A Brief History of the DSM

April 23, 2013 By

A Brief His­tory of the DSM

The first DSM appeared in 1952 and, since then, has gar­nered both acco­lades and crit­i­cisms. Once intended for today, guide­lines for diag­noses are quite elab­o­rate and, con­se­quently, con­tro­ver­sial. In par­tic­u­lar are con­cerns about the increase in sta­tis­tics for men­tal ill­nesses as a result of reclas­si­fy­ing what was once con­sid­ered part of every­day liv­ing (“nor­mal”) could poten­tially be reclas­si­fied pathological.

The DSM is a rel­a­tively young clas­si­fi­ca­tion sys­tem of men­tal dis­or­ders, fill­ing a need that has a long his­tory in med­i­cine and psy­chi­a­try. After two mil­len­nia of evo­lu­tion, with vary­ing emphases on patho­log­i­cal the­o­ries, eti­ol­ogy, and defin­ing fea­tures, and, most notably the prin­ci­ple objec­tives for its use (clin­i­cal? research? statistics?).

In North Amer­ica, the ini­tial stim­u­lus for a men­tal dis­or­ders clas­si­fi­ca­tion sys­tem was to sat­isfy a need for sta­tis­tics. In the mid 1800s world gov­ern­ments were rec­og­niz­ing the need to take respon­si­bil­ity for indi­vid­u­als with a men­tal ill­ness and the vol­umes of the cost of new care facil­i­ties was daunt­ing. Con­se­quently, the first 1840 the first vari­ant of a today’s clas­si­fi­ca­tion of men­tal dis­or­ders was cre­ated. And a small man­ual it was—having one cat­e­gory. Quite sim­ply “idocy/insanity.” By 1880, seven cat­e­gories were dis­tin­guished: mania, melan­cho­lia, mono­ma­nia, pare­sis, demen­tia, dip­so­ma­nia, and epilepsy. Apart from the need for cen­sus sta­tis­tics, the man­ual was used to deter­mine who could func­tion in soci­ety and who would need new, as yet not cre­ated, men­tal ill­ness services.

In 1917, the Amer­i­can Medico-Psychological Asso­ci­a­tion, fore­run­ner of the Amer­i­can Psy­cho­log­i­cal Asso­ci­a­tion, and the National Com­mis­sion on Men­tal Hygiene called for a more detailed diag­nos­tic sys­tem, still util­i­tar­ian in that it would gather uni­form sta­tis­tics across men­tal hos­pi­tals. It was still pri­mar­ily util­i­tar­ian with 22 diag­noses (the Sta­tis­ti­cal Man­ual for the Use of Insti­tu­tions for the Insane).

WWII

Chief con­cern in North Amer­ica soon became how to treat the large num­ber of return­ing sol­diers suf­fer­ing shell shock. The prac­ti­cal con­sid­er­a­tion now became para­mount, con­sid­er­ing the depen­dence of the armies upon med­ical assess­ment and fit­ness for duty deter­mi­na­tion. Con­se­quently, a new diag­nos­tic sys­tem and an expanded nomen­cla­ture (devel­oped by the US Army) was pub­lished (1943) and adopted by the US armed forces. The Vet­er­ans Asso­ci­a­tion par­tic­i­pated in the devel­op­ment of the expanded nomen­cla­ture and adopted by the Asso­ci­a­tion to bet­ter incor­po­rate the out­pa­tient pre­sen­ta­tions of WWII vets.

The next leap of devel­op­ment was urged by changes to the Inter­na­tional Clas­si­fi­ca­tion of Dis­eases which had, until 1948, focused exclu­sively on phys­i­cal ill­ness. Fol­low­ing the addi­tion of a sec­tion on men­tal dis­or­ders the APA pro­duced an adapted ver­sion of “Med­ical 203”, a pre­cur­sor to the DSM and con­sid­ered the orig­i­nal DSM. And this DSM was the first to include clin­i­cal util­ity among its objec­tives. How­ever, the man­ual reflected psy­chi­atric thought at the time, largely Freudian (which attrib­utes men­tal dis­or­ders to an individual’s child­hood expe­ri­ences and unre­solved issues from the past).

DSM-I listed 95 men­tal dis­or­ders. Two years later, that num­ber great to 130 (DSM-II).

The sub­jec­tiv­ity of diag­no­sis of both early ver­sions of the DSM were quickly crit­i­cized and responded to with a wealth of research demon­strat­ing wide vari­a­tion in diag­nos­tic rates of schiz­o­phre­nia in dif­fer­ent countries—the US hav­ing the high­est reported preva­lence. Most notably, psy­cho­log­i­cal David Rosen­han stud­ied the diag­nos­tic out­comes of eight healthy, oth­er­wise ‘nor­mal’ indi­vid­u­als sent to gain admis­sion to 12 dif­fer­ent psy­chi­atric hos­pi­tals, say­ing they ‘heard voices.’ Once admit­ted, they were to exhibit no symp­toms and act nat­u­rally and nor­mally. No hos­pi­tal detected that these were fake attempts at men­tal dis­or­der and all were diag­nosed with a men­tal ill­ness and pre­scribed med­ica­tion accord­ingly. That med­ica­tion, in turn, wildly var­ied across hos­pi­tal despite the same ini­tial symp­tom pre­sen­ta­tion across ‘patients.’

Post war

The DSM-III aimed to improve the uni­for­mity and valid­ity of psy­chi­atric diag­no­sis and pre­vent over­diag­no­sis. New the­o­ries of men­tal pathol­ogy were adopted, Freud was aban­doned, and symp­toms were diag­nosed based on pre­sen­ta­tion of symp­toms alone, all of which were more clearly defined. New objec­tives were also satisfied…those focus­ing on explicit diag­nos­tic cri­te­ria, a mul­ti­ax­ial sys­tem, and a descrip­tive approach that was neu­tral to the­o­ries of etiology.

Now reach­ing 188 diag­nos­tic cat­e­gories, and being as large as a typ­i­cal phone book, the DSM was stretch­ing itself fur­ther. A between-version revi­sion, DSM-IIIR, add yet another 27 cat­e­gories, bring­ing that total to 215. And more pages, of course.

New prob­lems. The chair of the DSM com­mit­tee, him­self, crit­i­cized the man­ual cit­ing med­ical­iza­tion of 20 to 30 per­cent of the pop­u­la­tion as chief among the problems.

The APA decided it was time for an even larger edi­tion and in 1994 pub­lished the 283-diagnosis 886 page tome, DSM-IV. The most notable evo­lu­tion was the require­ment in diag­no­sis of deter­min­ing “clin­i­cal sig­nif­i­cant dis­tress or impair­ment in social, occu­pa­tional, or other impor­tant areas of func­tion­ing.” Hmm. More sub­jec­tiv­ity and con­fu­sion because each indi­vid­ual will express dif­fer­ing expres­sions of what is ‘dis­tress­ing’ to them. And con­text is also largely a deter­mi­nant of func­tion­al­ity and dis­tress.
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About Home­wood

For more than 129 years, Home­wood has been a cor­ner­stone of Cana­dian addic­tion and men­tal health treat­ment. We save lives. We have helped thou­sands of Cana­di­ans for decades to cope with the dev­as­tat­ing effects of men­tal ill­ness and addic­tion. Founded in 1883, we are renowned for the qual­ity of our treat­ment, our med­ical integrity, and the breadth and depth of our inter­dis­ci­pli­nary team.

Home­wood is part of Schlegel Health Care, a family-owned health care orga­ni­za­tion based in Kitch­ener, Ontario, that incor­po­rates three other entities:

Home­wood Human Solu­tions (www.homewoodhumansolutions.com)

Home­wood Human Solu­tions™ offers a one-of-a-kind approach to the mar­ket: the high­est qual­ity of clin­i­cal sup­port and inter­ven­tion avail­able within the EFAP indus­try, and an unmatched con­tin­uum of ser­vices — span­ning health pro­mo­tion, men­tal health and addic­tions treat­ment, and prevention-focused work-life coun­selling services.

Home­wood Health Cen­tre (www.homewood.org)

Home­wood Health Cen­tre is Canada’s unsur­passed med­ical leader in addic­tion and men­tal health treat­ment, pro­vid­ing highly spe­cial­ized psy­chi­atric ser­vices to all Cana­di­ans. We are a 312-bed, Sched­ule 1 facil­ity under the Ontario Men­tal Health Act. We oper­ate nine pro­grams treat­ing a range of men­tal health and addic­tion issues.

Home­wood Health Cen­tre is located in Guelph, Ontario.

Home­wood Dis­abil­ity Treat­ment Pro­gram (www.homewood.org/disability-treatment-program)

Effec­tive dis­abil­ity man­age­ment for men­tal ill­ness must go beyond “man­ag­ing” dis­abil­ity to include both inpa­tient and out­pa­tient treat­ment. Treat­ment goals must incor­po­rate strate­gies for suc­cess­ful work rein­te­gra­tion to min­i­mize recur­rence and relapse.

The Home­wood Dis­abil­ity Treat­ment Pro­gram (HDTP) com­bines the ser­vices avail­able through the Home­wood Health Cen­tre – a nation­ally rec­og­nized men­tal health and addic­tion treat­ment cen­tre with the best national net­work of skilled men­tal health and addic­tion treat­ment pro­fes­sion­als through Home­wood Human Solu­tionsTM.

Schlegel Vil­lages (www.schlegelvillages.com)

Schlegel Vil­lages are designed, built and man­aged by the Schlegel fam­ily of Kitch­ener, Ontario. Our motto: “It Takes a Vil­lage to Care” lives on.

Cana­dian owned and oper­ated, our Vil­lages ben­e­fit from the Schlegel fam­ily hav­ing over 40 years of direct expe­ri­ence co-owning, man­ag­ing and oper­at­ing Long Term Care and Retire­ment Com­mu­ni­ties in Ontario. There are eleven Schlegel Vil­lages hous­ing approx­i­mately 2500 seniors. Each Vil­lage has a Long Term Care com­po­nent, with Full Ser­vice Retire­ment Liv­ing, Assisted Care, Mem­ory Care and Inde­pen­dent Liv­ing options being added in stages. The first Schlegel Vil­lage opened in 1998 in Guelph.

Have you vis­ited our Pin­ter­est site? We have many, many more info­graph­ics to peruse. Have a look here!

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Com­ments? Thoughts or resources to share?

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NOTE: The con­tent and opin­ions offered in Healthy Work­places blog posts do not nec­es­sar­ily reflect the for­mal stance of Home­wood Human Solu­tions, unless oth­er­wise iden­ti­fied. We bring this infor­ma­tion for­ward in the inter­ests of openly shar­ing val­ued infor­ma­tion in this time of fast-growing online con­ver­sa­tions and knowledge.

 

Employers challenged to ‘fix’ workplace mental health issues

October 11, 2012 By

In a sur­vey released Tues­day, polling com­pany Ipsos-Reid found that 22 per cent of Cana­dian work­ers are expe­ri­enc­ing depres­sion, which is a sim­i­lar per­cent­age to what ear­lier stud­ies have found in the pop­u­la­tion at large.

The sur­vey, which was com­mis­sioned by the Great-West Life Cen­tre for Men­tal Health in the Work­place, revealed that 84 per cent of employ­ers and man­agers say they believe it is part of their job to inter­vene when they feel an employee is exhibit­ing signs of depres­sion. But 63 per cent also said they would like to have more train­ing to deal with employ­ees who have depression.

Sum­ma­riz­ing the Globe and Mail report “Employ­ers alone can’t fix work­place depres­sion” (Andre Mayer, Oct 11, 2012):

1. While there is no clin­i­cal diag­no­sis of ‘work­place depres­son’, the stresses of the office can man­i­fest in tra­di­tional clin­i­cal depres­sive expression.

2. An April 2012 report by the Men­tal Health Com­mis­sion of Canada said that men­tal health prob­lems account for about 30 per cent of short‐ and long‐term dis­abil­ity claims. The same report claimed that in 2010, men­tal health con­di­tions accounted for 47 per cent of all approved dis­abil­ity claims in the Cana­dian civil ser­vice — nearly dou­ble the per­cent­age of 20 years ear­lier. (note, the rise in claims doesn’t mean that the mod­ern work­force is more toxic, some of the stigma has decreased, so peo­ple are more will­ing to talk about it).

3. It is esti­mated that between com­pen­sa­tion to sick work­ers and lost pro­duc­tiv­ity, men­tal health issues cost the Cana­dian econ­omy $50 bil­lion a year.

4. Deal­ing with the issues, some Cana­dian com­pa­nies are man­ag­ing both phys­i­cal and men­tal health issues among their employ­ees. The strate­gies include train­ing man­agers to iden­tify and reach out to depres­sive work­ers, and offer­ing finan­cial incen­tives for employ­ees to improve their phys­i­cal and men­tal well-being, which can include gym passes or a nom­i­nal pay­ment to undergo a well­ness assessment.

Take home mes­sage? Per­haps the most ben­e­fi­cial thing an employer can do is direct a psy­cho­log­i­cally ill worker to treat­ment, says Dr. Car­olyn Dewa, head of the Work and Well-Being Research and Eval­u­a­tion Pro­gram at the Cen­tre for Addic­tion and Men­tal Health.

 

 

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Are we all that anxious? More problems with the DSM

July 17, 2012 By

The debate about pro­posed changes for the DSM-5 con­tin­ues to boil.

Con­tin­u­ing the debate we’ve reported on in pre­vi­ous posts on this blog (Debat­ing the DSM-5 and DSM-5: Cause for seri­ous con­cern?), Sharon Bagely’s recent arti­cle “In the age of anx­i­ety, are we all men­tally ill?” presents three argu­ments. Quot­ing from the article:

The crit­i­cism rests on three argu­ments. First, the DSM fails to rec­og­nize that anx­i­ety is nor­mal and even ben­e­fi­cial in many sit­u­a­tions, so it con­flates a prop­erly func­tion­ing brain sys­tem with a pathol­ogy. Sec­ond, the DSM’s descrip­tion of anx­i­ety is more about enforc­ing social norms than medicine.

Finally, they say, anx­i­ety is adap­tive. Its brain cir­cuitry was honed by evo­lu­tion for a pur­pose. Only when that mech­a­nism mis­fires should a per­son be diag­nosed as men­tally ill.

“No human emo­tion is more basic than anx­i­ety,” said soci­ol­o­gist Allan Hor­witz of Rut­gers Uni­ver­sity. “Many forms of it sim­ply should not be cat­e­go­rized as dis­or­ders, because they’re the result of the way peo­ple evolved thou­sands of years ago, rather than some­thing going wrong.”

Coun­ter­ing these argu­ments, Dr. Car­olyn Robi­nowitz, a past pres­i­dent of the Amer­i­can Psy­chi­atric Asso­ca­tion who is in pri­vate prac­tice in Wash­ing­ton, D.C., com­ments “Peo­ple who crit­i­cize that are show­ing their bias…When we get bet­ter at diag­nos­ing hyper­ten­sion, we don’t say that’s terrible.”

No doubt this debate will con­tinue and hope­fully a bal­ance of evi­dence, best prac­tices, and clin­i­cal judge­ment will pre­vail over spe­cial inter­est group, polit­i­cal, social pol­icy, and/or com­mer­cial interests.

In the mean­time, we’ll do our best to stay calm.
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Databases for alcohol research

May 10, 2012 By

The National Insti­tute on Alco­hol Abuse and Alco­holism (NIAAA) has cre­ated a por­tal to sup­port researchers and prac­ti­tion­ers search­ing for infor­ma­tion related to alco­hol research. This page includes links to a num­ber of data­bases, jour­nals, and Web sites focused on alco­hol research and related top­ics. Also included is a link to the archived ETOH data­base, the pre­mier Alco­hol and Alco­hol Prob­lems Sci­ence Data­base, pro­duced by NIAAA from 1972 through Decem­ber 2003.

Both Cana­dian and Amer­i­can resources are listed.

Entry to the Alco­hol and Alco­hol Prob­lems main web­site. Click here.

Direct access to the resources list­ings. Click here.
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Released! Psychological Health and Safety Guide for Employers

April 27, 2012 By

As noted in an ear­lier post, we have been fol­low­ing progress on pro­duc­tion of the Psy­cho­log­i­cal Health and Safety Guide for Employers.

The full and com­plete action report is now released and avail­able from our media library (down­load here), from the Men­tal Health Com­mis­sion web­site as a PDF, or as an inter­ac­tive ver­sion.

To sum­ma­rize key points:

  • The Action Guide is based on the idea of pro­tect­ing employ­ees’ psy­cho­log­i­cal health and safety.
  • There will soon be a stan­dard for psy­cho­log­i­cal health and safety in the work­place, the National Stan­dard of Canada for Psy­cho­log­i­cal Health and Safety in the Work­place, sched­uled for release in late 2012.
  • A frame­work for psy­cho­log­i­cal health and safety action plan­ning and exe­cu­tion is being devel­oped con­sis­tent with ISO stan­dard for orga­ni­za­tional qual­ity (described below).

Under­stand­ing the P6 Frame­work is key to progress in the area of psy­cho­log­i­cal health and safety. There are six components:

  • Pol­icy: A clear state­ment of the organization’s commitment.
  • Plan­ning: Lay­ing out a log­i­cal model for change, objec­tives, processes, measurables.
  • Pro­mo­tion: Actions taken to pro­mote the gen­eral psy­cho­log­i­cal health of the workforce.
  • Pre­ven­tion: empha­sizes the need to ensure that staff under­stand the com­mit­ment to psy­cho­log­i­cal health and safety.
  • Process: empha­sizes the need to audit the ade­quacy of poli­cies and eval­u­ate the out­comes of actions.
  • Per­sis­tence: empha­sizes the role of man­age­ment and orga­ni­za­tional lead­er­ship in seek­ing con­tin­ued improvement.

In addi­tion to out­lin­ing the frame­work and pro­vid­ing sev­eral key resources for each com­po­nent of the P6 frame­work, the action guide:

  • Demon­strate that psy­cho­log­i­cal health and safety is a crit­i­cal con­cern for all Cana­dian employers.
  • Iden­ti­fies some effec­tive and fea­si­ble actions.
  • Pro­vides a tool to sup­port you in address­ing psy­cho­log­i­cal health and safety.

The report was authored by our psy­chol­o­gist col­leagues, and long-term men­tors of this blog post author: Drs. Merv Gilbert and Dan Bilsker from the Cen­tre for Applied Research in Men­tal Health and Addic­tion, Simon Fraser Uni­ver­sity (www.carmha.ca)

 

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Business Case Bibliography

April 25, 2012 By

Dr. Mark Attridge, one of the authors of our Annual Reports, has released a review paper on the topic of mak­ing the busi­ness case for pro­vid­ing men­tal health and addic­tion ser­vices to employ­ees and fam­ily members.

The list empha­sizes EAP ser­vices and most works exam­ine finan­cial issues of:

  • cost-benefit
  • cost-effectiveness
  • return-on-investment

The reports are pre­sented in five sec­tions by type of author source:

  • Brief reports in indus­try publications
  • Employer guides
  • Review papers in sci­en­tific journals
  • White papers and gov­ern­ment reports
  • Books

Down­load the bib­li­og­ra­phy here. EASNA Research Notes Vol­ume 2, Num­ber 4, Decem­ber 2011.

 

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Savvy Social Media Users “Liking” Health Care

April 19, 2012 By

Price Water­house Coop­ers Health Research Insti­tute has released a report sum­ma­riz­ing their con­sumer sur­vey of social media uti­liza­tion for health-related purposes.

Released April 2012, the report pro­vides an in-depth analy­sis and infor­ma­tive sum­mary of key issues in how con­sumers, and health­care orga­ni­za­tions, are using social media to meet their vary­ing needs.

From the report:

  • 42% of con­sumers have used social media to access health-related con­sumer reviews
  • 30% have sup­ported a health cause
  • 25% have posted about their health experience
  • 20% have joined a health forum or community
  • 61% are likely to trust infor­ma­tion posted by providers, and 41% are likely to share with providers via social media com­pared to 37% trust­ing infor­ma­tion posted by a drug com­pany and 28% likely to share infor­ma­tion with a drug company
  • more than 80% of indi­vid­u­als ages 18–24 would be likely to share health infor­ma­tion through social media
  • nearly 90% of indi­vid­u­als would engage in health activ­i­ties or trust infor­ma­tion found via social media
  • 45% of indi­vid­u­als ages 45–64 would be likely to share via social media
  • 56% would be likely to engage in health activities

Inter­est­ingly, “one-third of con­sumers sur­veyed said they would be com­fort­able hav­ing their social media con­ver­sa­tions mon­i­tored if that data could help them iden­tify ways to improve their health or bet­ter coor­di­nate care.”

And of par­tic­u­lar impor­tance to those providers and organzi­a­tions lag­ging behind in social media efforts:

45% of con­sumers said infor­ma­tion found via social media would affect their deci­sions to seek a sec­ond opin­ion and more than 40% of respon­dents reported that infor­ma­tion found via social media would affect the way they coped with a chronic con­di­tion or their approach to diet and exercise.

What does this mean for your busi­ness, clients, cus­tomers? The public?

Ulti­mately, you can ben­e­fit from more active online engage­ment with con­sumers. This calls for thought­ful and delib­er­ate use of social media and “embrac­ing social media as a mind­set not just a channel.”

Down­load the report here: health-care-social-media-report

Or visit the web­site sum­mary and link page: http://www.pwc.com/us/en/health-industries/publications/health-care-social-media.jhtml

About the report:

Social media is chang­ing the nature and speed of health care inter­ac­tion between con­sumers and health orga­ni­za­tions. This in-depth HRI report dives into what some of the largest health care com­pa­nies are doing in and with social media. The report’s find­ings are based on a sur­vey of more than 1,000 con­sumers and 124 health care exec­u­tives. Click below to see a snap­shot of social media activ­ity on com­mu­nity sites and health com­pany sites.


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Efforts to improve the experience of caregivers/individuals in health-care system

April 18, 2012 By

How do we improve the expe­ri­ence of indi­vid­u­als and care­givers as they move in, out of, and across the health-care sys­tem over time and as their health changes?

The Change Foun­da­tion has an ambi­tious, strate­gic goal for 2010–2013 out­lined in the attached doc­u­ment. The Foun­da­tion is focus­ing on the expe­ri­ences of indi­vid­u­als and their heatlh-care givers as they nav­i­gate the health-care system.

An infor­ma­tive doc­u­ment, with insight and issues rel­e­vant across the coun­try, to all care providers, local and regional pol­icy mak­ers, and beyond. Among the out­lined goals/strategies:

What are the lived expe­ri­ences of indi­vid­u­als and care­giver­sas they try to nav­i­gate their way across the con­tin­uum of care over time?

How can the process for pro­vid­ing health care bere­designed to yield bet­ter expe­ri­ences and out­comes for­peo­ple, espe­cially at difficult tran­si­tion points? •How can health-care users be involved in a mean­ing­ful way–with their per­spec­tives and expe­ri­ence taken into account–when changes are being con­tem­plated, con­ceived and introducee?

How much impact do fac­tors such as respect, empa­thy, fair­ness, con­ve­nience and pref­er­ences have on people’shealth-care experience?

What are the new ways and means to achieve bet­ter results,and what has to change?

From the Foundation:

What our goal is not about:

  • It’s not about improv­ing clin­i­cal care, per se–though thereis clearly a strong connection.
  • It’s not about exam­in­ing how indi­vid­ual health-care orga­ni­za­tions are pro­vid­ing patient-centred care or improv­ing­pa­tient sat­is­fac­tion rates for episodic care.
  • It’s not about advo­cat­ing for patient empow­er­ment; that’sthe purview of other organizations.
  • It’s not about pur­su­ing purely the­o­ret­i­cal inter­ests in people’s expe­ri­ence with tran­si­tions in care across the sys­tem; other orga­ni­za­tions are more suit­ably resourced to under­take this.

What our goal is about:

  • It is about prob­ing, defin­ing and iden­ti­fy­ing the value of rethink­ing and redesign­ing our health-care sys­tem from the user’s point of view, mind­ful of the needs of the peo­ple for whom it was designed–those who need health ser­vices and the peo­ple who sup­port them.
  • It is about look­ing at the whole jour­ney through the eyes of the indi­vid­ual, espe­cially at tran­si­tions between ser­vices and at expe­ri­ences over time.
  • It is about cap­tur­ing patient and care­giver expe­ri­ence and involve­ment with the health-care sys­tem, and using it as a tool to improve health out­comes and qual­ity of life.
  • It is about work­ing with providers to imple­ment ideas for change and improve­ment, derived from the expe­ri­ences of indi­vid­u­als and caregivers.•It is about pro­mot­ing indi­vid­u­als and care­givers as part­ner sin their own care–an ingre­di­ent of good qual­ity services.

Change Foun­da­tion 2010 2013 Strate­gic Plan

About the Change Foun­da­tion (www.changefoundation.ca). The Change Foun­da­tion is an inde­pen­dent pol­icy think tank, intent on chang­ing the health-care debate, health-care prac­tice and the health-care expe­ri­ence in Ontario.

 


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