Institutionalized care for the mentally ill has been replaced by a combination of effective drug treatments and services provided in communities. Some at-risk individuals are slipping through the cracks, Vancouver care providers warn

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In 1993, a prominent U.S. psychiatrist and author named Dr. E. Fuller Torrey conducted a survey of mental-health services in Vancouver and British Columbia.

He praised the region’s collective care for the mentally ill as the finest on the continent. But he also warned that could change, noting, as the Straight reported then, that “services in B.C. were deteriorating, the number of homeless people was rising, and it was becoming increasingly difficult to find a hospital bed for mentally ill individuals”.

Two decades later, Torrey worries he was right.

“British Columbia probably had the best services for people with severe mental illnesses in North America,” he said on the phone from New York City. “The last time I was in East Vancouver [in 2010], it was very clear, not only do you have a lot of drug problems there, but you also have a lot of very severely mentally ill people. It looked pretty bleak.”

Torrey wasn’t singling out Vancouver. He’s been equally critical of shifts in health services for the mentally ill right across North America. But because care provided by what was then called the Greater Vancouver Mental Health Service was so good, this city had the farthest to fall.

“It’s been very sad to see,” he said.

Torrey and nearly everyone interviewed for this series attributed, at least in large part, what they described as a decline in services for the mentally ill to the closing of Riverview Hospital, which occurred through a slow process that ended in 2012.

The facility had a long history by that point, having opened in 1913 as The Hospital for the Mind. The complex in Coquitlam was once home to a peak patient population of more than 5,500 people.

That was in the 1950s. In the decades that followed, Riverview saw its role in caring for the province’s mentally ill steadily reduced.

Across North America, institutionalized care for the mentally ill went out of fashion. Filling in the gaps—for the better, health-care workers almost unanimously agree—were family physicians, private psychiatric practices, effective drug treatments, and community care.

For many people with mental-health challenges, deinstitutionalization worked out very well. It’s allowed the vast majority to live stable and peaceful lives in communities of their choosing. But in Vancouver, many members of a small group have slipped through the cracks.

At some point, they were given a specific name: individuals with severe addictions and/or mental illness—SAMIs, for short.

According to a 2014 Vancouver Coastal Health discussion paper, there could be as many as 2,000 people that fall into that category living in the Downtown Eastside alone.

No quick fix

The Vancouver Police Department has taken a lead role in calling attention to this issue. On September 13, one year will have passed since police chief Jim Chu stood alongside Mayor Gregor Robertson and made a public plea for help.

“The answer for someone suffering a mental-health crisis is not a cop with a gun,” Chu said. “We need a shift from dealing with the crisis to preventing the crisis from occurring in the first place.”

Timed to coincide with the anniversary of that call, the Mayor’s Task Force on Mental Health and Addiction on September 10 made public a report that provides a status update on four short-term recommendations the VPD made in July 2013 as a plan to “stem the immediate crisis”.

Two suggestions were adopted by the province and fulfilled while two were not. One recommendation on which there has been little or no progress requests that the province add 300 “long-term and mental housing treatment beds”. The VPD had asked for, and the province failed to deliver, the exact kind of institutionalized care that was largely eliminated with the closing of Riverview.

At VPD headquarters at Cambie and West 5th, it was less than two minutes into an interview about mental health when Const. Brian Montague turned the conversation to the Downtown Eastside.

He described the community as a "natural nexus", where its low-income character attracts a disproportionate number of people with mental-health challenges and complicates those issues with addiction and substance abuse.

According to Montague, VPD officers respond to anywhere between 75 and 100 calls "involving a mental health component" every single day. (This statistic revises higher estimates that the Straight included in a story about police interactions with the mentally ill published on September 3.)

Those numbers, comprising 20 to 30 percent of all "reportable" incidents to which the VPD responds, translate to between 27,000 and 36,500 interactions a year.

"Our expertise is public safety, crime prevention, and investigating crimes, yet we’re asking our officers to be frontline mental health workers," Montague said. "The numbers speak for themselves. And this is not going to change anytime soon. There is no quick fix."

Re-examining the past

At the conclusion of a wide-ranging interview on mental health—a topic that the RCMP refused to speak on for this series—Montague recommended a report titled "Into the Future: the Coquitlam Health Campus".

"We don't agree with everything there but it’s worth reading," he said. “Deinstitutionalization has worked for many, many people. But there is a large group for whom deinstitutionalization simply is not the answer. These people, they need the medical system, not the justice system.”

The 29-page document makes a case for Riverview’s reopening.

In a telephone interview, Dr. John Higenbottam, clinical psychologist with UBC's faculty of medicine and the author of that report, argued that increases in psychiatric emergency admissions and police involvement with the mentally ill can be traced back to the slow emptying of Riverview.

"These problems began back in the '80s when there was substantial deinstitutionalization," he said. "Many people were moved to the community without adequate resources, in terms of housing and support services. And that group is still out there and is responsible for a lot of the ongoing pressures."

Higenbottam was quick to add that it's a minority of people with a serious mental illness that he was talking about, but he emphasized that it’s a group that requires extra care.

His June 2014 report notes that since deinstitutionalization, provincial governments across Canada came to realize that gaps had developed where severely mentally ill people did not have access to the levels of care they required.

"Accordingly, most provinces have retained or redeveloped their provincial psychiatric hospitals," he wrote. "Saskatchewan, which led the deinstitutionalization movement in Canada for example, is now redeveloping its provincial psychiatric hospital in North Battleford. Similarly, Ontario has maintained and redeveloped several provincial psychiatric hospitals."

Higenbottam singles out the Centre for Addiction and Mental Health (CAMH) in Toronto as "probably the best known example of a mental health campus in Canada".

Dr. Tony George holds the title of medical director for complex mental illness at that facility. In a telephone interview, he told the Straight that long-term inpatient care is something they offer, but one that is used as little as possible.

“We made the decision that we were not in the business of long-term inpatient care,” George explained. “But it [deinstitutionalization] hasn’t worked for everybody, that’s for sure.”

He noted that there remains a “fairly large” number of inpatient care beds at CAMH. A total of 600, with 250 of those reserved for longer hospital visits.

George said that for those individuals, lengths of stay usually range from 15 to 20 days for most patients, up to as long as 80 days for “the sickest of the sick”.

More beds coming

The B.C. Ministry of Health and B.C. Ministry of Justice both declined to make representatives available for interviews on the topic of mental health.

According to an email supplied by Health Ministry spokesperson Kristy Anderson, following Riverview’s closure in 2012, the province transferred the facility’s entire operating budget to regional health authorities. Today that money provides for 826 “specialized mental-health beds” located across B.C.

It’s stated there that the Health Ministry spent $1.3 billion on mental-health and substance abuse programs in 2012-13, a 59-percent increase in spending compared to 2000-01.

According to Andrew MacFarlane, director of mental health and addictions at Vancouver Coastal Health, one of the few options that exist for long-term inpatient care for the mentally ill in the Lower Mainland is the Willow Pavilion at Vancouver General Hospital.

He noted that that facility will soon be joined by the Joseph and Rosalie Segal Family Health Centre, which is planned to open in 2017. According to that project’s website, the new eight-story building will offer 100 private patient rooms as part of a range of mental-health and addiction services.

MacFarlane emphasized it's VCH’s preference to respond to patients with mental-health challenges in the communities where they live (a subject that will be explored in-depth in part three of this series). But he added that for a small group of particularly sick people, inpatient care remains “a part of the continuum”.

An extraordinary call

The VPD is diplomatic in its assessment of the province’s efforts to meet calls for assistance with mental-health care. At the same time, it has continued to describe the situation as a “crisis”.

“I think there has been progress,” Montague said. “I think part of that has been letting government know just how great the problem is. I think they are aware of it now.”

Libby Davies is the health critic for the federal Opposition. She has also represented Vancouver East (which includes the Downtown Eastside) since 1997.

In a telephone interview, Davies recalled a meeting she convened that year shortly after she was elected. She asked doctors with the B.C. Centre for Excellence in HIV/AIDS what was happening in the Downtown Eastside. The first point they raised was the closing of Riverview. (Though Riverview didn’t officially discharge its last patient until 2012, the facility was decommissioned through a lengthy process that began many years earlier.)

“There was no support or very few supports for anybody in the community,” Davies said. “So people ended up in the Downtown Eastside, in SROs, in terrible housing.”

Davies acknowledged that process began under the leadership of the B.C. NDP. But she questioned why, if doctors identified what was complicating care for the severely mentally ill nearly 20 years ago, the VPD is still asking for help on this issue.

“It’s extraordinary,” Davies said. “A police department feels compelled to write its own reports about mental health and state what they feel they can deal with and can’t deal with. It’s incredible.”

Chasing a crisis

This article is the second in a six-part series.

Part one: Vancouver police still seeking help to prevent a mental-health crisis

Part two: Amid a mental-health crisis, Vancouver care providers revisit the debate on institutionalization

Part three: Vancouver service providers fail to get ahead of a mental-health crisis

Part four: B.C. prisons lock mentally-ill offenders in isolation

Part five: Vancouver's ill and addicted lost in a mental-health care maze

Part six: Deaths involving police reveal a long pattern of mental illness and addiction