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Sectorization of psychiatric services continues

Montreal mentally ill still largely served according to their place of residence

Remnants of Montreal’s retired sectorization of psychiatric services linger despite Quebec’s introduction of a five-year Mental Health Action Plan (MHAP) intended to better guide mental health patients through the municipal psychiatric system.

Two weeks ago, a Montreal lawyer began the process of gaining authorization for a class-action lawsuit against the provincial government on behalf of patients who were denied non-urgent treatment at psychiatric hospitals because of where they live, a practice made illegal in Quebec in 1991 with a law on health and social services that stated all patients have the right to choose the hospital and doctor from whom they will receive services.

From the early 1970s until 2003, Montreal psychiatric patients were required to use services provided for them under a sectorization system according to their area of residence. A government web site, no longer in use, matched Montreal postal codes to the hospital serving that area to facilitate the process.

While patients should no longer be restricted in terms of where they receive treatment, a continually overburned health system continues to prevent the goals outlined in MHAP from being realized.

Old habits die hard

Ella Amir, director of Action on Mental Illness (AMI) Quebec – a grassroots organization supporting families of the mentally ill through advocacy, education, and guidance – was skeptical that the sectorization of services had been completely phased out. She pointed out that while Quebec laws do protect the rights of mentally ill patients to choose where they are treated, health care professionals sometimes continue to turn patients away based on their area of residence.

“Hospitals are so overburdened with patients that they aren’t likely to take someone from outside their sector,” she said.

According to a study released by the Canadian Institute for Health Information on August 19, psychiatric patients across Canada are released prematurely from general hospitals due to the great demand for beds in psych wings. On average, Quebec psychiatric patients in 2005-2006 were released after 21.1 days.

Doctor Jean-Bernard Trudeau, director of Professional and Hospital Services at the Douglas Mental Health Institute, admitted that health professionals in his hospital sometimes revert back to the sectorization system when dealing with patient intake.

“The sectorization of services was in place for a long time, and reflexes sometimes come back when [health care workers] tell people they aren’t in the right place,” Trudeau said.

Right to choose

Trudeau was glad that Montreal psychiatric institutions were phasing out the sectorization of services.

“It’s illegal to deny people beds depending on where they live. The sectorization of services doesn’t make sense,” he said.

Amir argued that the patients’ right to choose the hospital and doctor from whom they receive services is especially important in psychiatry.

“In psychiatry, the patient’s rapport with the treating psychiatrist is crucial,” Amir said. “Having a choice is very important in promoting and facilitating recovery.”

Amir added that Montreal’s long history with sectorizing services has led to an unequal distribution of quality mental health care services across hospitals in the city.

“The fact that people have to go to the hospital in their region may discourage healthy competition, and may encourage mediocrity. No matter what you do, people will still be obliged to go to your hospital. That leaves few incentives to maximize services,” she said.

Sectorizing from the bottom up

In December 2003, the city introduced 12 Health and Social Service Centres (CSSS) – responsible for directing mentally ill patients to the appropriate service according to region – to group together 54 Local Community Service Centres (CLSCs), hospitals, and community health services. The system was designed to relieve the pressure on hospitals by directing those who do not need to be hospitalized toward an alternative form of care in the area, while also allowing a CSSS to send patients for care in other regions if need be.

According to the government’s MHAP, 60 per cent of patients seeking treatment for mental illness do not need to be hospitalized. Every year, 142,000 Montrealers use municipal mental health care services.

Marie Boissonnault, head administrator for the psycho-social program for adults at the CSSS Vaudreuil-Soulanges, said her division does not have a psychiatrist on site. Lacking a hospital under its management, the CSSS Vaudreuil-Soulanges sends patients in need of psychiatric services unavailable at the nearby Valleyfield hospital to Montreal.

“There is a portion of our population who receives services in hospitals [other than Valleyfield], but that depends on the response of the hospital,” she said.

Boissonnault explained that her CSSS was in the process of solidifying links with mental health services in the area to better direct patients.

Amir noted that the reforms under MHAP had yet to be fully realized due to a slow implementation process.

“There has been no transfer of budget or staff from hospitals to CLSCs,” Amir charged.

Expansion of creative care

Despite a new system aimed to relieve centres of overcrowded waiting rooms, services offered by the CLSC des Faubourg in downtown Montreal are so highly demanded that security guards patrol its Ste. Catherine entrance. All mentally ill homeless people are directed to a specific hospital in Montreal that rotates month-by-month.

Alain Spitzer, director of the St-James Drop-in Centre for the homeless, claimed that the CLSC des Faubourg is too overwrought with patients to adequately serve their clientele, explaining that almost all of the Centre’s patients battle with some form of mental illness.

“There is only one CLSC in this very large area, and they’re swamped 24/7. There are lineups for everything,” he said.

Spitzer was convinced, however, that services offered through the Centre’s art room helped mentally ill clientele.

“Instead of feeling anxious and waiting to die, [our clients] can create something that makes them feel good about themselves,” he said.

Coordinator of the art program, Anne-Marie Beaulieu, explained that clientele who paint at the Centre often sell their work.

“When you create, you feel useful, and that’s what we value here. It’s good for their self-esteem.”