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.