Current Issues in Addictions and Mental Health

Introduction

About the Centre for Addiction and Mental Health
The Centre for Addiction and Mental Health (CAMH) was created in 1998 through the successful merger of the Addiction Research Foundation, the Clarke Institute for Psychiatry, the Donwood Institute and the Queen Street Mental Health Centre. 

CAMH is a teaching hospital fully affiliated with the University of Toronto and is the largest addiction and mental health facility in Canada.  It operates clinical, health promotion, education, and research facilities in Toronto, including internationally recognized biological, clinical and social research.  Its influence extends throughout the province with 28 satellite locations that ground CAMH clinical, health promotion, research and education efforts in the needs of Ontarians, and ensures that new knowledge is translated into addressing mental health and addiction problems in local communities. 

Purpose of this Report

The Centre for Addiction and Mental Health (CAMH) has prepared this report at a time when health care issues are prominent in public debate at the national, provincial and local levels. 

At the federal level, the Romanow Commission released its final report on the Future of Health Care in Canada a little less than a year ago.  In the province of Ontario, the recommendations of nine regional Mental Health Implementation Task Forces are being considered by the provincial government as they determine the next phases of mental health care reform.  This fall, Ontarians are being asked to elect provincial and municipal governments that will set critical health and social policy priorities in the province for the foreseeable future.  This will be followed by a federal election that will do the same at the national level for the remainder of this decade and beyond.  

In the mental health and addiction sectors, new research and clinical advances in the last ten years mean that we know more about the treatment, care and recovery of people with mental illness and addictions.  Unfortunately, the benefits of these advances are not being fully realized because mental illness and addictions continue to be viewed separately from physical health issues and have not been adequately included in health care reform initiatives.  This artificial separation between physical and mental health must end. 

To address these challenges, this report recommends that all levels of government work together to develop a National Action Plan for Mental Health that is linked to strategies to address addictions.  The report also provides advice about how governments can ensure mental health and addictions are brought into the mainstream of health care reform initiatives, how treatment and care can be improved, and how accountability at the program, agency, system and funder level can be strengthened.  Finally, building on CAMH's earlier work in diverse areas like housing, income and employment, the report recommends taking action outside of the traditional health care sector to create positive change for people with mental illness and addictions. 

The Need for Action

Twenty percent of the general population suffers from a mental illness or addiction in any given year and 3% suffer profound suffering and persistent disablement.  The impact of this is staggering: over 1.5 million Canadians are currently experiencing clinical depression, a disorder that affects 10-15% of Canadians at some point in their lives.  One of every eight Canadians will be hospitalized for mental illness at least once in their life, more than are hospitalized for cancer and heart disease.  According to the WHO these illnesses account for the greatest degree of disability, worldwide.  The disability is complicated by the effects it has on employment, social relationships and family functioning.

Left undiagnosed or untreated, mental health and addiction problems cause large productivity losses.  They have been estimated as amongst the most costly of all health problems.  Health Canada has reported that lost productivity due to workers being on disability or due to premature death was more than $8 billion in 1998.  It is also estimated that substance use cost the Canadian economy more than $18 billion in 1992, which represented 2.7% of gross domestic product in that year.

Despite the depth of these needs, mental health care has been called the "orphan" child of medicare because it has so often been neglected in health care funding and reform initiatives.  CAMH believes that the lack of attention and investment in addressing the mental health and addiction needs of Canadians is a reflection of the stigma and shame associated with these disorders.  This situation would not be tolerated for people suffering from physical illnesses of similar prevalence and severity. 

Recommendations

1) Governments must take leadership to develop a National Action Plan on Mental Health.

CAMH agrees with the Canadian Alliance on Mental Illness and Mental Health and the Canadian Mental Health Association that federal, provincial and territorial governments must work together to develop a National Action Plan on Mental Illness and Mental Health.  Canada lags significantly behind other countries that have successfully implemented strategies to improve mental health and reduce disability due to mental illness. 

A National Action Plan will lead to improvements in treatment and care by investing in research, data collection and information systems, mental health promotion and education, and implementing anti-stigma and anti-discrimination initiatives.  This work is timely because new research and clinical advances are raising hope about treatment and care, but are also raising challenges in terms of how new knowledge is implemented, and how uniformity of care and access is ensured. 

The recently released National Drug Strategy creates renewed opportunities to coordinate national efforts to address mental health with efforts to address addiction issues.  Given the high rate of concurrent disorders (mental health problems and addictions), links must be forged between these two strategies.  A National Action Plan on Mental Health and the new National Drug Strategy must complement one another so that for example, national monitoring of the prevalence of substance use disorders undertaken as part of the drug strategy could be made available to those involved in planning mental health services and services for people with concurrent disorders.

2) Include mental health and addictions in health care reform initiatives.

Mental health and addictions services must be included in health care reform initiatives at the federal and provincial levels.  The recently signed First Ministers Accord provides a critical opportunity to achieve this goal as governments accelerate primary care reform, implement new homecare funding and address the need for catastrophic drug coverage for Canadians.  CAMH was pleased to see mental health homecare included in the First Ministers Accord.  We were also pleased that the recently released Primary Health Care Transition Fund included mental health as a key priority for funding. 

CAMH supports these recent initiatives, but would take them one-step further to include people suffering from addictions.  The exclusion of people with addictions from existing reform initiatives is a grave oversight that serves no one well. It discriminates against people who need access to health services because of the nature of their illness and is poor public policy given the high rate of concurrent disorders between addictions and mental health.  It also perpetuates the current gap in services for people with mental illness and addictions, ensuring that some of those with the deepest needs have little hope of receiving treatment.  Funding to services for those with concurrent disorders should be increased and reform initiatives should seek to close this gap in the mental health and addictions systems.

CAMH also recommends that public funding for the costs of medications prescribed outside of institutions should be a priority.  This is very important for the clients we serve, as many need
long-term pharmacotherapy to maintain employment, housing and other community connections.  We urge the provincial government to continue to work with the federal, provincial and territorial governments to ensure mental health and addictions issues are included in reform initiatives.

3) Increase funding to the community-based sector and ensure a continuum of services and supports from community-based to hospital care.

Community-based mental health and addiction agencies have demonstrated their effectiveness in supporting people with serious mental illness and addictions to live in the community.  These services have also been shown to prevent hospitalization and shorten episodes of acute illness.  In Ontario, funding to community-based mental health and addiction services has been frozen for more than a decade.  Funding must be increased to ensure a continuum of services and supports from community-based to hospital care.  Government efforts to strengthen the continuum of mental health and addiction services should be targeted to:

• Increasing funding to community-based services so that people have access to a greater range of services for treatment, recovery and prevention;
• Early intervention programs that target risk factors and treat people when they have their first episode of illness;
• Programs that assist people to obtain and/or retain meaningful paid work through episodes of illness; and,
• Improving services for people at risk for or with both a mental health and addiction problem (concurrent disorders).

A comprehensive continuum of services must also include self-help, peer support and consumer advocacy initiatives because families and consumers have important knowledge and experience that contributes to treatment and care.  Governments should build the capacity of families and consumers to participate in service planning and delivery by supporting these initiatives.

4) Prevent and reduce homelessness.

People with mental illness and addictions, in addition to struggling with the burden of their illness, are at greater risk of homelessness because their housing, employment and income options are often limited.  While mental illness and addictions are not always a cause of homelessness, these illnesses increase the likelihood that a person's homeless episode will be longer.  Being homeless also contributes to poor mental health and substance use and for those with an existing mental illness, increases its duration and seriousness.

To prevent and reduce homelessness CAMH recommends the following strategies:

• Create more supportive and affordable housing including housing with an emphasis on harm reduction.  Access to housing is a key determinant of health and research has demonstrated that a diverse population of people with psychiatric disabilities can succeed in housing if appropriate supports are available.
• Create safe houses and crisis beds so that people experiencing episodes of acute mental illness can be stabilized before they need hospitalization and a loss of housing occurs;
• Improve access to case-management services so that more people with serious mental illness are "followed" through the system by someone who can make sure they get the services they need;
• Expand shared care teams in emergency shelters and drop-ins so they can continue to reach the seriously mentally ill who do not trust and otherwise would not have contact with the mental health system.  Maintain the non-coercive model of care of Shared Care teams so they can continue the focus on building long-term, trusting relationships with clients so integral to clinical success.
• Ensure emergency shelters have adequate funding to provide higher levels of support and care for people with mental illness and addictions.  Without more intensive supports, people with mental illness and addictions cannot access emergency shelters.
• Increase the availability of withdrawal management and addiction treatment services so that people do not lose their housing because they cannot get treatment when they need it.  Expand withdrawal management and addiction treatment services for women and aboriginal people for whom few services currently exist.

5) Enhance the focus on health promotion and prevention.

The prevention and health promotion aspects of addressing mental health and addictions have largely been ignored.  Yet we know that health promotion efforts early in life make a difference to health outcomes and life expectancy.  For example one out of every five children in North America shows signs of an emotional or behavioural problem the consequences of which can last a lifetime.  Unfortunately, funding to prevent mental health disorders and addiction problems in children and youth remain limited.

In addition to targeting funding to initiatives that intervene early to prevent and reduce mental illness and addiction problems, the determinants of health must be addressed.  Meeting people's social, economic and personal needs is key to overall physical and mental health and plays a key role in treatment and recovery.  This means ensuring people have access to housing, income, employment and social supports in addition to treatment and care. 

6) Act outside of the traditional health care sector: Ensure access to housing, supportive housing, income, and employment.

In keeping with our focus on health promotion and the determinants of health, CAMH believes it is good public policy to invest outside of the traditional health care sector.  Access to housing, income, and employment have been demonstrated to improve clinical status, reduce hospitalization, and enable people with mental illness to stay in their homes and communities. 

Housing and Supportive Housing

Housing has been widely acknowledged as a priority in mental health policy at both the federal and provincial levels.  What is needed now is action from federal and provincial governments to implement new housing and supportive housing programs based upon this existing policy and research foundation.  A body of experience and evidence has demonstrated that a diverse population of people with psychiatric disabilities can succeed in housing if appropriate supports are available.  Appropriate housing and supports can substitute for long-term inpatient care thereby decreasing reliance on high-cost hospital and institutional beds. 

Income

Access to adequate income is a key determinant of health and must be a priority in any mental health care strategy.  Many people with mental health problems must rely on government income programs, at some time during their illness, as their only source of income and access to prescription drug coverage.  Unfortunately, many government income programs provide benefits that are too low, create barriers to employment, and are not flexible enough to respond to the episodic nature of mental illness.  In addition, disability is often defined too narrowly for many people with mental illness or addictions to qualify.  In Ontario, for example, provincial income support programs exclude addictions from the definition of disability altogether.  These systemic barriers within government income support programs must be addressed to ensure people with mental health problems are able to access the basic supports that will help to keep them well. 

Employment

Like housing and income, access to employment is a key determinant of health.  People with a wide range of mental health problems can succeed in employment if flexible supports, responsive to their changing needs throughout treatment and recovery are available.  Supported employment opportunities play a key role in maintaining good mental health and preventing crises that might lead to a loss of housing or to hospitalization.  Programs focused on transitioning people to supported employment must be specialized and designed specifically to ensure that program expectations and outcomes accommodate, rather than exclude people who may need greater flexibility to achieve program goals.

Greater emphasis must also be placed on ensuring that people with mental health problems are meaningfully accommodated in the work place.  Access to skills development, training and education must also be improved by encouraging academic institutions and other learning environments to more appropriately accommodate people with mental health problems. 

7) Improve accountability

Put Consumers and families at the centre of reform

Putting people with mental illness and their families at the centre of reform initiatives must be part of government efforts to improve accountability to Ontarians.  People with mental illness have important experience and knowledge that is critical to understanding illness, treatment and care.  Because people with mental illness are particularly vulnerable, it is very important that mechanisms for consumer decision-making, choice and participation are protected.   Governments should build the capacity of consumers and families to participate in mental health and addictions planning and service delivery by supporting self-help, peer support and consumer advocacy initiatives.

Respond to the Needs of Diverse Communities

Diversity is a critical feature of Canadian society and mental health services and strategies must respond effectively to the different cultural and linguistic needs that all clients and stakeholders bring to their interactions with the health and mental health care system.  This must be a key objective for mental health policy makers and service providers if client outcomes are to be improved and the cost-effectiveness and efficiency of mental health care services is to be ensured.  Governments must take leadership to ensure that Canadians from diverse backgrounds and with diverse experiences are able to fully access and participate in mental health care planning and services.

People of colour, women, people with disabilities, gays and lesbians, transsexual and transgendered and many other marginalized community members experience individual and systemic discrimination.  These experiences have a powerful impact on mental health, mental illness, treatment and care.  Addressing discrimination in society at large as well as within health and mental health care services must be a key strategy to improve mental health. 

Develop a mental health and addictions management information system

There is a critical need for funding and policy support at both the federal and provincial level to ensure the development of information systems to support the treatment and care of people with mental illness and addictions.  

Information systems are also key to efforts to increase accountability at the program, agency, system and funder level for the outcomes that should be achieved in the mental health and addictions systems.  Opportunities for tracking and comparing service and outcome data have been difficult to achieve because managers have not had access to the management and decision support information systems they need.  Work should begin immediately on developing the infrastructure required for a mental health and addictions management information system.  In addition, a centralized information and referral system would improve access to mental health services and make the system easier to navigate. 

Improvements to the mental health and addictions systems through reorganized information and referral systems should enable clients to make informed choice and not limit the range of services and programs available to clients. 

Include mental health and addictions professionals in health human resource planning

Like other areas in the health care system, mental health and addictions suffer from a lack of coordinated planning for its health professionals.  There is no central planning mechanism to ensure appropriate distribution of these resources across communities or to co-ordinate hiring. Those who work in their own community practice decide where they wish to locate, the hours of operation they wish to keep and the type of service they wish to provide.   The distribution of medical and psychiatric resources geographically is a concern.  Billings to the provincial health insurance plan show differences in the percentage of the population accessing mental health services from a range of 6.6% in one area to 12.7% in another.  Mental health and addictions professionals must be included in efforts to improve health human resource planning overall. 

Conclusions

Reforming health care funding and delivery in Canada is currently high on the agenda of governments and the public.  Unfortunately, mental illness and addictions remain largely absent from these debates despite the fact that twenty percent of Canadians in any given year suffer from a mental illness or addiction, and 3% suffer profound and persistent disablement. 

This situation must change.  CAMH has recommended ways to bring mental health and addiction issues into the mainstream of health care reform initiatives.  We have also recommended that funding investments be directed to the community-based sector so a continuum of care from hospital to community can be realized.  Finally, we believe that investments must be made in housing, income and employment to support people's treatment and recovery. 

These recommendations are not new, but because the needs of people with mental illness and addictions have for so long been neglected in health care reform and funding initiatives they remain more urgent than ever.  As governments make key decision in the coming months about the future of health care in Canada, we urge them to include the needs of people with mental illness and addictions in their plans.

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