This chapter examines the role and responsibility of the federal government in developing policies and programs in the field of mental health, mental illness and addiction. It also outlines various federal initiatives relevant to the development of an overall framework for mental health, mental illness, and addiction. In doing so, it attempts to separate the initiatives of the federal government for populations directly under its jurisdiction from others with a broader national focus involving multi-jurisdictional issues, notably those of primary concern to Canada’s provinces and territories.
Section 9.1 provides an overview of the direct and indirect roles of the federal government in mental health, mental illness and addiction. Section 9.2 describes and assesses the direct role of the federal government with respect to the specific population groups that fall under its responsibility, including First Nations and Inuit; federal offenders; veterans and the Canadian Forces; Royal Canadian Mounted Police; and federal public servants. Section 9.3 examines federal interdepartmental coordination relevant to its direct role in mental health, mental illness and addiction. Section 9.4 reviews the roles and responsibilities of the federal government from a national perspective (indirect role); it also examines the legal and financial levers available to influence policy in the field of mental health, mental illness and addiction. Section 9.5 provides a general assessment of some federal policies and programs affecting the delivery of mental health services, addiction treatment and social supports. Section 9.6 discusses the potential for a national action plan. Section 9.7 examines mental health, mental illness and addiction from a population health perspective. Section 9.8 contains the Committee’s commentary.
To provide a “picture” of the extent of the federal government’s role in mental health, mental illness and addiction, the Committee’s researchers searched the federal consolidated statutes and regulations using the terms “addiction”, “disability”, “mental disorder”, “mental health”, “mental illness”, and “substance abuse”. Table 8.1 provides the list of federal legislation that makes reference to these terms.
It appears clearly that the federal government has a role on two fronts in mental health, mental illness and addiction. On one front, it is directly responsible for specific groups of Canadians. According to the 2003 Canada’s Performance Report to Parliament: “The federal government provides primary and supplementary health care services to approximately 1 million eligible people – making it the fifth largest provider of health services to Canadians. These groups include veterans, military personnel, inmates of federal penitentiaries, certain landed immigrants and refugee claimants, serving members of the Canadian Forces and the Royal Canadian Mounted Police, as well as First Nations populations living on reserves and the Inuit.” In addition, the federal government is a major employer with management of a large workforce with particular health-related concerns.
On the second front, the federal government is expected to bring a national perspective to the social policy field that includes mental health, mental illness and addiction. This is an indirect role incorporating broad responsibility to oversee the national interest of all Canadians. It discharges this responsibility in several ways, including funding transfers to the provinces, surveillance activities and data collection, funding and performance of research and development activities, drug approval process, the provision of income support and disability pension provisions for affected Canadians, social programming such as housing initiatives, funding the criminal justice system, and the operation of a number of programs to promote overall population health and well-being.
Canada Elections Act
Canada Pension Plan
Canada Student Financial Assistance Act
Canada Student Loans Act
Canadian Centre for Occupational Health and Safety Act
Canadian Centre on Substance Abuse Act
Canadian Forces Superannuation Act
Canada Health Act
Canadian Human Rights Act
Canadian Institutes of Health Research Act
Controlled Drugs and Substances Act
Corrections and Conditional Release Act
Department of Health Act
Excise Tax Act
Federal-Provincial Fiscal Arrangements Act
Food and Drugs Act
Income Tax Act
Members of Parliament Retiring Allowances Act
Parliament of Canada Act
Pension Benefits Standards Act
Personal Information Protection and Electronic Documents Act
Public Service Employment Act
Public Service Superannuation Act
Royal Canadian Mounted Police Superannuation Act
Supplementary Retirement Benefits Act
Vocational Rehabilitation of Disabled Persons Act
War Veterans Allowance Act
Youth Criminal Justice Act
Source: Law and Government Division, Library of Parliament.
In both roles, any consideration of a framework for mental health, mental illness and addiction cannot displace the primary responsibility of the provinces/territories for program design and delivery. There is, however, an overriding need to move toward a framework that works for all Canadians regardless of whether they fall under federal or provincial jurisdiction.
The distinction between the federal and the provincial/territorial responsibilities with respect to mental health addiction services has been clearly emphasized by Tom Lips, Senior Advisor, Mental Health, Healthy Communities Division, Population and Public Branch, Health Canada, when he stated:
The federal and provincial-territorial roles and responsibilities differ where mental health and mental illness are concerned. (…) Provincial and territorial governments have primary responsibility for the planning and delivery of health services for the general population. As you know, federal transfer payments contribute to health services delivery. The federal government has a special mandate for health service delivery to certain populations, notably First Nations people on reserve and Inuit. It also undertakes national health promotion efforts. Both levels of government have been involved in health promotion, research and surveillance, and have collaborated to address some service delivery issues, for example, identifying best practices.
In fact, the range of federal programs and services relevant to mental health, mental illness and addiction is very large. It includes multiple initiatives aimed at specific groups under its direct responsibility and many endeavours to address broader national population concerns. The following sections examine the more specific federal and the broader national perspectives and, where possible, provide some information to assess those program and service activities.
9.2 THE FEDERAL DIRECT ROLE
The following sections identify and assess the programs and initiatives in place for particular groups under direct federal jurisdictional responsibility.
9.2.1 First Nations and Inuit
Aboriginal peoples are defined in the Constitution Act, 1982 (section 35) as the “Indian, Inuit and Métis peoples of Canada.” Despite this broad constitutional definition, the federal government currently takes responsibility only for Indian people residing on-reserve and specified Inuit. Health Canada estimates that it serves approximately 735,000 eligible First Nations and Inuit people.
The provincial and territorial governments have general responsibility for Aboriginal peoples living off-reserve, including Métis and non-status Indian populations. These groups have access to programs and services on the same basis as other provincial residents. These jurisdictional divisions, in combination with the multifaceted nature of the Aboriginal population in Canada, have created serious barriers to the establishment of a comprehensive plan for the development of a genuine system of mental health, mental illness and addiction.
Over the years, the federal government has made several attempts to address mental illness and addiction in Aboriginal communities. In the early 1990s, the federal department of health, with the assistance of a multi-stakeholder steering committee, produced an “Agenda for First Nations and Inuit Mental Health.” It also targeted Aboriginal peoples in broader strategies such as the Drug Strategy, Family Violence Prevention Initiative, and Building Health Communities Initiative. In 1996, the Royal Commission on Aboriginal Peoples drew particular attention to the mental health problems that were linked to poverty, ill health and social disorganization in many communities.
The federal government’s response to the Royal Commission, Gathering Strength – Canada’s Aboriginal Action Plan, was announced in January 1998; it provided a strategy to begin a process of reconciliation and renewal of its relationship with Aboriginal peoples. Two significant initiatives had as their goal to give Aboriginal peoples more autonomy when addressing some of the concerns related to health and mental health. First, in 1998, the federal government funded the Aboriginal Healing Foundation, an Aboriginal-run, non-profit corporation to support community-based healing initiatives of Métis, Inuit and First Nations people on and off reserve directed to those who were affected by physical and sexual abuse in residential schools and to those affected indirectly by intergenerational impacts. Second, in 1999, Health Canada collaborated with several Aboriginal organizations to establish the National Aboriginal Health Organization. Officially incorporated as the “Organization for the Advancement of Aboriginal Peoples’ Health”, this new organization focuses on priority areas of health information and research, traditional health and healing, health policy, capacity building and public education.
In 2003, $1.3 billion over five years was committed to develop an effective and sustainable health care system for First Nations and the Inuit. In the Throne Speech of February 2004, the federal government made further commitments aimed at ensuring a more coherent approach to multiple issues affecting Aboriginal communities. It promised to set up an independent Centre for First Nations Government, renew the Aboriginal Human Resources Development Strategy, expand the Urban Aboriginal Strategy, and establish a Cabinet Committee on Aboriginal Affairs.
9.2.2 Assessment Relevant to First Nations and Inuit
At present, Health Canada and Indian and Northern Affairs Canada are the two major federal departments that provide health care, mental health services, addiction treatment and social services to First Nations and the Inuit.
Health Canada, through its First Nations and Inuit Health Branch, is responsible for the following programs that address mental illness and addiction:
· National Native Alcohol and Drug Abuse Program (NNADAP): This program is largely controlled by First Nations communities and organizations; it incorporates a network of 48 treatment centres and community-based prevention programs.
· National Youth Solvent Abuse Program: This program delivers, through 10 treatment centres, assessment, inpatient treatment and counseling intended for First Nations and Inuit adolescents with solvent abuse problems.
· Indian Residential Schools Mental Health Support Program: This program provides mental health and emotional support to eligible individuals who are resolving claims against the Government of Canada for abuse(s) suffered while attending Indian Residential Schools. It is provided by Health Canada in collaboration with Indian and Northern Affairs Canada.
· First Nations and Inuit Fetal Alcohol Syndrome/Fetal Alcohol Effects (FAS/FAE) Initiative: This purpose of this initiative, which is part of the Canada Prenatal Nutrition Program, is to raise awareness about FAS/FAE and to deliver programs that provide mental health services to persons at risk and detoxification services for pregnant women at risk, their partners, and their families.
· Non-Insured Health Benefits (NIHB) Program: NIHB provides eligible registered Indians and recognized Inuit and Innu with medically necessary health-related goods and services that are not covered by other federal, provincial, territorial or third-party health insurance plans. These benefits complement provincial/territorial insured health services and include drugs, medical transportation, dental care, vision care, medical supplies and equipment, crisis intervention and mental health counseling.
· Aboriginal Head Start on Reserve: This initiative is designed to prepare young First Nations children for their school years, by meeting their emotional, social, health, nutritional and psychological needs. This initiative collaborates with Health Canada's Brighter Futures and Building Healthy Communities programs. Additional collaboration involves Human Resources Development Canada's Child Care Initiative and the Department of Indian and Northern Affairs' Kindergarten program, both at national and local levels, to ensure that Aboriginal Head Start on Reserve fills gaps and complements existing programs.
At Indian and Northern Affairs Canada, social policy and programs include Child and Family Services, Social Assistance, Adult Care, the National Child Benefit program and other social services that address individual and family well-being. All have components relevant to mental health. Specific programs addressing mental illness and addiction include:
· Aboriginal Suicide Prevention Program: This program, which is provided in collaboration with the RCMP, teaches young adults and community caregivers how they can help prevent suicides. Participants are selected by elders and other Aboriginal community leaders.
· Aboriginal Shield Program: This program is provided in collaboration with the RCMP; it offers education on substance abuse to Aboriginal communities. The program assists Aboriginal and non-Aboriginal police officers as well as community leaders, health care workers, teachers and youth leaders.
· Family Violence Prevention Program: The program provides operational funding to shelters located in First Nations communities. It also funds community-based family violence prevention programs that aim to prevent incidents of family violence on reserves.
Witnesses told the Committee that federal programs addressing mental illness and addiction in First Nations and Inuit communities do not adequately address the needs of Aboriginal peoples. For example, Dr. Cornelia Wieman, Psychiatrist from the Six Nations Mental Health Services (Ohsweken, Ontario), talked about the psychiatric counseling sessions available under Health Canada’s Non-Insured Health Benefits Program:
[Under NIHB], the limit is 15 sessions with the possibility of renewing for a further
12. A total of 27 sessions for many people is not sufficient to help them adequately address their mental health concerns. The mandate of the NIHB program is to provide support for clients in crisis or who cannot access counseling by other means. That counseling could be from an outpatient psychiatric clinic or health service that is funded by the provincial health care system. They could also pay for private counselling.
The vast majority of my patients live on a limited income and would not be able to pay for private counseling. As a result of transportation and access issues, many are also not able to access counseling services in smaller communities nearby or in larger urban settings such as
Hamilton. You can tell that these people do fall through the cracks in the system.
Perhaps more importantly, witnesses identified the existing First Nations and Inuit program “silos” as a significant barrier to accessing needed mental health services and addiction treatment. Services and supports are provided without much collaboration by different departments, or by various departmental directorates or divisions. Moreover, the Committee was told that the current practice is to isolate problems on the basis of their symptoms – addiction, suicide, FAS/FAE, poor housing, lack of employment, etc. – and to design stand-alone programs to manage each one. This fragmented approach has had little success. Witnesses told the Committee that, in order to restore the well-being in First Nations and Inuit communities across the country, a significant re-thinking of, and departure from, current practice is needed.
The Committee was also informed that the fragmentation of services set up to solve interconnected issues is a real problem. In particular, we heard that First Nations and Inuit are poorly served by government program delivery models that stress services to individuals over holistic, more culturally-appropriate, services to communities. For example, Dr. Laurence Kirmayer, Director, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, stated:
Mental health perspectives tend to be focused on the individual and on individual vulnerability and affliction. This kind of data really points to the working of social forces – things that are affecting entire generations of people and we need to conceptualize it in that way. Within this pattern there is individual vulnerability; not everyone is affected the same way by the same adversity. However, the overall high rate suggests that many people are being affected and that there are things that lie outside of the individual that are at play. We have the challenge to characterize social forces and to think about ways of helping people to take that in hand.
Witnesses also stressed that the “one size fits all” approach to program and service delivery has not met the needs of Aboriginal peoples effectively. By and large, Aboriginal peoples know what their problems are, and are in better position to identify appropriate solutions, and to know what resources should be applied in accordance with community priorities. What this means, in structural terms, is that it would be far preferable for government departments to delegate to Aboriginal communities the authority to customize services and react flexibly to local circumstances. Accordingly, Aboriginal peoples should be supported in their development of their own solutions, rather than having solutions imposed upon them from “outside”.
To be successful, community-based initiatives must be accompanied by the development, in parallel, of community capacity adequate to deliver such programs effectively. Witnesses identified a critical shortage – if not absence – of adequately trained mental health and addiction professionals. In this perspective, Dr. Wieman stated:
One of the important ways in which access to health services and health outcomes, including mental health, can be improved is by training an increased number of Aboriginal health professionals. Barriers to seeking various mental health services could be overcome and providing more culturally relevant care could be accomplished. The Royal Commission on Aboriginal Peoples in 1996 recommended that 10,000 Aboriginal peoples be trained as health professionals in the next 10 years. We are now only two years away from 2006, and I do not believe that we are anywhere near that goal. Estimates state that there are approximately 150 Aboriginal physicians in this country, most of whom have trained to be family physicians. Off the top of my head, I would estimate the number of Aboriginal specialists at probably less than 25. I am only aware of two other Aboriginal psychiatrists in this country, with a fourth individual graduating from the residency program in
Manitoba this June.
The Committee was also informed that the needs of Aboriginal peoples are complex and that short term approaches often fail. More precisely, short term funding can materially restrict the ability of Aboriginal governments to develop the long term strategies needed to address the needs of their communities. It can take years to develop effective programs, and often, the shorter the time frame of a given project, the less potential there is for it to be effective.
There was also a general consensus among witnesses that the current funding levels for mental health services and addiction treatment in First nations and Inuit communities are inadequate. Brenda Restoule, Psychologist and Ontario Board Representative, Native Mental Health Association of Canada, explained:
Current funding is already inadequate, at best, and does not meet the needs of the community and its members. Since the funding formula is based on population size, many communities receive a small amount of funding, making it difficult or, in many cases, impossible, to deliver mental health counselling and intervention services. Most communities must use their funding to establish mental health promotion and mental illness prevention programs. Although these types of programs are needed, the funding does not allow for a continuum of care that is desperately needed for First Nation communities.
The funding is so low for the salary of mental health workers that professionals such as social workers, psychologists and psychiatrists often do not find it desirable to work in First Nation communities.
The Committee was informed that some provinces have integrated Aboriginal issues within their mental health strategies. To be truly successful, then, federal initiatives for Aboriginal mental health either on reserve or off-reserve should harmonize with the relevant provincial mental health plans and implementation strategies.
To sum up, federal and provincial programs directed to Aboriginal mental health, which focus on individuals or specific aspect of an issue, have been criticized for operating with a silo mentality that precludes their smooth coordination with other programs. The result is an hodge-podge of similar programs, different tiers of service delivery and a complex array of funding mechanisms that is bewildering to the individuals they are intended to serve and their families and communities. Ideally, a holistic or global approach would entail government departments pooling their resources so that interconnecting factors such as health, education, housing, and employment needs of individuals, families and communities could all be met or at least alleviated in a planned, structured and integrated way. Horizontal government initiatives would assist Aboriginal communities to plan and coordinate services better.
From a financial perspective, the lack of coordination often results in expensive and unnecessary program duplication. An environmental scan is required to determine what programs exist, where there is duplication across departments and organizations, where there are significant gaps in programming, as well as how best to maximize resources.
9.2.3 Offenders under the Federal Correctional System
Inmates in federal correctional institutions and others under the federal correctional system, those offenders who are sentenced to two years or more of incarceration, constitute another significant group of Canadians under federal health-related responsibility. Currently, Correctional Service Canada (CSC) manages about 12,600 inmates and 8,500 offenders on conditional release under parole officer supervision. The quality of mental health services and addiction treatment for federal offenders is a consideration for CSC but it is secondary to the primary focus of corrections, which is described as the “criminogenic” needs.
Federal offenders come completely under federal responsibility and are not considered as beneficiaries of provincial health care insurance plans. Françoise Bouchard, Director General, Health Services at CSC, observed that the legislative health care mandate of federal corrections is through the Corrections and Conditional Release Act, which states:
The service shall provide every inmate with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.”
With respect to mental health care, the goal of CSC is to provide: “a continuum of essential care for those suffering from mental, emotional or behavioural disorders (…) consistent with professional and community standards.”
When admitted to the correctional system, each individual is assessed and asked fundamental questions about his/her mental health, mental illness and addiction. Following assessment, a correctional plan is developed for each offender and the offender is directed to either a regular institution or one in which treatment is available.
Over the last decade, CSC has issued specific directives on mental health services and addiction treatment provided to federal offenders. In 1994, directives from the Commissioner were implemented for psychological services, including assessment; therapeutic intervention; crisis intervention; program development, delivery and evaluation. In 2002, directives on mental health services provided standards on assessment, diagnosis and treatment that affect the access to mental health professionals, emergency and community care, as well as transfers to psychiatric care and addiction treatment centres. The same year, the CSC Commissioner issued directives for methadone maintenance treatment (diagnosis and treatment). In 2003, directives for the purpose of offenders who are suicidal or self-injurious were released; they include prevention, assessment and treatment guidelines. Also in 2003, a directive on health services was issued that stipulates that the cost of providing mental health and addiction treatment will be the responsibility of CSC.
In addition to these directives, CSC has worked to develop a comprehensive health care strategy to address both the physical and mental health needs of offenders, including the integration of issues related to drugs and alcohol. Specific work on mental health policy included a 1991 Task Force report on mental health oriented to all offenders, a 1997 National Strategy on Aboriginal Corrections, and a 2002 mental health strategy for women offenders.
At CSC, the Aboriginal Initiatives Branch is mandated to create partnerships and strategies that enhance the safe and timely reintegration of Aboriginal offenders into the community. Aboriginal peoples represent less than 3% of the Canadian population, but account for 18% of the federally incarcerated population. Aboriginal-specific and culturally appropriate programs and services to address the needs of Aboriginal offenders in corrections include initiatives such as Aboriginal Healing Lodges (9 across Canada); Aboriginal Community Residential Facilities (23 across Canada); Aboriginal Community Reintegration Program; Elders working in institutions and in the community; and Transfers of Correctional Services to Aboriginal Communities (5 agreements signed). CSC is also responsible for the “National Strategy on Aboriginal Corrections” (currently being revised) that focuses on Aboriginal programs, Aboriginal community developments, Aboriginal employment/recruitment and partnerships on Aboriginal issues.
Women with particular mental health needs at all security levels may receive treatment in a specialized, separate 12-bed women's unit at the Regional Psychiatric Centre in the Prairies (RPC). This unit serves also as a national mental health resource for Anglophone women. Francophone women may receive treatment at Institute Phillipe Pinel in Montréal (Québec) where CSC has contracted for inpatient treatment services. Furthermore, the “2002 Mental Health Strategy for Women Offenders” provides a framework for the development of mental health services covering a continuum of care. The goal is to apply the elements of the strategy to all offenders and to include crisis intervention, acute care programs, chronic care programs, special needs units, outpatient treatment, consultation services, discharge and transfer planning, follow-up as well as interconnection with other programs and services.
CSC also delivers the “Substance Abuse Program” which consists of a range of institutional and community-based programs that are matched to the severity of the offender’s substance abuse problem. The program is cognitive-behavioural in orientation and includes a strong emphasis on structured relapse prevention techniques. The program is also responsible for the provision of methadone maintenance treatment.
9.2.4 Assessment Relevant to Offenders under the Federal Correctional System
Officials from CSC told the Committee that mental health care and addiction treatment are required to: reduce the disabling effects of mental disorders in order to maximize each inmate’s ability to participate electively in correctional programs, including their preparation for community release; help keep the prison safe for staff, inmates, volunteers and visitors; and decrease the needless extremes of human suffering caused by mental disorders.
The Committee heard that access to mental health services and addiction treatment, however, requires an enhanced CSC response capacity. CSC has 5 specialized treatment centres spread across the country, but they are not resourced at levels comparable to that of provincial forensic facilities. Although CSC has many psychologists, these are primarily engaged in risk assessment for conditional release decision-making. In addition, there is no specific training for correctional staff on mental illness and addiction. With respect to the Mental Health Strategy for Women Offenders, the Committee was told that the challenge of this new approach is that women requiring mental health intervention must move to another part of the country to obtain needed services.
Witnesses also talked about the need for better links between the federal and provincial governments and between the justice system and the provincial mental health services system. For example, Ms. Bouchard from CSC stated:
There is a need for a comprehensive, inter-jurisdictional strategy for the identification and management of offenders with mental disorders. While we try to do a comprehensive assessment at reception, much still needs to be done in respect of those identifying offenders who have mental health problems early in their sentences. That should also occur within the provincial systems as early as possible.
There is a need to have better links between the justice system and the health care system within the provinces. The search for solutions should start before imprisonment for those afflicted with mental health disorders. Within the federal corrections system, work is under way to improve capacities to assess and treat. However, we have no guarantees we will ever have additional resources to do that. We are, right now, conducting a review of our utilization of beds in our treatment centres to maximize and direct them to those who have the most needs. Sometimes that calls for a change of culture between correctional culture and treatment culture, so there is lots of work still to be done.
Our last observation is the issue of continuity of care when people are released. This calls for better links between us, at the federal correctional level, and our provincial counterparts and the community mental health care out there. Partnerships are key to address those gaps, but what will be the incentive to create those partnerships?
The Committee also heard about some discriminatory aspects of the judicial system. For example, Patrick Storey, Chair of the Minister’s Advisory Board on Mental Health (British Columbia), stated:
For federal offenders, it is difficult to access provincially funded mental health services in the community due to specific provisions of the Mental Health Act of
British Columbia. This act is, in itself, discriminatory to this population. It directs that directors of provincial facilities not provide care to people from federal institutions. That is a federal government funding responsibility, and so people who are in federal prison with mental illness trying to get a release into the community will not get service from the local mental health centre or from other services, which is intolerable. (…) Federal and provincial correctional authorities and health authorities must work together to address these deficiencies and reduce the discrimination faced by people in conflict with the law.
In addition, the Committee was told that there is a need to harmonize better the Criminal Code with provincial mental health legislation. The Schizophrenia Society of Canada explained that under the Criminal Code a judge may order a person who is found not fit to stand trial to undertake treatment to make them fit. However, neither the judge nor the Board of Review can order treatment of a person found not criminally responsible based on mental illness to make them well enough to be discharged. The theory is that the provincial mental health acts will do that. In some provinces, however, that does not happen. The Schizophrenia Society of Canada recommended that the federal government should amend the Criminal Code to allow the Review Board to order treatment necessary for the probable release of a person affected by treatable mental illness. In their view, this is preferable to requiring the same person to stay incarcerated for an unreasonable time because the untreated illness makes him/her a significant threat to the safety of the public.
Ms. Bouchard from CSC made some observations about the need for better community supports:
Addressing the needs of offenders who require specialized mental health intervention can reduce the “revolving door”' phenomenon. There is what we call a revolving door between corrections, both federal and provincial, but also the community, where often people who are afflicted with mental health disorders find themselves in the criminal justice system. While mentally disordered offenders are often less likely to reoffend – including violently – they are more likely to return to prison due to a breach of their release conditions – often as a result of inadequate support while they are in the community.
9.2.5 Veterans and Active Members of the Canadian Forces
Veterans Affairs Canada is responsible for delivering health services and pensions and for providing social and economic support to more than 150,000 aging Canadian veterans and members of the Canadian Forces (CF). The main beneficiaries are those veterans and civilians granted a pension or allowance.
The Canada Health Act specifically excludes CF members from the definition of “insured persons”. Therefore, CF members are not eligible for hospital care and physician services insured under provincial health care insurance plans. The Canadian Forces Health Services (CFHS) is the designated health care provider for 83,000 Regular and Reserve Forces personnel at home and on deployment. The CFHS provides access to more than 85,000 providers across the country. Atlantic Blue Cross Care has responsibility for program administration and payment.
Veterans Affairs Canada administers Ste. Anne’s Hospital, located in Ste-Anne-de-Bellevue, Québec. The hospital provides medical and paramedical services to its residing veterans, in addition to a wide range of recreational and social activities. Ste-Anne’s Centre, part of the hospital, provides mental health services to CF members and veterans; it has developed specialized expertise in the fields of post traumatic stress syndrome and dementia. Inpatient and outpatient care are also provided in contract hospital beds, in veterans’ homes, and in hospitals of choice.
Veterans Affairs Canada also provides pensions for disability or death and economic support in the form of allowances to various groups. These include: members of the Canadian Forces and Merchant Navy veterans who served in the First World War, the Second World War or the Korean War; certain civilians who are entitled to benefits because of their wartime service; former members of the Canadian Forces (including those who served in Special Duty Areas) and the Royal Canadian Mounted Police; as well as survivors and dependents of military and civilian personnel.
The Department of National Defence is responsible for “Strengthening the Forces”, a health promotion initiative designed to assist CF and Regular and Primary Reserve members to take control of their health and well-being. Suicide prevention and substance abuse interventions for tobacco and alcohol are two important components of this initiative. Mental health is an issue of concern within Strengthening the Forces. Beside its focus on active living, injury prevention and nutritional wellness, the initiative includes: “Addiction Free” (alcohol and other drug abuse, tobacco use cessation, problem gambling) and “Social Wellness” (stress management, anger management, family violence prevention, healthy families, suicide prevention, and spirituality).
Health Canada is responsible for occupational health and safety of CF members. The “Canadian Forces Member Assistance Program” is organized by the Workplace Health and Public Safety Program (WHPSP) at Health Canada; it is a 24/7 toll-free telephone service that provides confidential counseling services to help members and their families when they have personal concerns that affect their well-being or work performance.
9.2.6 Assessment Relevant to Veterans and Canadian Forces
Several reports have identified gaps in the care and treatment of CF personnel by the Department of National Defence specifically and, by extension, Veterans Affairs Canada. These included: the McLellan and Stow reports in April 1998, the Goss Gilroy Report in June 1998 and the October 1998 report from the House of Commons Standing Committee on National Defence and Veterans Affairs.
The departments responded with a series of initiatives relevant to mental health. In April 1999, the DND-VAC Centre for the Support of Injured and Retired Members and Their Families opened in Ottawa to provide information, referral and assistance support to former and current CF members and their families. Subsequently, legislative and regulatory reform made access to services and benefits more equitable to all CF members, regardless of whether the injury occurred in Canada or on foreign deployment. In April 2001, Veterans Affairs launched an Assistance Service for former members of the CF and their families who require professional counseling.
Recently, the major mental health focus for Veterans Affairs Canada and the Department of National Defence has been on the needs of CF members and veterans suffering from post-traumatic stress disorder and other operational stress injuries. In February 2004, they jointly announced a Canada Mental Health Strategy for the Canadian military. This strategy creates a network of mental health assessment and treatment facilities, educational forums, continuing education program and research for post-traumatic stress disorder and operational stress injuries.
9.2.7 Royal Canadian Mounted Police
The Royal Canadian Mounted Police (RCMP) is an agency of the Ministry of Public Safety and Emergency Preparedness Canada. In addition to federal policing services for all Canadians, it provides policing services under contract to the three territories, eight provinces (all except Ontario and Quebec), approximately 198 municipalities and, under 172 individual agreements, to 192 First Nations communities. The on-strength establishment of the Force as of January 1, 2004, was 22,239.
The definition of “insured persons” under the Canada Health Act excludes members of the RCMP. The administration of health care insurance for the RCMP has been the responsibility of Veterans Affairs Canada since 2003. Veterans Affairs Canada also assumes responsibility for the direct payment of disability pensions for approximately 3,800 RCMP pensioners as well as the provision of health care benefits for approximately 800 retired and civilian pensioners.
9.2.8 Assessment Relevant to Royal Canadian Mounted Police
Information about mental health, mental illness and addiction concerns within the RCMP was not readily available to the Committee.
9.2.9 Federal Public Servants
The federal government is a major employer. Although the size of its workforce diminished between March 1995 to March 2001 from 225,619 to 155,360 employees, it is reported to have grown in the last few years.
In its role as the general manager and employer of the federal public service, Treasury Board oversees benefits available to public servants such as the Public Service Health Care Plan that covers medical benefits and the Disability Insurance Plan that assures a reasonable level of income during periods of long-term physical or mental disability. It has mandated Health Canada to provide occupational health and safety services such as Employee Assistance Programs for Part I, Schedule I, Public Service employers.
The Public Service Health Care Plan (PSHCP) is a private health care insurance plan established for the benefit of federal public service employees, CF members, the RCMP, members of Parliament, federal judges, employees of a number of designated agencies and corporations, and persons receiving pension benefits based on service in one of these capacities. The PSHCP is funded through contributions from the Treasury Board of Canada, participating employers, and the Plan members. The administrator, Sun Life Assurance Company of Canada, is responsible for the consistent adjudication and payment of eligible claims.
PSHCP reimburses participants for all or part of costs they have incurred for eligible services and products, only after they have taken advantage of benefits provided by their provincial/territorial health care insurance plan or other third party sources of health care expense assistance. Eligible services and products are prescribed by a physician or a dentist who is licensed to practice in the jurisdiction in which the prescription is made. PSHCP reimburses eligible expenses on a “reasonable and customary” basis to ensure that the level of charges are within reason in the geographic area where the expense is incurred.
PSHCP covers the cost of visits to a psychologist up to a certain specified limit of maximum eligible expenses. A psychologist prescription covers up to one year of services. The current rate of payment from the plan is about 80 percent of $1,000 per calendar year, covering between 5 and 6 sessions per client.
Under the Long Term Disability Insurance Plan, benefits are payable for up to 24 months in respect of any medically determinable physical or mental impairment which a) results in the withdrawal of any mandatory licence required by the employee to carry out his or her occupation or employment, or b) renders the employee completely incapable of performing substantially all of the essential duties of his or her occupation or employment.
Short term counseling is offered through Employee Assistance Programs (EAP) that can assist people seeking help in juggling personal and work-related demands. A nationwide 24 hour toll-free (1-800) telephone line is operated by qualified and experienced bilingual counselors; access to counseling to over 600 qualified psychologists and social workers (or equivalent) is also provided. Referrals can also be made for employees with personal or work-related problems to resources within the Public Service or in the community, when appropriate, and follow-up is provided. Federal organizations that are clients of the Employee Assistance Society of North America include: Department of National Defence, Department of Veterans Affairs, Department of Justice, Office of the Auditor General of Canada, Health Canada, Parks Canada, Environment Canada, Citizenship and Immigration, Department of Indian Affairs and Northern Development, Fisheries and Oceans, and the Transport Safety Board.
The services described above do not replace those provided by the Public Service Health Program. Within the Healthy Environments and Consumer Safety Branch at Health Canada, the Workplace Health and Public Safety Program (WHPSP, formerly called the Occupational Health and Safety Agency) is mandated by Treasury Board to provide occupational health and safety services (including psychological services) for Part I, Schedule I, Public Service employers.
In addition, Critical Incident Stress Management Services (CISMS) are available for dealing with traumatic incidents such as the death or serious injury of a co-worker on the job, a mass casualty, a threat, personal assault or other forms of violence in the workplace. Employees in certain occupational groups known as “emergency service workers” ( e.g., law enforcement officers, firefighters, nurses and other health care workers, search and rescue teams) are at greater risk of experiencing traumatic incidents. Services include education/prevention, intervention, and evaluation.
9.2.10 Assessment Relevant to Federal Public Servants
Recent studies have explored the issue of stress and the need for the federal government as an employer to make a greater effort to ensure work/life balance and healthy living for its employees. In January 2003, the federally-sponsored National Study on Balancing Work, Family and Lifestyle conducted by Linda Duxbury and Christopher Higgins for Health Canada was released. It confirmed that employed Canadians wanted flexible work schedules, limits on overtime, opportunities for part-time work, telework and family care provisions to help them achieve a better sense of balance in their lives. The study included public (including 8 federal departments) as well as private sector employees and found that public servants take a significant number of “mental health” sick days and spend more on prescription drugs than private sector employees.
Another study conducted in 2002 by the Association of Professional Executives of the Public Service of Canada (APEX) found a significant increase in rates for coronary and cardiovascular diseases (CVD), particularly hypertension, among public employees. It also pointed to other key indicators of health status that demonstrated gradual deterioration. Among respondents, 95% reported sleep disturbances and an average of only 6.6 hours sleep per night; 15% reported depressed mood; 53% reported high levels of stress, almost twice the rate for the average Canadian of the same gender and age; and 19% reported musculo-skeletal problems related to tension. Overall, the data showed that as a group, public service executives experience stress in the high to extreme range.
Bill Wilkerson, co-founder of the Global Business and Economic Roundtable on Addiction and Mental Health stated that: “As an employer, the public sector needs to look deep within itself,” arguing that “we need governments as employers who lead by example in the promotion of mental health and prevention of mental disability.” Referring to the APEX study, he noted that “more than fifteen per cent of executives in the public service suffer depression – 50 per cent higher than the national average. (…) For senior civil servants, psychotropic medication is the prescription drug of necessity in 17.5 per cent of all drug utilization.”
9.2.11 Landed Immigrants and Refugees
Citizenship and Immigration Canada (CIC) has responsibility for the assessment of landed immigrants and refugees. In the past 10 years, Canada has welcomed yearly an average of some 220,000 immigrants and refugees. A landed immigrant is one who has been granted the right to live in Canada permanently by immigration authorities. Refugees who are accepted to Canada are also landed immigrants. Refugee claimants do not have landed immigrant status; they arrive in Canada requesting to be accepted as refugees.
Those claiming refugee status who are needy or living in a province with a three month eligibility waiting period for coverage under the provincial health care insurance plan can get emergency or essential health services through the Interim Federal Health Program at Citizenship and Immigration Canada (CIC). Landed immigrants arrange their own health care, including private insurance to cover the three month waiting period imposed in four provinces (British Columbia, Ontario, Quebec and New Brunswick). 
All applicants for permanent residence in Canada have a medical examination of their physical and mental condition. Based on this examination, applicants may be refused entry into Canada if they have a health condition that is likely to be a danger to public health or safety, or that could be very demanding on health or social services. Departmental information is not specific about possible responses to applicants with mental disorders of any severity.
With the knowledge that newcomers to Canada face tremendous challenges, Citizenship and Immigration Canada has several programs aimed at easing the stress of integrating into Canadian society. The department works with provincial/territorial governments and non-governmental organizations on several initiatives relevant to the positive mental health of immigrants. These include:
· Immigrant Settlement and Adaptation Program that funds organizations to provide services such as reception, orientation, interpretation, counselling and job search.
· Host Program that matches new arrivals with Canadian volunteers who offer friendship and introduce them to services in their community.
· Language Instruction for Newcomers to Canada Program that provides basic language instruction to adult immigrants to help them to integrate successfully.
For refugee claimants, the Interim Federal Health Program is available to cover some health care costs. Administered by Citizenship and Immigration Canada, it ensures emergency and essential health services for needy refugee protection claimants and those protected persons in Canada who are not yet covered by provincial health care insurance plans. The 2002-2003 Departmental Performance Report refers to additional funding of $7.6 million for the Interim Federal Health program, but does not indicate the program’s original cost. The Report for Plans and Priorities for 2003-2004 refers to the program as a “$50 million federal health insurance program covering emergency and essential health care for refugee claimants.” There is no breakdown of particular expenditures that might relate to mental illness or addiction. However, these could be significant, given that many refugee claimants have been victims of torture and other threats to their mental health.
9.2.12 Assessment Relevant to Landed Immigrants and Refugees
No information was readily available to assess federal mental health policies and programs designed for landed immigrants and refugees.
9.3 FEDERAL INTERDEPARTMENTAL COORDINATION RELEVANT TO ITS DIRECT ROLE
In looking at federal government activities with respect to the specific groups under its responsibility, there is little evidence to suggest that there are specific population-targeted strategies, let alone a broad all-encompassing federal strategy applicable to all groups. Efforts are not apparent currently to develop an overall coordinated federal framework with collaboration by all involved departments or agencies. In most cases, there is little indication of a thorough and inclusive population specific strategy for addressing the mental health needs of any of the groups under federal responsibility. The provision of mental health services and addiction treatment and efforts toward mental health promotion and mental illness prevention remain highly fragmented, divided among numerous departments and departmental directorates.
There are, however, two examples of federal interdepartmental efforts to coordinate activities with respect to health care and substance abuse that may provide some lessons for future efforts to do the same in the specific field of mental illness and addiction. These are the Health Care Coordination Partnership and Canada’s Drug Strategy.
9.3.1 Federal Health Care Partnership
The Federal Health Care Partnership, formerly called the Health Care Coordination Initiative, was established in 1994 by a partnership of federal departments that were separately providing health care products and services to specific groups of Canadians. These departments believed that they could lower costs and improve delivery by working together. At present, Veterans Affairs has the lead role with other partners including the Department of National Defence, the RCMP, the Canadian International Development Agency, Correctional Services, Citizenship and Immigration, the Treasury Board Secretariat, Public Works and Government Services, and the Privy Council Office.
The key objectives of the initiative are to negotiate joint agreements with professional associations, suppliers and retailers; coordinate purchases of specific health care supplies and services; improve the competitive environment by identifying alternatives to traditional service delivery; improve information sharing and collective decision making; facilitate joint policy analysis and development; support cooperative development of health and information management across federal jurisdiction; and create joint health promotion activities.
In 2002-2003, the partners jointly negotiated fees, bulk purchases and collaborative policy development that collectively resulted in improved quality of service to clients and $11.6 million in cost savings. Savings of $17.6 million were forecast for 2003-2004. To date however, although there is great potential for joint action, no such activities have been in the field of mental health, mental illness and addiction.
9.3.2 Canada’s Drug Strategy
The initial 1987 National Drug Strategy emerged from concern about the abuse of illegal drugs. In 1988, a national non-governmental organization, the Canadian Centre on Substance Abuse, was created by legislation to provide a focus for efforts to reduce the health, social and economic harm associated with substance abuse.
In 1992, Canada’s Drug Strategy was renewed and combined with the Driving While Impaired (DWI) Strategy. The continued objective was to reduce the harmful effects of substance abuse on individuals, families and communities by addressing both the supply of and demand for drugs. Coordinated by Health Canada (formerly the Department of National Health and Welfare), and involving several other departments, the Strategy sought to enhance existing programs and to fund new ones. Of the $210 million allocated to the initiative, 70% was directed to reducing the demand for drugs through prevention, treatment and rehabilitation and 30% to enforcement and control.
In 1998, the federal government reaffirmed its commitment to the principles of Canada’s Drug Strategy. Health Canada continued in its lead role and provided the chair for the Assistant Deputy Ministers’ Steering Committee on Substance Abuse and interdepartmental committees such as the Interdepartmental Working Group on Substance Abuse. The federal departments involved in the Strategy extended beyond those with direct responsibility for the health of Canadians; they included others with broader national and international relevance: Solicitor General, Foreign Affairs and International Trade, Finance, Canadian Heritage, Justice, Canada Customs and Revenue, Transport, Human Resources Development, Status of Women, Indian and Northern Affairs, Canada Mortgage and Housing Corporation, Treasury Board, and the Privy Council Office.
In its 2001 report, the Office of the Auditor General criticized Canada’s Drug Strategy for its fragmented approach and called for changes to the organizational culture throughout the federal government to emphasize structures and processes to maximize the benefits of working horizontally. When the comprehensive Drug Strategy for Canada was renewed in May 2003, the federal government committed $245 million and the support of fourteen collaborating federal departments. There will be a report to Parliament on the Strategy’s direction and progress in two years.
9.4 FEDERAL INDIRECT ROLE
In addition to its direct federal responsibility, the federal government has a major indirect role in developing a national, long term, cross-jurisdictional, integrated, mental health plan. Although some witnesses claimed that mental health has never been a priority for any level of government, they also stressed their belief that mental health, mental illness and addiction are concerns affecting the entire population of Canada. Therefore, the federal government, the ten provincial governments and the three territories have interconnected roles to play in meeting the health and health care needs of Canadians affected by mental illness and addiction.
There is, however, no centralized departmental capacity, either within Health Canada or any other federal department, or through some form of national structure, to coordinate or respond from a national perspective to the full gamut of mental health, mental illness and addiction issues. Moreover, few resources are devoted to the intergovernmental aspects of a national framework in this area. Currently, work through various federal, provincial and territorial forums is limited to exploring options in shared care initiatives in primary health care reform, homecare proposals, and telehealth. The federal government is sensitive to the need to approach all such issues in a way that respects the federal/provincial/territorial division of responsibilities and the primary responsibility of the provincial and territorial goverments for the provision of mental health services and addiction treatment.
A formal structure – the Federal/Provincial/Territorial Advisory Network on Mental Health – was established on 17 April 1986 to advise the Conference of Deputy Ministers of Health on ways and means of ensuring federal, provincial and territorial cooperation on mental health issues. It was mandated to:
· Consider issues delegated by the Conference of Deputy Ministers of Health, or accepted by a significant number of the provinces as matters where a general consensus of informed opinion would be helpful, and make recommendations, where appropriate;
· Advise on the development and implementation of policies and programs for mental health services, with the aim of developing a uniformly high level of quality and effectiveness across Canada;
· Provide a forum to assist the provinces and territories in the development, organization and evaluation of mental health services within each jurisdiction;
· Serve as a forum for the presentation and exchange of information, relevant data, current research findings and expert opinion between the federal and provincial governments, universities and treatment settings, on problems of jurisdiction, organization, legislation, service delivery, evaluation and other relevant issues;
· Make proposals for federal, federal-provincial and provincial strategies for mental health promotion, to enhance the mental health status of the population at large and particularly that of children and adolescents;
· Receive reports on current mental health activities and programs at the national level and give advice, direction and support to these, as may be appropriate.
The work of the F/P/T Advisory Network on Mental Health was at the time supported by the Mental Health Division of Health and Welfare Canada. This division was then part of the department’s Health Services and Promotion Branch. In the late 1990s, however, the Council of Deputy Ministers of Health withdrew its support for the F/P/T Advisory Network. As a result, it is now difficult to find funding even to bring together mental health policy makers from across the country so that they can share information and develop coherent policies and plans. A number of provinces still continue to participate in the F/P/T Advisory Network, but their work is limited by the funding they can provide themselves. According to Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, the dismantling of the F/P/T Advisory Network on Mental Health:
(…) has cut off a major venue for sharing and joint planning. Some jurisdictions continue to get together but struggle with funding. The number of meetings and jurisdictions participating has dropped off over the years. Special projects are funded on a formula basis with
Ontario covering the majority of the costs with Health
Quebec does not participate.
What then could the federal government do to encourage national coordination, collaboration and partnerships in the field of mental health, mental illness and addiction? There are two different types of levers available – legal (or policy) and financial (or fiscal) – for potential use in the mental health, mental illness and addiction area. While the federal government has legal authority through the power of criminal law, it has used its fiscal capacity to influence social policy. Neither lever, however, is well suited to achieve greater uniformity, establish and maintain standards, bring harmonization or establish national initiatives; these require a high degree of intergovernmental contact and willing collaboration.
9.4.1 Legal Levers
The federal government has several legal avenues for application in mental health, mental illness, and/or addiction. Over the years, criminal law, the Charter of Rights and Freedoms and human rights have been applied.
The Criminal Code has particular sections that relate to mental disorders. For example, a person can be found not criminally responsible for an offence on account of mental disorder. The Court can order the initial part of a custodial sentence to be served in a treatment facility, when an offender is found to be “suffering from a mental disorder in an acute phase” and is in need of immediate treatment.
With respect to addiction, Parliament has used the power of criminal law in several instances. This authority was used to pass laws regulating the sale, distribution and possession of psychoactive substances through the Controlled Drugs and Substances Act. The Tobacco Act provides for a broad range of restrictions on the composition of tobacco products, the access of young persons to tobacco products, tobacco product labelling, and tobacco product advertisement endorsement and sponsorship. For alcohol, the Criminal Code covers driving while impaired and the Broadcasting Act and the Code for the Broadcast Advertising of Alcoholic Beverages regulates advertising.
As discussed in the previous chapter, the Canadian Charter of Rights and Freedoms guarantees certain legal rights that have application in mental health and addiction. Relevant sections deal with such matters as the right to life, liberty and security and the right not to be subject to cruel and unusual punishment. The Charter also has emerged as a mechanism for the creation of national standards which Canadians can demand that both federal and provincial governments meet.
The Canadian Human Rights Act of 1977 provides a process for resolving cases of discrimination in areas of federal jurisdiction. Discriminatory actions and attitudes are discouraged by means of persuasion and education and by ensuring that those who have discriminated will bear the costs of compensating their victims. The Act applies to all federal government departments, agencies and Crown corporations, as well as federally regulated businesses and industries (e.g., banking, transportation and communications).
9.4.2 Financial Levers
Generally speaking, however, the federal government’s involvement is essentially fiscal in nature. As long as it does not legislate directly in relation to matters within the provincial/territorial jurisdictions, the federal government has used its taxing and spending power to launch a number of social program initiatives that are national in scope. Restraints on transfer payments to the provinces in the 1990s, however, prompted many provinces to demand that federal actions taken unilaterally with respect to transfers be replaced with processes involving greater provincial and territorial participation.
The federal spending power forms the basis for the Canada Health Act as well as for the current Canada Health Transfer and the Canada Social Transfer. It is the impetus for federal participation/incursion in other social policy areas such as housing and income security. The Canada Pension Plan (CPP), established by legislation in 1965, is another area where federal/provincial involvement. There are other such examples of social policy initiatives, income security for the disabled being one, that can enhance the mental health of all Canadians and, in particular, the quality of life of individuals with mental illness and addiction.
The area of mental illness, however, provides one example where the federal government’s constitutional spending power was applied and then withdrawn over the last 55 years. From the National Health Grants of 1948 to the First Ministers’ Accord on Health Care Renewal of 2003, federal funding arrangements have significantly affected mental illness and addiction either implicitly or explicitly.
Ambivalence over the place of mental health services in a national health care system was evident for many years the years. The 1948 National Health Grants Program, described as “the first stage in the development of a comprehensive health care insurance plan for all Canada,” encouraged “expansion of health services” including those for mental illness. One component of the program – the Mental Health Grant – was used to implement or expand mental health services, to strengthen professional and technical training facilities and to improve the quality and quantity of staff. In 1960-1961, the last year of the grant, some 53% of the funds were allocated to institutions, while 23% went to clinics and psychiatric units, 13% to training and 8% to research.
In 1957, however, the federal government’s Hospital Insurance and Diagnostic Services Act explicitly excluded psychiatric hospitals, although it did cover psychiatric services in general hospitals. This exclusion was based, at the time, by the view that mental hospitals provided custodial care and, as such, together with tuberculosis hospitals, nursing homes and other long term care institutions, they were not eligible for federal cost-sharing. In 1966, however, with the enactment of the Medical Care Act, public coverage was provided for physician services, including those provided by psychiatrists, regardless of setting.
The Federal-Provincial Fiscal Arrangements and Established Programs Financing Act, 1977 gave each province “block-funding”, a federal transfer payment based on its population and paid partly in cash and partly in tax points. This Act, under its definition of “extended health care services”, listed mental hospitals together with nursing home intermediate care service; adult residential care service; home care service; and ambulatory health care service.
In 1984, the Canada Health Act was enacted “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.” Most provisions of the two previous insurance Acts were consolidated in the new law; but one major change related to the new definition of extended care services: all references to mental hospitals was deleted.
In the 1990s, the role of the federal government in health care nationally and by extension its role in mental health was further curtailed as its transfer payments to the provinces and territories were reduced. In 1996, the Canada Health and Social Transfer (CHST) was established, merging the Established Programs Financing (EPF) and the Canada Assistance Plan (CAP); this left the provinces to decide themselves how to allocate their block funding among health care, post-secondary education and social programs.
When departmental legislation established Health Canada in 1996, it provided general guidance for the health minister concerning national health issues. More precisely, the Department of Health Act assigned responsibility to the Minister of Health to oversee “the promotion and preservation of the physical, mental and social well-being of the people of Canada.” This was interpreted as limiting the Minister to broad programs that promote and preserve mental and social well-being; monitoring mental health conditions or programs; conducting research and/or investigating mental health among other public health issues; and collecting and publishing statistics on mental health.
A turning point occurred in 1999 with the Social Union Framework and the related Health Accord that committed the federal government to increase funding for health care through the CHST, to ensure predictability of funding and to work collaboratively with all provincial and territorial governments to identify Canada-wide priorities and objectives. By 2000, the First Minister’s Communiqué on Health contained a pledge to “promote those public services, programs and policies which extend beyond care and treatment and which make a critical contribution to the health and wellness of Canadians.” In the 2003 Health Accord, the First Ministers agreed to provide first dollar coverage for a core set of fully portable home care services for community mental health services with access to them based on need. The plan is to have a range of services available including case management, professional services and prescribed drugs by 2006.
In addition to assistance with health-related services, the federal government has provided access to other programs to assist individuals with mental disability. For example, in 1961, the federal government agreed to share the cost of the Vocational Rehabilitation of Disabled Persons Program for mentally disabled persons of working age. In 1965, the Canada Pension Plan (CPP) offered disability benefits for a person with severe or prolonged mental disability. In 1966, the Canada Assistance Plan (CAP) offered the provinces 50% of the cost of shareable assistance and welfare services to people with disabilities, including mental disability. Cost sharing under CAP was considered instrumental in establishing community based social services integral to the provision of effective mental health supports in the community.
At present, through its Office for Disability Issues, Social Development Canada is the focal point within the federal government for work on the participation of Canadians with disabilities in learning, work and community life. Its key objectives include fostering policy and program coherence; building the capacity of the voluntary sector; creating cohesive, action-oriented networks and providing knowledge and building awareness. Other players include Canada Revenue Agency. Under the Income Tax Act, an individual with a severe and prolonged mental or physical impairment, or a person caring for a person with such impairment, can claim a disability tax credit.
Homelessness is another area in which the federal government used its spending power to facilitate development of a national framework. More precisely, the federal government launched in 1999 the National Homelessness Initiative (NHI), a community-based approach designed to alleviate and prevent homelessness. The initiative involves partnerships with all levels of government, the private sector and the voluntary sector. Its multidisciplinary approach reflects the belief that homelessness has no single cause and that the problem requires interventions in a number of areas, including the provision of shelter, opportunities for employment, mental health care, programs to combat drug abuse and welfare services. It recognizes the diversity of the needs of the homeless and the requirement for “tailored” responses and solutions relevant to specific communities.
While the federal government provides provinces and territories with funding in support of mental health services, social programs, income support and housing, the levels of funding for mental health services, per diem payments for transitional and supportive housing providers, and income assistance for individuals are all within provincial, territorial and municipal jurisdictions.
9.5 ASSESSMENT OF THE
FEDERAL ROLE WITHIN THE CURRENT NATIONAL FRAMEWORK
Canada Health Act
(…) when the Canada Health Act
was developed, mental health services provided in psychiatric hospitals
were excluded. The Act provides that only medically mental health
services provided in general hospitals and physician services will be
covered by the Act. This significant omission has left those trying to
provide mental health services at a serious disadvantage when providing
community based services.
[Dr. James Millar, Executive
Director, Mental Health and Physician Services, Nova Scotia Department
of Health (Brief to the Committee, 28 April 2004, p. 5.]
As mentioned above and previously,
the Canada Health Act expressly excludes from its definition of
comprehensiveness services provided in psychiatric institutions. Numerous
witnesses stated that this omission reinforces an artificial distinction
between physical and mental illness and contributes to the stigma and
discrimination associated with mental disorders. For example, Dr. Sunil V.
Patel, CMA President stated:
(…) it is (…) important to recognize the deleterious effect of the
exclusion of a “hospital or institution primarily for the mentally
disordered” from the application of the Canada Health Act. Simply put,
how are we to overcome stigma and discrimination if we validate these
sentiments in our federal legislation
Dr. Patel recommended that the Canada Health Act be amended to include psychiatric hospitals and that federal funding under the Canada Health Transfer be adjusted to provide for these additional insured services.
The Committee also heard that the exclusion of psychiatric hospitals from the Canada Health Act generates problems with respect to the principle of portability. More precisely, because psychiatric hospitals are explicitly excluded from the Act, they are not subject to reciprocal billing arrangements between provinces. Ray Block, CEO, Alberta Mental Health Board, stated that:
Case management also needs to be considered at a cross-jurisdictional level for those occasions when mental health patients from one jurisdiction need services while in another jurisdiction. Reciprocal arrangements relating to access and payment should facilitate their access to care as well as to the consistency and continuity of that care across jurisdictions. This would be a matter for discussion at a future federal/provincial/territorial Conference of Ministers of Health.
Moreover, numerous witnesses pointed out that many mental health services are provided in the community by providers other than physicians and are thus not covered under the Canada Health Act. This is particularly true for services provided by psychologists. In this context, Dr. Diane Sacks, President, Canadian Paediatric Society, told the Committee:
(…) currently, the majority of professionals who offer [cognitive behavioural] therapy are uninsured by most provincial health plans. There are trained, regulated professionals that, if society’s will was there, could treat many of our children and youth. (…) Having said that, there are professionals who can help make the diagnosis and treat these illnesses, but only if you have money, and lots of it. The waiting list to get the public school system or a community mental health centre to diagnose ADHD in
Toronto today is 18 months – that is two full school years. That is if you do not have money. If you happen to have $2,000, I can get you a psychologist within a week or two who will make a diagnosis and, if necessary, lay out for the school an extensive program to help your child succeed. Most employer-run insurance programs cover an average of only $300 for psychology. Most public programs cover zero.
In its brief, the Centre for Addiction and Mental Health (Toronto) stated that the Canada Health Act should apply to more than general hospitals and physicians and should include home care and prescription drugs prescribed outside of hospitals. In the view of the Centre, public funding for the cost of medications would make a tremendous improvement in the lives of many individuals with mental illness 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.
Many witnesses supported the work already underway by First Ministers to expand home care to individuals with mental illness. They contended that any national home care program should encompass both mental illness and addiction.
9.5.2 Federal Funding
Federal transfers to the provinces and territories for the purpose of health care are provided under the Canada Health Transfer (CHT). There has never been any, nor is there now, an identified, specific transfer to any province or territory dedicated to mental health care and addiction treatment. Currently, as a result of the 2003 First Ministers’ Accord on Health Care Renewal, the CHT provides funding for acute community mental health care, but no specific proportion of the transfer is expressly designed for this purpose.
The Mood Disorders Society of Canada recommended that federal transfer payments for the purpose of health care should have a portion dedicated specifically to the delivery of mental health care. The Society argued that two conditions should be attached to this funding: 1) provinces and territories should be prevented from reducing their spending on mental health care; 2) ongoing evaluations of provincial mental health care programs should be undertaken to ensure value for money.
Another proposal to raise revenue to support the treatment and prevention of addiction was made to the Committee. Called the “Behavioural Insurance Model”, this proposal is based on raising money for the purpose of addiction prevention and treatment through a certain dedicated percentage of revenues generated from behaviour associated with addiction (tobacco, alcohol, gambling).
The Ontario Federation of Community Mental Health and Addiction Programs informed the Committee that a Behavioural Insurance Model was introduced in 1999 by the Government of Ontario to fund an integrated array of services to address pathological gambling. Under this model, 2% of gross revenues from slot machines in provincial charity casinos and race tracks are dedicated to treatment, prevention and research. In 2002-2003, this formula generated approximately $36 million, an amount sufficient to support a comprehensive response to this serious problem.
In his brief, Dr. Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health (Toronto), stated
(…) it is important to recognize that a number of behaviours that have addictive liability are regulated by the state, which also derives considerable tax revenue from them. This includes tobacco and alcohol, and more recently gambling. It has been estimated that more than half the revenues from alcohol and gambling come from 10 per cent of people who spend the most money on these activities. This 10 per cent population is the one at highest risk to being addicted to these behaviours. Given that over half of tax revenues from these behaviours are coming from that part of the population that is most vulnerable, government, if only from a crisis of conscience, should challenge itself to develop a proactive strategy toward the prevention, treatment and research of addictive behaviours and their mental health comorbidities. But beyond that, there is strong evidence that social spending to prevent and treat addiction and mental health problems provides an enviable return on investment. It is not unreasonable to expect that more of the revenues that behaviours with addictive potential provide be invested in helping people who are harmed by these behaviours.
9.5.3 The National Homelessness Initiative (NHI)
In his submission to the Committee, Bill Cameron, Director General of the National Secretariat on Homelessness, stated that the NHI addresses mental health issues in two ways through 1) financial support for community initiatives and 2) partnership agenda on research.
The “Horizon Housing Society” is an example of community-based initiatives funded through the NHI; the Society acquired an apartment building in Calgary to be used as transitional housing for individuals with mental illness and addiction who are homeless or at risk of becoming homeless. The research agenda includes issues surrounding the availability and accessibility of mental health services for homeless people, the incidence of mental illness among homeless people and the causal relationship between deinstitutionalization and homelessness. Research under the NHI is also undertaken in partnership with CIHR.
According to Bill Cameron, many mental health services to homeless people end up being delivered in emergency departments. Moreover, the homeless population faces many barriers that impact their access to the mental health services they need. For example, many are unable to make health appointments, and their ability to access coordinated care is impaired by their lack of an address and/or place of contact. In particular, many women with serious mental disorders do not receive needed care, apparently because, in part, they are not perceived to have mental health problems and also because of a lack of services designed to meet the special needs of homeless women.
Mr. Cameron also identified other major gaps in community services and supports directed to the homeless population, including emergency housing, supportive housing, and community-based mental health services. According to Mr. Cameron, safe and affordable housing with individualized supports is a key factor in the in helping the homeless generally, but he stressed that this may not be enough for those with severe mental illness and addiction. Long term supporting facilities such as emergency shelters and supports and transitional housing are necessary to help the chronically homeless. There is also a need for preventative measures such as dedicated affordable housing for individuals discharged from psychiatric institutions and the provision of short term intensive support services to be available immediately to those discharged from acute care hospitals, shelters and jails.
9.6 THE NEED FOR A NATIONAL ACTION PLAN ON MENTAL HEALTH, MENTAL ILLNESS AND ADDICTION
Witnesses told the Committee repeatedly that Canada needs a national action plan on mental health, mental illness and addiction. Many countries have already adopted such a national mental health policy or action plan. For example, in 1992, Australia developed a national mental health strategy to improve the lives of individuals with mental illness; also in 1992, the United Kingdom developed an action plan in five key health areas, one of which was mental health, which established targets for improvement of the health of individuals with mental illness and to reduce the suicide rate; in 1999, the report of the US Surgeon General made a commitment to improve mental health within the United States.
Canada is currently characterized by a serious lack of leadership on mental health, mental illness and addiction which, in the view of many witnesses and the Committee, has created a large void: there is no focus on mental illness and addiction within health care reform initiatives; there is no clear delineation of roles and responsibilities of the various stakeholders. Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health (CAMIMH), stated:
The current status of mental illness and mental health in
Canada paints a very bleak picture, beginning with a large void in leadership. (…) no policies and very few processes exist to address mental illness and mental health at a national level in
Canada. There is no clear identification of the roles and responsibilities of the government players involved. One of the most significant barriers to securing a national action plan appears to be the division of powers between provinces/territories and the federal government for health and social services. This need not be a hindrance to developing a coherent approach that will meet the needs of Canadians equitably.
Many witnesses recommended a strong leadership role for the federal government in the development of a national action plan. The current lack of leadership, of course, has contributed significantly to the piecemeal approach of addressing mental illness and addiction, to the development of various models in different jurisdictions, resulting in duplication and waste of resources. For example, Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, stated:
Nationally, we are not doing (…) well. Provinces, individually, have been struggling with providing appropriate services and developed various models from the Mental Health Commission of
New Brunswick to the
Alberta Mental Health Board. The federal government has not provided leadership in developing a national strategy.
Similarly, Dr. Sunil V. Patel, President, Canadian Medical Association, told the Committee:
Canada is the only G8 country without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children’s mental health services and mental health.
National leadership on mental illness and addiction is long overdue. The federal government can play a major role in collecting national data, supporting research and knowledge dissemination, and educating Canadians about mental health, mental illness and addiction. Many witnesses stated that the federal government has a key role in addressing the housing, income and employment needs of individuals with mental illness and addiction. Moreover, there is the direct role of the federal government in the provision of mental health services and addiction treatment to Aboriginal peoples, federal inmates, the veterans and members of the Canadian Forces, RCMP and federal employees.
While numerous witnesses favoured national leadership, it was stressed that progress can only be achieved by the federal government in close partnership with the provinces and territories. For example, Dr. Pierre Beauséjour, Senior Medical Advisor, Alberta Mental Health Board, stated:
While we agree that national leadership by the federal government for the development of a national action plan on mental illness and mental health is crucial, we will propose that building consensus on national mental health goals, standards and accountability is imperative and that provincial/territorial leaderships in mental health are as necessary as federal leadership in that regard.
We firmly believe that a result-oriented partnership approach, a clear redefinition of roles and responsibilities and a synergy of efforts between the federal government and the provinces/territories will be needed for the development and implementation of a national cross-jurisdictional policy framework on mental health.
Witnesses argued that the national framework must set standards for service delivery covering all aspects of mental health from prevention, promotion and advocacy through community-based services to inpatient and specialty services. It must also provide services throughout the lifespan and ensure clarity of roles and responsibilities along the continuum of care. In addition, because most mental illnesses have their roots in childhood and adolescence, there must be a new focus on child and adolescent mental heath. Child and adolescent mental health has been ignored for too long. We must deal with problems early at their root before serious damage is done. In addition to children and adolescents, population groups also identified as in need of urgent action include Aboriginal peoples, senior Canadians, federal inmates, women and landed immigrants.
Another priority area within a national action plan is suicide prevention. The fact is that Canada, unlike Australia, Finland, France, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom and the United States, does not have a national suicide prevention strategy. Many witnesses who appeared before the Committee urged the federal government to work with the provinces/territories and relevant stakeholders in the development of such a strategy. According to Dr. Paul Links, Arthur Sommer Rotenberg Chair in Suicide Studies, countries that have implemented national strategies on suicide prevention have experienced reductions of between 10% to 20% in suicide rate. Moreover, the Centre for Suicide Prevention told the Committee that only two provinces – New Brunswick and Quebec – have implemented a suicide-specific prevention strategy. Witnesses urged the federal government to work with the provinces/territories and relevant stakeholders in the development of a national suicide prevention strategy.
A number of witnesses mentioned that there is an opportunity to coordinate a national mental health strategy with the National Drug Strategy. Given the high rate of concurrent disorders (mental illness and addiction), it is critical that links be forged between them. For example, national monitoring of the prevalence of substance use disorders through the National Drug Strategy would be of tremendous benefit to efforts to plan services for individuals with concurrent disorders.
Through the Canadian Alliance on Mental Illness and Mental Health (CAMIMH), some 20 NGOs representing individuals with mental illness/addiction, their families and service provider organizations have reached a consensus on the need for a national action plan on mental health, mental illness and addiction. This national action plan addresses four main areas: education and awareness; national policy framework; research; and surveillance:
· Public awareness campaigns and professional education in a wide range of social and medical courses can help reduce the stigma and discrimination that is associated with mental illness, addiction and suicidal behaviour.
· A national policy framework is required in terms of identifying and implementing best practices (for treatment, prevention and promotion) and planning human resources (psychiatrists, psychologists, psychiatric nurses, addiction specialists, social workers, etc.). National leadership is also necessary to develop a comprehensive cross-jurisdictional policy framework that can ensure equitable access to professional and community supports across the country.
· The federal government is best positioned to establish and support a national research agenda for mental health, mental illness and addiction. Priorities for research need to be identified, research funding needs to be increased, and the voluntary fundraising sector needs to be strengthened.
· A national surveillance system must be implemented to monitor accurately and evaluate the incidence and prevalence of mental illness and addiction (including suicidal behaviour). The information collected nationally could also be used to report on how well the system is meeting the needs of individuals with mental illness and addiction.
Many witnesses stressed that a national action plan for mental health, mental illness and addiction can only be developed through collaboration among the federal government, provincial and territorial jurisdictions, NGOs and other stakeholders including individuals with mental illness/addiction. In this context, the Schizophrenia Society of Canada stated:
It will take the work of all levels of government, working in concert with non-governmental organizations, to create and facilitate a national action plan. (…) Existing, capable agencies such as hospitals, professional associations and volunteer organizations that have been acting as band-aids in the current system are poised to be part of the mental health care solution in
Canada. The biggest challenge governments will face is coordinating a multi-tiered government system that was not designed to work together and integrating non-governmental organization into the system as a contributing partner. It is only through a concerted effort in these areas that Canada will witness a shift in mental health care that will effectively and efficiently treat and support individuals with mental illness and their families and reduce the burden to individuals, families and society caused by [mental disorders].
As stated by Phil Upshall, CAMIMH President, action must be taken now:
The time is now. (…) It has been fifteen years since the federal government released Mental Health for Canadians: Striking a Balance. Its policy document linked the national health promotion vision of “Achieving Health for All” to mental health. Other major reports, together with numerous provincial and regional policy and discussion documents have recommended significant changes to improve services and programs for: individuals with serious mental illnesses, children’s mental health services, suicide prevention, aboriginal peoples, and offender and prison populations. These reports continue to gather dust and Canadians continue to wait, as few of the recommendations and ideas have been implemented.
Overall, witnesses called for a commitment by all levels of government to act, to work together on developing common goals and on creating a cohesive, integrated national framework on mental health, mental illness and addiction. One overlooked element of federal government activity in this field appears to be its direct responsibility for over a million Canadians, some of whom are facing serious mental health issues.
9.7 AN APPROACH BASED ON POPULATION HEALTH
Not only must the health care system treat mental illness (…) but
Canada needs to take proactive steps based on the broader health determinants to protect and preserve the mental health of its entire population, including those living with mental illness. Improving the social conditions that we know are necessary for overall good mental health (e.g. healthy physical and social environments, strong coping skills, along with health services) is essential to support positive mental health and recovery from mental illness.
[Canadian Mental Health Association, Brief to the Committee, June 2003, p. 3.]
Mental health, mental illness and addiction are strongly influenced by a wide variety of factors including biology and genetics, income and educational achievement, employment, social environment, and more. This fact points clearly to the need to address mental health, mental illness and addiction from a population health approach, a broad perspective extending well beyond health care per se.
The Committee heard repeatedly that treatment and recovery are difficult to achieve when basic needs for shelter, income and employment are not met. Many witnesses pointed out that it would be 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 individuals with mental illness to stay in their homes and communities. Access to housing, income and employment are also key to someone’s ability to participate in society and to enjoy the rights of citizenship free from stigma and discrimination.
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 both levels of government to implement new housing and supported housing programs based upon the foundation of existing policy and research that has shown convincingly that a diverse population of individuals with mental disorders can succeed in housing if appropriate supports are available. Appropriate housing and supports can substitute for long term inpatient care thereby decreasing society’s and affected individuals’ reliance on high cost hospital and institutional beds.
Access to adequate income and employment is another key determinant of health that must be a priority in any mental health strategy. Many individuals with mental illness 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, don’t cover realistic living costs, 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 individuals with mental illness or addiction to qualify. In Ontario, for example, provincial income support programs exclude individuals affected by addiction from the definition of disability altogether. These systemic barriers within government income support programs must be addressed to ensure that individuals with mental illness and addiction are able to access the basic supports that will help restore them to health and keep them well.
Support for employment is also a key area in which governments can do more. Individuals with a 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 individuals with mental illness are meaningfully accommodated in the workplace. Access to skills development, training and education must also be improved by encouraging academic institutions and other learning environments to accommodate more appropriately individuals with mental illness.
9.8 COMMITTEE COMMENTARY
At present, the federal government has no comprehensive framework for mental health, mental illness and addiction federally or nationally. While several witnesses pointed to the fact that Canada stands alone among similar G8 countries in not having a national mental health policy reaching across the applicable jurisdictional boundaries, others noted the absence of an integrated framework even at the federal level with its responsibility for the provision of mental health services and addiction treatment to specific groups.
The lack of a federal framework may be primarily a function of inadequate collaboration, cooperation and communication among the various federal departments that have involvement in related or overlapping areas. However, it may also be a consequence of the difficulties of trying to address the multiple needs of very diverse populations. Whatever the reason, the Committee believes that despite its direct responsibility for the mental health needs of specific groups in the Canadian population, the federal government has made too little effort to coordinate its initiatives internally. In these areas, the federal government has both the right and the obligation to act and can do so without intensive (or even any) negotiations with other jurisdictions.
Similarly, the absence of an overall national framework may be attributed to some extent to the lack of clear role differentiation in these areas where provincial/territorial responsibility takes precedence. In general, the Constitution Act, 1867 gives the provinces power to legislate in the fields of health care, education, provincial jails, and the administration of the courts; while giving Canadian Parliament power over criminal law and procedure, as well as the management of penitentiaries. In addition to the power of criminal law, this leaves the federal government with two other potential constitutional powers when acting in a national capacity: its spending power; and the ability to pass laws for the peace, order and good government of Canada.
From both the federal and the national perspectives, it is obvious that the federal government’s role with respect to mental health, mental illness and addiction is not limited to the activities of the Health Canada. Related policies, programs and services fall in the broader social sphere as well as in the justice arena, outside the traditional health care sector. Other federal departments such as Human Resources Development Canada, Indian and Northern Affairs Canada, Veterans Affairs Canada, Correctional Services Canada, Justice Canada are among those that currently play a role in federal and national initiatives. And at the workplace level, Treasury Board as the employer of public servants has a major role to play in assisting its employees with issues related to mental health and addiction.
In looking at federal government activities with respect to the specific groups under its responsibility, there is little evidence to suggest the existence of strategies targeted at specific populations, let alone a broad all-encompassing federal strategy. No current efforts to develop an overall coordinated federal framework with collaboration by all involved departments or agencies are apparent. In most cases, there is little indication of thought being given to the development of a thorough and inclusive population specific strategy for addressing the mental health needs of any of the groups under federal responsibility. The provision of mental health services and addiction treatment and efforts toward mental health promotion and mental illness prevention remain highly fragmented, provided by numerous departments and departmental directorates. More collaboration would lead to a more integrated approach towards mental health. This would be an important step toward a policy based on population health.
The Committee also concurs with witnesses that better links are needed between the federal and provincial governments and among the various overlapping systems – health care, mental health, addiction, justice, social supports, etc.
Finally, it would also be important for the federal government to lead by example. If it is to play a leadership role in the development of a truly national action plan on mental health, mental illness and addiction, it must also show that it is willing and capable of providing mental health services to the populations for which it has direct responsibility. Clearly, there is a need to correct the ambivalent approach taken over the years by the federal government about the place of mental health in its policies and programs.
 The information contained in this section is based on the following five documents: 1) Leonard I. Stein and Alberto B. Santos, Assertive Community Treatment of Persons with Severe Mental Illness, New York, 1998; 2) World Health Organization, “Historical Perspective”, Section 3, in The Mental Health Context, Mental Health Policy and Service Guidance Package, Geneva, 2003; 3) World Health Organization, “Solving Mental Health Problems”, Chapter 3 in Mental Health: New Understanding, New Hope, Geneva, 2001; 4) Pamela N. Prince, “A Historical Context for Modern Psychiatric Stigma”, in Mental Health and Patients’ Rights in Ontario: Yesterday, Today and Tomorrow, published by the Psychiatric Patient Advocate Office, Ontario, 2003, pp. 58-60; 5) Canadian Mental Health Association, More for the Mind – A Study of Psychiatric Services in Canada, Toronto, 1963.
 Stein and Santos (1998), p. 6.
 Stein and Santos (1998), p. 6.
 Prince (2003), p. 58.
 WHO (2003), pp. 17-19, WHO (2001), p. 49, and Stein and Santos (1998), pp. 6-7.
 Stein and Santos (1998), pp. 6-7.
 Stein and Santos (1998), p. 8.
 Stein and Santos, (1998), pp. 6-8, and WHO (2001), p. 49.
 Canadian Mental Health Association (1963), p. 2.
 The information contained in this section is based on the following nine documents: 1) Health and Welfare Canada, Mental Health Services in Canada, Ottawa, 1990; 2) .E. Appleton, “Psychiatry in Canada A Century Ago”, Canadian Psychiatric Association Journal, Vol. 12, No. 4, August 1967, pp. 344-361; 3) Elliot M. Goldner, Sharing the Learning – The Health Transition Fund: Mental Health, Synthesis Series, Health Canada, 2002; 4) Cyril Greenland, Jack D. Griffin and Brian F. Hoffman, “Psychiatry in Canada from 1951 to 2001”, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. 1-16; 5) Quentin Rae-Grant, “Introduction”, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. ix-xiii; 6) Henri Dorvil et Herta Guttman, 35 Ans de Désintitutionalisation au Québec, 1961-1996, Annexe 1 du rapport du Comité de la santé mentale du Québec intitulé Défis de la Reconfiguration des Services de Santé Mentale, 1998; 7) Julio Arboleda-Florez, Mental Health and Mental Illness in Canada : The Tragedy and the Promise, Brief to the Committee, 19 March 2003; 8) Paula Goering, Don Wasylenki and Janet Durbin, « Canada’s Mental Health System », in International Journal of Law and Psychiatry, Vol. 23, No. 3-4, May-August 2000, pp. 345-359; 9) Donald Wasylenki, “The Paradigm Shift From Institution to Community”, Chapter 7, in Psychiatry in Canada: 50 Years, Canadian Psychiatric Association, 2001, pp. 95-110.
 Health and Welfare Canada (1990), p. 13.
 V.E. Appleton (1967), pp. 344-361.
 Elliot Goldner (2002), p. 1.
 Greenland, Griffin and Hoffman (2001), p. 2.
 Hydrotherapy, which is also called the water cure, is a mode of treating diseases by the copious and frequent use of pure water, both internally and externally. Insulin coma treatment was a rarely used treatment of mental illness by means of hypoglycaemic coma induced by insulin.
 ECT is a procedure that consists in passing a small electric current through a region of the brain for a period of 1-3 seconds for the purpose of inducing neurochemical changes associated with the relief of psychiatric symptoms; the electrical stimulation also induces a brief seizure, whose appearance is modified by muscle-relaxing drugs. It generally lasts 20-30 seconds and then ends spontaneously. The patient is anaesthetized and asleep during the treatment and the seizure.
 Health and Welfare Canada (1990), p. 13.
 Quentin Rae-Grant (2001), p. x.
 Greenland, Griffin and Hoffman (2001), p. 3.
 Greenland, Griffin and Hoffman (2001),, p. 2.
 Health and Welfare Canada (1990), p. 13.
 Dorvil and Guttman (1998), p. 116.
 Donald Wasylenki (2001), pp. 95-110.
 Such as the Bédard Commission in Québec (1961-1962) and the Blair Commission in Alberta (1967-1969).
 Canadian Mental Health Association, More for the Mind – A Study of Psychiatric Services in Canada, Toronto, 1963.
 As quoted and reported in Donald Wasylenki (2001), p. .96.
 Donald Wasylenki (2001), pp. 95-110.
 Health and Welfare Canada (1990), p. 15.
 Donald Wasylenki (2001), pp. 107-109.
Greenland, Griffin and Hoffman (2001), p. 4.
Greenland, Griffin and Hoffman (2001), p. 7.
 Don Wasylenki (2001), p. 97.
 Wasylenki (2001), pp. 107-109.
 Don Wasylenki (2001), pp. 107-109.
 Quentin Rae-Grant (2001), p. xi.
 This section is based on information provided in the two following documents: 1) Health Canada, “The Development of Alcohol and Other Drug Treatment in Canada”, in Profile of Substance Abuse Treatment and Rehabilitation in Canada, Ottawa, 1999, pp. 3-5; 2) Colleen Hood, Colin McGuire and Gillian Leigh, Exploring the Links Between Substance Use and Mental Health – A Discussion Paper, prepared under contract to Health Canada, 1996.
 Unless specified otherwise, the information contained in this section is based on the following documents: Provincial Mental Health Planning Project, Advancing the Mental Health Agenda – A Provincial Mental Health Plan for Alberta, April 2004; Alberta Children and Youth Initiative, Children’s Mental Health Initiative, Fact Sheet, February 2004; Alberta Mental Health Board, Brief to the Committee, 2003; Alberta Alliance on Mental Illness and Mental Health, Partnership, Participation, Innovation – A Blueprint for Reform, March 2003; Alberta Health and Wellness, “Transition Underway to Fewer Health Regions, Integrated Mental Health”, News Release, 23 January 2003; Alberta Mental Health Board, Business Plan, 2002-2005, 2002; Information on the website of the Alberta Alcohol and Drug Abuse Commission (www.aadac.com).
 Unless specified otherwise, the information contained in this section is based on the following documents: Mental Health and Addictions, Ministry of Health Services, British Columbia, Brief to the Committee, 9 September 2003; Mental Health and Addictions, Ministry of Health Services, British Columbia, Development of a Mental Health and Addictions Information Plan for Mental Health Literacy, 2003-2005, 4 February 2003; Government of British Columbia, Child and Youth Mental Health Plan for British Columbia, February 2003; Addictions Task Group, Kaiser Youth Foundation, British Columbia, Weaving Threads Together – A New Approach to Address Addictions in BC, March 2001; Minister’s Advisory Council on Mental Health, Moving Forward, Annual Report, 2001; Ministry of Health Services, British Columbia, Revitalizing and Rebalancing British Columbia’s Mental Health System – The 1998 Mental Health Plan, 1998; Information on the Website of the Provincial Health Services Authority (www.phsa.ca) and the British Columbia Mental Health Society or Riverview Hospital (www.bcmhs.bc.ca).
 Dr. Elliot M. Goldner, The Health Transition Fund – Sharing the Learning: Mental Health, Synthesis Series, Health Canada, 2002, p. 11.
 Unless specified otherwise, the information contained in this section is based on the following documents : Canadian Mental Health Association (Nova Scotia Division), 2004 Report Card on Mental Health Services Core Standards, 8 March 2003; Department of Health, Nova Scotia, Strategic Directions for Nova Scotia’s Mental Health System, 20 February 2003; Department of Health, Nova Scotia, Standards for Mental Health Services in Nova Scotia, 20 February 2003; Roger Bland and Brian Dufton, Mental Health: A Time for Action, submitted to the Deputy Minister of Health, Nova Scotia, 31 May 2000; IWK Health Centre’s Website (http://www.iwk.nshealth.ca/).
 Canadian Mental Health Association (Nova Scotia Division), www.cmhans.org.
 Unless specified otherwise, the information contained in this section is based on the following documents : Provincial Forum of Mental Health Implementation Task Forces, The Time Is Now : Themes And Recommendations For Mental Health Reform In Ontario, Final Report, December 2002; Forensic Mental Health Services Expert Advisory Panel, Assessment, Treatment and Community Reintegration of the Mentally Disordered Offender, Final Report, December 2002; Ministry of Health and Long-Term Care, Make it Happen – Operational Framework for the Delivery of Mental Health Services and Supports, Government of Ontario, 1999;
 Unless specified otherwise, the information contained in this section is based on the following documents : Ministère de la Santé et des Services Sociaux, Agir Ensemble – Plan d’action gouvernemental sur le jeu pathologique, 2002-2005, Government of Québec, 2002; Ministère de la Santé et des Services Sociaux, Plan d’action en toxicomanie, 1999-2001, Government of Québec, 1998; Ministère de la Santé et des Services Sociaux, Québec’s Strategy for Preventing Suicide, Government of Québec, 1998; Ministère de la Santé et des Services Sociaux, Plan d’action pour la transformation des services de santé mentale, Government of Québec, 1998, Comité de la santé mentale du Québec, Défis de la reconfiguration des services de santé mentale, Government of Québec, 1997.
 Information based on the following documents: Department of Health, Strategic Directions for Nova Scotia’s Mental Health System, Government of Nova Scotia, February 2003; Elliot M. Goldner, Synthesis Series – Mental Health, Sharing the Learning: The Health Transition Fund, Government of Canada, 2002; Government of Newfoundland and Labrador, Valuing Mental Health – A Framework to Support the Development of a Provincial Mental Health Policy for Newfoundland and Labrador, September 2001; Minister’s Advisory Council on Mental Health, Moving Forward, Annual Report, Government of British Columbia, 2001; Ministry of Health, Making It Happen – Operational Framework for the Delivery of Mental Health Services and Supports, Government of Ontario, 1999; Comité de la santé mentale du Québec, Défis – De la Reconfiguration des Services de Santé Mentale, Gouvernement du Québec, October 1997; Health Systems Research Unit, Clarke Institute of Psychiatry, Best Practices in Mental Health Reform, Discussion Paper Prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health, 1997; Alberta Mental Health Board, Building A Better Future – A Community Approach to Mental Health, Government of Alberta, March 1995.
 Federal/Provincial/Territorial Working Group on the Mental Health and Well-Being of Children and Youth, Celebrating Success: A Self-Regulating Service Delivery System for Children and Youth, Discussion Paper, Health Canada, 2000, pp. 8-10; External Advisory Committee for Child and Youth Mental Health, Child and Youth Mental Health Plan for British Columbia, February 2003 (Revised July 2004), pp. 4-9; Charlotte Waddell et. al. (April 2002).
 Canadian Mental Health Association, Brief to the Committee, June 2003, pp. 8-9.
 Dr. Sunil V. Patel, President of the Canadian Medical Association, Brief to the Committee, 31 March 2004, pp. 1-2.
 Patrick Storey, Chair of the Minister’s Advisory Board on Mental Health, British Columbia (15:8).
 Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, Brief to the Committee, 28 April 2004, pp. 5-6.
 Canadian Psychiatric Association and The College of Family Physicians of Canada, Shared Mental Health Care in Canada – Current Status, Commentary and Recommendations, A Report of The Collaborative Working Group on Shared Mental Health Care, December 2000.
 Irene Clarkson, Executive Director, Mental Health and Addictions, British Columbia Ministry of Health Services Brief to the Committee, 9 September 2003, pp. 5-6.
 Canadian Psychiatric Association, Human Resource Planning for Psychiatry in Canada – A Background Paper, unpublished document.
 Canadian Mental Health Association, Brief to the Committee, June 2003, p. 8.
 Statistics Canada, “Canadian Community Health Survey: Mental Health and Well-Being”, The Daily, 3 September 2003.
 Phil Upshall, President, CAMIMH, Brief to the Committee, 18 July 2003, p. 8.
 Dr. Donald Addington, Professor and Head, Department of Psychiatry, University of Calgary, Brief to the Committee, 29 May 2003, p. 3.
 Champlain District Mental Health Implementation Task Force, « Consumer Charter of Rights for Mental Health Services”, in Foundations for Reform, Section 3.1.4, Ontario, December 2002.
 Schizophrenia Society of Canada, Brief to the Committee, 2004, p. 5.
 Maureen Anne Gaudet, Mental Health Division, Health Services Directorate, Health Programs and Services Branch, Health Canada, Overview of Mental Health Legislation in Canada, 1994, p. 4.
 Maureen Anne Gaudet (1994), pp. 17-18.
 John E. Gray, Margaret A. Shone and Peter F. Liddle, Canadian Mental Health Law and Policy, 2000, p. 5.
 In some cases, however, the patient may choose to have the court order the hospital to suspend treatment.
 John E. Gray and Richard L. O’Reilly, “Clinically Significant Differences Among Canadian Mental Health Acts”, Canadian Journal of Psychiatry, Vol. 46, No. 4, May 2001, p. 320.
 John E. Gray, Margaret A. Shone and Peter F. Liddle, Canadian Mental Health Law and Policy, October 2000, p. 358.
 Treasury Board of Canada, Canada's Performance 2003 – Annual Report to Parliament, Ottawa, 2004, p. 30.
 Tom Lips, Senior Adviser, Mental Health, Healthy Communities Division, Population and Public Health, Health Canada (11:6).
 The information contained in this section is based on a paper by Nancy Miller-Chenier, Federal Responsibility for the Health Care of Specific Groups, Parliamentary Information and Research Services, Library of Parliament, forthcoming.
 Indian and Northern Affairs Canada, Gathering Strength–Canada’s Aboriginal Action Plan, Ottawa, 1997.
 Department of Finance Canada, The Budget Plan 2003, p. 13.
 Government of Canada, Speech from the Throne, 2004, pp. 9-11.
 Health Canada, Report on Plans and Priorities, 2003-2004, Estimates.
 According to information provided on the Website of Indian and Northern Affairs Canada (http://www.ainc-inac.gc.ca/sg/sg4_e.html).
 Dr. Cornelia Wieman (9:55).
 Dr. Laurence Kirmayer (9:42).
 Dr. Cornelia Wieman (9:55-56).
 Brenda Restoule (9:49).
 According to Ray Block, CEO, Alberta Mental Health Board, Brief to the Committee, 28 April 2004, p. 9.
 Correctional Service Canada, Report on Plans and Priorities, 2003-2004, p. 5.
 Françoise Bouchard (7:50).
 Ibid. (7:51).
 John Edwards, Commissioner, Commissioner’s Directive – Psychological Services, Correctional Service Canada, 30 December 1994.
 Lucie McClung, Commissioner, Commissioner’s Directive – Mental Health Services, Correctional Service Canada, 2 May 2002.
 Irving Kulik, Assistant Commissioner, Guidelines – Methadone Treatment Guidelines, Correctional Service Canada, 2 May 2002.
 Lucie McClung, Commissioner, Commissioner’s Directive – Prevention, Management and Response to Suicide and Self-Injuries, Correctional Service Canada, 3 September 2003.
 Lucie McClung, Commissioner, Commissioner’s Directive – Health Services, Correctional Service Canada, 17 March 2003.
 Aboriginal Initiatives Branch, Aboriginal Offenders Overview, Correctional Service Canada.
 Correctional Service Canada, National Strategy on Aboriginal Corrections.
 Jane Laishes, Mental Health, Health Services, Correctional Service Canada, The 2002 Mental Health Strategy for Women Offenders, 2002.
 Correctional Service Canada, Substance Abuse Program.
 Correctional Service Canada, Brief to the Committee, April 2004, pp. 13-15.
 The Shepody Healing Centre (Atlantic region) with 40 beds; the Archambault unit (Quebec region) with 120 beds; the Regional Treatment Centre (Kingston, Ontario) with 149 beds; the Regional Psychiatric Centre (Prairie region) is a 194 bed facility linked to the University of Saskatchewan through a special agreement; the Regional Treatment Centre in Abbotsford (Pacific region) with 192 beds.
 Correctional Service Canada, Brief to the Committee, April 2004, p. 19.
 Françoise Bouchard (7:54-55).
 Patrick Storey (15:8-9).
 Schizophrenia Society of Canada, Brief to the Committee, 2004, p. 9.
 Françoise Bouchard (7:54).
 Veterans Affairs Canada, Health Care Program.
 National Defence, Canadian Forces Health Services, Fact Sheets.
 Veterans Affairs Canada, Ste. Anne’s Hospital.
 Veterans Affairs Canada, Disability Pensions.
 National Defence, Strengthening the Forces.
 Veterans Affairs Canada, Government of Canada’s Response to the Standing Committee on National Defence and Veterans Affairs on Quality of Life in the Canadian Forces, 2001.
 Veterans Affairs Canada, Canada Mental Health Strategy, Backgrounder, 27 February 2004.
 Royal Canadian Mounted Police, About the RCMP.
 “Veterans Affairs Canada and the Royal Canadian Mounted Police Partner to Improve Services”, RCMP News Release, 17 February 2003.
 Treasury Board of Canada, Information for Federal Employees.
 Treasury Board of Canada, Public Service Health Care Plan – Benefits Coverage and Plan Provisions, July 2001.
 Treasury Board of Canada, Disability Insurance Plan, November 1993.
 Treasury Board of Cannda, Employee Assistance Program.
 Health Canada, Workplace Health and Public Safety Program.
 Health Canada, Ibid., “Traumatic Stress Management”.
 Linda Duxbury, Christopher Higgins and Donna Coghill, Voices of Canadians: Seeking Work-Life Balance, Health Canada, January 2003.
 APEX, Study on the Health of Executives in the Public Service of Canada, 27 November 2002.
 Bill Wilkerson, Text of a Speech to the Royal Ottawa Hospital Business Luncheon, 6 May 2004.
 Citizenship and Immigration Canada, Report on Plans and Priorities, 2003-2004.
 Citizenship and Immigration Canada, Immigrant Settlement and Adaptation Program.
 Citizenship and Immigration Canada, Host Program.
 Citizenship and Immigration Canada, Language Training.
 Citizenship and Immigration Canada, Performance Report for the Period Ending March 31, 2003.
 Citizenship and Immigration Canada, Report on Plans and Priorities, 2003-2004, p. .34.
 Treasury Board of Canada, Federal Health Care Partnership.
 Health and Welfare Canada, Mental Health Services in Canada, 1990, Government of Canada, 1990, pp. 22-23.
 Dr. James Millar, Nova Scotia Department of Health Brief to the Committee, 28 April 2004, p. 4.
 Department of National Health and Welfare, Annual Report for the Fiscal Year Ended March 31, 1948, Ottawa: King’s Printer, 1948, p.77.
 Health and Welfare Canada, Mental Health Services in Canada, 1990, Government of Canada, 1990, pp. 13-15.
 Federal-provincial Fiscal Arrangements and Established Programs Financing Act 1977, Chapter 10, 1977, Clause 27 subsection 8.
 Canada Health Act, 1984 (An Act relating to cash contributions by Canada in respect of insured health services provided under provincial health care insurance plans and amounts payable by Canada in respect of extended health care services) Chapter C-6, 1984, Clause 3.
 The CHST was established through separate budget bills tabled in February 1995 and March 1996. Its operation is governed by the Federal-Provincial Fiscal Arrangements Act.
 Department of Health Act, 1996, chapter 8.
 A Framework to Improve the Social Union for Canadians, An agreement between the Government of Canada and the Governments of the Provinces and Territories, 4 February 1999; and The Federal, Provincial, Territorial Health Care Agreement, 4 February 1999.
 News Release, First Ministers’ Meeting Communiqué on Health, September 2000.
 News Release, First Ministers' Accord on Sustaining and Renewing Health Care for Canadians, 23 January 2003.
 For more details on these federal programs, see William Young, Disability: Socio-Economic Aspects and Proposals for Reform, Current Issue Review 95-4E, Ottawa: Parliamentary Research Branch, 1997.
 Government of Canada, National Homelessness Initiative.
 Dr. Sunil V. Patel, President, Canadian Medical Association, Brief to the Committee, 31 March 2004, p. 3.
 Ray Block, CEO, Alberta Mental Health Board Brief to the Committee, 28 April 2004, p. 7.
 Dr. Diane Sacks, President, Canadian Paediatric Society (13:53-54).
 Centre for Addiction and Mental Health (Toronto), Brief to the Committee, 27 June 2003, p. 3.
 Acute community mental health care refers to acute care provided in the community to individuals with mental illness who have an occasional acute period of disruptive behaviour; the aim is to prevent or minimize recurrent institutionalization.
 Mood Disorders Society of Canada, Brief to the Committee, 12 May 2004, p. 7.
 Dr. Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health (Toronto), Brief to the Committee, 2004, p. 6.
 Bill Cameron, Director General of the National Secretariat on Homelessness, Brief to the Committee, 29 April 2004, p. 1.
 Ibid., pp. 1-2.
 Bill Cameron (2004), p. 2.
 Bill Cameron (2004), p. 3.
 Bill Cameron (2004), p. 4.
 See the Committee’s second report, Mental Health Policies and Programs in Selected Countries, for a full description of national mental health strategies in Australia, New Zealand, England and the United States.
 Phil Upshall, President, CAMIMH, Brief to the Committee, 18 July 2003, p. 7.
 Dr. James Millar, Executive Director, Mental Health and Physician Services, Nova Scotia Department of Health, Brief to the Committee, 28 April 2004, p. 3.
 Dr. Sunil V. Patel, President, Canadian Medical Association Brief to the Committee, 31 March 2004, p. 2.
 Dr. Pierre Beauséjour, Senior Medical Advisor, Alberta Mental Health Board, Brief to the Committee, 2003, p. 1.
 Dr. Paul Links (11:20).
 The following organizations have joined together to form the Canadian Alliance on Mental Illness and Mental Health: Autism Society of Canada, Mood Disorders Society of Canada, Canadian Medical Association, Canadian Health Care Association, National Network for Mental Health, Canadian Council of Professional Psychology Programs, Canadian Federation of Mental Health Nurses, Canadian Coalition for Seniors’ Mental Health, College of Family Physicians of Canada, Canadian Psychiatric Research Foundation, Canadian Association for Suicide Prevention, Canadian Association of Occupational Therapists, Schizophrenia Society of Canada, Canadian Mental Health Association, Canadian Academy of Child Psychiatry, Canadian Association of Social Workers, Canadian Psychiatric Association, Canadian Psychological Association, Native Mental Health Association of Canada.
 Canadian Alliance on Mental Illness and Mental Health, A Call for Action: Building Consensus for a National Action Plan on Mental Illness and Mental Health, Discussion Paper, September 2000.
 Schizophrenia Society of Canada Brief to the Committee, 2004, p. 3.
 Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health, Brief to the Committee, 18 July 2003, p. 7.