By Dr. Richard O’Reilly
Emeritus Professor of Psychiatry
Western University, London, Ontario
Many people have been touched, and no doubt shocked, by the story of Andrew Bryenton, the 39-year-old, father of two from Prince Edward Island (PEI), (as chronicled here in previous blogs, the Globe and Mail and Torstar) who worked as an assistant bank manager before he developed a psychotic illness, just 5 years ago. Andrew has now lost everything: his marriage; his children; his job; his home; and most importantly of all, his sanity.
Andrew’s case demonstrates just how destructive a psychotic illness can be. People in the prime of life, eminently successful in their relationships and vocational pursuits, can suddenly be struck down by hallucinations and delusions. But the story does not have to end with catastrophic losses. Although not perfect, antipsychotic medications reduce or completely resolve hallucinations and delusions for most sufferers. This allows the person to have a reasonable quality of life, though not always meeting their pre-illness potential. Unfortunately, psychotic illnesses are likely to recur if the person stops taking antipsychotic medication as it did in Mr. Bryenton’s case.
If you are reading this and are not a family caregiver, pause for a second of reflection. Andrew’s story could be your story, or the story of someone close to you. Put yourself in Andrew’s mother’s shoes. What would you want for your loved one? Certainly, you would not wish for the scenario that played out when Andrew left PEI and ended up in Ontario.
Andrew came to Ontario in January of this year. Media reports indicate that due to paranoia, Andrew avoids food banks and homeless shelters. He lives on the streets of Toronto – one of the riches cities in the world – relying on handouts from strangers to survive. But Andrew’s survival is far from assured. In addition to sleeping out in Ontario’s inclement winter weather, he has been seen walking up a highway off-ramp in Toronto: a behavior that puts his life, and possibly the lives of others, at risk. Andrew has been admitted to a psychiatric unit in Ontario on two occasions, but kept for only 72 hours each time, before being discharged back to the streets to fend for himself.
This surely cannot be right in an affluent, and so-called just, society? It’s hard to imagine what else, apart from symptoms of a mental illness, would have caused Andrew to walk up a highway off-ramp against on-coming traffic. If indeed mental illness caused this dangerous behaviour, Andrew meets the criteria for involuntary admission due to the risk of “serious physical impairment,” which is the legal terminology for someone unintentionally putting themselves at risk for serious injury or death.
Readers who are family caregivers will immediately recognize this story. Ill relatives are brought to hospital, sometimes by the police, or on an order issued by a justice of the peace, only to be discharged after 72 hours without treatment and without improvement. The tragic reality is that there are thousands of Andrews out there. Hospitals regularly discharge patients to homeless shelters, where they quickly fall prey to drug dealers and pimps. Very occasionally, the tragic story of one of these individuals or a member of their anguished family, appears in the media. Mostly they just fade into obscurity or die of neglect.
We expect the provision of healthcare in Ontario to improve over time. But 25 years ago, hospitals did not discharge patients to homeless shelters, let alone to the streets. This unacceptable approach started approximately 20 years ago and has become steadily worse as the number of hospital beds, needed to treat people with severely mental illness, has been progressively reduced. And here’s the thing, we are not at the bottom of this decline: there is absolutely no reason to believe that things are not going to get worse.
On a brighter note, there are solutions. First, we can reverse the decline in the availability of inpatient care. A reasonable availability of hospital beds would enable doctors to admit people like Andrew and to provide treatment in hospital until the patient’s hallucinations and delusions are controlled. Critically, it would also allow the hospitals to care for very disabled patients until a residential placement could be found that would provide the person with an appropriate level of support. In relation to this second point, Ontario needs to develop high support group homes in the community for the small percentage of people with marked psychiatric disabilities so that they can live with dignity. Finally, we need to fund more assertive community teams (ACTs). The Ontario government promised to fund a network of ACT teams when it closed the freestanding psychiatric hospitals. But the Ontario Association for ACT teams notes that the province is 50 ACT teams short of the required target and that many of the existing teams are underfunded.
Fixing these deficits in services for Ontarians with severe mental illness is eminently feasible …provided that there is the political will. Of course, providing these essential services will cost money. However, lack of money is not the problem. The problem is our society’s reluctance to spend money on services for people with severe mental illness. Governments repeatedly trumpet increased funding for “mental health services.” Bizarrely, few of these additional dollars go to services for people with the most severe illnesses such as psychosis. In other areas of health care, we prioritize the needs of the those with the most severe problems. I can’t think of another area of health care in which we prioritize spending on less severe problems while ignoring the basic needs of citizens who are the most severely ill.
Regrettably, I have to acknowledge that psychiatrists have been ineffective in preventing the deterioration of services for people with severe mental illness. While, there are many reasons for our failure, one is the lack of focus in psychiatric practice, which covers a wide range of problems. Psychiatrists who work with childhood behavioural problems or provide psychotherapy to people with relationship problems have very little, if any contact, with patients who suffer from psychotic illnesses. So, the voice of psychiatry is not unified in a clear demand that we prioritize the provision of services for the most severely ill patients.
Elsewhere, I have stated my belief that the families of people with severe mental illness must have a key role in designing and overseeing the services for this population. However, nobody is going to offer you that role – you have to demand it. The case of Andrew Bryenton puts a face on the failure of successive governments to use our tax dollars to provide essential services for people with the most severe mental illnesses. Andrew’s case has also generated significant media attention and provides an opportunity to highlight the critical deficits in our mental health system. Do not hesitate to call or write to your provincial member of parliament or to your local paper. Send a copy of these letters to Ministers Tibollo and Jones. These things make a difference. If you don’t make noise nobody is going to hear you, and if nobody hears you things will just continue to deteriorate.