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![img]](http://publications.cpa-apc.org/media.php?mid=272) Psychiatry in Canada:
50 Years (1951 to 2001)IntroductionQuentin Rae-Grant, MB, CHB, FRCPsych, FRCPC
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Psychiatry in Canada has undergone huge changes in theory, practice, principles, and perception. These changes have been influenced not only by changes in the medical and psychiatric world, but also by the geographical location of the country and its specific emphases.
Canada is the second largest country in the world. Placed on a map of Europe and Asia, Canada covers the whole area of Europe and part of Asia. Considering the diversity within these latter regions, the general congruence of Canada is remarkable. Regional differences exist, but these differences are hardly surprising and can well be attributed to distance and travel issues (and, in the case of Quebec, language). This congruence is even more remarkable when one considers that each of the ten provincial governments and the three territorial governments has the responsibility and control of health care within its own boundaries, despite the fact that funding comes from both the federal and provincial levels.
Canada celebrated its confederation in 1867 and patriated its constitution in 1982. These moves to greater independence were similarly reflected in the creation of the Canadian Psychiatric Association (CPA) in 1951. Until then, the American Psychiatric Association (APA) was the main affiliation for Canadian psychiatrists. Most had trained in the United States, Britain, or continental Europe and continued their contacts there. But the time had come when the APA could no longer fulfill the role of political advocacy and a separate organization was required. Similarly, few training opportunities existed, and the formal recognition of those that did, came from organizations in the US, as we learn in the chapters on undergraduate and postgraduate training. Relations with the APA have continued cordial and collegial, and at present, there are three district branches of the APA in Canada.
The beginning of this past half-century was marked by an aura of optimism derived from the experience of the need for, and value and recognition of, psychiatry during World War II. But the main location of services was in the mental hospitals with huge patient numbers, benign care, and few effective treatments. There were sedatives of varying degrees of effectiveness, electroconvulsive therapy without anaesthetics or muscle relaxants, and insulin coma therapy, which, when shown to have no value for people with schizophrenia in the 1960s, stopped soon after. Indeed, the lack of effective treatment was one reason for the relatively low esteem in which psychiatry was held.
The beginning of this same era saw the introduction of the first neuroleptic, chlorpromazine, an effective medication but one with a large side-effect profile. During succeeding years, and particularly in the last few, there has been a huge advance in the availability of various medications for many of the symptoms that trouble patients, and with significantly fewer side effects.
The practice pattern prevalent and popular in the 1950s was psychoanalysis, for those who could afford it. Freud and his successors taught from experience and from elaborate and detailed theory that made treatment both time- and resource-consuming. Few alternative treatments existed, apart from benign custodial care and the passage of time. This situation has rapidly been displaced by heavy reliance on pharmacology almost to the extent that the personal aspect of care, which had been the pride of psychiatry, has come to occupy a secondary role, certainly in the initial treatment of severe mental illness. Hopefully, and this is often emphasized, biopsychosocial models today are better able to incorporate inherited, developmental, and learning factors.
The initial years of the Canadian Psychiatric Association were met with lukewarm enthusiasm. Close ties with the APA continued: Dr. Ewan Cameron, one of the CPA founders, later became president of the APA. The other strong tie was with the Canadian Medical Association (CMA). Dr. R.O. Jones, the founding president of the CPA, later was the president of the CMA. As the history of the CPA chapter details, Jones fought vigorously to maintain this continuing closeness, which included having the annual meetings of the two organizations at the same time.
Click here to view past presidents of the CPA from 1951-2001.
Encouraging this move to separation from the APA was the dawning of a national health service. This service, Medicare, in effect, means that all Canadians and immigrants are covered for all major illnesses at no direct cost any where in the country. Medicare was funded by the federal and provincial governments, but the control and management was provincial. Negotiations for the conditions and payments for doctors (psychiatrists were represented by a section of the provincial medical association) were conducted at the provincial level by the provincial medical associations. This same structure, in essence, prevails today.
It must also be recognized that several provinces had provincial psychiatric associations in place before the CPA was created. The provincial organizations have worked in parallel and recently, increasingly closely with the national organization.
Perhaps the most distinctly Canadian development for psychiatry was the decision to include the funding of acute care units in general hospitals and to make these units part of the shared funding arrangement. This development was strongly advocated by the CPA. Unfortunately, psychiatric hospitals remained outside this arrangement. What this meant was a vigorous development and close attachment to general medicine, while long-term patients remained the responsibility of the older institutions. This situation had the effect that the community mental health centre movement that flourished and then died in the United States was represented in Canada by these general hospital units, which continue to thrive today.
Like other countries, Canada has been influenced by the shift from institutional to community care. With advances in treatment much can be done, and done better, on an outpatient basis. Unfortunately, this situation does not apply to all cases, particularly the most severe and repetitive. The family supports withdraw, exhausted. Beds continue to be closed, with the promise that the money and services saved will be given to care in the community. These promises are not always kept or are put in place after, rather than before, closures. As those in larger cities are aware, the number of homeless persons is increasing, as is the population who have their homes on the street. As well, forensic psychiatry programs are under ever-increasing pressure for space.
The face of psychiatry, like the face of medicine, changed as Canada became a multinational society. Practitioners come from all over the world to practice here. As well, there has been a rapid increase in the proportion of women in psychiatric practice; indeed, in medical schools women have outnumbered men in recent years.
Geographically, Canada is a huge country, but most of our population lives close to the Canada-US border. By preference that area seems to be where psychiatrists choose to practice. Although there have been numerous attempts to induce them (financially or otherwise) to settle in underserviced areas, few have succeeded. Probably the most successful effort was recruiting family practitioners already established in underserviced areas to enter further training in psychiatry. It was hoped that after completing training in a larger centre, the family practitioners would move back to areas in need of psychiatrists. Another alternative, by no means unique to Canada, was to recruit from other countries.
Overall, and despite assertions to the contrary, the pace of work continues to increase. The move in 1994 to reduce the number of places in medical schools is only now showing up as deficiencies in the number of practitioners in all areas of medicine, not the least in psychiatry.
There have been vigorous attempts to deal with the stigma attached to mental illness through educational programs. In addition, some courageous public figures have raised awareness by giving their personal and family experiences of the burden of mental illness. Despite these attempts, the stigma still exists, particularly in other areas of medicine and in business. Ample evidence exists of the cost of illness on productivity and time off, but nothing changes; abuse of alcohol is much more acceptable than a diagnosis and treatment of a mental illness.
Before walking away in despair from the issue of mental illness, we should recognize that at least part of this despair may derive from the fact that we have no cures. Indeed, we have no illnesses. We have syndromes and clusters but as yet no definitive tests for our diagnoses. With the developments in genetics and in neurotransmitter understanding we may have begun to address this need for diagnostic tools, but these tests are not yet available. Remember that syphilis carried a huge stigma until penicillin arrived. Similarly, tuberculosis was dealt with by removing patients from the community into sanitoria. Treatment consisted of lung collapse till the arrival of streptomycin. This led rapidly to closing the treating institutions or changing their focus to providing mental health care or facilities for the developmentally challenged.
Around the world, the two main issues for health care are lack of human resources and the cost of providing care. Disputes over the latter have been around in Canada since the beginning of government funding and have escalated in the last few years, as our chapter on this subject describes. The aging of the population contributes to increasing costs, but the major cause is rapidly advancing technology, which delivers much more specific information or treatment but at huge costs, particularly when the new techniques are used in addition to those that already exist (for example, x-rays plus CAT scan plus MRI). Factor in the costs of newer medications and the burden is major. Canadians strongly support the health care system and its openness to those who need it, but waiting lists are getting longer, even for urgent procedures.
The other side of the coin of burgeoning new-technology costs is that these same investigative tools have added to the rate of advancing knowledge and understanding, particularly of the brain and how it functions. All 16 Canadian universities with medical schools have active programs in many areas, as detailed in some of the chapters. We may not have found the penicillin or streptomycin for mental illnesses, but we are rapidly getting closer. If the past 50 years have seen great change, the next 50 are fated to move forward at lightning pace. We need to be prepared.
This book is the result of the combined effort of the contributors, who all are busy but volunteered their time willingly for this significant occasion. While each chapter is a skillful review of a particular area portraying the essence of a subject, it cannot include everything. Where there are omissions, on behalf of the authors, our apologies. Furthermore, each chapter is written in the unique style of the author. To have evened to a common standard would not have done justice to the range, variety, and inclusiveness that are quintessentially Canadian.
To order a copy of this Anniversary book, download our online order form and fax or mail to the Canadian Psychiatric Association.
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May 16, 2012
