DAY 6: Mental illness: poverty’s dark side

 

By STEVE BUIST

Dr. Walter Owsianik digs into his breakfast, then gets straight to the heart of the matter.

“I see a lot of folks who are poor and mentally ill, ” said Owsianik, a family doctor who has spent three decades practising medicine in Hamilton’s North End.

“We have a huge mental-illness population down in the core.”

The Spectator’s massive health mapping project of Hamilton neighbourhoods backs up Owsianik’s blunt assessment.

The 10 neighbourhoods with the highest rates of psychiatric-related emergency-room visits are all concentrated in a central chunk of the lower city ranging from Queen Street to Wentworth Street, and from Aberdeen Avenue to just north of Barton Street.

At one extreme is the poor inner-city neighbourhood that lies between Queen Street North, Cannon Street West, James Street North and the rail line north of Barton Street.

Here, the rate of psychiatric-related emergencies was 88 for every 1,000 people in the neighbourhood.

At the other extreme is the wedge-shaped rural Flamborough neighbourhood between Highway 8 and Middletown Road, where the rate of psychiatric-related emergencies was just 2.6 per 1,000 people.

That’s a startling difference of 34 times from highest to lowest across the city._GMY0755

Like so many other health factors measured in this project, there are clear connections between high rates of psychiatric emergencies and poverty.

The five neighbourhoods with the highest rates of psychiatric-related emergencies are also the five neighbourhoods with the lowest median incomes per person in all of Hamilton.

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A closer look at the data shows the important intersection between physical health, mental health and social factors.

■ Five of the top 10 neighbourhoods with the highest rates of psychiatric emergencies were also among the top 10 for the highest rates of overall emergency-room visits.

■ Five of the neighbourhoods with the highest rates of psychiatric emergencies were also among the 10 highest rates of urgent hospital admissions.

■ The top 27 highest rates of psychiatric-related emergencies are all found in the former City of Hamilton, and 25 of those are located in the lower-central city.

Colour in a map with those 25 neighbourhoods and you’d cover almost the entire lower city from Gage Avenue to Highway 403, from the waterfront to the foot of the Mountain.

Take those same 25 lower-city neighbourhoods with high rates of psychiatric emergencies and 22 of them show up among the top 30 highest rates of people living below the poverty line.

One of the strongest connections that shows up is the link between psychiatric-related emergencies and the rate of people who report having no family physician when they visit emergency departments.

In fact, the five neighbourhoods with the highest rates of psychiatric-related emergency visits also make up the top five neighbourhoods of people reporting no family physician, when two student-dominated neighbourhoods are stripped out of the data.

“There’s a core group of people that call all the time for the same type of mental health issues, and you recognize them as soon as you pull up, ” said Jessica Bartley, a paramedic who works exclusively in Hamilton’s inner-city neighbourhoods.

“You see them all the time, you know them by name, you know what they’re like, you know their birthdate, you know where they live if they have a residence.”

The James-to-Queen Street neighbourhood with the highest rate of psychiatric-related emergencies is a prime example of how mental health collides with a number of other poor health and social outcomes.

In addition to having the highest psychiatric emergency rate, that same neighbourhood suffers from the fourth-lowest median income per person in Hamilton, the fifth-highest rate of people reporting no family physician, the sixth-highest rate of emergency-room visits, the ninth-highest rate of children living below the poverty line and the 10th-highest rate of female single-parent families.

This is no great surprise to Owsianik, who deals with these types of complex, overlapping problems on a daily basis.

“I’ve had patients who have purposely camped out for the summer, ” he said. “It blows me away that they would choose to live in the woods, but when you’re mentally ill, you may have a paranoia that someone in the house is going to kill you so you prefer the woods or the streets.

“You get a bit discouraged by all this but I feel that I’m trying to do my bit to make their lives a little less painful. Short of taking them home with you …” he paused, then added: “I don’t know. That’s what some of them need, a family and a mother.”

■  ■  ■

Meet Dr. Jennifer Brasch, director of psychiatric emergency services at St. Joseph’s Healthcare in Hamilton.

It’s a service, she admits, that seems to get busier with each passing year.

In the past 15 years, Brasch said, the percentage of psychiatric emergency patients who need to be admitted to hospital has increased from 25 per cent to more than 40 per cent.

That’s a sign that the psychiatric cases showing up on St. Joe’s doorstep are more complex and difficult to treat.

One of the key issues is the lack of a family physician for these patients.

“They don’t have access to a family physician so when they know they need mental health care, they have to go to the emergency room and they try not to do that until they are in crisis, ” said Brasch. “People rarely come to the emergency room saying ‘I know I’m getting depressed, can you help me before I hit rock bottom?’

“If they had a family doctor, they’d do that._GMY9690

“As an emergency psych service, we see people who are in crisis primarily, ” Brasch added. “It’s fairly rare for someone to get to us who’s not in crisis.”

Brasch then talks about the circular nature of the problems faced by people with mental health issues.

They may not be able to work, which means they rely on social assistance, which often leads to living below the poverty line, which means living in places with low rents, which means living in neighbourhoods with higher crime rates and drug use and fewer resources, which perpetuates mental illness.

“Many of the people we see from these neighbourhoods have no resources and have very little resilience and struggle with enormous stresses that, frankly, would challenge many of us, ” said Brasch.

“I see some of these people and they have next to no money, no family support and they’re unable to work for whatever reason, and then they have another loss and suddenly, they’re homeless.

“It’s very difficult to have positive mental health if you’re homeless.”

She describes the case of one patient she saw recently in St. Joe’s psychiatric emergency department. It’s a frightening example of how one incident can lead to a downward spiral.

The patient was a skilled tradesman who owned a home and had a job with a company. He is divorced with children who were part of his life.

The man suffered an accident that left him unable to work. He eventually lost his home, spent much of his time worrying and became very depressed.

The man then began drinking excessively and ultimately gave up contact with his children because he didn’t want them to worry about him.

Brasch said she tried to convince the man that his children might want to help, “but he doesn’t see it that way, ” she noted.

“He was a contributing member of society, ” Brasch said sadly. “He’s become depressed, he’s become anxious, he’s drinking to self-treat, he’s lost his home, he’s become quite reclusive.

“He’s living in cheap hotels and moving from one to another because he feels he bothers people.”

■  ■  ■

There was a time when the prevailing philosophy was out of mind, out of sight.

Institutionalization was the norm for people with psychiatric problems.

“When the HamiltonPsychiatric Hospital was built, it was built out in the country so that the residents could farm the land as part of their therapy, ” said Brasch. “People used to drive from downtown Hamilton for a Sunday afternoon drive to go and watch the people at the psych hospital.”

The pendulum has since swung to shorter hospitalizations and independent living in the community.

“Hamilton has a number of very good programs to support people in the community, ” Brasch added.

In some ways, Hamilton has become a victim of its own success.

A strong network of food banks, support programs and lodging facilities — many of them in the central lower city — combined with cheap housing, means that Hamilton has become a magnet for people in surrounding areas who suffer with mental illness.

A decade ago, the provincial government decided to download the costs of social services to municipalities.

That policy shift has long raised the question of whether Hamilton is adequately reimbursed for the costs of treating people from outside who migrate to the city to take advantage of better services and lower housing costs.

“We’d developed a comprehensive network of social and health services here that serviced a much wider geographic catchment area, ” said Terry Cooke, former regional chair of Hamilton-Wentworth, now president and CEO of the Hamilton Community Foundation.

“When that stuff was shared mostly by the provincial tax base, it was equitable; and while it was a strain, we could support it.

“When it became largely the domain of municipal government, it became financially crippling, ” Cooke added, “and it became a vicious spiral because at the same time we had an economic downturn that drove up demands for services.”

If there’s one area that could use improvement, Brasch noted, it’s the need for more programs that deal with concurrent disorders — people, for example, who require treatment for mental illness as well as a substance abuse problem.

“You go to detox and they say ‘Well, you’re suicidal, you’ve got to get that fixed before we can help you, ‘” said Brasch.”You go to a psych clinic and they say ‘Well, you’re drinking daily, my drugs won’t help you until you stop drinking.’

“It puts people in a very difficult position, because if you’re really depressed, it’s hard to stop drinking, ” she added.

“So if we see someone who is depressed and drinking, are they depressed because they’re drinking or are they drinking because they’re depressed?”

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A BOLD 10-YEAR PLAN TO FIGHT HOMELESSNESS

Mental illness is often a package deal, linked with homelessness and poverty.

Two years ago, the city of Calgary made a bold pronouncement that it was going to tackle one of those three problems.

The Alberta city announced the introduction of a 10-year plan to eradicate homelessness by 2018.

With commitments from Calgary’s heaviest hitters, a model has been developed that other Canadian cities, including Hamilton, could find useful.

While the Alberta oil boom brought prosperity to Calgary, it also brought an unwelcome side-effect — a dramatic increase in homelessness.

In less than two decades, the number of homeless people in Calgary grew by nearly a factor of 10 — from 447 in 1992 to 4,060 in 2008.

A report on homelessness for the City of Calgary calculated that “the average annual cost of system usage, such as hospitals, corrections and shelters, by a homeless person in Calgary is estimated to be approximately $100,000.”

If that’s accurate, it means the annual cost of Calgary’s homeless problem amounted to more than $400 million in 2008.

Two years into the project, the Calgary Homeless Foundation reports that more than 1,200 people, including 220 families, have received housing and support.

 

HOW WE DID IT

The Spectator, in collaboration with health researcher Neil Johnston, obtained nearly 400,000 anonymized records representing hospital admissions and emergency room visits for every person listing Hamilton as a home address, for the period April 1, 2006, to March 31, 2008.

The records were grouped into geographic areas called census tracts, roughly equivalent to city neighbourhoods. Census tracts are used by Statistics Canada to measure a wide variety of social, economic and health variables within urban regions of Canada. For this project, there were 130 usable census tracts for the amalgamated City of Hamilton.

Twelve health variables and 12 social and economic variables were chosen. With the help of McMasterUniversity mapping expert Patrick DeLuca, maps were created for each variable, showing the differences between Hamilton’s 130 neighbourhoods. Also created was a death statistics map and an overall ranking map.

The maps, rankings and rates were then analyzed to examine the connections between health and socioeconomic variables in Hamilton’s neighbourhoods.

 

MAP STATISTICS:

PERCENTAGE OF PEOPLE 15 YEARS AND OLDER LIVING BELOW THE POVERTY LINE

CR-Day6-Map-LICOAll

HIGHEST

1. 5370049 (James Street North Cannon Street EastWellington Street North King Street East) 48.0%

2. 5370048 (Queen Street North Cannon Street West James Street North King Street West) 45.4%

3. 5370037 (Queen Street S. King Street West James StreetHunter Street West) 44.2%

4. 5370051 (Wentworth Street North Cannon Street EastSherman Avenue North Main Street East) 42.0%

5. 5370063 (James St. N. rail line Wellington Street North Cannon Street East) 40.9%

LOWEST

1. 5370142.01 (Middletown Rd. Highway 8 Governors Road Flamborough border) 0.4%

2. 5370084.03 (Green Road Highway 8 Millen Road Escarpment) 1.4%

3. 5370144 (Highway 6 Flamborough-Puslinch Townline Millborough Line Concession 5 East Robson Road Parkside Drive) 2.1%

4. 5370121 (GovernorsRoadBrantCounty border Jerseyville Road Alberton Road Garner Road Martin Road Binkley Road) 2.3%

5. 5370142.02 (Highway 8 Flamborough border Gore Road Middletown Road) 2.6%
RATE OF PSYCHIATRIC-RELATED EMERGENCY ROOM VISITS PER 1,000 PEOPLE

CR-Day6-Map-PsychRt

HIGHEST

1. 5370064 (Queen Street North rail line James Street North Cannon Street West) 87.9

2. 5370063 (James St. North rail line Wellington Street North Cannon Street East) 75.7

3. 5370049 (James Street North Cannon Street EastWellington Street North King Street East) 62.0

4. 5370037 (Queen St. South King Street West James StreetHunter Street West) 61.9

5. 5370048 (Queen Street North Cannon Street West James Street North King Street West) 59.6

LOWEST

1. 5370142.02 (Highway 8 Flamborough border Gore Road Middletown Road) 2.6

2. 5370142.01 (Middletown Road Highway 8 Governors Road Flamborough border) 2.9

3. 5370140.04 (Hamilton Street Burlington border Highway 6 north of Dundas Street) 3.1

4. 5370122.01 (Wilson Street West Shaver RoadGarner RoadFiddlers Green Road) 5.0

5. 5370086 (Waterfront Stoney Creek border Escarpment Glover Road) 5.4

 

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