This train has left the station: Dr. Brian Rush on the integration of mental health and addictions service systems

Polite clapping is not unusual after a professor concludes a lecture. What is unusual is a spontaneous round of enthusiastic applause when the professor simply enters the auditorium.

Dr. Brian Rush delivers his inaugural lecture as a full professor with the UofT Department of Psychiatry. Photo Howard Chow, UofT

Yet that is what happened when Dr. Brian Rush, CAMH Senior Scientist and Co-Section Head of the Health Systems Research and Consulting Unit, walked into the College Street auditorium to give his inaugural lecture as a full professor with the UofT Department of Psychiatry last month. The admiration, respect and affection engendered by Dr. Rush’s presence amongst his colleagues was palpable.

Dr. Don Wasylenki, Professor and Chair of the Department of Psychiatry at UofT introduced Dr. Rush as a strong advocate in the area of concurrent disorders, a leading researcher internationally in alcohol and drug treatment, as well as a teacher, educator and mentor. Brian’s lecture was entitled “The Integration of Mental Health and Addiction Services and Systems: Where we have been, why we have gone there, and what lies ahead,” taking a wide angle view of a subject that forms the very foundation of CAMH.

Brian’s discussion of concurrent disorders began with an image of a tightly knotted rope, and a clear example of why recovery from combined substance misuse and a mental illness can be so challenging. An adolescent who begins drinking heavily and consistently in his youth and develops depression in his early thirties has a concurrent disorder that becomes harder to ‘pull apart’ and treat successfully the longer the two illnesses exist together.

People with concurrent disorders are not a homogenous group. While overall 15-20% of the Canadian population who have a mental health problem will have a concurrent substance use problem, the rate of overlap go up amongst young males (55%), substance users (70-80%), and those in the correctional system (80-90%).

Dr. Don Wasylenki, Professor and Chair, UofT Department of Psychiatry, with Dr. Brian Rush and Dr. Benoit Mulsant, CAMH Physician-in-Chief.

“Witnessing and experiencing violence as a child is the number one predictor of developing a concurrent disorder,” Brian explained.

While the impact of having a concurrent disorder is high, such individuals are about twice as likely to be underserved. “Even today in some jurisdictions in Canada, people are asked to leave a drug-free Addiction program if they are on medication for a mental health issue,” Brian said.

Brian made it clear that while traditionally the mental health and addictions systems have existed in two silos that “don’t talk to each other very well,” things have had to change. “The integration train has left the station,” he said. “We just don’t know yet where the train is going.”

The province of Alberta has just brought its mental health and addiction services together. And in Ontario, Family Health Teams are merging mental health and addiction services within the context of primary care, and beginning to forge new relationships with local specialty services.

“What top-down strategies are required to sustain the bottom-up integration?” Brian asked. “If we are going to support an integrated system, we need to provide a support mechanism and knowledge exchange for concurrent disorders across the province.”

“The integration process—bringing together policy, research, and knowledge exchange—we lived it through the CAMH merger,” Brian explained proudly.

Formerly with the Addiction Research Foundation’s Evaluation Office in London, Brian told the story of how he first met Dr. Paula Goering from the Clarke Institute of Psychiatry at the time of the CAMH merger, 11 years ago, and discovered that the work they were doing on health services and population health research-- in addictions and mental health respectively-- fit together extremely well.

“This was the first truly integrated part of CAMH.” The two scientists have been working together ever since.