Mental Health, Mental Illness and Addiction

1. Mental Health, Mental Illness and Addiction Standing Senate Committee on Social Affairs, Science and Technology: Progress Report Senator Michael Kirby 4 October 2004 Toronto

2. The Work of the Committee • In February 2003, the Committee embarked on a major study on mental health, mental illness and addiction. • From February 2003 to May 2004, we held 24 public hearings and heard 104 witnesses, for a total of 55 hours. • We also received 114 submissions and 43 letters.

3. Structure of the Reports & Timeframe • In November 2004 the Committee will table three reports: • First Report: Findings in Canada • Second Report: International Perspectives (Australia, New Zealand, United Kingdom, United States) • Third Report: Issues and Options • This will be followed by a set of national public hearings taking place across the country from February to June 2005. • In November 2005, the Committee will table its report on recommendations for reform.

4. Major Findings • High prevalence, heavy burden, but largely unmetneeds • Some groups are particularly vulnerable: children and adolescents, Aboriginal peoples, individuals with complex needs • Impact of stigma and discrimination • System fragmentation, little integration and lack of coordination • No national policy for mental health, mental illness and addiction • Inadequacy of funding for mental health services and supports, addiction treatment and research

5. 1. Prevalence… • Mental illness and addiction affect 1 in 5 Canadians (lifetime prevalence). • Those aged 15 to 24 are more likely to be affected than any other group. • More than 90% of suicide victims have a diagnosable mental disorder. • Prevalence of mental disorders among seniors in nursing homes and long term care settings is very high. • Prevalence of mental disorders among Aboriginal peoples, homeless people and inmates much higher than in the general population. • Mental illness and addiction rank first and second as a cause of disability in the workplace.

6. … and Costs • The economic impact of mental illnesses in Canada was estimated to be $14.4 billion in 1998. • The cost of substance abuse was estimated at $8.8 billion in 1992. • The cost of suicide was estimated at $850,000 per suicide death in 1996. • Employers pay 2/3 of all costs associated with mental illness and addiction in the form of lost productivity, absenteeism, disability, wage replacement costs, employee group health care premiums and prescription drugs.

7. 2. Vulnerable Populations • Children and adolescents: the onset of most adult mental disorders occurs during childhood and adolescence; this points to the need for early detection and intervention. • Aboriginal peoples: they suffer significantly higher rates of mental illness, addiction and suicidal behaviour than the general population. • Individuals with complex needs, such as those with concurrent disorders and dual diagnosis, homeless people and inmates. • The needs of these vulnerable groups require major intergovernmental and cross-sectoral action from various systems: health care, mental health services, addiction, education, social services, housing, justice, welfare, etc.

8. 3. Stigma and Discrimination • Discourages people from seeking needed treatment. • Leads to government under-funding of research, treatment and support services. • Perpetuates outdated treatment methods within the health care system itself. • Role of eduational compaigns; role of the media; educating health care professionals. • Lessons from other countries (Australia, New Zealand, United Kingdom).

9. 4. System Fragmentation and Lack of Integration • Many players involved: all levels of government, various institutions, multiple sectors, a variety of providers, diverse advocacy groups. • “Silo approach”: little collaboration and coordination among the various players. • The Committee was told that what is needed is a seamless navigation between each service as recovery takes hold and an individual moves from discharge, through skills enhancement, to housing and employment.

10. 5. No National Policy for Mental Health, Mental Illness and Addiction • Unlike many other developed countries, Canada does not have a national action plan for mental health, mental illness and addiction. • Various levels of government are all involved in the funding and delivery of mental health services and addiction treatment. • Perhaps more importantly, there are currently no national vision, goals, objectives and standards to guide the funding and delivery of mental health services and supports and addiction treatment. • There is a clear need for leadership if Canada is to move forward in ensuring uniformity and equity in service provision.

11. 6. Inadequacy of funding • The Committee heard that mental health services and addiction treatment are under-funded in relation to the prevalence and economic burden of illness. • There is currently no funding dedicated expressly for mental illness and addiction. • There are multiple sources of funding with little joint inter-ministerial collaboration. • There is no accountability for the use of public funding for mental health/addiction purposes.

12. Selected Issues and Options • Patient/client-oriented system • Disbanding the silo approach • Combating stigma • Workplace issues • Infrastructure (human resources and information systems) • Direct and indirect federal role • National action plan • Funding

13. 1. Patient/Client Oriented System • There is a desperate need for a patient centered system with a focus on recovery and personalized care plans. • Funding must follow the patient. • What set of incentives can be introduced to achieve a truly patient/client-oriented system? • What can be done to ensure the provision of culturally appropriate services and supports?

14. 2. Disbanding the Silo Approach • There are so many different players involved that it is almost overwhelming task to get them all on board and doing the same things. • How can mental health services and addiction treatment be best integrated? How can the mental health/addiction treatment be integrated with the health care system? How can these be integrated to the broader social system (housing, education, welfare, justice, etc.)? • Will the various organizations be prepared to give up some of their autonomy to help make integration happen? • As a first step towards systemic integration, which community services and supports should be given priority?

15. 3. Combating Stigma • For many individuals with mental illness and addiction, the stigma and discrimination they confront is as important a source of stress as the disorder itself. • Combating stigma and discrimination requires a multi-pronged effort sustained over a long period of time. • Should Canada develop a national anti-stigma strategy? • What role can the media play in changing public attitudes towards individuals with mental illness and addiction? • What lessons can be learned from Australia (teaching journalists about mental disorders) and the United Kingdom (training a group of affected individuals to speak to the media)? • More generally, what can governments do to promote mental health?

16. 4. Workplace Issues • Mental performance – motivation, knowledge, judgement, the ability to communicate – drives competitiveness in the global economy. • Employers can play a major role in addressing mental illness and addiction in the workplace. • We must begin with combating stigma and discrimination. • What changes, if any, need to be made to disability plans? To EAP programs? • How can employers enhance return-to-work policies to accommodate individuals with mental illness and addiction?

17. 5. Human Resources • There are critical shortages of professionals in the field of mental illness and addiction. • Should a national human resource strategy be put in place? • Should medical billing schedules be modified so as to provide an incentive to family physicians to devote more time to individuals with mental disorders? • Should we embed mental health services and addiction treatment directly into a primary health care model? • Should the curriculum in nursing schools and faculties of medicine be revised so as to provide further training and education on mental illness and addiction? • Should we follow the example of New Zealand and implement a training program to provide formal qualification for community mental health support workers?

18. 5. (con’t.) Information Systems • Canada currently lacks a national information database on the prevalence of mental illness and addiction. Canada also lacks the information system required for reporting on performance. • Should the federal government, in collaboration with various stakeholders, establish a national information system? • Does the EHR system currently being developed by Infoway raise particular concerns with respect to patients with mental illness and addiction? For example, do psychiatric records differ from other types of medical records? Are there particular privacy concerns that need to be addressed with respect to information about mental health/addiction?

19. 6. Direct Federal Role • The federal government has a direct role with respect to First Nations and Inuit, inmates in federal penitentiaries, veterans, RCMP and the military. • The federal direct approach is highly fragmented. There has been no efforts to coordinate a strategy among the various federal departments. • What can be done to better integrate and coordinate the current federal approach to mental illness and addiction for Canadians falling under its responsibility?

20. 6. (con’t) Indirect Federal Role • The federal indirect role derives from its broad responsibility to oversee the national interest of all Canadians. • Over the last 55 years, the federal government has been ambivalent in its indirect role about mental health, mental illness and addiction. • The Canada Health Act excludes services provided by psychiatric institutions; no specific portion of federal transfers is expressly dedicated to mental illness/addiction. • Should the federal government consider enacting a “Canada Mental Health Act”?

21. 7. National Action Plan • Should we implement a national action plan? How can we involve all levels of government? What should the federal role be? • Should we have a common vision and shared objectives, along with 13 provincial/territorial action plans? • How can we involve all stakeholders (nurses, family physicians, psychiatrists, psychologists, social workers) and all sectors (health care, mental health, addiction, community support, education, housing, justice, etc.)? • Where should we start – awareness campaigns, suicide prevention, research, acute clinical services, community supports, early intervention, legal issues? • How can we ensure that individuals with mental illness and addiction and their families fully participate in the development of an action plan?

22. 8. Funding • Yes, more money is needed, more people and more resources. • But we also need to change the way we go about allocating these resources. • How much more is needed? Where should the additional money come from? Should funding for mental illness and addiction be “ring fenced” as in Australia? • How can governments, providers and NGOs be made accountable for their use of public mental health/addiction funds?

23. Involvement of the Mental Health/Addiction Community • The Committee strongly hopes that the mental health/addiction community will participate in its cross-country hearings. • The support given so far has been tremendous and played a central role in our report findings. • The involvement of the whole mental health/addiction community is critical and essential to the success of the Senate Committee’s report on recommendations for reform.

24. Conclusion • The Committee strongly believes that by working closely with mental health/addiction groups, we can make a real difference in the lives of Canadians living with mental illness and addiction and their families. • Making a tangible difference is the goal of the Committee’s study.