Staying Away from the Edge: Reflections on World Mental Health Day

Opinion by EHN Guest Writer

Written by Adam Fisher, a former Director at Renascent and EHN Canada, writer, researcher, and photographer. He has been in recovery since June, 2004.

Today is World Mental Health Day, a day created to provide encouragement and opportunity for people to talk about their experiences—people with mental health disorders, people caring for others with mental health disorders, and people working on solutions to mental health disorders. World Mental Health Day also gives anyone affected by mental health disorders the opportunity to talk about their struggles and about ways to improve access to high-quality mental healthcare for people worldwide.

When you have a mental health condition, you spend your life on the edge. Most of the time you don’t know how close you are to it—how close you are to tumbling down into the abyss. On good days you wonder whether there is an abyss at all; on bad ones you wonder if letting yourself collapse into it might just be easier than another day of darkness. All that’s certain is that you’re on the edge of something.

There are countless confusing aspects to living with a mental health disorder. Being unstable. Being obsessed. Being in flux. Being on the edge.

Being uncertain.

You get chicken pox, you know it. You break your arm, you know it. But mental illness—with its shifts from rational to irrational, from balanced to unsteady—isn’t as obvious as that. The edge is often shrouded in fog and difficult to see, but you can feel it when you’re close.

I can see the edge more clearly now than when I was first diagnosed with major depression in 1996, but that doesn’t insulate me from the nauseating, paralyzing feeling when I get drawn back too close to it.

The Edge and the Abyss

In his powerful book, The Noonday Demon: An Atlas of Depression, author Andrew Solomon writes about both the edge and the abyss.

“If you stand on the edge of a cliff and look down, you feel dizzy. You think you’re going to fall, and if you look for too long, you will. You’re paralyzed,” he writes, explaining the feeling of his own mental illness. “I think depression is not…going over the edge itself, but drawing too close to it, getting to that moment of fear when you have gone so far, when dizziness has deprived you entirely of your capacity for balance.”

“Depression relies heavily on that paralyzing sense of imminence,” he continues. “Terror of the fall grips you even if that terror is what might make you fall. What is happening to you in depression is horrible, but it seems to be very much wrapped up in what is about to happen to you. Among other things, you sometimes feel you are about to die. The dying would not be so bad, but the living at the brink of dying, the not-quite-over-the-geographical-edge condition, is horrible.”[1]

Living with any mental health disorder is horrible. Depression is the most common of mental health conditions, affecting an estimated 300 million people globally,[2] but every mental illness can exact a toll on a person and have a devastating impact on their ability to lead a healthy, stable life. If depression is the tip of the iceberg, then there are many mental health conditions that make up the enormous mass that lies below the surface of the water: anxiety disorders, mood disorders (bi-polar, depression, etc.), personality disorders, schizophrenia, substance use disorders, trauma-related disorders (such as post traumatic stress disorder), eating disorders. These conditions often go undetected for years, and can cause tremendous damage in someone’s life.

Accessing Healthcare for Mental Health Conditions

Back in 1996, after years of self-medicating a problem that I didn’t understand and couldn’t explain, and with no one to interpret the foreign language that all the research literature used (emotional dis-regulation? anhedonia?) I finally reached out for help. That’s probably giving myself too much credit. After several friends had tip-toed around the subject with some “what’s wrong?”, “are you ok?” and “you sure you’re alright? You seem, I don’t know, down,” kind of questions, one of them finally suggested that I “…talk to someone.” Fortunately, by the random good fortune that a close family friend worked as an experienced and well-connected psychiatrist, I was able get assessed quickly and provided access to treatment options and helpful medications. But many (most?) Canadians don’t share this experience. Navigating the mental health system can be enormously frustrating and accessing a trained mental health therapist and treatment options often come only after languishing on long waiting lists—and at significant expense.

These waiting lists are not what we expect from the great Canadian healthcare system our neighbors to the south so glowingly refer to—especially during election years.

I interviewed Dr. Patrick Smith, past CEO of the Canadian Mental Health Association (CMHA) and current CEO of the Veterans Affairs-run Centre of Excellence for PTSD and Related Mental Health Concerns. Dr. Smith explained where the gaps in our healthcare system are when it comes to mental health. “Our universal healthcare system is a point of pride for Canadians. But the reality is, we don’t have a universal healthcare system, but a universal medical system that doesn’t guarantee access to some of the most basic mental health services and supports.”

So physical issues we’ve got covered, but with mental health, we’re clearly struggling to close the gaps that prevent people from receiving appropriate, government covered treatment when they need a check up from the neck up.

And these gaps are not going unnoticed. In a re­cent poll, 59% of 18-to-34 year olds questioned consider mental illness to be an epidemic in Canada, followed closely by addiction (56%). Physical illnesses such as cancer (50%), heart disease and stroke (34%), diabetes (31%), and HIV/AIDS (13%) were significantly less of a concern to this group.[3]

Dr. Smith is concerned, but not surprised, by these figures. “I think we have to take this information at face value and take it seriously. The factors that may be contributing to this perception that it is an epidemic are varied. For one, there is greater awareness of the seriousness and prevalence of these mental health issues and the greater awareness leads to a realization that the public health response has been sorely lacking.”

Canada Lags Behind in Mental Health Treatment

That sometimes glacially slow and “sorely lacking” response means many Canadians end up relying on their family doctor when they experience depression, anxiety, post traumatic stress disorder (PTSD), addiction and a host of other mental health conditions. And those types of complex conditions require specialized training that most family doctors don’t have. In a study done by the National Institutes of Health in the United States, family doctors demonstrated an alarmingly poor ability to properly diagnose subjects presenting with mental health disorders. Out of 51 subjects who presented with 94 symptoms of a range of mental health conditions, 79% were unrecognized and went undiagnosed by their doctor. Often the best your family physician can do is send you home with a list of phone numbers or email addresses for therapists.[4]

Mental health is an area where Canada falls behind many other developed nations, according to Dr. Smith. “Our universal healthcare in Canada doesn’t even cover basic services such as counselling and psychotherapy provided by trained clinicians such as psychologists, social workers and addiction counsellors. Other developed countries rely on these practitioners as the foundation—the bedrock—of their response to mental health conditions. We have these care providers in Canada, but they are mostly sitting on the sidelines of a publicly-funded system that is heavily focused on doctors and nurses. They are part of the appropriate response, for sure, but not adequate on their own, especially when we know that there are many evidence-based treatments, such as Cognitive Behaviour Therapy (CBT), that have great effectiveness but are mostly only available in Canada if you can pay out of pocket.”

CBT’s effectiveness as a therapeutic tool is reinforced by its inclusion in the Mood and Anxiety Program (MAP) at Bellwood Health Services. As part of the biopsychosocial model which provides the framework for the seven-week, residential program, CBT has shown in studies to be as effective in treating depression as prescription antidepressants. CBT is just one of many evidenced-based tools that the interdisciplinary MAP team (which draws upon the expertise of psychologists, psychiatrists, psychotherapists, social workers, recreational therapists, nutritionists, occupational therapists and physical health professionals) employ in treating a range of mood and anxiety disorders.

“The biopsychosocial model is one that considers and links the role of physical, psychological, and social factors in mental health conditions such as depression.” explains Dr. Hester Dunlap, Lead Psychologist at Bellwood.

Studies have also shown that CBT can be as effective in treating depression as prescription antidepressants and is also used effectively in the treatment of phobias and Obsessive Compulsive Disorder (OCD).

Insufficient Funds for Mental Healthcare Spending

Programs like this aren’t covered under Canada’s current healthcare system.

“When we look at the public health response to issues such as heart disease, stroke and diabetes we know there has been significant investment in both treatment and research for these illnesses,” continues Dr. Smith, “but what have we done when it comes to mental health concerns?”

What has been done is a lot of hand-wringing and anti-stigma hash-tagging—and to be fair, great progress in how the public views mental health has been made—but the appropriate funding that would even the playing field between people with mental health complaints and those with physical ailments hasn’t followed. Even mental health conditions that require hospitalization, and are therefore covered, are still treated differently than physical ones. According to Health Quality Ontario, the agency entrusted with the oversight of healthcare in our most populous province, only one in three patients discharged from a hospital psychiatric ward has a follow-up appointment within one month, compared to 100% of patients discharged after having a heart attack.[5]

And the politicians can’t push this buck back onto their constituents, because 85% of Canadians say mental health services are among the most underfunded services in our healthcare system, and even more agree (86%) that the Government of Canada should fund mental health at the same level as physical health.[6]

“Canada spends the lowest percentage of our health spending on mental health—lower than any other G7 country,” continues Dr. Smith. “What we have spent over the decades has been focused on crisis and acute services. Many mental health concerns, much like diabetes, asthma, cardiac disease, are chronic and not acute. The disconnect between the total burden of illness for mental health problems (including substance use disorders and addiction) and the investment in our response is staggering and can only be explained by long-standing and engrained systemic stigma and discrimination in the face of evidence-based services and supports that we know have positive effects,” he explains.

The True Size of the Problem

“There really is no excuse that these services and supports aren’t readily available to all Canadians who need them–regardless of their ability to pay for them. Not only is it the right thing to do to make these services and supports available to those who need them, it’s the only fiscally responsible thing to do because the cost of inaction is exacting a financial toll on our society that may soon be increasingly difficult—if not impossible—to reverse,” cautions Dr. Smith.

“Instead of treating all the frogs in the pond one-by-one, perhaps it really is time for us to look at the pond,” he concludes.

There is much work to be done. We are still very much in the dark regarding some areas of mental illness, and in others we have made enormous leaps forward. Yes, help can come frustratingly slowly, and can be expensive, but as someone who has battled mental illness for 25 years, I have to say that I feel hopeful. There has never been a time where we better understood how the correct interventions and care can provide those afflicted with the opportunity to lead happier, healthier, safer lives.

Globally, 2.5 trillion dollars will be spent caring for people with mental health conditions this year. By 2030 that number is expected to climb to 6 trillion.[7] Many would understandably recoil from those numbers, and there’s no question they show just how many people are suffering from poor mental health across the world, but 6 trillion dollars is a shocking amount of money. Yet, we spend this money without hesitation to help people with mental health conditions who, not so long ago, were ignored.

That knowledge, that powerful, measurable proof that in 2019 empathy outweighs scorn and understanding exceeds ignorance, is enough to keep me fighting to stay on the right side of the edge—and not look down—for as long as I can.

There is Help

If you or a loved one has a mental health condition and a concurrent substance use disorder don’t hesitate to reach out. Our admissions counsellors are standing by to help you get the recovery process started.

REFERENCES

[1] Solomon, A. (2015). The Noonday Demon–An Atlas of Depression. Retrieved from: http://andrewsolomon.com/books/the-noonday-demon/

[2] World Health Organization (WHO). (2017, 7 April). Depression: Let’s Talk. Retrieved from: https://www.who.int/mental_health/management/depression/en/

[3] Canadian Mental Health Association, (2018, 17 September). Mental Health in the Balance: Ending the Health Care Disparity in Canada. Retrieved from: https://cmha.ca/documents/over-half-of-canadians-consider-anxiety-and-depression-epidemic

[4] Jones, L.R, Badger L.W, Ficken R.P, Leeper, J.D, Andersen R.L. (1998). International Journal of Psychiatry. Mental health training of primary care physicians: an outcome study. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/3170078

[5] The Globe and Mail. (2019, 16 May). Retrieved from: https://www.theglobeandmail.com/opinion/editorials/article-canadas-health-care-system-is-failing-people-with-mental-illness/

[6] Canadian Mental Health Association, (2018, 17 September). Mental Health in the Balance: Ending the Health Care Disparity in Canada. Retrieved from: https://cmha.ca/documents/over-half-of-canadians-consider-anxiety-and-depression-epidemic

[7] Insel, T. (2011, 28 September). National Institute of Mental Health (NIMH). Post by Former NIMH Director Thomas Insel: The Global Cost of Mental Illness. Retrieved from: https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/the-global-cost-of-mental-illness.shtml