 per 1000 population (P = 0.01), representing 32.5% relative growth between 2006 and 2011…”

· “Hospitalizations were rare in our study; however, the relative increase from 2006 and 2011 was 53.7% (2.9 to 4.5 per 1000 population, P < 0.01).”

· “Office-based physician visits increased 15.8% between 2006 and 2011.”

The Institute of Clinical Evaluative Sciences nicely summarizes the paper with this graph.

The authors note:

Our findings are consistent with earlier studies that reported rising trends in access to acute care services among children and youth. A US report by the Health Care Cost Institute found that hospitalizations for mental health and substance abuse among children age 18 years and younger, covered through private health insurance programs, grew 24% (2007 to 2010). Similarly, Pfuntner et al reported an 80% increase in the rate of hospital stays for mood disorders among 1- to 17-year-olds, between 1997 and 2010. Our study is the first to concurrently evaluate acute care (ED and hospitalization visit rates) and outpatient care…

They then push further:

The fact that ED visit rates are increasing at a faster rate than outpatient visits suggests that children and youth are accessing services in the ED rather than outpatient resources when they need access to mental health services. This is consistent with related evidence of poor access to nonacute, community-based resources. While we are also unable to measure need for ED services, it is unlikely that the observed increase was solely due to an increase in mental illness and addiction burden or acuity of presentation requiring ED services in Ontario during the study period.

A few thoughts:

1. This is a big paper.

2. Like other papers looking at Canadian psychiatric services, it says much about access – and indicates significant issues.

3. Their main conclusion is worth repeating: “This is consistent with related evidence of poor access to nonacute, community-based resources.”

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.