Opinion

Surely, the time has come for psychiatric hospitalization at home. What’s holding us back?

In late February 2016, Celina Caesar-Chavannes, then Member of Parliament for Whitby and Prime Minister Justin Trudeau’s parliamentary secretary, was having a mental breakdown. Her friends were so worried that they took her to the emergency department at Sunnybrook Hospital in Toronto, where she registered under the alias of Lisa May.

The doctor on duty informed her that she needed to be admitted but no beds were available.

Great, I thought! Here was a person in a mental-health crisis so afraid of the stigma of hospital admission that she used a false name. Here was a person coming up against Canada’s chronically severe mental-health bed shortage that the service I had founded in Kitchener-Waterloo in 1989 – Intensive Home Treatment ( IHT), called the Hazelglen service after its location – was designed to address. Plus, she was in a position of power and influence and could have this model of treatment adopted in Canada by talking it up with “the right people.”

IHT can treat about 30 per cent of patients who would otherwise need admission. In addition, it enables early discharge from hospital for about 40 per cent of patients. It features a multidisciplinary team that makes daily or more frequent visits to patients’ homes, works with their families and social networks and provides the complete range of treatment patients would get in hospital. Literally, psychiatric hospitalization at home. With IHT, Cesar-Chavannes would have avoided the emergency department and received urgently needed treatment in her home.

I had been on a mission to disseminate this model of mental-health care ever since my book, Home Treatment for Acute Mental Disorders: An alternative to hospitalization, was published in 2005, to positive reviews from American psychiatric journals. Anita Everett, the director of the U.S. government’s Substance Abuse and Mental Health Services Administration, even wrote the forward.

I founded Hazelglen in 1989 as director of the psychiatric ward at Kitchener’s Grand River Hospital, where we had been facing a seemingly insoluble and alarming bed crunch since 1980. The path to a solution arrived fully formed in August 1982, when I read a review of Home and Hospital Psychiatric Treatment, a book by psychiatrist Fred Fenton. It described research carried out in 1978 at Montreal General Hospital in which selected patients in the emergency department needing admission were randomly assigned either to hospital treatment or IHT. Results showed that for many patients, IHT was as effective and safe as hospital treatment as well as cheaper and preferred by patients and families.

The first move in my mission was an interview at the Ontario Ministry of Health (MOH). Kitchener Member of Provincial Parliament John Milloy promised to arrange one. Six months later, telephone messages from his aides reassuring me they were working on it ceased.

My letters to the MOH received bureaucratic non-answers. I tracked down the MOH’s senior mental-health planner but she had no idea how IHT could be adopted in Ontario.

My letter to Member of Parliament Andrew Telegdi went unanswered.

The Mental Health Commission of Canada (MHCC) “leads the development and dissemination of innovative programs and tools to support the mental health and wellness of Canadians,” that “should be recovery oriented by upholding the principle of least intrusive interventions,” i.e., avoid hospital admission All the more surprising then that my letters to the commission went unanswered. Consequently, I wrote to its founder, Senator Michael Kirby, in February 2011 but never received a reply.

Shortly after this, at an MHCC presentation to psychiatrists, I asked how or whom I should contact about IHT. The presenter clearly had no idea, prompting others in the audience to remind her she hadn’t answered my question.

Hospitals would be pleased to hear about IHT, I thought. It would reduce pressure on their emergency departments and on mental-health beds. In September 2010, I arranged a conference call with the director of finance and research and two policy staff of the Ontario Hospital Association. They did not know how to introduce IHT into hospitals.

After encountering other roadblocks, I was thrilled to meet with Caesar-Chavannes at her Whitby office on Dec. 19, 2016, a meeting that coincided with Federal Minister of Health Jane Philpott’s negotiations with the provinces to earmark some transfer monies for mental health. Caesar-Chavannes agreed to have her aide communicate with Philpott’s people, noting the mental-health bed shortage was nationwide.

Several years later, the current shenanigans between provinces and Ottawa make my efforts now look naive and quixotic.

When I started Hazelglen, there were scattered IHT teams in the United Kingdom, where it is called Crisis Resolution and Home Treatment (CRHT), and a few in the U.S. and Australia. In 2001, the U.K.’s National Health Service developed a plan to create IHT teams throughout the country – 330 in total, making IHT one of its major planks in mental-health policy. Many countries have followed suit, using the CRHT model as the template for policy development, including Ireland, Australia, New Zealand, Norway, Belgium, Germany, the Netherlands, Greece, Spain and Switzerland.

Treatment by a CRHT team is now the default disposition – ahead of hospitalization – for three acute severe mental disorders, according to guidelines of the UK’s National Institute for Care and Clinical Excellence (NICE), an independent body that reviews the research and makes recommendations in the management and treatment of all clinical conditions. These guidelines are widely respected internationally.

For acute schizophrenia and psychosis, acute bipolar disorder and acute severe depression with suicidal thoughts, NICE guidelines recommend CRHT should first be considered before admitting a patient to hospital.

Mental health patients can wait for days in emergency departments for a bed.

Illustrating the sea change in the recommended balance between community care and hospital care in clinical decision making are the June 2022 NICE Guideline for Severe Depression:

1.16.11: Consider Crisis Resolution and Home Treatment for people with more severe depression who are at significant risk of

  • Suicide, in particular for those who live alone
  • Self-harm
  • Harm to others
  • Self-neglect.

And 1.16.13: Consider inpatient treatment for people with more severe depression who cannot be adequately supported by a CRHT team.

Canadian Schizophrenia Guidelines have adopted the NICE guideline and two provinces have adopted IHT to a limited degree: B.C. and Quebec. A team in Quebec City treats only actively psychotic patients and has been featured in a Radio-Canada program. There are two other IHT teams in Montreal.

B.C.’s adoption is an illustration of how innovation does or does not get disseminated in Canada. In 1997, Don Wasylenki, a psychiatrist in Toronto, created the Home Treatment Program for Acute Psychosis to serve the 400 severely ill patients in a continuing-care service, 80 per cent of whom suffered from schizophrenia, schizoaffective disorder or paranoid disorder. Whenever these patients deteriorated to the point of needing hospital admission, they were given the choice of home-based treatment or hospital admission. None chose the hospital.

Details of the service were presented to senior personnel in the Ontario MOH, and to senior management and medical directors of 10 provincial psychiatric hospitals. Workshops were delivered at five sites.

However, these systematic efforts to disseminate the IHT model came to naught. On the other hand, the initiative of one person 5,000 kilometres and four provinces away in Victoria, B.C., was successful. Elizabeth Howey, a clinical nurse specialist in Victoria, initiated a pilot IHT service, the first of five such services in the province based on Wasylenki’s research. Ironically, Wasylenki’s own service did not survive in Ontario.

So, what are the current most important challenges in the mental-health system that IHT could address?

Firstly, the mental-health bed shortage. Mental health patients can wait for days in emergency departments for a bed. During the pandemic, psychiatric patients often formed the largest group of patients in emergency departments, says Eddy Lang, head of the Department of Emergency Medicine at the Cumming School of Medicine in Calgary. Patients often get sicker in the emergency department and can go through cycles of agitation punctuated by the need for sedation and, sometimes, physical restraint.

Secondly, the lack of timely, adequate follow-up after discharge. Two thirds of patients don’t see a psychiatrist within one month of discharge. That period can pose substantial risks of serious and even life-threatening adverse outcomes such as suicide. Under IHT, teams stay involved until patients are discharged to a follow-up service.

Thirdly, some patients are particularly ill-suited to a psychiatric ward. Recent immigrants and refugees who speak little English; Indigenous people; patients with post-partum disorders; developmentally disabled individuals; first episode psychosis patients; those who are homeless; frail elderly patients. It can be quite a list.

The difficulty in disseminating IHT is a perfect example of “Medicare’s arrested development,” as described by the Advisory Panel on Healthcare Innovation, commissioned by former federal Health Minister Rona Ambrose and chaired by David Naylor.

Two things stood out in Naylor’s report: the risk-averse culture of Canadian health care and the NIH (Not Invented Here) syndrome.

NIH was illustrated in a phone call I had with a psychiatrist regarding a plan to create an acute day hospital program to divert some patients away from hospitalization to alleviate pressure on beds. Since many severely ill patients would be unable to attend a day program, why not plan an IHT service instead, I asked?

“I worked extensively in a CRHT service in England before I emigrated to Canada five years ago,” the psychiatrist said and explained that the department head dismissed the idea with the comment: “Oh, that’s one of those British-Australian things.”

Canadians are ill-served by their mental-health system. They cannot access mental-health beds. They are admitted unnecessarily. They are kept in hospital too long.

We must give them safe, effective options like IHT if we are to meet their needs appropriately.

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4 Comments
  • Dr. Rob Murray says:

    MAiD, Psychiatrists and the Stigmatized Hidden Ignored Epidemic of Lyme Disease

    The golden age of discovery in medicine is over. The paradigm of modern medicine is to palliate with treatments that provide life-time annuities to the pharmaceutical industry. The profits from this industry pays for research, medical schools and political parties. There are few medical sleuths doing fine tissue research looking for the root cause of disease. Historically microbes were usually found to be responsible for inflammation. The rheumatologist is no longer interested in what is causing your RA.
    In 2018 Goldman Sachs said it’s official, shareholder preferences now drive medicine and shareholders are no longer interested in cures, new antibiotics or vaccines.

    Medical specialists are siloed and Lyme is an example of hidden expanding yet ignored epidemic where, very conservatively, there is at least 90% under-reporting similar to the United Sates. The main problem is the long term disability insurance industry doesn’t want to underwrite the costs of treating Lyme and red-flagged it as being too expensive to treat. Insurance industry executive conspired with infectious disease doctors to narrowly define the disease so that few could pass and to limit treatment to a single short term bacteriostatic agent. Infectious disease doctors are paid as expert witnesses to deny long-term disability insurance benefits from those that can’t pass the high bar they set.

    All epidemics from polio to COVID have their chronic form but despite overwhelming evidence from animal and human autopsy studies the existence of chronic Lyme is not recognized by AMMI members in Canada who owe their loyalty and take their direction from the private 13,000 member IDSA organization. The IDSA was given control of Lyme and all the procedures around it by the highly conflicted CDC organization.

    Infectious disease doctors are very uncomfortable with microbes that can cause neurologic disease. Long-COVID may have finally shaken some physicians out of their comfort zone long enough to take a second look at their biases around invisible diseases such as fibromyalgia, ME/CFS and long-Lyme.

    Ticks are responsible for 90% -95% of zoonotic diseases in Canada but the ones we hear about are mosquito-borne. We were making progress with the 2016 Conference to Develop a Federal Framework on Lyme Disease but that changed when CPHO, Dr. Greg Taylor was replaced by Infectious disease doctors Howard Njoo and Theresa Tam. The final status quo Framework was completed without consultation or transparency behind closed doors. It didn’t follow the Conference Summary Report, produced no new made-in-Canada Lyme disease guidelines and wasn’t in compliance with the Act. It was designed to convince politicians that they were in good hands and ceded authority back to the same people responsible for the situation.

    Complex disseminated Lyme disease can mimic many other serious diseases such as ALS, MS, Alzheimer’s, Parkinson’s etc. and is difficult to diagnose. Diagnosis may depend on what specialist the patient sees and what lens they are using.

    The test currently used in Canada misses at least one third of those that truly do have the disease. The test doesn’t work on those that suffer from neuroborreliosis. The test is based on obsolete 1960’s technology measuring antibody response. It was only meant to help the clinician confirm their clinical diagnosis. There is no serologic test that can rule out Lyme disease. This is a clinical disease and must be diagnosed clinically based on the history and presentation but physicians are instructed to demand objective signs such as the EM rash or heart block that they can measure. 95% of Lyme symptoms can’t be measured.

    Before authorities knew what they were dealing with they attempted to place the disease in a box and the mistake they made was to confuse the disease with the test they developed rather than the symptoms. It’s the test that got us into all this trouble and it should be scrapped.

    Lyme is a stigmatized disease that doesn’t photograph well. It seldom kills outright; as the girl in the award winning documentary “Under Our Skin” says, “you don’t die, you just wish you were dead”. Patients are often faced with deep institutionalized discrimination; suicide is not an infrequent outcome.

    This is a hidden ignored epidemic in Canada and the numbers just keep growing [prevalence] year after year. A small percentage of a very big number is still a big number. No one is assessing the escalating burden. The only thing rare about Lyme in Canada is to get a diagnosis. It’s wrong when it is easier to kill someone than to cure them with a combination of off the shelf 75 year old antibiotics.

    The IDSA 30-year fixation on the acute stage of Lyme [the rash] after early treatment conveniently avoids the late stage manifestations of Lyme, which are crippling to the patient and unresponsive to short-term antibiotic treatment. We are dealing with a serious life-threatening/ life-altering, multi-staged, multi-system infection misclassified as a simple nuisance disease with consequences that belong to the same health threat category as HIV/ AIDS, Zika, Ebola cancer etc. The IDSA, PHAC and AMMI Canada’s inaccurate conceptualization of disease has influenced the nation’s perceptions and response to Lyme.

    There are two schools of thought about Lyme disease. The Lyme community is very grateful for the leadership shown by psychiatrists such as Dr. Brian Fallon, Columbia Lyme & TBD Research Center and Dr. Robert C. Bransfield, past President of the International Lyme and Associated Diseases Society [ILADS]. ILADS is a nonprofit, international, multidisciplinary medical society dedicated to the appropriate diagnosis and treatment of Lyme and associated diseases. Dr. Bransfield removes the stigma from the disease, telling his patients “of course you are ill, your brain is infected.”

    AMMI members are only interested in patients that can pass their test. Once they have been treated and are still suffering they are of no concern to infectious disease doctors who claim that the original diagnosis must have been wrong or the patient is suffering from post-treatment symptoms. Family docs who have to live with their patients are abandoned. They are advised that there is need to check the references because it has all been done for them and it is all based on top notch peer-reviewed, blinded science. They bare advised to treat their patients nicely, just get them out of the office and send them to someone such as the physiotherapist who can make them feel better. When you do check you soon realize that 80% of the evidence they claim is based on the lowest form, namely expert opinion -their own.

    Medicine is based on science until that science becomes inconvenient as in the case of Lyme. PHAC, CIHR, Health Canada, AMMI Canada, NML and the Pan-Canadian Public Health Network may speak with one voice on the Lyme file but that is not a substitute for being scientifically correct. PHAC has prioritized the preservation of the antibiotic supply over returning Canadians to health. Patients are just road kill on the way to industry profit. This situation is a travesty. Medicine is self-regulating but that only works if everyone is behaving altruistically.

    The opinions expressed are those of the author.

    Sincerely

    Dr. Rob Murray [DDS retired]
    Lunenburg, NS
    Board member Canadian Lyme Disease Foundation [www.CanLyme.org]

    References:

    1.) The Need for Clinical Judgment in the Diagnosis and Treatment of Lyme Disease, Maloney EL, JPANDS 14[3]: p82-89 Fall 2009:
    http://www.jpands.org/vol14no3/maloney.pdf

    2.) Controversies in Persistent [Chronic] Lyme Disease, Maloney EL, J Infus Nurs
    39[6]: 369-375; 2016-Nov:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102277/

    3.) Conquering Lyme Disease – Science Bridges the Great Divide, Brian A. Fallon, MD, Sotsky J, Columbia 2018: https://www.columbia-lyme.org/conquering-lyme-disease-science-bridges-great-divide

    4.) CHRONIC, The Hidden Cause of the Autoimmune Pandemic and how to Get Healthy Again, Steven Phillips, MD, Parish D, HMH 2020: https://stevenphillipsmd.com/the-book/

    5.) Crypto Infections, Denial Censorship and suppression – the truth about what lies behind chronic disease, Dr. Christian Perronne, Hammersmith Health Books 2021

    Resource: Free CME Approved online course – presenter Dr. Monica Embers

    6.) Chronic infection and the etiology of dementia [CME Course with references] (IN)Visible, https://learn.invisible.international/courses/chronic-infection-and-the-etiology-of-dementia/

  • may says:

    Well all the mental health activists and accountants closed all the mental hospitals in Toronto a long time ago. Maybe a mistake?
    Giving mental health care in the home might be a solution, if the home of the patient is suitable.

    My mother who was elderly and had a tendency to fall was put in a bed meant for someone with a mental health issue at St Joseph’s hospital in Toronto twenty five years ago. I assumed it was due to a shortage of beds. Maybe they are not using the beds meant for those with mental health issues for that purpose for some reason.

  • Ed Weiss says:

    Thank you, Dr. Heath, for sharing your experience on this very fascinating alternative to psychiatric hospitalization. The lack of imagination on the part of those who make decisions around health care implementation never ceases to amaze. I’m curious if this model would work in a more rural/remote setting, or if it’s only been successful in more urban centres?

    • David Heath says:

      That’s a question I have long thought of Ed. All the teams involved in the research and in articles about IHT appear to be in urban areas. I think there would be two main factors to be considered here. Acceptable travel times from the team’s base to the patient’s home. And ,,what is the total population of the rural team’s catchment area balanced with having enough staff to cover 9 am to 9pm and on call 9pm to 9 am . At Hazelglen we decided to use 30 minutes travel time from team base to home as a guide. At that time Kitchener Waterloo was smaller and many patients lived in the surrounding rural area

Authors

David Heath

Contributor

Psychiatrist David Heath founded Canada’s first psychiatric hospitalization at-home service (Intensive Home Treatment) in Kitchener-Waterloo in 1989. He is the author of Home Treatment for Acute Mental Disorders: An Alternative to Hospitalization (free on Kindle).

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