Cover Story: The scourge and stigma of mental illness on the farm
Tuesday, March 2, 2010
Farm life is often more than usually stressful. And for those who suffer from depression or other forms of mental illness, help is not always available and attitudes not always sympathetic. Here are the stories of some who have been struggling with this affliction
by MARY BAXTER
In the 1990s, Tom Greensides held life by the tail. As chair of the Grape Growers of Ontario, president of the Ontario Fruit and Vegetable Growers Association and one of the pioneers of the Agricultural Adaptation Council, he was a recognized leader in Ontario's farm community.
Tom juggled community commitments with running his Grimsby-area farm (80 of the farm's 95 acres were planted to juice grapes), and working as United Agri Products Canada Inc.'s plant nutrient manager for Eastern Canada. Sometime in that decade, though, this energetic father of two, and stepfather of two others, lost his enthusiasm for community involvement. He dropped his activities.
Then, routine tasks on the farm, such as spraying his crop, became difficult to manage on his own.
One day, on the way to making a sales call, Tom started to weep.
He couldn't stop. "Even at that point I didn't know what was wrong but I knew something was," he says. Shaken, he cancelled his appointment and headed straight to his family doctor.
He learned that he was experiencing depression.
Tom's story might sound unique, but it's not. Provincial statistics indicate that one person in five will suffer a serious mental illness – such as depression, bipolar mood disorder or schizophrenia – or an addiction in their lifetime. The World Health Organization lists depression as the leading cause of disease-related disability and predicts it will become the second leading contributor to global disease by 2020
(See Figure 1).
It strikes regardless of region, status, financial circumstances or sex. A study by the Centre for Addiction and Mental Health (CAMH) concluded the costs to Ontario in 2000 for mental illness and substance abuse, including tobacco, was $33.9 billion. Mental illness alone cost Ontario nearly $22 billion in that year.
As Tom's experience exemplifies, farmers are just as capable of experiencing mental illness as anyone else. In fact, national and international studies suggest farmers' mental health may be at greater risk than the general population.
A 2005 survey commissioned by the Canadian Agricultural Safety Association found nearly two thirds of Canadian farmers felt stressed and one out of five felt very stressed.
Melisse De Dobbeleer, a Chatham psychotherapist and social worker who specializes in working with rural clients, sees a lot of depression, anxiety-related problems, addictions and anger-management issues that she attributes to the "unique stressors from farming."
These include families who spend significant amounts of time together because of working side by side, and worries about farm finances. The Safety Association survey puts farm finance worries at the top of its stress list, along with poor harvests or production and government policy. The study found weather, the BSE crisis and pressure to maintain the family farm to be other common triggers.
Susan Wells, family services manager for Haldimand-Norfolk REACH (Resource, Education And Counselling Help), says marginalization may be another stress factor. She uses the example of attitudes towards tobacco growers. As concerns grew about tobacco's health effects, its growers experienced criticism from the general population.
"In this area, many of the growers are Europeans who come with a strong work ethic," she explains. To them, farming is not just a job or a career. "Farming is every aspect of who they are." When the community at large doesn't value what they produce, "that's a very traumatic marginalization." Farmers end up feeling "very, very trapped."
That's exactly how Wendell Palmer felt in 2003 when representatives from the Niagara Falls Humane Society and local police descended on his mixed farm. Under instructions from a government vet, police repeatedly shot his prize boar after having mistakenly determined it was injured with no chance of recovery. "It seemed like they were all powerful," he says. "There was nobody on my side."
After the incident, he talked about choosing suicide if he had to live under the Society's control. He feared he might attack officials if they returned to his farm. Recognizing he presented a danger to others, Wendell sought psychiatric help.
The spectre of suicide looms large in rural Ontario's communities. Fuelling the concern is past experience with suicides following the 1980s farm interest rate crisis, as well as international studies that have identified higher-than-average suicide rates in farm communities.
"We don't hear about all of them, but we do hear about suicides of farmers, especially those who have lost everything after working their whole lifetime or who inherited the family farm and lose it all," says Michael Benin, executive director of the Haldimand-Norfolk branch of the Canadian Mental Health Association (CMHA) (See Figure 2).
Struggles with substance abuse
Suicide is not considered a mental illness, but studies indicate a pronounced relationship between the two. A 2005 New Brunswick study found that 97 per cent of the 102 suicide victims studied had one mental health problem; 75 per cent had two or more; and 61 per cent had problems with drugs or alcohol. Factors that preceded suicide included depression, alcoholism, marital difficulties, loss or potential loss of freedom or physical autonomy.
CAMH studies indicate the relationship between substance abuse and mental illness is strong, too. Nearly one third of those diagnosed with a mental illness will struggle with substance abuse at some point in their lives and 37 per cent of alcoholics will experience mental illness. That percentage rises to 53 for those addicted to other substances.
Addiction can be a real problem on the farm, says De Dobbeleer. "I see a lot of men who have been injured through farming-related accidents who get addicted to pain killers, and I also see alcoholism," she says. "It starts out as a way of coping with stress and then takes on a life of its own, causing stress within the family."
Michael Rosmann, an Iowa-based psychologist specializing in agricultural populations, says substance abuse is growing on U.S. farms. Farmers might turn to highly addictive drugs such as methamphetamines and cocaine to keep alert during long days of planting and harvesting, or other substances to cope with physical pain. Studies have shown that in times of crisis, such as the BSE outbreak, substance abuse and suicide become epidemic. These high rates recede once the crisis eases, he says.
Rosmann attributes mental health risks on the farm not only to the unique combination of external pressures farmers face but also to culture and the realities of living on the land, which require different survival skills than in an urban area.
The Safety Association survey also underscores farmers' tendency to try to cope on their own when encountering stress. Forty per cent of the survey's 1,100 respondents said they could effectively manage stress on their own (48 per cent for those over the age of 65). Only 17 per cent reported that they had spoken with a health care professional about stress.
Research shows that privacy is extremely important to farmers, who are mostly men, and that women are more likely to reach out for help than men. That jibes with Diane Quadros' experience. "Looking back on the eight years I've been doing this, I have worked with women farmers but cannot recall working with a male," says the Leamington-based community support worker for the Windsor-Essex County branch of the CMHA.
Their work ethic can complicate an understanding of symptoms and pressure farmers to meet what they feel are the expectations of their families and friends. Work is a must and, if there is no apparent physical ailment to explain their inactivity, farmers may judge themselves, notes Quadros.
"The word ‘lazy' comes to mind."
Treatment-resistant depression
Tom Greensides, now 63, for whom depression started in his 50s, wonders if he experienced bouts when he was middle-aged but dismissed them because he was able to fight them off. "Usually it starts earlier in life for people," he explains.
Putting a name to his condition was merely the beginning of a long, tough journey for him. Although he received prompt treatment, his depression persisted. Medication – he's tried 25 types since his diagnosis and currently takes six – held it at bay for a while but, like a recurring nightmare, it returned.
He sought electroconvulsive therapy in 2002. Short-term relief followed, so he persisted with several more sessions.
By then, however, it had become apparent that he suffered from a rare form of treatment-resistant depression.
In 2005, his doctor told him he could do nothing more. Tom decided to kill himself.
He shaved his beard so no one would recognize him, packed whisky and pills and returned to a woodlot behind the farm where he grew up in Niagara Township. It was the Saturday of the Victoria Day weekend. He woke 30 hours later, stumbled from the woods and collapsed on the front lawn of a nearby house. When people ran out, he asked them to call an ambulance.
Tom continues to battle with the desire to end it all. "It's not that I want to die; it's just that I want it (the pain) to end," he explains, his voice gravelly and matter-of-fact over the telephone. His feelings for his family keep him alive and he knows suicide is not the answer. "That which I value most I would hurt the most if I was to do something like that."
Mental health workers in rural areas emphasize that when one person is not well it affects the entire family – and the business. In the case of Tom and his wife Gayle, it brought the question of succession to a head much earlier than expected. Tom's sons weren't interested in taking over the farm. "The economics are challenging, so it would be hard for them to buy it, and we weren't in a position where we could give it to them and not have the money to buy another house." So, in 2007, they sold it.
Now, Tom lives on long-term disability. He spends his days walking, sometimes up to seven miles, to help ease his symptoms. And he'll help out his sons when he can with baby sitting or by lending a hand with one son's maintenance business.
He has also been accepted as a participant in a University of Toronto study that involves using electrode implants to stimulate the production of a chemical that can help fight depression. He's been told around 80 per cent of those who have received the procedure experience some degree of improvement, with some becoming drug free and their depression eventually cured.
Treatment so far has not relieved his depression, but Tom insists he is "blessed" with lots of medical help. From the perspective of access in rural areas, he is lucky: his psychiatrist, in St. Catharines, is only a 20-minute drive away.
But others in rural areas are not so lucky. Interview after interview with mental health professionals and those living with mental illness unearth difficulties in getting access to care. Services are centralized in cities and clinics are closed during the hours farmers would be most likely to use them. There's often confusion about which service to contact and little information-sharing or collaboration between services. Service cuts have led to burgeoning caseloads and few resources for treating conditions such as anxiety. Wait times to see a psychiatrist run from several weeks up to eight months.
Other problems emerge when you talk to farmers about the problem – having to repeat your story over and over again to every mental health worker you see; being prescribed expensive medications and having no benefits plan to help pay for them; weight gain from medication taken; no comprehension of farm realities. De Dobbeleer recalls one dairy farmer being told by a doctor to go on vacation. She laughs: "Ok, sure. You're going to come do my chores a couple of times a day?"
Ten-year mental health strategy
Ontario's medical communities are aware of and concerned about service inequities. In its 2009 report, the Southwest Local Health Integration Network notes that incidences of mental illness and addiction problems are growing in its area and prioritizes improving mental health service delivery to rural areas. The network includes Grey, Bruce, Huron, Perth, Middlesex, Oxford and Elgin Counties. "This anticipated service gap is reinforced when one considers future demand based on projected population growth," the report states ominously.
Ontario's Ministry of Health and Long Term Care has set this fall as the target to roll out a 10-year mental health and addictions strategy. The strategy will look at rural issues, says Andrew Morrison, a ministry spokesman.
How thoroughly these will be addressed is uncertain. A provincial panel struck last year to address challenges of health delivery in Northern Ontario and rural areas is not looking at rural mental health delivery at all, even though many of the issues are shared.
Not the least of these, according to a CMHA Ontario branch report, is the lack of a standardized definition of what constitutes rural. Without this, measurement of the mental health of Ontario's rural residents becomes impossible, as does the ability to "identify needs, gaps, as well as plan and monitor health services," the report states.
Morrison says that mental health wasn't included in the panel because panel members did not want to duplicate work already underway in the development of the mental health strategy.
Not all is doom and gloom in rural areas. The emphasis on community is a key strength in coping with mental illness, says Benin. "The traditional farming community takes care of its own the best it can and, when it can no longer do so, that's when it seeks services," he says.
But tightly knit communities do have drawbacks. "You live in a fish bowl," says De Dobbeleer, and that can exacerbate stigma, one of the greatest hurdles those living with mental illness encounter.
James Joyce, a former dairy goat producer who lives near Dunvegan, 40 minutes from Ottawa, says stigma has affected not only his family but also efforts to establish peer support for caregivers in their area.
Five-and-a-half years ago James' son, Brendan, then in his early 20s, was diagnosed with bipolar disorder. Right from the start, the family decided not to pretend their son's illness was anything other than what it was. "I thought it was disrespectful to his condition," says James.
Mental health workers consider a home, a friend and a job vital for fostering mental health and, during his recovery, Brendan searched for part-time employment, applying at a local gas station after seeing a "help wanted" sign in the window, only to be told the position was filled and the sign was removed. The next day, the sign was back up.
James and his wife, Terry Sweitzer, work with the Champlain East/ Champlain Est CMHA to provide support groups for those giving care to family members or friends living with mental illness. They have tried unsuccessfully to establish support groups to serve rural residents.
James wonders if the location of the Association's Alexandria satellite office, where the rural groups would have been held, might be one reason.
"If you're parked there and you're in front of that office, everybody knows where you're going and people recognize other people's cars."
There have been other hurdles.
Two years ago, when Terry asked to post information about a course for caregivers at a library in Maxville, the librarian refused. James says the librarian told Terry no one in the area was mentally ill.
"Oh my God," burst out an appalled Pamela Haley, manager of Library Services for Stormont, Dundas and Glengarry County Library, after hearing about the incident. The county system operates the library in Maxville.
Haley says the poster would have met the library's current guidelines for posting. But these were established last summer – ironically, to ensure consistent standards were being applied through the library system. Haley was not in her current position when the incident took place and, according to James, the librarian is retired.
Medical misunderstanding
Karen Hammond (not her real name) experienced stigma in a place she least expected: the medical community. Karen is a livestock producer in southwestern Ontario.
Troubles for Karen and her husband began when their daughter, one of the couple's four children, was 12. "She was acting very agitated," Karen recalls, "very much like a two-year-old, banging her head against the wall, being angry, a lot of outbursts of anger, not wanting to be touched and yet wanting to sit on your lap – some really bizarre behaviours - and I thought she was suicidal from the things she had been saying."
They took her to their family doctor, who recommended taking her to emergency. They did, but the doctor there concluded she was fine. Karen says the doctor cautioned that it was "a misuse of public services to bring your child to the emergency room just because you can't get along."
On the advice of a psychologist, the couple sought medical help several times again, even travelling to a more distant urban centre. Each time they were turned away.
Part of the problem was their daughter, who didn't want treatment. "She actually started going into the library at her school and reading psychology books on this," says Karen; "so she was prepared to say the right things." Privacy laws prevented the parents from speaking to doctors without their daughter present.
The situation escalated. "One night she stole a scalpel from the barn and she carved ‘help' on both of her arms," says Karen. "I said to her, you have to let us help you find this help."
In Ontario, those appearing to be suffering from a mental illness but don't want help can be brought into hospital for a 72-hour psychiatric assessment or examination. The order must come from either a doctor or a justice of the peace. So they asked their family doctor for a referral to a psychiatric department in a nearby hospital.
The doctor refused, recommended a group home and called Children's Aid. He later relented and provided the referral, but refused to see the family any more. "He thought we were overreacting."
It took 12 hours and three interviews with different psychiatric nurses to gain admission. Then Karen learned there was no psychiatrist on staff to see her daughter within the 72-hour period. She pleaded with her daughter to remain until a psychiatrist returned. Her daughter agreed. She was diagnosed with clinical depression and provided with medication.
She did well as long as she was medicated, says Karen. But once her daughter began to feel better, she dropped her medication. The depression returned, as did suicide attempts. "Because there's no care in the county, the last time we asked the doctor to help us, they sent three police cars out and took her away in handcuffs."
Karen's daughter is now 22 and lives in the city. She keeps in touch with her family but resists medical intervention although she still suffers from depression.
Karen wonders whether, if her daughter had obtained help sooner, her adjustment to living with a mental illness would have been smoother, for research has shown that the earlier mental illness is treated, the better the chances of reducing its severity.
Stigma and shame complicate family relations, too, sometimes preventing people from obtaining the help they need. For example, a recent Canadian study suggests 38 per cent of parents with a mentally ill child will not seek help for their child's illness because of the opprobrium attached to it.
Sons susceptible?
For his part, Tom believes he inherited his illness, which he describes as an imbalance in his brain chemistry, from his maternal grandfather. At times, his grandfather would retreat to his room, pull down the blinds and stay in his bed, sometimes for days. "I never heard about this until I became sick."
Three of Tom's cousins have depression and he fears that his own sons, John and Harold, might be susceptible. "They're very worried, as I am, about whether they might get this," he says. That's part of the reason he's participating in the research study. "I want to help find answers in case they are struck down with it some day."
Many of those involved in delivering mental health services say putting a face to the illness is one of the best ways to combat the stigma associated with it. Stepping forward is not easy and can be viewed as a great risk. One person interviewed for this article, fearing personal information would be published, threatened legal action. "I am well-known by many people in the farming community and I do not want my personal business discussed in public, nor do I want phone calls to me asking about what they read in the magazine," the person wrote. "Even with a name change, farmers will guess who the story is about."
Tom still experiences stigma. He's lost a close friend. He's had people tell him to pull himself up by his bootstraps or take vitamin E. Last Christmas, he had to chide his brother about using the word "crazy." But speaking out is worth the risk because he believes it fosters understanding.
While writing this article I deliberated whether to disclose my experiences as the sister, daughter, niece and granddaughter of people who live, or lived, with mental illness. My personal connection is too significant not to mention. Like Karen, I have pleaded for help in hospital emergency rooms only to have doctors dismiss the need to treat a suffering family member. Like Tom's brother, I have used words such as "crazy" and "nuts" without appreciating how they might affect a loved one who lives with mental illness.
And, like Tom, I have encountered people who open up about their experiences after learning about mine.
"I think people are basically very good; I think they're just afraid of something they don't understand," says Tom. "Twenty years ago, I would have been no different." BF