PARLIAMENT of CANADA
Home Parliamentary Business Senators and Members About Parliament Visitor Information Employment
 
 

OUT OF THE SHADOWS AT LAST 

Transforming Mental Health, Mental Illness and Addiction Services in Canada

The Standing Senate Committee on Social Affairs, Science and Technology


PART VI
Strategic Planning and Inter-governmental Coordination


CHAPTER 15:
MENTAL HEALTH PROMOTION AND MENTAL ILLNESS PREVENTION

15.1      INTRODUCTION

I was trained in a medical model in nursing….  So many of us spend so much time at the end of a fast flowing stream where there is a ton of people drowning at the bottom.  We spend time trying to pull them out and figuring out how to keep them from drowning as opposed to moving upstream to figure out what is pushing them in to start with.  —Cheryl Van Daalen[305]

Text Box: Mental health promotion emphasizes positive mental health, as opposed to mental illness.  Much of the emphasis in this report is on services for those living with mental illness.  But what about preventing mental illness from occurring in the first place? 

 

Text Box: The prevention of mental disorders is a related approach that addresses the risk factors associated with mental illnessDuring its hearings, the Committee heard from a number of witnesses who called for greater efforts in mental health promotion and mental illness prevention, two approaches that address factors that may lead to mental illness. By so doing, they reduce both the likelihood of developing mental illness and its severity in the population. 

 

Mental health promotion focuses on the foundations of good mental health.  Broadly speaking, it emphasizes positive mental health, as opposed to mental illness.  It addresses the determinants of mental health — the many personal, social, economic and environmental factors that are thought to contribute to mental health, and to the overall health and well-being of the population.  Such factors include healthy childhood development, income and social status, and education.

The prevention of mental ilness is a related approach that addresses the risk factors associated with mental illness — such as substance abuse, parental mental illness, and child abuse and neglect — and the protective factors associated with good mental health — such as self-esteem, social support, and a healthy start in life.

While there is a good case to be made for both of these approaches, it is also necessary to develop further evidence linking the various implicated determinants and good mental health.  With so many factors at play, it is difficult to be sure of the impact of each determinant individually.  Many of them fall outside the fields of health and medical care — an additional complication for researchers.  Work is under way to improve the evidence base, but much more needs to be done.

This chapter provides an overview of the guiding principles and strategies for mental health promotion and the prevention of mental ilness, including the need for more and better evidence and for research.  It reviews the role of the federal government and makes recommendations for improving mental health promotion and mental illness prevention, particularly with regard to preventing suicide.

15.2      MENTAL HEALTH PROMOTION:  THE DETERMINANTS OF MENTAL HEALTH

Text Box: The central concept behind health promotion is that health is determined by many interacting social, psychological, and biological factors that are amenable to intervention by individuals and society.  The central concept behind health promotion is that health is determined by many interacting social, psychological, and biological factors that are amenable to intervention by individuals and society.  Mental health promotion employs the same concept.  Mental health is not considered merely as the absence of mental illness, but rather as “… a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”[306]

Determinants of health, according to the World Health Organization (WHO), are “those factors that can enhance or threaten an individual’s or a community’s health status.”  They can be matters of individual choice or social, economic, and environmental factors beyond the control of individuals.  The determinants of health recognized by Health Canada and the Public Health Agency of Canada are:Text Box: The health promotion approach focuses on improving the health of the population by addressing determinants of health that are amenable to change, recognizing that doing so is a long-term process yielding results only in a future more distant than the usual political or even research horizon.

 

 

 

 

§         income and social status;

§         social support networks;

§         education;

§         employment/working conditions;

§         social environments;

§         physical environments;

§         personal health practices and coping skills;

§         healthy childhood development;

§         biology and genetic endowment;

§         health services;

§         gender; and

§         culture.[307] 

In the Committee’s second on-line consultation, almost three-quarters of participants (72%) believed that to improve the mental health of Canadians, we must first address the real causes of most mental illness and addictions — including poverty, poor housing and other social conditions.

 

The health promotion approach focuses on improving the health of the population by addressing determinants of health that are amenable to change, recognizing that doing so is a long-term process yielding results only in a future more distant than the usual political or even research horizon.  The basic action strategies of health promotion were accepted by the international community in 1986 at the First International Conference on Health Promotion. They are set out in the Ottawa Charter for Health Promotion:

§         build healthy public policy,

§         create supportive environments,

§         strengthen community action,

§         develop personal skills, and

§         reorient health services.[308]

In August 2005, these principles were reiterated at the Sixth Global Conference on Health Promotion, which produced the Bangkok Charter for Health Promotion in a Globalized World.  This Charter called for political action to implement strategies for health promotion.[309]

Using these internationally agreed-upon frameworks and guidelines for health promotion generally, comparable frameworks have been developed for mental health promotion.  In 2004, the WHO summarized the current thinking on mental health promotion:

1.      Promotion of mental health can be achieved by effective public health and social interventions. The scientific evidence base in this area is relatively limited, but evidence at varying levels is available to demonstrate the effectiveness of several programmes and interventions for enhancing mental health of populations.

 

2.      Intersectoral collaboration is the key to effective programmes for mental health promotion. For some collaborative programmes, mental health outcomes are the primary objectives; however, for the majority these may be secondary to other social and economic outcomes but are valuable in their own right.

 

3.      Sustainability of programmes is crucial to their effectiveness. Involvement of all stakeholders, ownership by the community, and continued availability of resources facilitate sustainability of mental health promotion programmes.

 

4.      More scientific research and systematic evaluation of programmes is needed to increase the evidence base as well as to determine the applicability of this evidence base in widely varying cultures and resource settings. [310]

 

Text Box: Population health strategies should be “long term, national in scope and based on multi-departmental efforts across all jurisdictions”.The Committee has commented on health promotion in its earlier reports on the health system.  In Volume Five of The Health of Canadians — The Federal Role, the Committee wrote “there are potentially enormous benefits to be derived from health and wellness promotion, illness prevention and population health…”  Noting that population health strategies should be “long term, national in scope and based on multi-departmental efforts across all jurisdictions,” it said the federal government should continue to provide leadership and devote more resources to them.  The Committee also recognized that population health strategies must be adapted to local conditions and their design and implementation must involve local communities. [311]

There is evidence of links between determinants of health and the health status of the Canadian population. In Volume Six of The Health of Canadians, the Committee advocated continued research in the area but also noted problems with the establishment of cause and effect relationships:

In the first place, the multiplicity of factors that influence health status means that it is extremely difficult to associate cause and effect, especially since the effects of a given intervention are often obvious only after many years.  Because political horizons are often of a shorter-term nature, the long timeframe for judging the impact of policy in this area can be a serious disincentive to the elaboration and implementation of population health strategies.

Furthermore, it is very difficult to coordinate government activity across the diverse factors that influence health status.  The structure of most governments does not easily lend itself to inter-ministerial responsibility for tackling complex problems.  This difficulty is compounded several times over when various levels of governments, together with many non-governmental players, are taken into account, as they must be if population health strategies are to be truly effective.

Although many difficulties are associated with developing an effective population health approach, the Committee believes it is important for Canada to continue to strive to set an example by exploring innovative ways to turn good theory into sound practice that will contribute to improving the population’s health status.[312]

In its current study on mental health, mental illness and addiction, the Committee has previously stressed the critical importance of combating stigma and discrimination.[313]  It pointed out that reducing stigma and combating discrimination “requires a multi-pronged effort sustained over a long period of time and includes: ongoing community-based education and action, media campaigns, and forums of exchange between affected individuals and other Canadians to enhance public awareness, and professional awareness campaigns to reduce structural discrimination in the health care system and in the mental health system itself.”[314]  The Committee is also aware that educational campaigns must be complemented with policies that create environments that support change in people’s attitudes and behaviours.

The Committee will address the issue of stigma and discrimination in greater detail in the next chapter. Briefly, we believe that a Canadian Mental Health Commission should be established immediately to undertake a systematic and long-term campaign to combat stigma and discrimination (see Chapter 16).

 

15.3      MENTAL ILLNESS PREVENTION:  RISK FACTORS AND PROTECTIVE FACTORS

While mental health promotion addresses the determinants of health with the goal of improving positive mental health, mental illness prevention focuses on reducing risk factors associated with mental illness and enhancing protective factors that inhibit its onset or shorten its duration.  A WHO report on the prevention of mental illness provides the following definition:

Text Box: Mental illness prevention focuses on reducing risk factors associated with mental illness and enhancing protective factors that inhibit its onset or shorten its duration.

…mental disorder prevention aims at ‘reducing incidence, prevalence, recurrence of mental disorders, the time spent with symptoms, or the risk condition for a mental illness, preventing or delaying recurrences and also decreasing the impact of illness in the affected person, their families and the society.’[315] 

 

Text Box: Risk factors are those that increase the probability of the onset, severity, and duration of major health problems.  Protective factors are those that improve people’s resistance to risk factors and, therefore, to mental disorders.Risk factors are those that increase the probability of the onset, severity, and duration of major health problems.  Protective factors are those that improve people’s resistance to risk factors and, therefore, to mental illness.[316] 

 

 

Text Box: Some strategies for the prevention of mental disorder are similar to those for mental health promotion — such as improved housing and access to education and reduced economic insecurity.  Other strategies are more tightly focused — such as coping with parental mental illness, intervening in the workplace, and improving the mental health of elderly populations.Mental health promotion and mental illness prevention often form part of the same set of interventions, even though they produce “different but complementary outcomes.”[317] Some strategies for the prevention of mental ilness are similar to those for mental health promotion — such as improved housing and access to education and reduced economic insecurity.  Other strategies are more tightly focused — such as coping with parental mental illness, intervening in the workplace, and improving the mental health of elderly populations.[318]

 

As with mental health promotion, mental illness prevention must be based on an understanding of the causes (etiology).  However, as the U.S. Surgeon General has pointed out,

…for most major mental disorders, there is insufficient understanding about etiology and/or there is an inability to alter the known etiology of a particular disorder.  While these have stymied the development of prevention interventions, some successful strategies have emerged in the absence of a full understanding of etiology.[319]

In developing prevention interventions, the WHO suggests a number of steps to take, including: assessing needs; disseminating best practices; implementing high-quality, evidence-based programs on a large scale; and developing systems for quality assessment and improvement, ensuring those programs’ sustainability.[320]

15.4      THE NEED FOR EVIDENCE

To be successful, mental health promotion and mental illness prevention interventions must be based on evidence.  They require the cooperation of different levels of government, service providers, non-government organizations and affected individuals, and they also require substantial investments — both of which will not be forthcoming unless all stakeholders have a good idea what the probable outcomes of their cooperation and investment will be.

Text Box: Mental health promotion and disorder prevention interventions must be based on evidence.  This need for evidence was made clear by the Office of the Auditor General of Canada.  After reviewing Health Canada’s population health projects, the Auditor General’s 2001 report said that “choosing the ‘right’ priorities at the outset is a critical step toward committing resources to areas that will yield the most benefit in improved population health.”[321]  The Auditor General also expected that priorities would be chosen “on the basis of good, evidence-based information such as surveillance data and evaluations of population health programs.”[322]

Text Box: It is clear that more data are needed on the effectiveness of mental health promotion and disorder prevention policies and programs.In 2004, the WHO published reports summarizing the evidence relating to the effectiveness of mental health promotion and mental illness prevention interventions.  While good evidence was found for some interventions, particularly at the individual level, the WHO considered the economic data on the relative costs and benefits of interventions to be sparse.[323] 

While the WHO argues that plausible interventions should still be carried out in the absence of outcome evaluations,[324] it is clear that more data are needed on the effectiveness of mental health promotion and mental illness prevention policies and programs.

During the course of the Committee’s hearings, some witnesses called on the federal government to gather and disseminate information on mental health promotion and mental illness prevention.  Ms. Christine Davis, President, Canadian Federation of Mental Health Nurses, testified:

The federal government must play a role in making the connections between the social determinants of health and the promotion of mental health for children, youth, their families and adults.[325]

Ms. Jennifer Chambers, Coordinator, Empowerment Council, recommended that a national mental health legal advocacy organization serve as a clearinghouse for information needed by advocates across the country.[326] 

Dr. Mimi Israël, Psychiatrist-in-Chief; Co-director, Clinical Activities Directorate, Douglas Hospital; and Associate Professor, Department of Psychiatry, McGill University, also called for a centralized structure that would, among other things:

§         pool data from epidemiological and population studies to measure and monitor population health needs that are changing as our environment changes;

§         orient research agendas and research fund allocations;

§         translate research findings once they are collected from international health policies aimed at promoting health or preventing illness; and

§         centralize the preparation and dissemination of information such as public education and awareness campaigns…[327]

Other witnesses called for mental health promotion and mental illness prevention to be part of a national action plan for mental health.  As Ms. Nancy Beck, Director, Connections Clubhouse, testified:

The plan should focus on a population health model, paying attention to prevention, promotion, community care, clinical care, education, research and advocacy. Health Canada’s website has incredible resources around the topic of population health. They have been doing research in this area for decades, but I have yet to see that evidence put into operation.[328]

This was echoed by Ms. Annette Osted, Executive Director, College of Registered Psychiatric Nurses of Manitoba:

We believe that both provincial and national action plans should include a strong mental health promotion plan based on the determinants of mental health. It is evident that mental illness and mental health problems have significant social as well as physical implications. To ensure the sustainability of our health system for future generations, more emphasis must be placed on the health, including the mental health of our population.[329]

15.5      ROLE OF THE FEDERAL GOVERNMENT

Over the years, the federal government has issued several documents that touch on the promotion of mental health and the prevention of mental illness.  In 1974, A New Perspective on the Health of Canadians was issued by the then Minister of National Health and Welfare, Marc Lalonde.  With regard to mental illness, the Lalonde report said:

Much needs to be done … in informing the public and modifying attitudes towards mental illness.  Much needs to be done also in preventing mental illness, identifying positive health factors and promoting them.

The pathological processes at work in our families, our school systems and in our society’s value system indicate that programs of prevention directed at large population groups are desperately needed.  These programs of prevention would have the advantage of reducing the risks of mental illness while permitting a sharing of responsibility which would abate some of the guilt which individuals find so intolerable.[330]

In 1986, the then Minister of National Health and Welfare, Jake Epp, released Achieving Health for All: A Framework for Health Promotion.  It expanded on the Lalonde report, focusing on the broader social, economic and environmental factors that affect health.  It set out three challenges:

§         reducing inequities;

§         increasing prevention; and

§         enhancing coping.[331]

This was followed in 1988 by Mental Health for Canadians: Striking a Balance, in which mental health promotion was put in terms of these three challenges.  It suggested a number of actions, including:

§         expanding the body of knowledge concerning the nature and causes of good mental health and prevention of mental illness;

§         coordinating policies to ensure a mental health perspective is brought to bear on relevant issues; and

§         committing resources to community development and community-based programs and services.[332]

In 1994, the federal, provincial, and territorial Ministers of Health officially endorsed the population health approach.  In Strategies for Population Health: Investing in the Health of Canadians, they set out three strategic directions for national action:

§         Strengthen public understanding of the broad determinants of health, and public support for and involvement in actions to improve the health of the overall population and reduce health status disparities experienced by some groups of Canadians.

§         Build understanding about the determinants of health and support for the population health approach among government partners in sectors outside health.

§         Develop comprehensive intersectoral population health initiatives for a few key priorities that have the potential to significantly impact population health.[333]

Text Box: Addressing preventable risk factors can have a positive impact on the mental health of the population.  But this requires a strongly coordinated effort.  The Integrated Pan-Canadian Healthy Living Strategy represents additional efforts in health promotion.  This federal/provincial/territorial initiative aims to improve the overall health of Canadians by addressing preventable risk factors.  The federal/provincial/territorial Ministers of Health agreed to work together on the Integrated Pan-Canadian Healthy Living Strategy in 2002.[334]  The initial emphasis of the Strategy is on physical activity and healthy eating and their relationship to healthy weight, but it will eventually be expanded to address other priority health issues such as mental health.[335] 

Addressing preventable risk factors can have a positive impact on the mental health of the population.  But this requires a strongly coordinated effort.  The Committee believes that the approach that has been developed under the Integrated Pan-Canadian Healthy Living Strategy should be expanded to include mental health as a priority health issue; it recommends therefore:

 

 

103

That mental health be included as an immediate priority health issue in the Integrated Pan-Canadian Healthy Living Strategy.

 

In its submission to the Committee, the Canadian Psychological Association suggested that a Canadian Mental Health Guide be created.  Modelled on Canada’s Food Guide, it would

… help reduce stigma and discrimination by recognizing that mental health is part of everyday life, promoting and supporting psychological resilience, enhancing early detection and so on.Text Box: The Canadian Psychological Association suggested that a Canadian Mental Health Guide be created modeled on Canada’s Food Guide.

 

 

 

The Guide would give concrete advice on topics such as:

§         Mentally healthy activities for all ages.

§         Early warning signs of psychological stress and what to do about them.

§         Normal reactions to life events such as death, tragedy, failure, or loss.

§         Ways to improve psychological resilience.

§         What is normal in terms of sadness, anxiety etc., and how to recognize when normal reactions might become an illness.[336]

The Committee sees merit in this proposal and therefore recommends:

 

 

104

That the Public Health Agency of Canada, in collaboration with other stakeholders, prepare a Mental Health Guide for Canadians and ensure its broad distribution.

 

Text Box: Within the Public Health Agency of Canada, the Mental Health Promotion Unit is the focal point of efforts to improve positive mental health and well-being in the Canadian population.  Within the federal government, Health Canada and the Public Health Agency of Canada are both centrally involved in health promotion and illness prevention.  Within the Public Health Agency of Canada, the Mental Health Promotion Unit is the focal point of efforts to improve positive mental health and well-being in the Canadian population.  The mandate of the Unit is to:

… promote and support mental health and reduce the burden of mental health problems and ilness, by contributing to:

·         the development, synthesis, dissemination and application of knowledge;

·         the development, implementation and evaluation of policies, programs and activities designed to promote mental health and address the needs of people with mental health problems or illness.[337]

Text Box: The Committee believes that the federal government needs to increase its capacity to identify national priorities for interventions in mental health promotion and disorder preven¬tion, and to translate these priorities into action.  Other federal institutions are also involved in activities related to health promotion. The Institute of Population and Public Health within the Canadian Institutes of Health Research (CIHR) “supports research into the complex interactions (biological, social, cultural, environmental) which determine the health of individuals, communities, and global populations; and into the application of that knowledge to improve the health of both populations and individuals.”[338]  The Institute of Neurosciences, Mental Health and Addiction, which supports research on the functioning and disorders of the brain, the spinal cord, the sensory and motor systems, and the mind, constitutes another example.[339]

A further example is the Canadian Institute for Health Information (CIHI), which manages the Canadian Population Health Initiative; its mission is to:

§         foster a better understanding of factors that affect the health of individuals and communities, and;

§         contribute to developing policies that reduce inequities and improve the health and well-being of Canadians.[340]

As well, Statistics Canada collects and disseminates statistics on the health of Canadians.  It conducts population health surveys, including the Canadian Community Health Survey - Mental Health and Well-being, which was designed to provide national estimates of major mental illness and problems.[341]

Nevertheless, the Committee believes that the federal government needs to increase its capacity to identify national priorities for interventions in mental health promotion and mental illness prevention, and to translate these priorities into action.  Given the overlap between mental health promotion and general health promotion, the Public Health Agency of Canada should continue to be the focal point for mental health promotion. 

To complement the work of the Public Health Agency of Canada, the proposed Canadian Mental Health Commission, as outlined in Chapter 16, will include a Knowledge Exchange Centre that works with existing agencies to foster the collection of data relevant to mental health and illness and the exchange of information. The Committee therefore recommends:

 

 

105

That the federal government commit sufficient resources to enable the Public Health Agency of Canada to take the lead role in identifying national priorities for interventions in the areas of mental health promotion and mental illness prevention and to work, in collaboration with other stakeholders, toward translating these priorities into action.

That all mental health promotion and mental illness prevention initiatives contain provisions for monitoring and evaluating their impact.

That the Knowledge Exchange Centre (see Chapter 16) work closely with existing bodies such as the Canadian Institute for Health Information, Statistics Canada and the Canadian Institutes of Health Research to collect and disseminate data on evaluations of mental health promotion and mental illness prevention interventions, including campaigns to prevent suicide.

That, in this context, the Canadian Mental Health Commission (see Chapter 16) explore the possibility of:

·         developing common measures to evaluate mental health promotion and mental illness prevention interventions;

·         analyzing federal policy initiatives for their probable mental health impact;

·         identifying clusters of problems and/or at-risk populations that are not currently being addressed.

15.6      SUICIDE PREVENTION

The Committee has identified suicide prevention as another priority.  As noted in the Third Interim Report, every year some 3,700 Canadians kill themselves.  Although suicidal behaviour is not itself a mental disorder, it is highly correlated with mental illness and addiction — more than 90% of suicide victims have a diagnosable mental illness or substance use disorder.[342]

Text Box: Although suicidal behaviour is not itself a mental disorder, it is highly correlated with mental illness and addiction — more than 90% of suicide victims have a diagnosable mental illness or substance use disorder.This link between suicide and mental illness was borne out by a recent study of deaths by suicide in New Brunswick.  It found that in the large majority of the 102 suicide deaths examined, the “victims had a long-standing trajectory of persistent difficulties in terms of personal development, consisting of an accumulation of personal, family, psychological, psychiatric and social problems.”[343]  The study also found that there tended to be “serious addiction problems among the suicide victims.”[344]  It observed  that:

… in general, members of the public can clearly recognize signs of distress and suicidal behaviours.  But for many, the next essential step of getting a friend or family member to the appropriate services has not yet become a natural response.[345]

Text Box: Suicidal behaviour can be addressed by promotion and prevention interventions.As this study suggests, suicidal behaviour can be addressed by promotion and prevention interventions. This echoes A Report on Mental Illnesses in Canada, which concluded:

Promotion of mental health of the entire Canadian population, reduction of risk factors and early recognition of those at risk of suicidal behaviour play essential roles in decreasing suicide and attempted suicide.[346] 

Text Box: By making people more aware of the signs of suicidal behaviour, the hope is that those considering suicide will be encouraged to seek help.By making people more aware of the signs of suicidal behaviour, the hope is that those considering suicide will be encouraged to seek help and that it will be available to them, beginning with interventions by family, friends and neighbours.

Available evidence indicates that when communities work together to increase awareness, the suicide rate can indeed be reduced.  One campaign that is often mentioned was conducted by the U.S. Air Force; it “focused on removingthe shame associated with mental health problems and on increasingsocial support, coping skills, and help seeking.”  As a result, the number of suicides was reduced by one-third.[347]

Text Box: Available evidence indicates that when communities work together to increase awareness, the suicide rate can indeed be reduced.Although many provinces, territories and communities have developed suicide prevention programs,[348] Canada does not have a national suicide prevention strategy. Many believe the federal government should work with the provinces, territories, and relevant stakeholders to develop one.[349]  To quote the Honourable Elvy Robichaud, Minister of Health and Wellness, Province of New Brunswick,

Another area that would benefit from federal involvement is the issue of suicide prevention and awareness.  We have recently released a research study on suicide in New Brunswick. It is clear that this is a complex issue, and is everyone’s responsibility, not just the health and mental health care systems.

Opportunities to provide public information, share knowledge and best practices, and exchange successful programs and initiatives would be beneficial to all jurisdictions and the people they serve.[350]

Text Box: Canada does not have a national suicide prevention strategy.

 

 

Text Box: An Aboriginal Youth Suicide Prevention Strategy is designed to support communities in their efforts to prevent youth from becoming suicidal.The federal government is currently working on an Aboriginal Youth Suicide Prevention Strategy in partnership with the Assembly of First Nations and the Inuit Tapiriit Kanatami, with input from other national Aboriginal organizations, provinces and territories, and federal departments.  Mr. Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada, told the Committee that the Strategy had been announced in September 2004; $65 million was allocated to it over five years.  It is designed to support communities in their efforts to prevent youth from becoming suicidal, in particular by reaching out to youths who are at risk of committing suicide and by preventing suicide clusters that are frequently observed in the aftermath of a completed suicide.[351] 

The federal government is also involved in research on suicide. In 2003, Health Canada and the CIHR’s Institute of Neurosciences, Mental Health and Addiction held a conference to define a research focus related to suicide.  The participants identified six major themes: suicide in social and cultural contexts, evidenced-based standards, mental health promotion, multi-dimensional models explaining suicide, spectrum of suicidal behaviours, and a national database for suicide-related research.[352]

In October 2004, the Canadian Association for Suicide Prevention, a group of professionals working to reduce the suicide rate,[353] published a Blueprint for a Canadian National Suicide Prevention Strategy.[354]  In his appearance before the Committee, Dr. Paul Links, Professor of Psychiatry, University of Toronto, and President of the Canadian Association for Suicide Prevention, called for federal leadership in developing a national suicide prevention strategy:

Text Box: The Committee believes there is merit in advancing the Canadian Association for Suicide Prevention’s initiative aimed at development of a national prevention strategy.All levels of government, various community agencies and organizations, survivors and clients need to be involved, but it is clear that we must have federal leadership to set out policies, provide resources and set outcome targets, including actual reduction in suicide rates.[355]

The Blueprint for a Canadian National Suicide Prevention Strategy includes many of the concepts that have been touched on in this chapter.  It sets out a number of goals, including:

§         Promote awareness in every part of Canada that suicide is our problem and is preventable;

§         Develop broad-based support for suicide prevention and intervention;

§         Develop and implement a strategy to reduce stigma, to be associated with all suicide prevention, intervention and bereavement activities; and

§         Develop, implement and sustain community-based suicide prevention programs, respecting diversity and culture at local, regional, and provincial/ territorial levels.

The Committee believes there is merit in advancing the Canadian Association for Suicide Prevention’s initiative aimed at development of a national prevention strategy.  The Committee therefore recommends:

 

 

106

That the federal government support the efforts of the Canadian Association for Suicide Prevention and other organizations working to develop a national suicide prevention strategy.

That the Canadian Mental Health Commission (see Chapter 16) work closely with all stakeholders to, among other things:

·         develop consistent standards and protocols for collecting information on suicide deaths, non-fatal attempts and ideation;

·         increase the study and reporting of risk factors, warning signs and protective factors for individuals, families, communities and society;

·         support the development of a national suicide research agenda along the lines proposed by the Canadian Institutes of Health Research.

15.7      CONCLUSION

At the beginning of this chapter, we asked whether it is possible to prevent mental illnesses in the Canadian population by intervening to address their causative factors.  The available evidence shows that some interventions aimed at mental health promotion and mental illness prevention are effective in reducing the onset of mental illness and/or its severity and duration.  Such interventions should be pursued further and, at the same time, additional evidence of their impact must be collected and assessed.  Armed with such evidence, governments and other stakeholders will be more ready to make sustained and long-term investments to help improve the mental well-being of the Canadian population.


CHAPTER 16:
NATIONAL MENTAL HEALTH INITIATIVES

16.1      TOWARD A NATIONAL MENTAL HEALTH STRATEGY

Text Box: Canada is alone among the G8 countries not to have a national mental health strategy.From the very beginning of its study of mental health, mental illness and addiction, the Committee has heard the call for a national mental health strategy.[356] Many witnesses have stressed the tremendous significance of and need for such a strategy, noting that Canada is alone among the G8 countries not to have one. In fact, it has been five years since the Canadian Alliance on Mental Illness and Mental Health issued A Call for Action: Building Consensus for a National Action Plan on Mental Illness and Mental Health.Text Box: Not having a national strategy symbolizes neglect of mental health issues by government.

While it is important to point out that there is no evidence to suggest that Canada treats people living with mental illness significantly differently than other highly industrialized nations, nevertheless the absence of a national approach to mental health issues represents an important national deficiency. Not having a national strategy symbolizes neglect of mental health issues by government; it also forecloses on a number of very concrete initiatives that would benefit people living with mental illness throughout the country.

 

16.1.1    What Kind of National Mental Health Strategy Is Needed?

Text Box: There is a leadership role for the federal government in the development of a national approach to mental health.  The provinces and territories are responsible for delivering health services, including mental health services, to the general population.Although many witnesses expressed support for the concept of a national strategy or plan, their views varied on its exact purpose and what it should contain. There were many suggestions relating to the role of the federal government in creating such a strategy.

Phil Upshall, National Executive Director of the Canadian Alliance on Mental Illness and Mental Health, testified that:

The Canadian Alliance on Mental Illness and Mental Health advocates for an overarching national action plan. … Our preferred option is a national action plan that is developed by a distinguished blue-ribbon panel including consumers, patients and families, which will advise the policy work of the federal, provincial, and territorial governments. We think that this is an essential element of a national strategy.[357]

For its part, the British Columbia Schizophrenia Society suggested that:

A national mental health plan should be developed to (i) focus on standardized care for the seriously mentally ill; and (ii) monitor outcomes across the country. A Canadian national mental health plan should also establish national standards for education, early intervention and family support that will lead to improvements in treatment and care for Canadians with serious mental illness.[358]

Some believed the federal government should take the lead in developing a national plan that would, in the words of Tina Pranger, Mental Health Consultant to Health and Social Services in Prince Edward Island, “provide direction to the provinces and territories in developing, refining and supporting their own mental health plans” and “include national standards for service delivery.”[359] Others, such as Jocelyne Green, Executive Director, Stella Burry Community Services in St. John’s, insisted on the need for the federal government to provide “targeted and significant levels of funding for mental health services” that the provinces could access only “if they deliver programs in line with national standards, with no ‘ifs’, ‘ands’ or ‘buts.’”[360]

From the beginning, the Committee has recognized that mental health, mental illness and addiction issues resonate with every level of government; they affect, to all intents and purposes, the entire population of Canada. Strategies are required at every level — locally, regionally, provincially, federally, and nationally.

The Committee believes it important to make the significant distinction between “national” and “federal,” and to be clear on what a feasible national mental health strategy could look like in Canada. Many tend to look on the federal government as the repository of all national efforts and, therefore, call on it to initiate the development of national strategies, independent of the particular sphere of activity.

With mental health reform, however, this approach cannot work. While there is a leadership role for the federal government in the development of a national approach to mental health, this level of government is not responsible for its development and enforcement. The Committee believes that, in Canada, any attempt to establish a national approach in health care related areas, including mental health,[361] must take into account, among other factors, the reality of which organizations actually deliver health-related services and supports and the fiscal capacities of each level of government.

It bears repeating that the provinces and territories are responsible for delivering health services, including mental health services, to the general population. The federal government carries this responsibility only for recognized or registered First Nations and Inuit, Canadian Forces personnel, federal offenders, and a few others that fall under the federal jurisdiction.[362]

The federal government’s influence on the way health care is delivered is largely exercised through its fiscal capacity, i.e., its spending power. The provinces and territories receive federal grants in exchange for agreeing to respect certain conditions on how they use these transfers. This is how federal legislation such as the Canada Health Act works. This basic fact sets limits to the role that the federal government can play in developing a national strategy or a national action plan relating to responsibilities that fall primarily within the jurisdictions of the provinces and territories.

 

16.1.2   Elements of a “National Strategy”

Text Box: This report can serve as the basis upon which a national mental health strategy could be developed.Does this report contain the elements of a “national strategy”? The answer depends on what one expects a national strategy to contain. Some of the ground-breaking recommendations put forward here by the Committee are, indeed, national in scope. But this report also contains recommendations directed at all levels of government (federal, provincial/territorial, regional and local) as well as at the providers of mental health services and supports. To some extent, at least, the report can serve as the basis upon which a national mental health strategy could be developed.

As in its previous reports on the acute care system, the Committee has made recommendations in this report on issues that fall outside the jurisdiction of the federal government. No effective, systematic approach to the delivery of mental health and addiction services could have been made otherwise.

Text Box: A mechanism of some sort is needed both to undertake certain critical tasks at a national level and also to maintain a needed national focus on mental health issues.The Committee recognizes that neither the provider groups nor the provincial or territorial governments to which many of the recommendations in this report are addressed are under any obligation to respond to our recommendations. Nevertheless, in our experience with previous health reports, we have found that if recommendations are based on careful consideration of the evidence, they are often received favourably by those to whom they are addressed, jurisdictional boundaries notwithstanding. The Committee is hopeful, therefore, that its recommendations on mental health, mental illness and addiction will be considered on the basis of their merit by all those to whom they are directed.

An overarching question the Committee believes of particular importance, given the extent to which the mental health sector has been neglected over the decades, is how to maximize the chances of this report’s recommendations being acted upon. It has become clear that a mechanism of some sort is needed both to undertake certain critical tasks at a national level and also to maintain a needed national focus on mental health issues.

 

16.1.3   The Creation of the Canadian Mental Health Commission

Text Box: The creation of the Canadian Mental Health Commission heralds a new era in mental health in Canada.The Committee’s key recommendation to achieve this objective, a proposal to create a Canadian Mental Health Commission, was made public by the then Minister of Health, the Honourable Ujjal Dosanjh, on 24 November 2005, tabled in the Senate of Canada and released on the Committee’s website. Minister Dosanjh announced that the Government of Canada, along with all provincial and territorial Ministers of Health, with the exception of Quebec, had already agreed to the creation of the Commission; their agreement was based on the proposal that the Committee submitted to a meeting of the federal/provincial/territorial Ministers of Health on 23 October 2005. Steven Fletcher, health critic for the Conservative Party in the 38th Parliament, also expressed his support for the establishment of a national Mental Health Commission.

Before presenting an expanded version of this proposal, the Committee would like to comment on the significance of its having already been endorsed and on the role the new Commission will play in the development of a “national” approach to mental health in Canada.

The announcement that a Canadian Mental Health Commission would be created was the culmination of several months of consultations between the Committee and many mental health stakeholders across the country. It was greeted with universal enthusiasm by those concerned with mental health issues in Canada. For example, Dr. John Service, Executive Director of the Canadian Psychological Association, wrote:

It is our belief that the announcement of the Commission was an historic event in Canada. It has the potential to significantly change the way we deal with mental health issues in this country. For the first time, we will have a pan-Canadian forum to examine and draw attention to successes and gaps and to work with governments and stakeholders to improve the lives of Canadians.

It is remarkable that the federal, provincial and territorial governments came together in such a short period of time to agree on a Commission. It is a testament to the fact that governments recognize the extent of the need and the necessity to address the need as quickly as possible. The governments are to be congratulated for their willingness to collaborate and to come to an agreement.[363]

The Canadian Collaborative Mental Health Initiative (CCMHI) also applauded the announcement and pointed to the potential advantages of the Commission’s structure:

A real strength of the Commission will be the partnerships it will develop with governments, employers, mental health stakeholder organizations and, in particular, Canadians living with mental illness and their families and caregivers. Advisory committees to the Commission will also play a big role in ensuring the breadth of mental health issues in Canada are well understood and adequately represented.[364]

Text Box: The Commission will operate at arm’s length from government; a majority of its board of directors will come from outside government, as will its Chair.For its part, the Canadian Mental Health Association (CMHA) saw the establishment of a Commission on Mental Health and Mental Illness “as a momentous step towards the development and implementation of a strategy to address the mental health needs of all the people of Canada.”[365]

Dr. Paul Garfinkel, President and CEO of the Centre for Addiction and Mental Health, stressed the importance of the proposal’s emphasis on reducing stigma and ending discrimination:

Every day we hear from patients and their families who delayed seeking treatment because they feared the social stigma that a diagnosis of mental illness or addiction would bring. In fact, research shows that two-thirds of affected people never seek treatment. The power of stigma cannot be underestimated, and this commitment by the Federal Government to create a national commission to help educate Canadians about the reality of mental illness — with the ultimate goal of eliminating all forms of discrimination against people and families living with mental illness — will be welcomed from coast to coast.[366]

It is no exaggeration to say that the creation of the Canadian Mental Health Commission heralds a new era in mental health in Canada. For the first time, there will be a body that can help to channel institutional and financial resources at a national level into a sector that has been systematically neglected. The Committee wholeheartedly commends all the Ministers of Health who have signed on to this proposal, as well as the Government of Canada for agreeing to fund the Mental Health Commission.

While the financial resources that are required for the Commission will come from the federal government, its institutional structure also encompasses the other levels of government in addition to non-governmental stakeholders. The Commission will operate at arm’s length from government; a majority of its board of directors will come from outside government, as will its Chair (the Mental Health Commissioner of Canada). Thus, no single group, including government, will be able to dominate the Commission’s Board of Directors. In this sense, it is very much a “national,” as opposed to a “federal,” undertaking.

 

16.1.4   The National Dimension in This Report

Text Box: The Mental Health Transition Fund will permit the transfer of federal funds to the provinces and territories for their use in accelerating the transition to a mental health system predominantly based in the communities in which people with mental illness and addiction live.The creation of the Mental Health Commission is, in the Committee’s view, one of the two key components of what could be called a “national strategy” contained in this report. The second involves the creation of a Mental Health Transition Fund. If agreed to by the federal government, this Fund will permit the transfer of federal funds to the provinces and territories for their use in accelerating the transition to a mental health system  predominantly based in the communities in which people with mental illness and addiction live. The rationale for this fund is set out in detail in Chapter 5; later in this chapter (see section 16.5) we discuss how large this fund should be and how the money should be raised.

Text Box: The Committee’s recommendations, implemented in full, would also move the reform agenda forward in immediate and concrete ways, including by providing funding for transformative change by the provinces and territories.The Committee recognizes that many other recommendations in this report also have a national dimension, despite being directed only at one or another level of government. For example, the investment of an additional $25 million annually in mental health services research, as recommended in Chapter 11, will have a national impact, although the recommendation is directed solely to the federal government.

The recommendations involving the Mental Health Commission and the Mental Health Transition Fund, however, entail the creation of a new institution that brings together not only the different levels of government with responsibility for providing mental health services and supports, but also the people who actually deliver those services as well as the people who benefit from them.

The potential impact of creating of a Mental Health Commission is substantial. Should the Transition Fund also be created, these two entities will represent a truly momentous injection of institutional and financial resources into a sector that has been neglected for decades. The lives of many thousands of Canadians can be improved.

Nevertheless, the Committee hesitates to call this report a national strategy or plan. In other countries, such plans typically specify details about how various services should be provided and who will be responsible, and to whom, for the plan’s implementation.[367] Important specifics of this kind are not contained in this report; nor would it have been appropriate for the Committee to have included them.

Nonetheless, the national measures that the Committee has recommended in this report lay a firm foundation for an exploration of how a mental health plan could be developed, negotiated, and endorsed by all stakeholders. The Committee’s recommendations, implemented in full, would also move the reform agenda forward in immediate and concrete ways, including by providing funding for transformative change by the provinces and territories. In addition, the activities that the Mental Health Commission will undertake on its own (anti-stigma work and establishing a knowledge exchange centre) will significantly alter the landscape for people living with mental illness.

Thus, there is a plan of action in this report with a “national” dimension to the recommendations it contains. The plan is a feasible one tailored to the realities of health care delivery in Canada. The Committee fervently hopes that all stakeholders will agree that its implementation promises a huge advance for people living with mental illness and addiction.

16.2      A PROPOSAL TO ESTABLISH A CANADIAN MENTAL HEALTH COMMISSION

In this section, the Committee’s proposal to create a Mental Health Commission is reproduced as tabled in the Senate of Canada on 24 November 2005.[368] Section 16.4 contains additional comments on the proposal that the Committee feels it is important to make, including a more detailed discussion of the tasks the Commission will undertake “in-house” (a ten-year anti-stigma campaign and the establishment of a Knowledge Exchange Centre).

16.2.1   Rationale: Why a Commission?

Text Box: No existing organization has a mandate that encompasses, or could be modified to encompass, a majority of the factors set out.Several factors led the Committee to recommend the creation of a Canadian Mental Health Commission:

a)      Although the Committee’s work and, importantly, recent actions by several provincial governments have begun to focus a long-overdue spotlight on mental health, it remains that the whole complex, pervasive problem of mental illness and addiction in Canadian society continues to be neglected. The Canadian Mental Health Commission will provide a much needed national (not federal) focal point that will keep mental health issues in the mainstream of public policy debates in Canada and accelerate the development and implementation of effective solutions to the long-standing problems of this sector.

b)      Those most directly affected are people living with mental illness, their families, friends and employers. But, given that, each year, one in five Canadians will experience a mental illness, virtually all Canadians will be affected, directly or indirectly, by mental illness and/or addiction. Mental illness is truly of national concern.

c)      No single level of government has the resources needed to deal with the full range of mental health issues on its own. Creating a national focus will add substantial value, especially with respect to exchanging information and facilitating collaboration among governments and between governments and stakeholders.

d)      In both public and private sector businesses and workplaces, mental health problems and substance abuse disorders are responsible for a large proportion of all disability, absenteeism and diminished workplace productivity. The proportion of workplace disability associated with mental illness and substance abuse is rising more rapidly than those associated with other illnesses and has been estimated to cost Canadian companies about $18 billion a year in recent years.[369] The economic as well as the social implications are both obvious and of universal concern.

e)      In every government, whether federal, provincial, territorial or municipal, responsibility for mental health issues is dispersed among several departments and agencies — health, social services, housing, etc.  Managing issues that span ministerial/departmental boundaries is notoriously hard; truly effective ways of doing so are few and far between.  The Canadian Mental Health Commission will benefit all governments by facilitating the exchange of information on best practices on how to deal with this classic interdepartmental issue.

f)       There is, as well, no easy mechanism now available for stakeholders in the mental health sector to exchange knowledge and distribute information about best practices coast to coast to coast. A national Knowledge Exchange Centre will be an integral part of the Canadian Mental Health Commission.

g)      Canadians must become better educated about the reality of mental illness. They must be encouraged to understand and be more tolerant of people living with mental illness and addiction. To those ends, a national campaign is needed to combat the stigma and discrimination associated with mental illness. Such a campaign will be most effectively managed nationally by the Canadian Mental Health Commission.

The Committee considered alternatives to the creation of a national commission. It concluded, however, that no existing organization has a mandate that encompasses, or could be modified to encompass, a majority of the factors set out above. For example, the mandate of the Canadian Centre for Substance Abuse is too narrow to encompass the range of mental health issues of concern to this Committee. Moreover, it has no role in changing public attitudes.

Text Box: The Canadian Mental Health Commission will not have any role in monitoring any government’s performance in dealing with mental health and addiction.While mental health falls naturally under the purview of the Health Council of Canada, its chair, Michael Decter, has told the Committee that it will be some years before the Council’s extremely full agenda will be cleared sufficiently to address mental health adequately. The Health Council’s mandate also includes monitoring the performance of all government health care systems. The Canadian Mental Health Commission proposed by the Committee explicitly will not have any role in monitoring any government’s performance in dealing with mental health and addiction.

It is clear to the Committee that a new national organization is required. It must be emphasized, however, that the success of the proposed Commission in contributing to improvement of the mental health of Canadians depends critically upon there being in place strong structures and committed people at the provincial and territorial level to translate policy, knowledge and ideas into action on the ground. This is true also with respect to the mental health services provided by the federal government through its various entities such as the First Nations and Inuit Health Branch of Health Canada and Correctional Service Canada.[370]

The Committee’s intention is that the work of the Canadian Mental Health Commission will complement, and not replace, that being done by existing structures and people at the federal, provincial and territorial levels.

Finally, consistent with its view that structural solutions to any problem should not be permanent, the Committee recommends that the Commission “sunset” in ten years.

 

16.2.2   Guiding Principles of the Canadian Mental Health Commission

Text Box: Be an independent, not-for-profit organization at arm’s length both from governments and from all existing mental health “stakeholder organizations”.The key principles are that the Commission:

 

 

§         Be an independent, not-for-profit organization at arm’s length both from governments and from all existing mental health “stakeholder organizations”;

§         Make those living with mental illness, and their families, the central focus of its activities;

§         Build on and complement initiatives already under way throughout Canada, and avoid duplicating the roles and activities of those currently working in mental health;

§         Establish partnerships with governments, employers, mental health research organizations and service providers, other health care organizations, and the spectrum of existing national and international mental health stakeholders;

§         Put its emphasis on evidence-based mental health policies and methods of service delivery;

§         Rigorously evaluate, assess and report on its own activities, in order to ensure their appropriateness and efficacy and to maintain the Commission’s credibility with governments, its collaborating stakeholders and the Canadian public.

 

16.2.3   Mission/Mandate of the Commission

The mission of the Commission is:

§         To act as a facilitator, enabler and supporter of a national approach to mental health issues;

§         To be a catalyst for reform of mental health policies and improvements in service delivery;

§         To provide a national focal point for objective, evidence-based information on all aspects of mental health and mental illness;

§         To be a source of information to governments, stakeholders and the public on mental health and mental illness;

§         To educate all Canadians about mental health and increase mental health literacy in Canada, particularly among those who are in leadership roles such as employers, members of the health professions, teachers, etc.;

§         To diminish the stigma and discrimination faced by Canadians living with a mental illness, and their families.

 

16.2.4   The Commission’s Method of Operation

Text Box: The Commission will form collaborative relationships that amount to partnerships with governments, employers, mental health stakeholder organizations, professional associations, research organizations and, in particular, those Canadians living with mental illness and their families.To discharge its mission, the Commission will form collaborative relationships that amount to partnerships with governments, employers, mental health stake­holder organizations, professional associations, research organizations and, in particular, those Canadians living with mental illness and their families. Such relationships will be developed with existing organizations and committees such as the Canadian Institute for Health Information, the Canadian Institutes of Health Research, the Canadian Alliance for Mental Health and Mental Illness and its constituent organizations, the Global Economic Roundtable on Mental Health and Addiction, the Canadian Centre for Substance Abuse, the Public Health Agency of Canada,  federal/provincial/territorial Committees on Mental Health and Substance Use, and other relevant organizations and committees concerned with mental health and addiction.

Text Box: Two advisory committees are obligatory — one composed of representatives of all federal/ provincial/ territorial governments and another of representatives from Canada’s Aboriginal communitiesThe coordinating functions and collaborative role of the Commission will help to reduce duplication of effort and to facilitate cooperation among all stakeholders, particularly governments and service providers.

In order to discharge its collaborative mandate, the Commission will establish, in addition to partnerships, a number of advisory committees.  While it will be up to the Commission to decide on their number and composition, two advisory committees are obligatory — one composed of representatives of all federal/provincial/territorial governments and another of representatives from Canada’s Aboriginal communities.[371]

The Commission will assist governments, employers, and service providers in a non-confrontational way, recognizing that the circumstances in which mental health policies and services are provided in every community are distinct. Yet every community can benefit from lessons learned elsewhere, especially given the linkage between the most effective mental health services and primary and community-based care — areas in which best-practice information would be particularly helpful both to communities seeking to improve the effectiveness of their own services and to provincial and territorial governments.

 

16.2.5   Activities of the Commission

The Commission’s activities can be divided into six broad categories:

a)       Development of a National Mental Health Strategy

§         Proposing goals relating to mental health, mental illness and addiction and a framework for a national strategic plan to achieve them, recognizing that such a plan must:

o        take into account existing federal, provincial and territorial mental health plans;

o        reflect the fact that governmental responsibility for mental health  is very much inter-ministerial in nature (i.e., not confined to ministries of health);

§         Providing information to governments, stakeholders and the public on mental health issues (section 16.2.9 expands on the benefits of the Commission’s being a source of information to governments on such issues);

§         Reporting annually to the Federal/Provincial/Territorial Conference of Deputy Ministers of Health and the Deputy Ministers responsible for Social Services (and of other ministries/departments as required);

§         Ensuring that the specific issues on which the Commission will focus at any given time are in accordance with the interests of its Board and its committees as they evolve over time.

b)       Synthesizing Relevant Knowledge for Application to the Canadian Context

§         Developing reliable and valid measures, indicators and tools to facilitate monitoring by governments and health authorities of the performance of their mental health systems over time;

§         Developing benchmark capacity requirements for different types of service along the entire spectrum of mental health services.

c)        Encouraging Research

§         Through the Canadian Institute for Health Information and Statistics Canada, collecting on a regular basis data on the mental health status of Canadians and providing, on the Commission’s website, a comprehensive database for use by researchers and governments;

§         Encouraging the Canadian Institutes of Health Research (CIHR) to support research into the best structures and/or mechanisms to supply, most efficiently, the wide range of services required by people living with mental illness and addiction;

§         Encouraging CIHR to support research on how to measure the outcomes of mental health services so that governments can assess the success and effectiveness of their mental health programs.

d)       Collaborative, Integrative and Networking Activities

§         Supporting consensus-building activities relating to adoption of the best evidence-based clinical and service-delivery practices and system-level approaches;

§         Facilitating the sharing of knowledge across jurisdictions and stakeholder groups regarding effective approaches, developments and innovations;

§         Promoting the integration of primary care services with other forms of service delivery, such as secondary and tertiary treatment services, health promotion and disease prevention programs;

§         Fostering greater collaboration between addiction and mental health stakeholders with a view to improving services and supports for the many individuals coping with addictions who are also living with mental illness;

§         Providing information on how services for people with concurrent disorders can be most effectively and efficiently integrated;

§         Working with employers and organizations, such as the Business Roundtable on Mental Health, Mental Illness and Addiction, to develop programs to reduce the burden of mental illness and addiction on those affected and on the economy.

e)        Public Education and Public Awareness

§         Implementing a national anti-stigma program to educate Canadians about the reality of mental illness, with the ultimate goal of eliminating stigma and all forms of discrimination against people and families living with mental illness;

§         Mounting targeted communications campaigns on specific aspects of mental illness (e.g., the signs of serious depression) aimed at specific target audiences (e.g., school-aged children);

§         Educating Canadians on ways and means of optimizing their own and their loved ones’ mental health;

§         Promoting population mental health and the prevention of mental illness and addiction;

§         Sponsoring activities such as conferences, seminars, and an annual awards program to celebrate people who provide exceptional leadership in mental health.

f)        Knowledge Exchange

§         Creating an Internet-based national Knowledge Exchange Centre for the distribution of information about mental health;

§         Publishing studies, reports and other documentation on mental health;

§         Monitoring national and international developments in mental health policies and services and, where relevant, incorporating this information into the website of the Knowledge Exchange Centre;

§         Text Box: The Commission is to be advisory and facilitative, not operational in nature, apart from its commitment to undertake some project and research work that is consistent with its mission.Making the Knowledge Exchange Centre accessible to people living with mental illness, their families and caregivers, employers, researchers, governments and other stakeholders;

 

 

§         Linking the Knowledge Exchange Centre website with relevant sites operated by provincial governments and stakeholder groups.

The Commission will both contract out projects and undertake work itself on behalf of various Canadian and international institutions, including both governments and non-governmental organizations in the private sector.

It is important to emphasize that the Commission is to be advisory and facilitative, not operational in nature, apart from its commitment to undertake some project and research work that is consistent with its mission.

Specifically, the Commission will not:

§         Provide any services itself, except for its management of the Knowledge Exchange Centre and the national anti-stigma campaign, or in association with its doing work under contract for other institutions;

§         Monitor the performance of any government with respect to mental health services. The Commission will recognize explicitly that each government’s approach to providing mental health services will reflect the particular characteristics of that jurisdiction.

 

16.2.6   Composition of the Board of the Commission

Text Box: No nominee can represent a specific organization; each must be widely recognized as reflective of the mental health community at large.The Commission will be established under federal legislation or other appropriate authority (e.g., through incorporation as a not-for-profit corporation).

In structuring the Commission’s Board, two principles must be kept in mind:

§         First, as set out in the guiding principles outlined above, the Commission will operate “at arms-length both from governments and all existing mental health stakeholder organizations.” Therefore no single stakeholder group, including government, may have a majority of seats on the Board;

§         Second, to facilitate its effectiveness, the Board should not be too large. Adequate input from all stakeholder groups can be ensured through the judicious use of advisory committees (including the federal/provincial/territorial governmental advisory committee and the Aboriginal advisory committee specified above).

These two constraints, together with the precedents established by the composition of the Boards of the Canadian Institute for Health Information and the Canadian Patient Safety Institute, lead the Committee to recommend that the Board of the Canadian Mental Health Commission have nineteen members, approximately one-third from governments and approximately two-thirds without any government affiliation or connection.

 

Therefore, the Board of the Commission will consist of:

a)      Five provincial governmental nominees chosen as follows: one from the Atlantic provinces, one from Quebec, one from Ontario, and two from the Western provinces.

b)      One member nominated jointly by the three territorial governments.

c)      One member nominated by the federal government.

d)      Eleven nominees at large, chosen by the seven government nominees to represent a wide range of stakeholders involved in mental health issues, including those living with mental illness, their families, caregivers, service providers, the professions, employers, etc. No nominee can represent a specific organization; each must be widely recognized as reflective of the mental health community at large.

e)      A non-governmental chair (the Canadian Mental Health Commissioner) chosen by the seven government nominees.

Board members will serve three-year terms and be eligible for renewal once. All, including the Commissioner, will be part-time.

 

16.2.7   Staff of the Commission

The full-time staff of the Commission, initially consisting of 25 to 30 people, will be under the direction of an Executive Director.

 

16.2.8   Funding for the Commission

All funding (the amount of which is currently under study by the Senate Committee) will be provided by the federal government. The budget will consist of:

§         Core funding for the Commission’s  Board, staff, and operations;

§         Funding “earmarked” for establishment and management of the Knowledge Exchange Centre;

§         Funding “earmarked” for public education and anti-stigma and other communications campaigns.

 

16.2.9   Appendix

Every government faces a myriad of issues as it attempts to improve services to people living with mental illness.  While some of these issues are specific to a jurisdiction, many others are broadly applicable across jurisdictions.  It is with respect to the latter that the Commission can play a valuable role for all governments by providing information on what has proven to be most effective in other provinces and other countries (i.e., best practices), sparing each government from having to gather and assess the information on its own.

Four such issues illustrate the point:

a)       Strategic Investment Decisions

To plan effectively for the transformation of the mental health service delivery system across the continuum of provincial, regional and community-based services, it is critical that governments have available, evidence-based information with respect to the most effective practices elsewhere in Canada and in other industrialized countries.  In the absence of such information, governments have little defence against pressures to adopt particular policies and practices based only on anecdotal evidence or representing “flavour-of-the-month” fads.

Having collected information on and evaluated practices used elsewhere, the Commission will provide leadership in building a natural consensus around best practices.

b)       Primary Care and Community-Based Service Delivery

Experiments in new ways of integrating mental health services into multidisciplinary primary care clinics and of delivering community based services are taking place across the country. Evaluation of the effectiveness of these experiments and developing a comparison of evidence-based best practices will be very useful to governments and service providers alike.

c)         Chronic Mental Illness

People living with a chronic mental illness need a range of services, many of which (social housing, for example, and various types of income support and training programs) are not provided by health departments. Given that they are usually the responsibility of different government departments, often there is no mechanism, or at least no easy mechanism, to coordinate the range of services needed by a single consumer. Because no single department “owns” or has sole responsibility for a person living with a mental illness, even an aggressive case manager — clearly part of the solution to the problem — will have difficulty crossing departmental lines.  That some of these services, social housing for example, have fallen out of political favour in recent years makes solving the problem even more difficult.

The Commission will help governments in two ways: 

§         First, by evaluating mechanisms that have been used elsewhere to coordinate effectively multi-department services for a single consumer, and proposing options for governments to consider.

§         Second, by identifying gaps in the services required and encouraging governments to fill them.

d)       Mental Health Human Resources

It is widely acknowledged that a severe shortage of mental health human resources exists across the whole spectrum of mental health service providers.  It is also acknowledged that existing training programs (and programs designed to update the skills of people currently working in the field) need modification.

For example:

§         Few people are trained in how to help those who suffer from concurrent disorders.  Often someone with both a mental illness and an addiction is treated sequentially; the treatment is frequently ineffective because the problems are linked.  The solution to this problem requires significant change in the training of mental health workers.

§         Nurse practitioners and nurses need more training in how to help people living with a mental illness and how to identify the presence of concurrent disorders.  This requires changes in academic curricula, always a very slow and difficult thing to achieve. Family members also need training of the same kind but in community settings.

§         Scope of practice rules must be modified if multi-disciplinary primary care clinics are to become the predominant point of entry into a transformed mental health system.  There is bound to be resistance to such changes.

§         Assessment of the skill set required to provide various mental health services will enable accurate forecasts to be made of the numbers of mental health workers of different categories required in Canada in the future.

By providing an informed, authoritative source of national pressure, equally independent of government, advocacy groups, service providers, and those responsible for providing training and education programs for mental health workers, the Commission will reinforce governments as they seek changes of the kind listed above.

16.3      GETTING THE COMMISSION UP AND RUNNING

As noted earlier, on 24 November 2005, Minister Dosanjh announced that the Government of Canada, along with all provincial and territorial Ministers of Health, with the exception of Quebec, had agreed to the creation of the Canadian Mental Health Commission and the Government of Canada agreed to fund the Commission. The Committee believes that it is essential to move forward quickly, and recommends:

 

 

107

That a Canadian Mental Health Commission be established and that it become operational by 1 September 2006.

That the guiding principles, mandate, method of operation and activities of the Canadian Mental Health Commission be as specified in sections 16.2.2 to 16.2.5 of this report.

That the composition of the Board of the Commission and its staff be established as set out in sections 16.2.6 and 16.2.7 of this report.

 

That the Government of Canada provide $17 million per annum to fund the operation and activities of the Commission; of this amount, $5 million per annum should be dedicated to a national anti-stigma campaign, $6 million per annum devoted to the creation of the Knowledge Exchange Centre and $6 million per annum used to cover the operating costs of the Commission.

16.4      FURTHER COMMENTS ON THE PROPOSAL TO CREATE A CANADIAN MENTAL HEALTH COMMISSION

16.4.1   The Nature of “Representation” on the Commission

Text Box: It will be crucial to establish a balance in selecting the 12 non-governmental directors. The Committee believes very strongly that these directors should neither be, nor be seen as, “representatives” of any particular stakeholder group or organization.It is important to make a few additional remarks on the how the Committee envisages choosing the members of the Board of Directors of the Canadian Mental Health Commission and on the nature of their role.

 

 

Text Box: There can be no room on the Board for the kind of “silo” approach that is still all too common in the organization and delivery of mental health services and supports.The composition of the Board of the Commission was crafted so that it will be able to propose and advocate for innovative policy and educational initiatives that will significantly improve the lives of people living with mental illness across the country. In determining the number of governmental representatives on the Board, both the Committee and the provincial governments with which it has consulted believe it important to include a representative from the three territorial governments, in great measure because of their significant Aboriginal populations. The Committee believes this is one way to ensure that the concerns of Canada’s Aboriginal peoples are at the forefront of the Commission’s activities.

It will be crucial to establish a balance in selecting the 12 non-governmental directors. The Committee believes very strongly that these directors should neither be, nor be seen as, “representatives” of any particular stakeholder group or organization.

It will, of course, be essential that the full range of views and expertise from all stakeholder groups be heard, not only via the various advisory committees to be created by the Commission but also at the Board of the Commission itself. However, it is critical that Board members not see themselves, or be seen, as representing any of the narrowly focused interest groups that now constitute integral parts of the current mental health system. There can be no room on the Board for the kind of “silo” approach that is still all too common in the organization and delivery of mental health services and supports. The Board members must be capable of looking at the broad system as a whole and making this the centre of the Board’s concerns.

The key to the success of the Commission will be its ability to take into account a wide cross-section of views and to distill these into a coherent overall program that will improve the lives of people living with mental illness and addiction from coast to coast to coast. The non-governmental members of the Board must be carefully selected to ensure that they bring a diversity of experience to the table but are nonetheless able to look at what needs to be done primarily from the broad perspective of the country as a whole.

There is no doubt that the Board will need in its membership people with knowledge of a variety of mental health constituencies. They must include, first and foremost, people living with mental illness themselves as well as their families. In addition, there must be individuals who understand and have experience of issues confronting people of Aboriginal origin, and the special needs of children and youth, as well as service providers inside and outside the medical professions, and experts in as many areas of mental health as possible.

Additional input from all of these constituencies will also be channelled into the Commission through advisory committees that will be created. In this way, the Committee believes it will be possible for the Commission to have access to the full range of views that will be needed to make sure that its initiatives respond to the needs of Canadians living with mental illness without developing a structure for the Commission that would be so unwieldy as to prevent it from completing its mandate.

 

16.4.2   Anti-Stigma Campaign

Text Box: The Committee has included development of a sustained anti-stigma campaign as a key element of the mandate of the Canadian Mental Health Commission.

Text Box: The Committee believes that there is much to learn from the separate, not-for-profit, private company that was funded by the Australian government called “beyondblue.”In its first report on mental health, the Committee devoted an entire chapter to the issue of stigma and discrimination.[372] Witnesses have consistently told the Committee that a systematic effort to reduce stigma and combat discrimination is essential to improving the situation for people living with mental illness.

During its cross-country hearings, this point was reiterated by Jean-Pierre Galipeault of The Empowerment Connection:

[A]ll of the efforts in terms of mental health policy development, system reform, consumer and family member involvement will be unattainable without making some efforts to address the issues of stigma and discrimination.[373] 

The Committee has included development of a sustained anti-stigma campaign as a key element of the mandate of the Canadian Mental Health Commission. While it will be up to the Commission to work out the details of how this campaign should be undertaken, the Committee believes it is important to summarize the results of its own findings on this issue.

In its first report, the Committee quoted Professor Heather Stuart from Queen’s University, who emphasized the importance of carefully targeting anti-stigma interventions. She told the Committee:

With respect to anti-stigma interventions, how do we stop stigma and discrimination? We are learning from the World Psychiatric Association work that one size does not fit all. It is a waste of time and energy to embark on a large, public education campaign that is designed to improve literacy as an anti-stigma intervention because segments of the population have different views.[374]

Professor Stuart also noted the connections amongst a number of dimensions to anti-stigma work. She told the Committee that the need to carefully target anti-stigma interventions also pointed to the importance of reaching people at an emotional as well as an intellectual level; it was also important to involve people living with mental illness themselves in these campaigns:

When we talked about targeting things, we were trying to target experiences. We figured out we had to get them at an emotional level. We had to make them aware that their whole system of beliefs was somehow ill-founded. One of the best ways to do that was to construct situations in which people who have a mental illness could meet people who have perhaps never met someone with a mental illness, under controlled and constructive kinds of situations. They would talk about their mental illness. They would convey factual information, but more important, they would convey information at a human level. That is what made the difference.[375]

This point was reinforced by Tara Marttinen, who told the Committee of her experience of speaking about her own illness:

I have spoken to a diverse range of individuals and groups regarding my illness. Because I am healthy, fairly articulate and approachable, people are generally more receptive to learning about the disease, and I try to shatter those barriers of stigma that people often have. Hence, I strongly recommend implementing a mental health ambassadors program that is not volunteer-based. I believe this should be a paid position and this program would eliminate some of the stigma I think that a lot of people with mental illness have to endure.[376] 

Jean-Pierre Galipeault told the Committee that this kind of effort has to be undertaken at the local level, and sustained over time.

One approach is the old grinding approach, what I am starting to call the “one-block-at-a-time” approach.  A couple of years ago a manager of a mental health program in downtown Dartmouth asked me how can we make sure that consumers are viewed as full citizens. I think part of the answer is those of us who are involved in this [have] a responsibility to assist in this regard.  I told her to take a one-block or a two-block radius of  you’re the program location and hold a town hall meeting and have consumers present and talk to the citizens in that area. I told her to start knocking on doors, dropping off flyers, inviting people out and letting them know how consumers contribute to the economic well-being of that two-block community and how they contribute to the cultural mosaic of that community.  You work those two blocks for a period of months or a year and then you spread out to two more blocks.  I think it is a long, slow approach, but I think it is part of the solution.[377]

Several witnesses also highlighted the importance of making resources available across the country to support this kind of campaign. The Honourable Elvy Robichaud, Minister of Health and Wellness in New Brunswick, told the Committee:

Stigma is more difficult to address, and is not open to legislative protection as is discrimination under the human rights legislation. In this area, the federal government could play a major leadership role. Anti-stigma and social marketing campaigns are costly and often beyond the fiscal resources available in our province, or if we did it on our own. It might be a whole lot better if all jurisdictions would get into the act and have something that is at least essentially the same. Usually we can adapt to most any Canadian jurisdiction. Further, this is an area in which the federal government has demonstrated competence and leadership — for instance, on the tobacco campaign — and one in which federal initiatives would be beneficial to all provinces and territories.[378]

Reid Burke, Executive Director, Canadian Mental Health Association of Prince Edward Island, emphasized both the need to sustain anti-stigma campaigns over time and the need to focus on the potential for recovery:

Social marketing and changing attitudes is the way to go.   It is not going to happen with one campaign.  ParticipAction took 10 or 15 years and now everybody well understands how important that is.  If we want to call it “mental fitness” or “mental wellness,” there needs to be a concerted effort in this country to put money into social marketing that normalizes mental health.  I do not think that will take away from the devastating effects of the illness, but we need to promote hope, as well as recovery and resilience.[379]

The Committee was very impressed by initiatives undertaken by the Australian government to educate people about the realities of mental illness and to combat stigma. In particular, the Committee believes that there is much to learn from the separate, not-for-profit, private company that was funded by the Australian government called “beyondblue.” The company was established in October 2000 with the objective of promoting a better understanding of depression. It works in partnership with health services, schools, workplaces, universities, media and community organizations, as well as with people living with depression, and thus brings together both expertise in depression and personal experience of the problem.[380]

In its plan for the years 2005-2010, beyondblue notes that:

§         Text Box: The various initiatives undertaken in Australia had helped improve “mental health literacy in the Australian population by about 10 percentage points since 1996.”As an independent national body, beyondblue can reach beyond government politics and policies into states, territories and local communities and across regional and rural Australia. beyondblue will establish new and expand existing programs to meet emerging national priorities for prevention, treatment and awareness of depression, anxiety and related substance use disorders.

 

§         beyondblue’s collective national strengths are greater than an individual state-based focus on depression. It is cost-effective for all state and territory governments to conduct their promotion, prevention and early intervention strategies for depression and related disorders in partnership with beyondblue. The return on investment through delivery of national programs and website provides outcomes that are greater in value than the individual contributions made by state and territory governments.

§         States and territories already benefit from the greater understanding of depression generated by beyondblue’s national awareness programs, positive media and community profile, and the beyondblue website with its series of clinical fact sheets; interactive on-line depression self-assessment; media centre and supporting links.[381]

Mr. Dermot Casey, Assistant Secretary, Health and Priorities and Suicide Prevention, for the Department of Health and Ageing, Government of Australia, told the Committee that the various initiatives undertaken in Australia had helped improve “mental health literacy in the Australian population by about 10 percentage points since 1996.” He also told the Committee that:

our hospital contact data and our health service contact data show that there is a greater proportion of the population seeking care than was the case when we did our epidemiology study. We would conclude from that that they are now at least more prepared to seek treatment…[382]

A recent study of the impact of beyondblue confirmed Mr. Casey’s assessment, and noted that:

The data are consistent with beyondblue having had a positive effect on some beliefs about depression treatment, most notably counselling and medication, and about the value of help-seeking in general. These findings suggest that national awareness campaigns may be effective in improving community mental health knowledge. The data also demonstrate the potential value of population monitoring of mental health literacy.[383]

There are thus six points that stand out in with regard to building an anti-stigma campaign in Canada. The evidence strongly suggests that, to be successful, an anti-stigma campaign must:

1.       Be carefully targeted to specific audiences;

2.       Be sustained over a substantial period of time;

3.       Both educate people about the reality of mental illness and engage them at an emotional level;

4.       Involve people living with mental illness as spokespeople;

5.       Focus on the potential for recovery and highlight the positive contributions made to local communities by people living with mental illness;

6.       Text Box: These lessons should guide the Mental Health Commission in the design and implementation of the anti-stigma campaign with which it has been charged.Deploy national resources that can be adapted to regional and local circumstances.

 

 

 

The Committee believes that these lessons should guide the Mental Health Commission in the design and implementation of the anti-stigma campaign with which it has been charged.

 

16.4.3   Knowledge Exchange Centre

As outlined above, the second major task that the Canadian Mental Health Commission will undertake is the creation of a Knowledge Exchange Centre. Many witnesses pointed to the need for such a centre.

Moreover, in October 2005, the Committee received a detailed proposal from three distinguished academics that contains recommendations that align very closely with the Committee’s intentions. The following observations draw on this submission by Goering, Goldner and Lesage[384] and expand on the description contained in the Committee’s proposal to create the Commission reproduced above (see section 16.2.1).

Text Box: “A national, dedicated focus for carrying out the mental health services knowledge translation function, currently does not exist.”The authors call for the creation of a “Canadian Mental Health Services Knowledge Translation Network” that is very similar to the Knowledge Exchange Centre and related functions of the Commission in the Committee’s proposal. The network would be 

a dedicated national, expert resource to facilitate mental health services knowledge translation, including the use of research syntheses and best practices across the country regarding the organization and delivery of mental health prevention, treatment, rehabilitation and support services. …The Network would facilitate the exchange of the best available knowledge between mental health services knowledge producers and users across Canada. It would facilitate the translation of mental health services research into “on the ground” policies and practices.[385]

Based on a scan of several organizations in Canada (including the Canadian Centre on Substance Abuse, the Canadian Institute for Health Information, and the Canadian Institutes of Health Research) the authors found that “while several individuals and organizations across Canada are engaged in mental health services knowledge translation activities in a variety of capacities, this function is typically not their primary focus,” and that “a national, dedicated focus for carrying out the mental health services knowledge translation function, currently does not exist.”[386]

The Committee agrees that these functions can best be carried out by a “neutral source, one that is not affiliated or driven by any current mandate or particular stakeholder interests, other than knowledge translation.”[387] Such an organization would produce “research syntheses, national and best practice reports regarding the organization and delivery of mental health prevention, treatment, and rehabilitation and support services”[388]  targeted at governments, providers, and people living with mental illness and their families.

The authors point out that:

Effective knowledge translation also requires expertise in determining what constitutes quality knowledge and the ability to develop and apply optimal methodologies for effective knowledge transfer and utilization. Expertise on mental health service and system issues is vital given the particularly difficult and complex issues with which this sector must grapple — stigma and discrimination, and a low public policy profile.[389]

This would entail both “pushing” research results out to users and facilitating the ability of people to “pull” material from the organization’s database, as well as allowing exchanges between both “pushers” and “pullers.” Thus it would be possible to do the following:

“Push” research findings out to users:

§         Translation of available high-quality, relevant mental health prevention and services research;

§         New mental health services research syntheses/summaries;

§         New national reports on the state of the mental health system;

§         New national reports on the status of mental health of Canadians;

§         New best-practice reports on mental health services; and

§         Toolkits that provide means of evaluating the fidelity and outcomes of programs.

Facilitate user “pull”:

§         Database of existing knowledge syntheses, national and best-practice reports;

§         Mental health services knowledge needs assessments; and

§         Capacity development through the training and education of knowledge users —  i.e., federal, provincial and territorial planners, decision-makers and leaders of service providers and community organizations, as well as advocates for people living with mental illness.

Facilitate exchange between “pushers” and “pullers”:

§         Provide a rapid response consultation service on priority areas, based on the best available knowledge;

§         Educational symposia, seminars, and workshops that facilitate knowledge exchange; and

§         A comprehensive Internet-based knowledge exchange portal.[390]

Text Box: The Committee believes that the Canadian Mental Health Commission should draw on these observations as it establishes the Knowledge Exchange Centre.The Committee also agrees with the authors that the Knowledge Exchange Centre should “collaborate with existing organizations within and outside of the federal and provincial/territorial governments to avoid duplication and ensure that its efforts add value.”[391]

The authors also rightly point out that there are many tasks that the Centre should not undertake, including: 

§         Funding and undertaking specific research projects;

§         Recreating existing knowledge, data, or information;

§         Recreating existing knowledge transfer tools and resources (e.g., Canadian Health Services Research Foundation);

§         Maintaining research databases;

§         Providing 1-800 service for consumers seeking to access mental health services;

§         Directing consumer/provider/system advocacy; and

§         Implementing knowledge (i.e., policy or service implementation at the provincial, regional, local and individual levels).[392]

The Committee believes that the Canadian Mental Health Commission should draw on these observations as it establishes the Knowledge Exchange Centre.

 

16.5      THE NEED FOR FEDERAL INVESTMENT IN MENTAL HEALTH

Text Box: During the transition period the old system must be sustained until the new one can take its place.As discussed in Chapter 5, a number of significant benefits would be realized by accelerating the transition to a community-based system of mental health care. Research reviewed in that chapter shows that community care leads to better mental health outcomes,[393] and that treatment within the community environment can improve access to care while making the mental health care system more sustainable. It also enables greater participation in the organization and running of the system by people living with mental illness and their families, community organizations, and voluntary health organizations.

Text Box: In order to complete this transformation of the mental health care system from an institutionally based system to one that is predominantly based in the community, a targeted investment by the federal government is needed in the form of a Mental Health Transition Fund.Text Box: The provision of mental health services and supports in the community fosters recovery by giving people living with mental illness more autonomy and independence. They gain the ability to live in their communities with minimal intervention by formal services; to the greatest extent possible, they make their own decisions.Most importantly, the provision of mental health services and supports in the community fosters recovery by giving people living with mental illness more autonomy and independence. They gain the ability to live in their communities with minimal intervention by formal services; to the greatest extent possible, they make their own decisions.

Text Box: Far too many people living with mental illness have ended up in prisons and homeless shelters — indeed, prisons and shelters have become the asylums of the 21st century. Alternatively, families have been burdened with responsibility for care.

Text Box: The Mental Health Transition Fund (MHTF) should have two main components: a Basket of Community Services (BCS) to assist provinces to provide services and supports in communities to people living with mental illness, and a Mental Health Housing Initiative (MHHI) to provide federal funds for the construction of new affordable housing units, as well as for rent supplementsDespite these benefits, we saw in Chapter 5 that the movement toward a community-based system has not fully taken root. In many cases, deinstitutionalization has been undertaken without the necessary community supports being in place. The result has been that far too many people living with mental illness have ended up in prisons and homeless shelters — indeed, prisons and shelters have become the asylums of the 21st century. Alternatively, families have been burdened with responsibility for care.

Text Box: Both of these initiatives would be subject to the same ten-year sunset provision as the Canadian Mental Health Commission.Text Box: The costs of supporting and treating people in the community are roughly equivalent to the costs of the old institution-heavy system.Part of the problem has been that it has proven difficult to fund the costs of transition from institutional to community care. During the transition period the old system must be sustained until the new one can take its place. As explained in Chapter 5, the Committee believes that in order to complete this transformation of the mental health care system from an institutionally based system to one that is predominantly based in the community, a targeted investment by the federal government is needed in the form of a Mental Health Transition Fund.

Text Box: The MHHI, it has a specific target — the elimination of discrimination in the provision of affordable housing to people living with mental illness.In the Committee’s view, this Mental Health Transition Fund (MHTF) should have two main components: a Basket of Community Services (BCS) to assist provinces to provide services and supports in communities to people living with mental illness, and a Mental Health Housing Initiative (MHHI) to provide federal funds for the construction of new affordable housing units, as well as for rent supplements so that people living with a mental illness, who could not otherwise afford to do so, can rent suitable accommodation at market rates.

Both of these initiatives would be subject to the same ten-year sunset provision as the Canadian Mental Health Commission; neither would entail new open-ended funding obligations on the part of the federal government.

Text Box: The Mental Health Transition Fund is a genuine transition fund. It is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another.With regard to the BCS, research shows that the costs of supporting and treating people in the community are roughly equivalent to the costs of the old institution-heavy system.[394] This means that once a new “steady state” has been achieved, it will be sustainable with the same level of provincial government spending as was devoted to the institutional system it will have replaced. This will allow withdrawal of support by the federal government after a transition period. With regard to the MHHI, it has a specific target — the elimination of discrimination in the provision of affordable housing to people living with mental illness; it too will end after ten years.

As noted in Chapter 5, the Committee has been very careful in crafting its recommendations to ensure that the Mental Health Transition Fund is a genuine transition fund. It is designed solely to cover the costs associated with the shift from one way of organizing mental health services to another that will cost the same once the transition is complete. In this, it is unlike many other federal initiatives that have also been called “transition funds,” such as the Primary Care Transition Fund. Too often, such federal initiatives have entailed the creation of new programs that must either be supported by new provincial money or disbanded once the federal funding that sparked their creation has come to an end. Such initiatives place subsequent ongoing obligations on provincial and territorial governments to fund them.

The Committee believes strongly that the federal government must provide the funds needed to accelerate the transformation of the mental health care system. Therefore, the Committee recommended in Chapter 5:

 

 

108

That the Government of Canada create a Mental Health Transition Fund in order to help accelerate the transition to a system in which the delivery of mental health services and supports is based predominantly in the community.

That this Fund be made available to the provinces and territories on a per capita basis, and that the Fund be administered by the Canadian Mental Health Commission that has been agreed to by all Ministers of Health (with the exception of Quebec).

That the provinces and territories be eligible to receive funding from the Mental Health Transition Fund for a Basket of Community Services, as long as these projects:

 

 

·         Would not otherwise have been funded; that is, these projects would represent an increase in provincial or territorial spending on mental health services that is over and above existing spending on services and supports plus an increment equal to the annual percentage increase in overall spending on health;

·         Contribute to the transition towards a system in which the delivery of mental health services and supports is based predominantly in the community.

That, as part of the Mental Health Transition Fund, the Government of Canada create a Mental Health Housing Initiative that will provide funds both for the development of new affordable housing units and for rent supplement programs that subsidize people living with mental illness who would otherwise not be able to rent vacant accommodation at current market rates.

That, in managing the housing portion of the Mental Health Transition Fund, the Canadian Mental Health Commission should work closely with the Canada Mortgage and Housing Corporation.

 

The requirement that Transition Fund monies be incremental to current provincial/territorial spending on mental health should not act as a disincentive to improved productivity in delivering mental health supports and services. The availability of new funds should not deter anyone in the mental health system from actively working to use all public funds as efficiently as possible. The Committee believes it important that savings derived from productivity increases be available to health departments to invest throughout the health care system and not exclusively on mental health and addictions.

 

16.5.1   Managing the Transition Fund

The Committee believes strongly that the Canadian Mental Health Commission should manage the Mental Health Transition Fund. Text Box: The Canadian Mental Health Commission should manage the Mental Health Transition Fund.The Commission will be a truly national body with expertise like none other in mental health care. It will be able to consult all stakeholders on how best to ensure that the fund is used effectively, and it will be able to collaborate with the provinces and territories on the design, administration and implementation of the fund.

As discussed in Chapter 5, the Commission would not direct how the monies from the Basket of Community Services portion of the fund should be utilized, other than to ensure that they are used to support the transition to community-based services (such as Assertive Community Treatment Teams, Home Withdrawal Management Programs, Intensive Case Management and Crisis Intervention Services) and to verify that federal money is used to increase the amount that provinces and territories would otherwise have spent on mental health services and supports. The Committee has deliberately left open which specific programs would be covered under the Basket of Community Services. In other words, it has not attempted to define a comprehensive list of services and supports that would be eligible to receive money from the Mental Health Transition Fund.

Text Box: The fund should be distributed to the provinces and territories on the basis of population.In Chapter 5, the Committee explained the many reasons for adopting such a non-prescriptive approach. In part, it is based on the recognition that the Committee does not have the necessary expertise to undertake such a task. There is also the reality of regional and local diversity of circumstance — needs are so varied, resources so differently distributed that it would not be appropriate for any national body to attempt to specify in detail which services and supports deserve to be funded. Any examples that are given in this report are just that — examples of the kinds of services and supports the Committee believes should qualify for Transition Fund support.

Text Box: Territorial governments should receive additional funding to assist the provision of community-based mental health care services to remote populations.  Text Box: In the case of Prince Edward Island, careful consideration should be given to the possibility of adjusting the per capita funding level.The Committee also believes that the fund should be distributed to the provinces and territories on the basis of population. However, access to family and community-based health care services is a particular challenge in the territories, where the distribution of small populations across vast and remote regions poses huge obstacles to community-based delivery of mental health services.

 The federal government recognized these difficulties at the September 2004 First Ministers meeting on health care by creating a Territorial Health Access Fund ($150 million over five years). The Committee also acknowledges the particular circumstances and needs of the territories. It believes that they should receive additional funding to assist the provision of community-based mental health care services to remote populations.  The Committee therefore recommends:

 

 

109

That the territories receive additional funding from the federal government, over and above their per capita allocation from the Mental Health Transition Fund, in order to assist them in addressing the needs of remote, isolated and non-urban communities.

 

The Committee also recognizes that similar concerns have been raised concerning per capita funding by some of the smaller provinces. The Committee believes that in the case of Prince Edward Island, careful consideration should be given to the possibility of adjusting the per capita funding level in order to ensure that sufficient funds are transferred to that province to enable it to complete the transition to a community-based mental health delivery system.

As noted in Chapter 5, the federal government, stakeholders, and Canadians in general are entitled to know that money from the Mental Health Transition Fund is: (a) spent on community-based mental health projects; and (b) used to increase the total amount each jurisdiction is spending on enhancing mental health and treating mental illness. The goal is that the Transition Fund be used to support transformation of the mental health care system, not as a substitute for existing provincial or territorial spending.

The Committee realizes that provinces and territories are not in favour of having to report to the federal government or a national organization on how they manage their health care spending. Nonetheless, the Committee strongly believes that there should be some form of accountability for the use of money from the Fund. Therefore the Committee recommends:

 

 

110

That the use of the monies from the Mental Health Transition Fund should be subjected to an external audit, to be performed by provincial auditors general in order to ensure that the monies are spent in a manner consistent with the two objectives of the Transition Fund, namely:

(a)        to fund community based mental health services and supports; and

(b)        to increase the total amount each jurisdiction spends on enhancing mental health and treating mental illness.

 

Text Box: Segregation would help to prevent money from the Mental Health Transition Fund from simply disappearing into the acute care system.Subjecting the use of money from the Transition Fund to an external audit will also help to ensure that these funds are effectively segregated from the rest of the health care system. By making it easier for provincial and territorial health ministers and deputy ministers to resist internal pressure from other spending demands of their government, that segregation would help to prevent money from the Mental Health Transition Fund from simply disappearing into the acute care system.

 

16.5.2   Estimating the Overall Cost of the Basket of Community Services

Text Box: The Committee believes that ten years is a realistic time frame for transition, although it recognizes that it may not be possible to put in place at once all the programs that are needed. Instead, it may be necessary to begin slowly and increase the flow of funds over time.There are currently no reliable data on what it would cost to complete the transformation of the mental health care system from an institutional base to one that is predominantly based in the community. An accurate assessment would require a needs-based analysis not just in each province and territory but within the regions of each jurisdiction, given that the services available and the unmet needs vary greatly across the country and from community to community.

The mental health care “system” is diverse and fragmented; most services and supports operate independently of one other. It is thus very difficult to assess even approximately the needs and the capacity shortfalls in the current system. Consequently, the Committee has relied upon the work of others to establish a reasonable estimate of the size of an effective transition fund.

In 2000, the Ontario Minister of Health and Long-Term Care established nine regional task forces to develop recommendations for regional and local improvements to mental health services across Ontario; these included restructuring the psychiatric hospital system, community reinvestments and the implementation of mental health reform.[395] The Toronto-Peel Mental Health Implementation Task Force, like the other regional task forces, made a wide range of recommendations affecting the full spectrum of mental health care services.[396] It also provided an overall costing estimate to transform the mental health care system in that region.[397]

The Committee’s estimate of the overall cost of transforming the mental health system is based on the work of this task force. Rather than attempt to cost out each and every recommendation, the Toronto-Peel Task Force provided an overall, “order-of-magnitude” estimate of the increases required in the base funding for mental health care services in its region. It concluded that, to achieve an adequate transformation, the region’s mental health system required an investment of approximately $245 million over five years.

The report by the Toronto-Peel Task Force is one of the few detailed, systematic attempts to examine the needs of the mental health care system in Canada and provide an estimate of the costs of transforming that system. While the Committee realizes that the area studied is largely urban, it combines a fairly well serviced area, Toronto, with one of the most poorly serviced areas in Ontario from a mental health service and support perspective, Peel.[398]

Furthermore, the Toronto-Peel region incorporates a high degree of socio-economic diversity. The Task Force had to balance the gaps and capacity needs of each part of the region. Similarly, it would be up to each province and territory to determine where services are most needed and where additional resources would be most effectively allocated. The Committee believes that the costing estimate of the Toronto-Peel Task Force is a useful base from which to calculate what the needs of the mental health care system might be in Canada generally.

In order to determine the overall size of the transition fund for all the provinces and territories, the Committe extrapolated on the basis of population from the Toronto-Peel region to the rest of Canada. In 2001, when the last census was conducted, Toronto-Peel constituted 30.42% of the population of Ontario; Ontario constituted 38.02% of the population of Canada. By extrapolation, the total required for Canada would be $2.148 billion.

The Toronto-Peel Task Force requested that the recommended increase in funding be allocated over five years. The Committee believes, for two reasons, that it would be preferable to spread the allocation to the Mental Health Transition Fund over ten years:

§         First, given the human resource and supportive housing shortage facing the mental health sector, the Committee does not believe that the system could effectively absorb the full transition funding in five years.

§         Second, it is unreasonable to expect the federal government to be able to afford to close the service funding gap in a period as short as five years.

The Committee believes that ten years is a realistic time frame for transition, although it recognizes that it may not be possible to put in place at once all the programs that are needed. Instead, it may be necessary to begin slowly and increase the flow of funds over time. Therefore, the Committee recommends:

 

 

111

That the Basket of Community Services component of the Mental Health Transition Fund average $215 million per year over a ten year period, for a total of $2.15 billion.

 

This is a lot of money, but the total pales in comparison to the estimated $2.7 billion the province of Ontario alone spends on mental health care each year[399] or to the $14.4 billion that mental illness and substance use problems cost Canada in 1998.[400]

 

16.5.3   Mental Health Housing Initiative

Text Box: Among the homeless, it has been estimated that between 30% and 40% have mental health problems.Text Box: The percentage of Canadians who are living with mental illness who need access to such housing is almost double the percentage of people in the general population whose housing needs are not being met. This constitutes discrimination against people living with mental illness.As discussed in greater detail in Chapter 5, one of the biggest problems facing people with mental illness is the lack of affordable housing. Because people with mental illness often have little or no income, they are often forced to live in neighbourhoods characterized by high crime rates, drugs and violence. Among the homeless, it has been estimated that between 30% and 40% have mental health problems.[401]

According to data provided by the Canada Housing and Mortgage Corporation, 15% of the Canadian population as a whole is in need of housing that is adequate, suitable, and affordable.[402] At the same time, the housing situation confronting people living with mental illness is considerably worse; 27% (approximately 140,000) are in need of adequate, suitable, and affordable housing.[403] In other words, the percentage of Canadians who are living with mental illness who need access to such housing is almost double the percentage of people in the general population whose housing needs are not being met. The Committee believes that this constitutes discrimination against people living with mental illness.

Text Box: More affordable housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people living with a mental illness can live in their communities.According to the Canadian Mental Health Association, between 1980 and 2000, the number of affordable housing units created by the Government of Canada dropped from 24,000 to 940.[404] In many communities, adequate and affordable housing is beyond the means of people who rely on publiclyfunded income support. For example, in British Columbia, people on disability benefits or social assistance receive $325 for shelter costs per month, yet average market rents in Metropolitan Vancouver are over $600 per month; even run-down single-room-occupancy hotel rooms cost $350 a month on average.

The Committee concluded unequivocally in Chapter 5 that: more affordable housing units are required; more assistance is needed so that people can afford to rent existing apartments at market rates; and more supportive services are needed so that people living with a mental illness can live in their communities.

It is critical that a significant increase in community-based supportive services for people living with mental illness be part of any housing initiative targeted at people living with mental illness. Otherwise, such a program cannot achieve its objectives. Therefore, all such services must be eligible for funding under the Basket of Community Services portion of the Mental Health Transition Fund.

Text Box: The Committee considers inexcusable the lack of affordable and appropriate housing for people living with mental illness.The federal government has begun to reinvest in affordable housing, primarily through the Canada Mortgage and Housing Corporation. It recently extended the National Homeless Initiative, which funds community supports such as emergency shelters and drop-in centres. It also established the Residential Rehabilitation Assistance Program, which provides assistance to low-income households, persons with disabilities and Aboriginal people to bring their homes up to minimum health and safety standards, as well as repair shelters for victims of family violence and support home adaptations for low-income seniors.[405]

In addition, through the Affordable Housing Initiative, the federal government has agreements with the provinces and territories to share the cost of the construction of new affordable housing units, as well as to provide rental supplements to low-income households. The federal government does not have any housing programs, however, designed to meet the specific needs of people living with mental illness.

Text Box: Approximately 56,500 people living with mental illness would need access to some form of affordable housing in order to bring down the proportion of people living with mental illness in need of housing to the national average. The Committee has recommended that 57,000 new affordable housing units be developed.The Committee considers inexcusable the lack of affordable and appropriate housing for people living with mental illness. It is appalling that the proportion of people with mental illness in need of housing (27%) is nearly double that of the population as a whole (15%). According to the Canada Mortgage and Housing Corporation, approximately 56,500 people living with mental illness would need access to some form of affordable housing in order to bring down the proportion of people living with mental illness in need of housing to the national average.[406]

 

Ideally, the Committee would like to see all Canadians have access to affordable housing; but this is not a realistic goal in the short term. Text Box: When the Mental Health Housing Initiative is launched, its initial focus should be on rent-subsidized units because of the need to act quickly to address the housing shortage.The Committee does want, however, an end to the current discrimination against people living with mental illness; this is why it has recommended the establishment of the Mental Health Housing Initiative as part of the Mental Health Transition Fund. This is also why the Committee has recommended that 57,000[407] new affordable housing units be developed.

Text Box: The federal government pay the full share of the rent subsidies for the first three years.The needs of people living with mental illness are not all the same — some require supportive services while others who are more independent have trouble finding adequate housing. The Committee believes that a program to meet the core housing need of people living with mental illness should establish a 60/40 mix of rent subsidies relative to the construction of new housing units.

The Committee also believes that when the Mental Health Housing Initiative is launched, its initial focus should be on rent-subsidized units because of the need to act quickly to address the housing shortage.[408] The MHHI should be modelled on existing housing programs and “cost-shared” with the provinces in the same way that current supportive housing projects are — such as those targeted at people who are currently homeless.

The Committee feels so strongly that the housing shortage must be addressed immediately, that it is recommending that the federal government pay the full share of the rent subsidies for the first three years. This will kick-start the program and allow time for agreements to be reached subsequently with the provinces and territories.

More specifically, the Committee is recommending that in years 1 through 3 of the MHHI, 80% of the people provided with housing should receive a rent supplement of $6,020 in the first year and $4,250 annually thereafter. The remaining 20% should move into newly constructed units costing $75,000 per unit.[409] In years 4 through 7, the proportion of rent supplements to newly constructed units should be 60/40, and in years 8 through 10 the proportion should be 40/60.

The table below shows that the total cost would be $2.24 billion over ten years at an average annual cost of $224 million.

The MHHI would draw on evidence-based housing policies and best practices in supported housing. Consideration should also be given to innovative approaches by governments, health authorities and non-profit organizations, such as aggregating their subsidies to allow partnerships with tenants in the purchase of housing properties. Such approaches may help to address the economic realities of escalating rents and capital costs.

 

Table: Costing Analysis of the Mental Health Housing Initiative

Year

# of new units

Cost of new units

# of new rent supple-ments

Cost of new rent supple-ments

# of continued rent supple-ments

Cost of continued rent supple-ments

Total rent supple-ment cost

Total annual cost

# of people removed from core housing need

1

1,129

84.675

4,520

27.210

0

0.000

27.210

111.885

5,649

2

1,129

84.675

4,520

27.210

4,250

19.210

46.420

131.095

11,295

3

1,129

84.675

4,520

27.210

9,040

38.420

65.630

150.305

16,947

4

2,260

169.500

3,388

10.198

13,560

28.815

39.013

208.513

22,595

5

2,260

169.500

3,388

10.198

16,948

36.015

46.212

215.712

28,243

6

2,260

169.500

3,388

10.198

20,336

43.214

53.412

222.912

33,891

7

2,260

169.500

3,388

10.198

23,724

50.414

60.611

230.111

39,539

8

3,388

254.100

2,258

6.800

27,112

57.613

64.413

318.513

45,186

9

3,388

254.100

2,259

6.797

29,371

62.413

69.210

323.310

50,832

10

3,388

254.100

2,258

6.797

31,629

67.212

74.008

328.108

56,478

Total

22,591

1694.325

33,887

142.815

 

403.325

546.140

2,240.465

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    Source: Based on data provided by the Canada Mortgage and Housing Corporation. All costs are in millions of dollars.

 

The Committee therefore recommends:

 

 

112

That the Government of Canada invest $2.24 billion over ten years in the Mental Health Housing Initiative (MHHI) that is to be established as part of the Mental Health Transition Fund.

That the MHHI have as its goal to reduce the percentage of Canadians living with mental illness in need of housing that is adequate, suitable and affordable from 27% to the national average (15%) of people in need of such housing, specifically by providing 57,000 people living with mental illness with access to affordable housing.

 

 

That, over the life of the MHHI, 60% of its funds be allocated to providing rent supplements to people living with mental illness who would otherwise be unable to afford to rent accommodation at market rates, and the remaining 40% be devoted to the development of new affordable housing units.

That, in order to provide immediate assistance to as many people as possible, during the first three years of the MHHI, fully 80% of available funds be allocated to rent supplements; and that during this period the federal government pay the full share of the rent subsidies, after which the cost of the rent subsidies be shared according to existing federal-provincial-territorial arrangements.

That innovative approaches by governments, health authorities and non-profit organizations be supported, such as aggregation of subsidies to allow partnerships with tenants in the purchase of housing properties.

That, following the ten-year life of the MHHI, the Canada Mortgage and Housing Corporation be mandated to maintain the percentage of people living with mental illness who are in need of housing that is adequate, suitable and affordable at the same percentage as that of the population as a whole.

 

16.5.4   Other Elements in the Transition Fund

In addition to the Basket of Community Services and the Mental Health Housing Initiative, the Committee believes that several other important elements should be part of the Transition Fund.

16.5.4.1         Initiatives with a Specific Focus on Substance Use Disorders, Addictive Behaviour and Concurrent Disorders

Text Box: Mental illness and substance use disorders are often concurrent.Text Box: 30% of people diagnosed with a mental illness will also have a substance use disorder in their lifetime, and 37% of people with an alcohol use disorder (53% who have a drug use disorder other than alcohol) also live with a mental illness.The Canadian Addiction Survey, a recent national epidemiological study of substance use and addictive behaviour across Canada, estimated that approximately 3.5 million Canadians had a substantial problem with alcohol consumption, 2.1 million with cannabis use, and 330,000 with other illicit drug use.[410] For many, such substance use problems and addictive behaviours have devastating consequences that result in profound harm and suffering. Morbidity and mortality data reveal high rates of suicide associated with alcohol and drug use, accidental deaths and disability (including motor vehicle related deaths and disability), violent behaviour and criminal activity, physical illness and the spread of infectious diseases such as hepatitis C, tuberculosis and HIV/AIDS.  A 1996 study by the Canadian Centre on Substance Abuse, The Costs of Substance Abuse in Canada, estimated that the economic cost of substance use problems in 1992 in Canada was $18.4 billion, including the direct costs of health care and law enforcement and indirect costs due to loss of productivity.[411]

Publicly funded prevention, treatment and support services for substance use problems and addiction are provided primarily by provincial and territorial governments as a category of general health services. Ideally, a broad set of coordinated services and supports would be available to address substance use problems, such as the continuum of services described in the recent B.C. government framework, Every Door is the Right Door: A British Columbia Framework to Address Problematic Substance Use and Addiction:[412]

§         Health Promotion and Primary Prevention Initiatives, including universal and selective prevention activities;

§         Secondary Prevention/Early Intervention, including indicated prevention, early identification and early treatment activities;

§         Standard Treatment and Self-management with Selected Supports;

§         Intensive Treatment, Long-term Rehabilitation and Support.

Programs that are designed to meet the needs of specific populations, such as older adults, youth, and Aboriginal peoples, are also required for optimal prevention and treatment of substance use disorders. In addition, initiatives are required to address other addictive behaviours such as problem gambling.

Text Box: It has been common for clients to be excluded from mental health services if they admitted to substance use problems. Similarly, clients were often excluded from addiction treatment programs if they admitted to the use of antidepressant medications.Throughout most of Canada, a complete and comprehensive set of services and supports to address substance use problems and addictive behaviours is unavailable. It is impossible to obtain an accurate estimate of the total funding allocated by the provinces and territories to address substance use and other addictive behaviours, because expenditures for these services are blended into overall health care costs. National figures on the number of Canadians involved in addiction treatment programs are also not available. The Canadian Centre for Substance Abuse estimates that approximately $400 million per year is currently being spent across the country on substance use disorder treatment services.[413] A recent national epidemiological survey undertaken by Statistics Canada found that only a small proportion of individuals with substance use disorders and addictive behaviours receive treatment. [414]

The relationship between services for mental illness (such as treatment for depression, anxiety disorders and schizophrenic disorders) and services for substance use disorders (including treatment for problematic alcohol use, withdrawal management services, methadone maintenance for opiate addiction and needle exchange programs) has been the subject of much discussion and debate across Canada. In previous decades, services for the two types of disorder were administered separately; they developed divergent treatment philosophies, used different terminology and constituted different “cultures” that were often in conflict.

Mental illness and substance use disorders are often concurrent; it is quite common for people to suffer from both. Research has shown that 30% of people diagnosed with a mental illness will also have a substance use disorder in their lifetime, and 37% of people with an alcohol use disorder (53% who have a drug use disorder other than alcohol) also live with a mental illness.[415]

The “culture clash” between mental health services and addiction services has created substantial problems for clients, particularly those with concurrent disorders. As a result of conflicting approaches to treatment, clients have often received confusing and inconsistent information and advice. It has been common for clients to be excluded from mental health services if they admitted to substance use problems. Similarly, clients were often excluded from addiction treatment programs if they admitted to the use of antidepressant medications.

Text Box: The federal government should provide an additional $50 million to focus service reform initiatives that address substance use problems, addictive behaviour and concurrent disorders, essentially doubling the amount spent on Canada’s Drug Strategy.Efforts to improve the integration of mental health and addiction services are currently underway in many parts of Canada. Most clients welcome greater integration but some providers do not welcome the change. Providers of treatment for addiction often express concerns about what they anticipate to be the “medicalization” of services; mental health providers fear, on the other hand, that their clients’ symptoms will be inadequately addressed and treated. In many jurisdictions, providers from both groups are receiving joint training to develop more comfort when providing treatment to people with mental health problems, substance use disorders or concurrent disorders.  The administration of mental health and addiction services has been integrated in some provinces and territories, whereas in others separate administrative structures have been maintained.

Canada’s Drug Strategy[416] was developed as a federally coordinated initiative to reduce the harm associated with the use of narcotics, controlled substances, alcohol, and prescription drugs. It includes education, prevention and health promotion initiatives as well as enhanced enforcement measures. The Strategy involves a number of federal departments together with provincial and territorial governments, addictions agencies and non-governmental organizations, such as the Canadian Centre on Substance Abuse. The federal government has committed $245 million over five years, or an average of $49 million per year, to this strategy.[417]

The Committee is convinced that the federal government can and should do more to address substance use problems, addictive behaviour, and concurrent disorders. Specifically, the Committee believes that the federal government should provide an additional $50 million for services and supports for people living with concurrent disorders. The Committee therefore recommends:

 

 

113

That the Government of Canada include as part of the Transition Fund $50 million per year to be provided to the provinces and territories for outreach, treatment, prevention programs and services to people living with concurrent disorders. As with the rest of the Transition Fund, this money would be managed by the Canadian Mental Health Commission, but in respect of this component of the fund there should be close consultation with the Canadian Centre for Substance Abuse, as well as the provinces, territories, and other stakeholders.

 

In concert with the Drug Strategy funds, this additional federal investment represents a significant opportunity to improve prevention and treatment services for people with concurrent disorders. It should be noted that in 2004-05, the federal government collected almost $1.3 billion in excise duties on alcohol; its expenditures on substance use are less than 4% of what it collects in excise duties.[418]

16.5.4.2            Telemental Health[419]

Text Box: It is important for the federal government to assist with the deployment of telemental health initiatives throughout the country.As discussed in Chapter 12, there is enormous potential to telemental health, especially because the process of psychiatric diagnosis is not primarily a physical one, but relies on verbal and non-verbal communication. One of the most frequently cited benefits of telehealth is its potential to increase access to health services generally in rural and remote communities, and in particular to mental health services. This is especially important for northern Aboriginal communities with no or limited access to psychiatric services.

Funding for telemental health services comes largely from provincial and territorial governments. All provinces and territories have been experimenting with telemental health and some have already embarked on program implementation, despite the high upfront costs. The Committee believes that it important for the federal government to assist with the deployment of telemental health initiatives throughout the country.

Over time, and once the infrastructure is in place, the provinces and territories should find that the savings (e.g., reduced transportation and other costs) made possible through the implementation of telemental health services are sufficient to fund the operation of those services. The Committee recommended in Chapter 12 that the federal government assist provinces with the transition towards this “steady state” and recommends:

 

 

114

That the Government of Canada provide the provinces and territories with $2.5 million per year to help them move forward with their plans for telemental health. This money would be part of the Mental Health Transition Fund and be administered by the Canadian Mental Health Commission.

 

16.5.4.3            Peer Support

Text Box: A designated national fund be established to provide stable funding to existing peer development initiatives, build new initiatives and establish a network of self-help and peer support initiatives.In Chapter 10, the Committee documented the tremendous importance of self-help and peer support for people living with mental illness and their families. The Committee recognizes the financial difficulties faced by many of the organizations that provide these services across the country.  Hence, the Committee recommended in Chapter 10 that a designated national fund be established to provide stable funding to existing peer development initiatives, build new initiatives and establish a network of self-help and peer support initiatives. Therefore, the Committee recommends:

 

 

115

That the Government of Canada provide the provinces and territories with $2.5 million per year for peer support and self-help initiatives. This money would be part of the Mental Health Transition Fund and be administered by the Canadian Mental Health Commission.

 

  16.6      RESEARCH

In addition to the various elements of the Transition Fund, the Committee reiterates its support for research. Research into mental illness and addiction is of enormous importance. It can lead to meaningful improvements in the lives of people living with mental illness and addiction in Canada.  That is why, in Chapter 11, the Committee recommended:

 

 

116

That the federal government commit $25 million per year for research into the clinical, health services and population health aspects of mental health, mental illness and addiction.

That these funds be administered by the Canadian Institutes of Health Research (CIHR), through the Institute of Neurosciences, Mental Health and Addiction under the guidance of a multi-stakeholder board and in consultation with the Canadian Mental Health Commission.

That this $25 million be incremental to the funding currently provided to the CIHR.

 

16.7      FUNDING THE FEDERAL INVESTMENT IN MENTAL HEALTH

Text Box: The Committee has always believed that the responsible course of action is not simply to recommend that the federal government spend more money in a particular area but also to suggest how it can be raised to pay for implementation of the Committee’s recommendations.Text Box: This revenue would still go into the Consolidated Revenue Fund but be subject to the requirement that it be spent entirely and exclusively on the programs recommended.The Committee has always believed that the responsible course of action is not simply to recommend that the federal government spend more money in a particular area but also to suggest how it can be raised to pay for implementation of the Committee’s recommendations. The Committee took this approach in its October 2002 final report on the acute care (hospital and doctor) system. In that report, the Committee recommended that $5 billion be raised annually through a National Health Care Insurance Premium. While the federal government decided not to adopt the Committee’s recommendation, nonetheless, in the September 2003 federal/provincial/territorial health accord, it did agree to contribute to the provinces and territories essentially the same amount of money for health care as had been recommended by the Committee.

Based on the calculations presented in this chapter, the amount of money that is required for mental health, mental illness and addiction supports and services is only one-tenth of the amount of new spending that the Committee recommended be put into the acute care system.

The Committee believes that the new revenue it is recommending be raised should be earmarked for spending on mental health, mental illness and addiction. This revenue would still go into the Consolidated Revenue Fund but be subject to the requirement that it be spent entirely and exclusively on the programs recommended in sections 16.3 and 16.4 above.  

Objections have sometimes been raised to earmarked taxes because they reduce governments’ ability to adjust their spending as priorities change.  While the Committee is sympathetic to this objection in general, it believes that an exception ought to be made for the money recommended for mental health, mental illness and addiction for the following reasons:

§         Given that Canadians living with a mental illness or a substance use problem have been neglected, or at best substantially under-served, for so long, an extraordinary signal of support is necessary from the federal government. Such a signal would be given by its preparedness to earmark a source of new revenue specifically for them.

§         A clear precedent for earmarked taxes has been established by the federal government’s recent decision to give a certain percentage of gas taxes directly to municipalities.

§         Given that mental health and substance use issues touch the lives of essentially the entire population, the Committee believes that Canadians will agree with the proposal to pay a small amount to improve the lives of people living with these problems.

Text Box: The Committee believes that the proposal outlined below will be acceptable to the Canadian public.The Committee believes that the proposal outlined below will be acceptable to the Canadian public. In fact, there is considerable research evidence to suggest that taxes earmarked for a specific purpose are likely to be more acceptable to voters than are tax increases that provide governments with additional general revenue.

The Committee realizes that there is no “best” way of raising the required revenue. Four tests for examining possible sources of revenue were used:

1.       The revenue should be easy to collect and entail minimal additional administrative costs — that is, the method of raising funds should be very efficient.

2.       It should be easy to explain to Canadians the nature of, and the rationale for the chosen source of revenue.

3.       The method proposed for raising the revenue should be politically feasible, that is, acceptable to most Canadians.

4.       It should be easy for people outside government to calculate how much money was raised and to verify that it was indeed spent on mental illness and substance use problems; that is, it should be easy to hold government accountable.

After careful consideration, the Committee recommends:

 

 

117

That, in order to raise additional revenue to pay for the recommended federal investments in mental health, mental illness and addiction initiatives, the Government of Canada should raise the excise duty on alcoholic beverages by a nickel a drink, that is by 5 cents a standard drink.

 

One standard drink in Canada is 13.6 g of alcohol — a 12-ounce bottle of beer, a five-ounce glass of wine or 1.5 ounces of 80-proof liquor.[420] Five cents per drink translates into 5 cents on a bottle of beer, approximately 25 cents on a bottle of wine, and approximately 85 cents on a bottle of spirits.

For the reasons explained below, the Committee believes that this increase in excise duty should not apply to alcoholic beverages with an alcohol content of 4% and lower; it should not apply to light beer or other low-alcohol beer.

In fact, the Committee believes that society would benefit from a shift in consumption from higher- to lower-alcohol beer. Therefore, the Committee recommends:

 

 

118

That the Government of Canada lower the excise duty by 5 cents a drink on beer of alcohol content between 2.5% and 4%, and the excise duty on beer of alcohol content under 2.5% should be eliminated entirely.

 

In all, these changes to the federal excise tax on alcohol would raise approximately $478 million per year. The calculation is presented in the box at the following page.

The Committee believes that Canadians are not likely to object to an increase of only 5 cents per drink, especially since the federal excise duty on alcohol has not risen since 1986;[421] the Consumer Price Index (CPI) has risen by 64.25% since then.[422] In real terms (i.e., after inflation), the increase in the excise duty would be about half the rate of inflation. In 2004-2005, the revenue from excise duties on alcohol was $1,286,128,496.[423] The revenues of $478 million from the “nickel a drink proposal” would increase this amount by 37%.

REVENUE FROM THE “NICKEL A DRINK” PROPOSAL

 

Beer

According to Statistics Canada, approximately 2,232,756,000 litresof beer were sold in Canada in 2004.* The typical bottle of beer (one standard drink) contains 341 ml. Thus, the equivalent of 6,547,671,544 bottles of beer was sold in 2004. Based on information from the industry, approximately 82% of the beer sold in Canada has an alcohol content greater than 4%. If the excise duty on this beer were raised by 5 cents, this would generate $268,454,534 in revenue annually, provided consumption remained at the same level.

If the excise duty on beer with an alcohol content of 4% and lower were reduced by 5 cents from the current rate, this would lower revenues by $58,929,044.

Very little beer sold in Canada has an alcohol content of 2.5% and lower. If the excise duty on this beer were eliminated, this would reduce revenues by about $740,000.

 

Spirits and wine

In 2004, the total volume of absolute alcohol from spirits sold in Canada was 54,683,000 litres; from wine, the total was 38,611,000 litres. One standard drink contains 13.6 g of alcohol, or 17.325 ml. If the excise duty were increased by 5 cents per standard drink, this would generate revenue of $269,246,753 from spirits and wine, provided consumption remained at the same level. 

 

The total revenue from the “Nickel a Drink” proposal would be approximately $478 million per year.

 

* Information on the amount of beer, spirits and wine sold in Canada was obtained from Statistics Canada, The Control and Sale of Alcoholic Beverages in Canada, 2004, 63-202-XIE.

It should be noted that while the current excise duty on spirits is based on volume of alcohol, the excise duty on wine is based on volume sold. Consequently, unless the federal government decides to change the method of calculating the excise duty on wine (there would be some merit in doing this, as fortified wines are taxed less on a per standard drink basis than other wines), the revenue generated would likely differ slightly from the calculation given.

 

Other important benefits could be gained by shifting consumption away from higher-strength to lower-strength beer. There is good evidence from Australian studies that the consumption of lower strength beer leads to a measurable reduction in impaired driving, and that geographic regions with higher proportional sales of lower-strength beer also have less alcohol-related violence and fewer hospital admissions related to alcohol consumption.[424]

In 2001, the Australian federal government, persuaded by the evidence that reducing taxes on lower-strength beers was good for public health and safety, introduced differential excise tax rates for beer as follows:

§         Low-alcohol beer (not exceeding 3% alcohol/volume): $15.96 per litre of alcohol;

§         Mid-strength beer (>3%, <=3.5% alcohol/volume): $17.33 per litre of alcohol;

§         High-alcohol beer (exceeding 3.5% alcohol/volume): $22.68 per litre of alcohol.

The combination of less alcohol per drink and lower tax rates per unit of alcohol resulted in substantial retail price advantages for lower-strength beer. As a result, about 40% of the volume of the Australian beer market now consists of low- to mid-strength beer, between 2.5% and 3.8% alcohol.[425]

The Australian experience suggests that there could be multiple benefits for Canada were it to introduce simultaneously:

§         A 5-cent (nickel) excise duty increase on a standard drink of alcohol with the proceeds earmarked for mental health and substance use problems; and

§         A marked reduction in taxes on lower-strength beer.

These benefits would include:

§         More mental health and substance use services funded from the approximately $478 million per year that would be raised by the increased excise duty;

§         Incentives for the manufacture, marketing and sales of products with a lower alcohol content;

§         A probable reduction in the harms associated with alcohol due to a shift of consumption to products of lower strength.

The Committee has anticipated a variety of possible objections to its recommendation for a “nickel a drink” increase in the alcohol excise tax. Our responses to them are as follows.

§         To those who say that government should not increase any tax, we say that there is no free good or service. We say also that services must be improved now for Canadians living with a mental illness or a substance use problem;

§         To those who may say it is wrong to raise money based on alcohol consumption to help provide services to people living with a mental illness, we think this a misunderstanding of our proposal. Because we are recommending increased federal expenditures of nearly $500 million per year out of the Consolidated Revenue Fund, we need to recommend a way to replenish that fund with an equivalent amount. We insisted that our revenue-raising proposal meet the four tests we set out earlier in this section. The Committee believes that our proposal satisfies all four tests.

§         Our revenue-raising proposal is not linked to our expenditure proposal in any causal way. The only connection is that the amounts of money are equivalent. Indeed, the Committee has deliberately avoided raising questions here about the nature of a causal link, if any, between mental health and substance use disorders. Rather, the Committee has simply made a recommendation to the government that is both economically sound and, in our view, politically feasible.

16.8      TOTAL COSTS AND OPTIONS FOR BALANCING REVENUES AND EXPENDITURES

The total annual cost of implementing the Committee’s recommendations is outlined in the following table.

Item

Cost

($ million per year)

Mental Health Commission

17.0

Mental Health Housing Initiative

224.0

Basket of Community Services

215.0

Concurrent Disorders Program

50.0

Telemental health

2.5

Peer support

2.5

Research

25.0

Total

536.0

 

 

 

 

 

 

 

 

The $17 million budgeted for the Mental Health Commission is broken down as follows:

§         Anti-stigma program: $5 million per year. This investment would be supplemented by the Commission’s solicitation of public service announcements using the same communications materials developed for the paid social marketing campaign. In all, as much as $8 million a year, a significant communications undertaking, would fund the anti-stigma campaign.

§         Knowledge Exchange Centre: $60 million over ten years, an average of $6 million per year. The Committee has prepared and will submit to the federal government a detailed ten-year budget for the Knowledge Exchange Centre. Costs will be higher in the initial years as the information infrastructure required for the Centre is constructed, and will decline gradually as a stable operating environment is established.

§         Operation of the Commission: $6 million per year. This includes the basic operating costs of the Commission, its Board, and the advisory committees and working groups it will create, as well as the Commission’s contribution to joint projects undertaken with other governments and non-governmental organizations. The Committee has prepared a detailed budget, based on the operation of the Health Council of Canada, for submission to the Government of Canada.

Given that the anticipated revenue generated from the “nickel a drink” proposal would be $478 million per year, a shortfall of $58 million per year is left between the Committee’s recommendations and its proposed source of revenue. The Committee believes that the cost estimates for the construction of new housing units may be high,[426] so the discrepancy between revenues and expenditures may disappear once the programs are in place.

Should a shortfall persist, the Committee’s preference would be that it be made up from general revenues. Failing that, there are several other ways to bridge the potential gap:

§         The housing costs could be spread out over 15 rather than 10 years. This would reduce the average annual cost by $62 million, from $224 million to $162 million.

§         The Canada Mortgage and Housing Corporation has a large annual surplus from its mortgage insurance program. By 2009, it is estimated that CMHC will have $4.5 billion more than is necessary in capital reserves for that program. Some of these funds could be spent on the housing needs of people living with mental illness.

§         The least palatable option from the Committee’s perspective would be to leave in place the excise duty on beer with an alcohol content of 4% and under. Were this tax to remain, revenue would increase by approximately $58 million.

16.9      CONCLUSION

As noted earlier, the Committee believes that implementing the recommendations contained in this chapter — together with all those made throughout this report — will allow, for the first time, national resources to be channelled into fostering the mental health of Canadians. They will also establish a solid basis for maintaining a national focus on mental health issues and pave the way for the further development of a national approach to mental health, mental illness and addiction in Canada.


[305]  6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14mn-e.htm?Language=E&Parl=38&Ses=1&comm_id=47

[306]  World Health Organization. (November 2001) “Mental health: strengthening mental health promotion.” Fact Sheet No 229. http://www.who.int/mediacentre/factsheets/fs220/en/.

[307]  Public Health Agency of Canada. (March 2004) “What determines health?” http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html#determinants.

[308]  Public Health Agency of Canada. (November 1986) “Ottawa Charter for Health Promotion: An International Conference on Health Promotion.” http://www.phac-aspc.gc.ca/ph-sp/phdd/docs/charter/.

[309]  World Health Organization. (August 2005) The Bangkok Charter for Health Promotion in a Globalized World. http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html.

[310]  World Health Organization. (2004) Promoting Mental Health: concepts, emerging evidence, practice: summary report, p. 59. http://whqlibdoc.who.int/publications/2004/9241591595.pdf.

[311]  Standing Senate Committee on Social Affairs, Science and Technology. (April 2002) The Health of Canadians — The Federal Role, Vol. 5, pp. 154-173. http://www.parl.gc.ca/Content/SEN/Committee/371/soci/rep/repapr02vol5-e.pdf.

[312]  Standing Senate Committee on Social Affairs, Science and Technology. (October 2002) The Health of Canadians — The Federal Role, Vol. 6, pp. 251-252.     http://www.parl.gc.ca/Content/SEN/Committee/372/soci/rep/repoct02vol6-e.pdf.

[313]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 3 —Mental Health, Mental Illness and Addiction: Issues and Options for Canada, Chapter 4, Section 4.1, p. 25.:  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report3/repintnov04vol3-e.pdf.

[314]  Ibid.

[315]  World Health Organization. (2004) Prevention of mental disorders: effective interventions and policy options: summary report, p. 17. http://whqlibdoc.who.int/publications/2004/924159215X.pdf.

[316]  Ibid., p. 20.

[317]  Ibid., p. 18.

[318]  Ibid., pp. 24-36.

[319]  U.S. Department of Health and Human Services. (1999) Mental Health: A Report of the Surgeon General, Rockville, MD, p. 62. http://www.surgeongeneral.gov/library/mentalhealth/home.html.

[320]  World Health Organization. (2004) Prevention of mental disorders: effective interventions and policy options: summary report, pp. 52-56.

[321]  Office of the Auditor General of Canada. (2001) Report of the Auditor General of Canada—2001, Chapter 9, “Health Canada: A Proactive Approach to Good Health,” p. 1.    
http://www.oag-bvg.gc.ca/domino/reports.nsf/html/0109ce.html/$file/0109ce.pdf.

[322]  Ibid., p. 9.

[323]  World Health Organization. (2004) Promoting Mental Health: concepts, emerging evidence, practice: summary report, p. 47.

[324]  Ibid., p. 46.

[325]  20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/42362-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[326]  15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/SOCI/05evb-e.htm.

[327]  6 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/14ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[328]  9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[329]  31 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/SOCI/16eva-e.htm.

[330]  National Health and Welfare. (1974) A New Perspective on the Health of Canadians, pp. 61-62.

[331]  Health Canada. (2001 [1986]) Achieving Health for All: A Framework for Health Promotion.                       http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2001-frame-plan-promotion/index_e.html.

[332]  National Health and Welfare. (1998) Mental Health for Canadians: Striking a Balance.

[333]  Federal/Provincial/Territorial Advisory Committee on Population Health. (1994) Strategies for Population Health: Investing in the Health of Canadians, pp. 35-37. http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/e_strateg.pdf.

[334]  Public Health Agency of Canada. (February 2005) “Healthy Living.”  http://www.phac-aspc.gc.ca/hl-vs-strat/.

[335]  Coordinating Committee for the Intersectoral Healthy Living Network. (September 2004) First Meeting Report, Ottawa, p. 3. http://www.phac-aspc.gc.ca/hl-vs-strat/pdf/meeting_sept04.pdf.

[336]  Canadian Psychological Association. (July 2005) Recommendations to the Standing Senate Committee on Social Affairs, Science and Technology.

[337]  Public Health Agency of Canada. (January 2003) “Mental Health Promotion.”
http://www.phac-aspc.gc.ca/mh-sm/mentalhealth/mhp/index.html.

[338]  Canadian Institutes of Health Research, Institute of Population and Public Health. (May 2003) “What We Do.” http://www.cihr-irsc.gc.ca/e/12199.html.

[339]  Canadian Institutes of Health Research, Institute of Neurosciences, Mental Health and Addiction. (April 2003) “About INMHA.” http://www.cihr-irsc.gc.ca/e/8579.html. See also Chapter 14 for a more detailed discussion of INMHA’s activities.

[340]  Canadian Institute for Health Information. (March 2004) “About the Canadian Population Health Inititiative.” http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=cphi_aboutcphi_e.

[341]  Statistics Canada. (July 2005) “Canadian Community Health Survey - Mental Health and Well-being.”  http://www.statcan.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=5015&lang=en&db=IMDB&dbg=f&adm=8&dis=2.

[342]  Standing Senate Committee on Social Affairs, Science and Technology.  (November 2004) Report 3 —Mental Health, Mental Illness and Addiction: Issues and Options for Canada, Chapter 4, Section 4.2, p. 27.

[343]  Government of New Brunswick, Department of Health and Wellness. (April 2005) Research Project on Deaths by Suicide in New Brunswick between April 2002 and May 2003, p. 7. http://www.gnb.ca/0055/suicide-e.asp.

[344]  Ibid.

[345]  Ibid., p. 8.

[346]  Health Canada. (2002) A Report on Mental Illnesses in Canada, p. 102.http://www.phac-aspc.gc.ca/publicat/miic-mmac/.

[347]  Knox, K. L., et al. (December 2003) “Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study.” British Medical Journal, Vol. 327, No. 13. http://bmj.bmjjournals.com/cgi/content/full/327/7428/0-b.

[348]  Health Canada. (2002) A Report on Mental Illnesses in Canada, p. 102.

[349]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 3 —Mental Health, Mental Illness and Addiction: Issues and Options for Canada, Chapter 4, Section 4.2, p. 27.

[350]  11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15eve-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[351]  20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/42362-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[352]  Canadian Institutes of Health Research. (February 2003) Press Release, “Canadian suicide experts focus on finding solutions.” http://www.cihr-irsc.gc.ca/e/8106.html.

[353]  Canadian Association for Suicide Prevention. “Purpose and Function.” http://www.thesupportnetwork.com/CASP/purpose.html.

[354]  http://www.suicideprevention.ca/.

[355]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[356]  As indicated in Chapter 3, the Committee has not been able to devote as much attention to substance use issues as it intended when it embarked on its study of “mental health, mental illness and addiction.” The Committee recognizes that in previous decades, services for the two types of disorder were administered separately; they developed divergent treatment philosophies, used different terminology and constituted different ‘cultures’ that  were often in conflict. However, the limitations of this report with respect to substance use issues means that the Committee has been unable to examine fully the similarities and differences in approach in the mental health and substance use fields. Although some examples are drawn from the substance use sector, the main thrust of this chapter concerns the implementation of mental health initiatives at the national level. It would clearly not be appropriate for the Committee to assume that conclusions it has reached after carefully considering the mental health evidence necessarily apply with respect to substance use issues. Some may apply, but the Committee has attempted to avoid any unwarranted assumptions in this regard. There is, however, an important recommendation in this Chapter that the federal government inject an additional $50 million per year in concurrent disorder programs (see section 16.5.4.1).

[357]  21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[358]  British Columbia Schizophrenia Society. Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology.

[359]  16 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47

[360]  15 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[361]  It is worth reiterating that, although the range of supports and services that are part of the mental health “system” extend well beyond the sphere of health departments, the services and supports that are the responsibility of health departments are nonetheless clearly critical ones.

[362]  See Chapter 13, “The Federal Direct Role.”

[363]  Dr. John Service. (28 November 2005) Letter to the Standing Senate Committee on Social Affairs, Science and Technology.

[364]  CCMHI. (28 November 2005) Press release: Canadian Collaborative Mental Health Initiative applauds the establishment of landmark Commission. http://www.ccmhi.ca/en/news/press/Newsrelease_Nov28.htm.  

[365]  CMHA. (24 November 2005) News release: Commission established to serve country’s mental health needs. http://www.cmha.ca/bins/content_page.asp?cid=6-20-21-965-809.

[366]  CMHA. (24 November 2005) News release: Organizations laud Kirby Committee's proposed new Canadian Mental Health Commission.           http://www.newswire.ca/en/releases/archive/November2005/24/c9611.html

[367]  See: Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 2 — Mental health, mental illness and addiction: Mental health policies and programs in selected countries.     http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report2/repintnov04vol2-e.pdf.

[368]  With some minor editing to improve clarity.

[369]  See Chapter 8, “Workplace and Employment.”

[370]  See Chapter 13, “The Direct Federal Role” for a full discussion of the role of the federal government in delivering mental health services to the client groups for which it has direct responsibility.

[371]  See Chapter 13, “The Direct Federal Role,” and Chapter 14, “Aboriginal Peoples of Canada,” for further discussion of the importance of this recommendation.

[372]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 3.

[373]  9 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[374]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada. Chapter 3.

[375]  Ibid.

[376]  16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47

[377]  9 May 2005,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[378]  11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15eve-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[379]  16 June 2005,  http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[380]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 2 — Mental health, mental illness and addiction: Mental health policies and programs in selected countries, Chapter 1, p. 17. http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report2/repintnov04vol2-e.pdf.

[381]  beyondblue: The Way Forward 2005 — 2010.  http://www.beyondblue.org.au/index.aspx?link_id=2.18&tmp=FileDownload&fid=88.

[382]  Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 2 — Mental health, mental illness and addiction: Mental health policies and programs in selected countries, Chapter 1, p. 17.      http://www.parl.gc.ca/Content/SEN/Committee/381/soci/rep/report2/repintnov04vol2-e.pdf.

[383]  Jorm, A., Christensen, H., and Griffiths, K. (2005) The impact of beyondblue: the national depression initiative on the Australian public’s recognition of depression and beliefs about treatments. Australian and New Zealand Journal of Psychiatry, Vol. 39, p. 253.

[384]  Goering, P., Goldner E., and Lesage, A. (October 2005) Proposal submitted to the Committee by Research in Addictions and Mental Health Policy Services, Canadian Mental Health Services Knowledge Translation Network.

[385]  Ibid., p. 4.

[386]  Ibid., p. 8.

[387]  Ibid.

[388]  Ibid., p. 3.

[389]  Ibid., p. 9.

[390]  Ibid., p. 11.

[391]  Ibid., p. 5.

[392]  Ibid., p. 12.

[393]  See Chapter 5, “Toward a Transformed Delivery System.”

[394]  Ibid.

[395]  Ontario Ministry of Health and Long-Term Care. (1999) Making it Happen.

[396]  Toronto-Peel Mental Health Implementation Task Force. (December 2002) The Time Has Come: Make it Happen — A mental health action plan for Toronto-Peel.

[397]  Many regions had difficulty accurately determining the level of current funding, and what information they did collect indicated a wide regional disparity of per capita funding levels for mental health care within the province of Ontario.

[398]  Toronto-Peel Mental Health Implementation Task Force. (December 2002) The Time Has Come: Make it Happen — A mental health action plan for Toronto-Peel, p. 314.

[399]  Provincial Forum of Mental Health Implementation Task Forces. (2002) Final Report—The Time is Now: Themes and Recommendations for Mental Health Reform in Ontario, p. 62.

[400]  The $14.4 billion is the total of $6.3 billion in direct health care costs and an estimated $8.1 billion in indirect costs related to premature death and productivity loss. See: Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, p. 101.

[401]  See Chapter 5, “Toward a Transformed Delivery System.”

[402]  According to the Canada Housing and Mortgage Corporation, “core housing need refers to households which are unable to afford shelter that meets adequacy, suitability, and affordability norms. The norms have been adjusted over time to reflect the housing expectations of Canadians. Affordability, one of the elements used to determine core housing need, is recognized as a maximum of 30 per cent of the household income spent on shelter.” See: Canada Housing and Mortgage Corporation. (undated) Affordable housing.  http://www.cmhc-schl.gc.ca/en/corp/faq/faq_002.cfm.

[403]  Canada Mortgage and Housing Corporation. (7 October 2005) Letter to the Standing Senate Committee on Social Affairs, Science and Technology.

[404]  Canadian Mental Health Association. (April 2005) Meeting the mental health needs of the people of Canada: A Submission to the Senate Standing Committee on Social Affairs, Science and Technology.

[405]  Canada Mortgage and Housing Corporation. (22 November 2005) News release: National renovation and homeless programs extended.

[406]  Canada Mortgage and Housing Corporation. (7 October 2005) Letter to the Standing Senate Committee on Social Affairs, Science and Technology.

[407]  This figure represents a rounding-up of the estimate of 56,500 that was provided by the Canada Mortgage and Housing Corporation.

[408]  The federal government currently has cost-sharing agreements with the provinces and territories for rent supplements and the construction of new affordable housing units. See: Canada Mortgage and Housing Corporation. (7 October 2005) Letter to the Standing Senate Committee on Social Affairs, Science and Technology.

[409]  The cost of newly constructed units is based on the federal government contributing half of the costs to a maximum of $75,000. It is likely that the actual cost of new units will be significantly lower.

[410]  Canadian Centre on Substance Abuse. (November 2005) Brief to the Standing Senate Committee on Social Affairs, Science and Technology.

[411]  Canadian Centre on Substance Abuse. (1996) The Costs of Substance Abuse in Canada.

[412]  British Columbia Ministry of Health. (2004) Every Door is the Right Door: A British Columbia Framework to Address Problematic Substance Use and Addiction.

[413]  Canadian Centre on Substance Abuse. (2005) Addiction Treatment Indicators in Canada.

[414]  Statistics Canada. (2004) Canadian Community Health Survey 1.2.

[415]  Skinner, W., O’Grady, C., Bartha, C., and Parker, C. (2004) Concurrent substance use and mental health disorders: An information guide. Toronto: Centre for Addiction and Mental Health.

[416]  For more information, see: Health Canada. (October 2005) Canada’s drug strategy. http://www.hc-sc.gc.ca/ahc-asc/activit/strateg/drugs-drogues/index_e.html.

[417]  Health Canada. (May 2003) Canada’s drug strategy.
http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/2003/2003_34bk1_e.html.

[418]  Receiver General of Canada, Public Accounts of Canada, 2004-05, section 4.7. This amount does not include GST collected on the sale of alcoholic beverages.

[419]  See Chapter 12, “Telemental Health in Canada,” for a more detailed discussion of telemental health.

[420]  Health Canada. (2000) Straight Facts about Drugs and Drug Abuse, p. 30.

[421]  The excise duties and taxes were changed for alcohol (beer, spirits and wine) were changed in 1991 with the introduction of the GST.  This change in rates was “revenue-neutral”; that is, the excise tax and duty rates were increased to produce the same combined sales and excise tax and duty revenues as under the old federal sales tax system.

[422]  This is according to an inflation calculator on the Bank of Canada’s website: http://www.bankofcanada.ca/en/rates/inflation_calc.html.

[423]  Receiver General of Canada. (2005) Public Accounts of Canada, 2005, section 4.7.

[424]  Tim Stockwell. (October 2005) Brief to the Standing Senate Committee on Social Affairs, Science and Technology.

[425]  Ibid.

[426]  In particular, the calculation may be high as it was made based on the federal government’s 50% contribution being $75,000 per new housing unit.


Top of document