Opinion

Ontario’s mental health laws must change to protect our most vulnerable patients

When people begin to show symptoms of psychosis, they are facing a crucial and vulnerable moment when timely treatment can prevent needless suffering and death.

Yet, Ontario’s current mental health laws make it difficult for front-line physicians like us to provide evidence-based treatments to people in crisis.

Psychosis is a condition that is widely misunderstood, misrepresented and stigmatized. Illnesses that can cause symptoms of psychosis, such as schizophrenia and bipolar disorder, affect about three per cent of the population. Symptoms often begin in one’s early or late 20s. Psychosis may manifest as delusions, which are false beliefs maintained despite rational evidence to the contrary. It can also appear as hallucinations, like hearing voices that are not there. Other signs include social withdrawal, disorganized behaviour or disorganized speech.

When a person shows symptoms of psychosis, maintaining a job becomes difficult or impossible; family relationships become strained; physical health suffers. Tragically, people with psychosis can become homeless, victims of violence or incarcerated.

Early intervention and treatment can mitigate the severe impacts of psychotic illnesses and provide individuals with the best chance of returning to their pre-illness levels of functioning.

However, two aspects of our mental health laws not only create barriers to treating our most vulnerable patients but are harming them.

First, many patients with psychosis are unaware of their symptoms and their symptoms’ impact. Consequently, they can’t appreciate treatment benefits or options. Such individuals are considered incapable of directing their own mental health care and frequently refuse psychiatric treatment unless it is forced in hospital during an involuntary admission with their substitute decision-makers’ consent.

But in Ontario, despite their mental deterioration, patients cannot be involuntarily hospitalized unless there is a safety risk to themselves or others, or have experienced a response to treatment in the past and a substitute decision-maker consents to treatment in a psychiatric facility.

Ontario should make involuntary admission accessible to people needing treatment that can only be provided in a psychiatric facility when they are at likely risk of substantial mental or physical deterioration, are incapable of consent to psychiatric treatment and consent from their substitute decision-makers has been obtained.

As it stands, those experiencing psychotic symptoms for the first time, or who have never engaged in treatment, cannot receive psychiatric care through involuntary hospital admission in Ontario unless they are a danger to themselves or others. In other words, for individuals with no insight into their condition, and who are undergoing mental or physical deterioration, the law does not allow for involuntarily hospitalized treatment without evidence of past effective treatment, regardless of the severe mental and psychosocial repercussions of the untreated illness.

This chicken-and-egg scenario is harming our most vulnerable patients.

This chicken-and-egg scenario is harming our most vulnerable patients: We can’t compel you to get treatment unless we have proof it has worked before, but we can’t get proof because we can’t compel you to get treatment unless you are a danger to yourself or society.

People are then left untreated for years, indefinitely debilitated by psychotic symptoms, resigning families to burn-out or risk losing loved ones to a marginalized existence and homelessness.

The majority of Canada’s provinces and territories permit involuntary admission to prevent substantial mental deterioration when other criteria are met. However, Ontario is the only jurisdiction that limits involuntary admission for incapable persons with a likely risk of substantial mental or physical deterioration only to those with past documented responses to treatment. Thus, Ontario’s laws discriminate against people without a history of response to treatment.

The second issue is that once admitted to hospital, incapable patients can legally decline treatment consented to by their substitute decision-makers, meaning they remain untreated while they challenge their finding of incapacity to the Ontario Superior Court.

This appeal occurs after the patient has already exercised a right for legal representation at an independent review board (consisting of a lawyer, a community member and a health professional) that has reviewed the facts. These appeals take months, even years, to clear the protracted court systems.

Untreated patients are either held in hospitals – detained but untreated – or discharged to the community while their untreated symptoms continue to erode their lives. Patients can incur social and financial risks, become suicidal or agitated, and suffer legal consequences for causing harm to property or others. This process is not the case in most of Canada, where treatment pending appeal is the law.

In these jurisdictions, treatment can start after a review board confirms a patient’s incapacity while the patient simultaneously fulfills a right to appeal the decision in court. In Ontario, data collected by the province’s Consent and Capacity Board has found that the majority of appeals are withdrawn, dismissed or abandoned before they reach court. Thus, the appeal process only interferes with effective treatment rather than its intended purpose of facilitating patient rights.

The appeal process only interferes with effective treatment rather than its intended purpose of facilitating patient rights.

All Ontarians are entitled to timely and publicly funded psychiatric treatment.

A defined group of people with specific needs should not be denied care because their illness interferes with their capacity to fully engage in treatment decisions. This is the opposite of prudent, evidence-based care. Legislative changes will align Ontario with the majority of Canada to facilitate psychiatric care for those who need it the most, creating a more equitable and effective mental health system.

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10 Comments
  • cortney says:

    Thank you very much for posting this article. I have a family member who currently is experiencing this, and cannot see that he needs help. This has been very difficult on my family members, we have twice appeared before a justice to get a form 2, because he has made threats to hurt himself and family members, in both cases, he was held for 72 hours, and then a form 3 was issued. He in both cases refused any form of treatment, and has was released each time. His fears and delusions only continue to grow, it feels like our family has been ripped apart, and no one can do anything to help him. Something needs to change, there needs to be an option to advocate for someone who is incapable at present of advocating for themselves. He is currently living in a car, cannot hold down a job, becomes aggressive and threatening towards others. He no longer wants to speak to family members as he feels the family is locking him up on purpose to steal his ideas, and that we are being paid to do so. Its unfortunate that Ontarios system is so broken, that those who need it the most are falling in the cracks of the system.

  • Marilyn Baker says:

    The Ontario system is a joke ! I am so thankful that my loved one lives in BC. He has a severe mental illness and has been hospitalized in both provinces. In Ontario, medical staff couldnt wait to get rid of him, and were absurdly secretive and unhelpful. I think that the lack of sound legislation in Ontario has had a detrimental effect on medical staff. They actually start believing that the patients “rights” are more important than their lives and health, and regularly turn them out onto the streets to fend for themselves. In BC doctors recognize that psychosis renders a person unable to understand and direct their own care. They also recognize the importance of family to offer emotional support to very frightened young adults who do not understand what is happening to their brains. Once treated and stabilized, loved ones are made voluntary and can go on to lead good lives with ongoing family support and medical treatment. Ontario, please don’t be an outlier! You are hurting your most vulnerable patients!

    • Annick Aubert says:

      You have shouted what I have been wanting to say for a long time but was too scared to utter. I have not lost faith in the Drs though, they are constantly harassed by the survivors and the deniers..and at CAMH they are under the eye of the Empowerment Council..and have been so since the 1990s……On October 23 1990 I was the Dr’s witness at an Ontario Board Review..and on October 23rd Michael Bay said the the Board ha no difficulty whatsoever in upholding…etc.. and the Board thanked the Dr., the staff and the family member…. Then in 1992…after again “differences” with the Council..and the possibility of yet other review or reviiews.. I gave up and said I would not look after the patient anymore…. Less than 2 weeks after I received a call from an OPP officer asking me if I knew a certain person, I answered that I knew someone who was responding to that name but that his name was different..the officer asked me for the name which I gave……told me that this person was in a hospital West of Toronto.. my friend had eloped and was most probably hitchhiking his way to Vancouver..the officer encouraged me to go and pick him up.. he told me how to get to that hospital on and off the 401.. I rented a car and went and picked him up the same night.. The next day I brought him back to CAMH to learn that another review was scheduled for the day or the day after…my friend then shouted that he was fed up with them grabbed my hand and started running…….the ensuing few minutes were proper vaudeville..The official asked me if I was willing to run with the man who was holding my hand when I said yes he then asked my friend to sign a release and cancel the Board……. I wrote a letter of thanks to the OPP……Thank you Marilyn you gave me the courage to speak up…

  • Bridget Hough says:

    There is a slight inaccuracy in this article. It says that if an involuntary patient appeals their involuntary status it is referred to “the Courts” which implies it is the general court system that deals with the matter. Not true. A Review Board can be convened right in the hospital in a matter of days and the case dealt with very quickly. However, they’re right in that the patient can’t have involuntary treatment during this time.

  • Susan Inman says:

    Many thanks for publishing this very important article.
    In B.C., our strong Mental Health Act protects people trapped in severe mental illnesses. However, it’s under a Charter Challenge from groups telling us that our Act is out of date and we must emulate Ontario’s Act which they say protects human rights. It’s crucial that people like these front line workers inform the public about how this version of ‘protecting human rights’ refuses to acknowledge the reality of severe psychotic disorders. Families in Canada aren’t well-organized to fight for the protections that our family members need and it’s such a relief to see a courageous group of physicians publish an article like this. I hope the mainstream press will have a chance to read this. Maybe if we all send it to various journalists they will have a chance to better understand the issues.

  • Heather Whiting says:

    Excellent thought provoking article discussing Ontario’s current Mental Health Act and the need for it to be revised to ensure people suffering from serious mental illnesses receive the right care in the right place and at the right time.

  • Albert Ho says:

    Thanks for addressing this important topic.

  • Mary V. Seeman MD says:

    The aim of mental health legislation (which is similar in most of the Western world) is to protect severely ill patients’ independence and prevent malevolent others from taking advantage of them. I have (though rarely) seen this happen when unhappy spouses have wanted to hospitalize husbands/wives for their own reasons, usually in connection with divorce and child custody. But I have never, in 60 years of practising psychiatry, seen substitute decision makers who are parents try to take advantage of a son or daughter. Perhaps changing the Mental Health Act to at least allow parents to make decisions for their adult ill children would have a chance. That would be so helpful.

    • Bridget Hough says:

      Right on, Mary! Glad to hear you’re still going strong.

    • Jane Duval says:

      Hello Dr Mary Seeman — So pleased to see you weighing in on this!

      Here in BC, 2 independent psychiatrists must agree re need for committal & treatment – a good safeguard against the fraud and collusion you describe. (After committal, patients also have the right to yet another “2nd opinion” from any BC physician.)

      But BC families and professionals must constantly fight civil libertarian groups to avoid Ontario’s nightmare scenario, where unfortunate “treatment refusers” can be hospitalized without treatment for years –often in seclusion and restraints. Unthinkable despair for the families, and an awful situation for caring professionals who have the very treatment needed to free the patient from the prison of their psychosis, but can’t legally administer it . Instead, doctors and nurses find themselves in the position of jailers rather than healers. Not only does it make no sense; it’s unutterably cruel.

Authors

Angela Onkay Ho

Contributor

Angela Onkay Ho, HBSc, MD, FRCPC, is an Assistant Professor with the Department of Psychiatry at the University of Toronto.

Lyndal Petit

Contributor

Lyndal Petit, BScOT, MD, FRCPC, is a Psychiatrist in Ottawa.

Kashif Pirzada

Contributor

Kashif Pirzada is an emergency physician in Toronto and faculty member at the University of Toronto and a founder of the Critical Drugs Coalition, a group of pharmaceutical experts, physicians and others working on alleviating future drug shortages in Canada.

Karen Shin

Contributor

Karen Shin, MD, FRCPC, is Interim Psychiatrist in Chief, St. Michael’s Hospital – Unity Health Toronto, and an Assistant Professor with the Department of Psychiatry at the University of Toronto

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