Submission to Standing Senate Committee on Social Affairs, Science and Technology

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.
Addiction and Mental Illness in Canada

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.

CAMH's Submission to the Standing Senate Committee

The Standing Senate Committee has asked Canadians to answer the question:

Excluding increased funding, what are the three most important areas of government responsibility (either federal or provincial) that need to be improved to ensure adequate and timely access to needed mental health services?

CAMH has interpreted this question broadly. While we believe that access to mental health services must be improved, we also believe that mental health services should not be viewed in isolation from the other systems and supports that are so critical to prevention, treatment and recovery of mental illness. For this reason this submission recommends that the Standing Senate Committee take a broad view of the policy levers that will improve mental health.

CAMH has also focussed its comments on those areas in which we believe there is opportunity to make systemic and long-term change. We have suggested a number of ways in which mental health can be included in overall health care reform initiatives. Promising action has begun in this regard as evidenced by the recent First Ministers' Accord and we urge the Standing Senate Committee to reinforce and encourage these efforts.

Finally, CAMH believes that the lack of attention and investment in addressing the mental health 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. CAMH believes that national leadership is long overdue to bring attention, focus and resources to mental health issues so that suffering and disability due to mental illness can be prevented and reduced. Research findings in the last ten years have led to novel approaches to diagnosing mental illnesses and addictions and have created new and improved approaches to treatment. We must make it possible for all Canadians who need them to access these improved diagnostic tools and treatments.

Three Priorities for Action

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

Treatment and recovery are difficult to achieve when basic needs for shelter, income and employment are unmet. CAMH believes it is good public policy to take action to address these needs since access to housing, income, and employment has been demonstrated to improve clinical status, reduce hospitalization, and enable people with mental illness to stay in their homes and communities. Access to housing, income and employment are also key to people's ability to participate in society and to enjoy the rights of citizenship free from stigma and discrimination.

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 and Employment

Access to adequate income and employment 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.

Support for employment is also a key area in which governments can do more. 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. 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.

2) Include mental health in health care reform initiatives.

Include mental health and addictions in the definition of health and illness

Mental health and addictions services are a key component of primary and acute care. Hospitals that care for those with mental illness must not be excluded from the Canada Health Act. Doing so stigmatizes and discriminates against sick people and reinforces an artificial distinction between physical and mental illness that serves no one well. CAMH urges the Senate Committee to end this separation so that mental health issues are considered part of defining overall health and well-being. CAMH also recommends that mental health and addictions be included in primary care reform efforts. In order to meet the needs of people with mental health problems and addictions, primary care must include access to a multi-disciplinary team of care providers with strong and immediate links to the specialized mental health and addictions system, twenty-four hour access to care, access to services that promote and maintain health, and coordinated case management.

Expand coverage under the Canada Health Act

CAMH believes the Canada Health Act should apply to more than acute care institutions and physicians. That is why CAMH has supported the call to include home care under the Act and to ensure public funding for the costs of medications prescribed outside of institutions. Public funding for the costs of medications would make a tremendous improvement in the lives of many people with mental health problems who require long-term pharmacotherapy. For these individuals, access to medication is key to their ability to maintain employment, housing and the other community connections that support treatment and recovery.

CAMH urges the Senate Committee to reinforce the work already underway by First Ministers to expand home care to people with mental illness. CAMH would take this one step further and include people with concurrent disorders and addictions in any national home care program. Access to ongoing and comprehensive supports in the home and community is critical to efforts to maintain good health and to prevent, reduce and respond to acute episodes of illness for those with mental health problems and addictions.

3) Develop a National Action Plan on Mental Health.

National leadership on mental health issues is long overdue. CAMH has already stated that we believe the federal government has a key role in addressing the housing, income and employment needs of people with mental health problems. CAMH also believes the federal government should work with Canadians and other stakeholders to develop national standards, collect national data, support research and knowledge dissemination and to educate Canadians about mental health and mental illness. There is also a clear federal role in the direct provision of health and mental health care to aboriginal people.

Canada lags behind many other nations that have successfully implemented National Mental Health Strategies to promote mental health and to reduce disability due to mental illness. Federal leadership would help to bring focus to mental health and mental illness within health care reform initiatives, to encourage the integration of research findings and clinical practice, to coordinate and clarify the roles of various levels of government, to address stigma and discrimination, and to promote mental health so that people can participate meaningfully in Canadian society.

CAMH agrees with the Canadian Alliance on Mental Illness and Mental Health and the Canadian Mental Health Association that a National Action Plan on Mental Illness and Mental Health must be developed. Given the advances in knowledge and understanding of mental illness over the last ten years, action now is particularly timely. New research and clinical advances are raising hope about the treatment and care of people with mental health problems, but also raise challenges in terms of how new knowledge is implemented, and how uniformity of care and access is ensured.

There is also an opportunity, given the recent release of a National Drug Strategy, to coordinate efforts at the national level to address both mental health and addiction issues. Given the high rate of concurrent disorders (mental health problems and addictions) it is critical that links be forged between a National Action Plan on Mental Health and the National Drug Strategy. For example, national monitoring of the prevalence of substance use disorders through the National Drug Strategy would provide tremendous benefits to efforts to plan services for people with concurrent disorders.

To address this range of issues, CAMH recommends that a National Action Plan include the following components:

Public education, health promotion, anti-stigma and anti-discrimination initiatives;
Research;
Information and data collection systems; and
A national policy framework.

A National Action Plan must also be supported by appropriate mechanisms within government to provide a focal point for decision-making, leadership and action. For this reason, CAMH recommends that the federal government create a mandate within government and across ministries for leadership and action on mental health issues.

In addition, CAMH believes that a successful National Action Plan must be based on the following principles:

Consumers and families must be at the centre of reform

Putting people with mental illness and their families at the centre of reform initiatives should be part of government efforts to improve accountability to Canadians. 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. The federal government should build the capacity of consumers and families to participate in mental health planning and service delivery by supporting self-help, peer support and consumer advocacy initiatives.

The needs of diverse communities must be addressed

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. The federal government 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.

People must have access to a continuum of services and supports from hospital to community-based care

Ensuring access to a continuum of services and supports is critical to the development of an effective strategy to address mental illness and addictions. This means that governments must invest in the community-based sector, as well as hospitals and institutions. A broad continuum of services and supports, including supportive housing and income supports, is key to effectively meeting the different needs of people at different stages of illness and recovery. It is also key to ensuring a responsive mental health system able to prevent acute episodes of illness, or to reduce their intensity and duration. Efforts should be targeted to:

Improving access by applying new knowledge and increasing the capacity and 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)
Integration of the mental health and addiction sectors must be encouraged

Given the high rate of concurrent disorders between addictions and mental health, it is imperative that addictions be included in health and mental health care reform initiatives. Access to services for people with mental illness and addictions is extremely limited, 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. In addition, governments should take action to ensure housing and supports with a harm reduction approach are available for people with concurrent disorders.

The focus on health promotion and prevention must be enhanced

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. Yet funding to prevent mental health disorders and addiction problems in children and youth are limited. As we stated earlier, we must end the separation between physical and mental health and include the prevention of mental illness and the promotion of mental health within overall national health care objectives.

Mental health professionals must be included 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 professionals must be included in efforts to improve health human resource planning overall.

Conclusion

CAMH is pleased to have this opportunity to contribute to the Standing Senate Committee's deliberations and is heartened by the commitment and focus the Committee is bringing to its consideration of mental health issues.

Mental illness and addiction in Canada generates tremendous suffering and disability - a situation we do not believe would be tolerated for physical illnesses of similar prevalence and severity. CAMH urges governments to act to address this issue. Consumers, clinicians, researchers and policy makers have developed a strong body of knowledge upon which governments can draw.

CAMH recommends three areas in which government action is needed:

Act outside of the traditional health care sector: Ensure access to housing, supportive housing, income and employment;
Include mental health in health care reform initiatives; and
Develop a National Action Plan on mental health.

CAMH further recommends that the National Action Plan on mental health be based on the following principles:

Consumers and families must be at the centre of reform;
The needs of diverse communities must be addressed;
People must have access to a continuum of services and supports from hospital to community-based care;
Integration of the mental health and addiction sectors must be encouraged;
The focus on health promotion and prevention must be enhanced; and
Mental health professionals must be included in health human resource planning.