Children's mental health services are the “most neglected piece” of the Canadian health care system, says Senator Michael Kirby, chair of a committee examining Canadian mental health issues.
The Standing Senate Committee on Social Affairs, Science and Technology plans to make recommendations on a national strategy for mental health in early 2006. The committee hopes to spark a debate around ways to improve mental health services and addiction treatment.
During cross-Canada hearings this year, Kirby says he was struck by the stigma surrounding mental illness, particularly in children. If mental health services generally are the orphan of the health care system, then children's services are the “orphan of the orphan,” he says.
“A lot of people don't want to talk about it,” Kirby told CMAJ. That's one reason the shortage of child psychiatrists and community-based services has not attracted the same media attention as wait lists, he says. Without that media attention, Kirby adds, the issue will not rise higher on the political agenda.
“Frankly, the people affected by mental health [problems] don't have the voice that people suffering from breast cancer and heart disease and other problems do,” Kirby says.
Kirby hopes the committee's report will help policy-makers and politicians understand the need to devote more resources to children's mental health.
The Canadian Academy of Child and Adolescent Psychiatry estimates the need for child and adolescent psychiatrists at 1 per 4000 youth. That means there should be nearly 2000 psychiatrists to serve the 7.8 million Canadians age 19 and under. In reality, there are about 480. In Ontario in 2002, the latest year for which the Academy has figures, there was 1 psychiatrist for every 32 000 youth. Quebec has 1 for every 11 000.
The other provinces are similarly stretched, says Academy President John Leverette.
This has resulted in long waiting lists. In 2004, 66% of respondents to CMA's National Physician Survey rated access to psychiatric care in their community as fair or poor.
The gap is expected to widen, given that the majority of practising child and adolescent psychiatrists are nearing retirement and there are only about 10 new graduates annually in English-speaking Canada.
Another major problem is a lack of continuity of care. In Nova Scotia, for example, children's mental health programs serve children 16 and under, while adult services begin at age 19. “Nobody handles you if you're 17 or 18,” Kirby says.
Lack of public funding for psychological services in most provinces and cuts to special education programs in schools and to other community mental health resources has increased the pressure on the system generally, says Kirby.
“The ability to get additional treatment, counselling and other things just doesn't exist unless the family can afford to pay for it themselves,” he says. “The reality is that lots of people can't.”
Early diagnosis, which is particularly critical in children (Br J Psychiatry 2005;48 [suppl]:108-10), is also underfunded, as are prevention programs, say experts testifying at the committee. The onset of most mental illnesses occur in adolescence or early adulthood, reports the Public Health Agency of Canada.
Anxiety disorders are the most prevalent mental illness in children 4 to 17, at 6.4% of the population, followed by attention-deficit /hyperactivity disorder (4.8%), conduct disorder (4.2%), depressive disorders (3.5%), substance abuse (0.8%) and pervasive developmental disorder (0.3%) (Can J Pyschiatry 2005;50:4).
Treatment is just one component of an adequate public health strategy, which should concentrate on prevention, says Dr. Charlotte Waddell, assistant professor in child psychiatry at the University of British Columbia.
“What you really have to do is appeal to people's sense of responsibility and duty and care for the next generation,” agrees Kirby. “The real reason for doing it is because it's absolutely damn well the right thing to do.” — Laura Eggertson, CMAJ
Figure. Providing child mental health services is the “right thing to do.” Photo by: Art Explosion