when help means losing choice: the reality of rural mental health care
7 minute read
dr. kirsten jewell, emergency department director and chief, muskoka algonquin healthcare, photographed at the huntsville district memorial hospital in huntsville, ontario on wednesday, july 15, 2026. story is about how ill equipped rural and other smalltown hospitals are to treat emergency mental health patients, who end up becoming involuntary patients in these hospitals until better treatment can be secured for them. photo by peter power
muskoka algonquin healthcare’s two cottage-country hospitals are not built for mental health care. yet hundreds of people come to them every year in need of it. and the hospitals’ emergency departments must somehow meet that need.
partly as a result, about 99 per cent of the psychiatric admissions at these two hospitals in 2024-25 were involuntary: 291 out of 295.
many of ontario’s smaller or rural hospitals are in similar straits. they may not have psychiatrists or psychiatric nurses on staff, but they end up forcibly admitting almost all the psychiatric patients who show up at the er and are deemed to need care.
in parry sound, for example, of 161 people who came to hospital for mental health care in 2024-25, 158 (98 per cent) were admitted against their will. in espanola, a similar percentage were involuntary admissions. at bluewater health in petrolia, it was 96 per cent, and in timmins, 94. at hôpital notre-dame hospital in hearst, ont., 94 per cent of psychiatric admissions were involuntary.
(health sciences north in sudbury, which is not a small or rural hospital, has a percentage of 81 per cent; that is, 1,384 of 1,702 psych admissions for the period in question were involuntary.)
some people came to the er themselves; others were brought by family or friends. police likely brought some. all were judged by an emergency physician to be too sick to leave of their own accord.
these rates were far above the ontario average of 68.5 per cent for all involuntary psychiatric admissions in 2024-25, according to data provided to the investigative journalism bureau by the canadian institute for health information.
the data suggest the kind of mental health care you get in ontario depends on where you live. hospitals not designated to provide this care are still receiving mental health patients, with few tools to cope.
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these hospitals may not have a psychiatrist or psych nurse on call. a harried emergency doctor toggling between a cardiac arrest and a broken bone may not have time to sit with a psychotic or suicidal individual and persuade them to stay in hospital of their own accord. without resources in the community to provide outpatient care, a doctor may decide the only option is to force a patient to stay in hospital – often in a locked room – until they can be transferred to another facility equipped to provide proper care.
“having a kid, or anybody, wait in that room just for admission to see a psychiatrist for two, three days is terrible. and it makes the patient not want to come back if they are in crisis again,” said dr. kirsten jewell, head of emergency medicine for muskoka algonquin.
“they need to get to the help they need and not just stay waiting in our emergency department eating egg salad sandwiches. that’s not good enough.”
jewell has been practising emergency medicine for more than a decade in the region where she went camping as a kid. she loves working at the fast-paced front door of the health system. she has seen her region’s challenges in providing mental health care in a system that “fails at outpatient psychiatry across the board.”
in many areas of ontario, a person with worsening mental illness may not be able to see a specialist in the community for weeks or months. in jewell’s small hospitals, there’s “no urgent voluntary admission,” she said; the person must apply in advance to get into the closest hospital with psychiatric beds available. under those circumstances, a doctor at a small hospital may feel it is unsafe to discharge the patient in the meantime.
jim hanna, a spokesperson for west parry sound health centre, said the health centre “is not a psychiatric services provider, so the patients admitted come to us in crisis before they can be safely admitted” to a better-suited hospital. he did not say how long a patient might be held involuntarily until then.
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a spokesperson for espanola general hospital declined comment.
by comparison, 29 per cent of psychiatric admissions at toronto’s centre for addiction and mental health are involuntary. at the royal ottawa health care group, which also focuses on mental health, the rate of involuntary admissions as a share of total psychiatric admissions is about 15 per cent. that’s partly because, in these better-equipped centres, a specialist may be able to connect people with outpatient care or convince them to stay in hospital of their own accord.
and some benefit from a different patient profile. the royal does not have an emergency department. instead, said spokesperson alyssa nader, patients are referred from elsewhere, and may already have been stabilized before arriving.
neither ontario’s ministry of health nor health minister sylvia jones’s office responded to requests for comment about rural mental health care.
a mental health emergency visit can often be “a failure of the system,” but it also shows a disparity in care, said dr. david gratzer, psychiatrist-in-chief at sinai health and a former attending psychiatrist at the centre for addiction and mental health.
“if a person had a crushing chest pain at 3 in the morning and went into one of these hospitals, i think they would be seen in a timely way and get excellent care … in contrast, i think, in some parts of the province, when a patient with a mental health crisis walks in at 3 in the morning, they don’t get that sort of care … why are standards so different for one set of problems as opposed to the other?”
gratzer says there are costs to involuntary care.
“imagine you’re 18, and you’re starting to hear voices, and you’re deeply frightened, and your family convinces you to go to an emergency department, and you end up in restraints in an involuntary stay,” gratzer said.
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“i do this work, and sometimes those scenarios are completely unavoidable and sometimes the staff do those things understanding how stressful it is for the patient, but also understanding that his or her safety and the safety of the staff are paramount.
“but it makes it just that much more difficult to engage people and follow up with them.”
emergency medicine veteran dr. alan drummond knows what it feels like to try to quickly determine the danger a person might present to themselves or — far more rarely — someone else.
“if i was going to have some sort of magic wand, i would actually try to convince the system that psychiatric emergencies are as important as medical or surgical emergencies. psychiatric patients are second-class citizens in the canadian emergency department,” he said. “they don’t get the care they deserve in a timely manner.”
for drummond, who practises in perth, the nearest referral centre is in brockville, about 64 kilometres away. if he can’t get psych patients there by a certain time of day, they’re stuck overnight against their will in ill-suited spaces at his hospital.
“we have had patients commit suicide, actually, in our department because of lack of observation,” he said. the issue, he added, is not the paperwork. “it’s the way we look at the psychiatric emergency.”
jennifer chambers, a patient advocate and executive director of the empowerment council at the centre for addiction and mental health, isn’t surprised by hospital-level disparities in involuntary care.
smaller or non-specialized hospitals may lack the resources to determine whether someone poses a danger to themselves, she said. and fewer community resources can mean people are in worse shape when they arrive at the emergency department in smaller centres.
“it’s kind of a myth that psychiatry has a high degree of accuracy predicting risk.” so determining whether someone must be forced to stay in hospital can come down to culture, she said, with some hospitals more risk-averse than others.
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when people come to muskoka algonquin’s hospitals in huntsville and bracebridge, a nurse assigns them a score from one to five, with one being the most acute. usually, jewell said, a psychiatric emergency such as a psychotic break or a severe desire to kill oneself is a two. that would normally necessitate a quick physician consultation, but “if somebody is coming in with chest pain that could be a heart attack, i need to decide who i need to see first. and so sometimes the mental health patients, yes, are in crisis, but do end up waiting a little while.”
once she has assessed a mental health patient, jewell may hold a person, without formally admitting them, overnight until a social worker comes in. if they need to be hospitalized against their will, they’ll be placed in a locked room – assuming it’s available – until staff can arrange a transfer. she wants this to change.
jewell wants to set up virtual consults with psychiatrists farther afield who may be able to provide better perspective on what a person needs.
connecting a patient to other, better-resourced facilities may mean “admission avoidance,” said the hospital corporation’s interim director of outpatient services, stephanie crampton. that could include specialized care delivered virtually through the emergency department.
being hospitalized against your will can cost you your job, your home, and custody of your kids. it can also be traumatizing, says ottawa lawyer melissa lukings.
“over the longer term, you’re looking at people who have a heightened fear of seeking care voluntarily. i have patients, once they get out, they’re like, ‘yeah, if ever i feel like this again i’m not going to the hospital.’”
the investigative journalism bureau (ijb) at the university of toronto’s dalla lana school of public health is a collaborative investigative newsroom supported by postmedia that partners with academics, researchers and journalists while training the next generation of investigative reporters.
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