"SPEAK OUT  BRAVELY; LISTEN COMPASSIONATELY"

Summary of Sen Kirby Reports on pdf download

A SUMMARY AND ANALYSIS OF THE REPORTS

OF THE STANDING SENATE COMMITTEE ON

SOCIAL AFFAIRS, SCIENCE & TECHNOLOGY

MICHAEL J. KIRBY, CHAIR, NOVEMBER 2004

February 2005

Report prepared for CMHA National by:

www.hsresources.ca

The name of this report,

Speak out Bravely; Listen Compassionately

is extracted from the Senate Committee reports. The statement was written as a challenge to Canadians in the hope they would actively participate in the proposed public consultations.

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1.0 Introduction

The Standing Senate Committee on Social Affairs, Science & Technology has its origins in 1908 as the Committee on Public Health and Inspection of Food. It received its present name in 1983 along with an expanded mandate to examine matters relating to Veterans, Indian, Inuit, youth and consumer affairs, culture, the arts, labour, health and welfare, pensions, housing, fitness, amateur sport, and employment and immigration.

On June 7th of 2001, the Committee held, as part of its multi-phase study on general health and health care, a roundtable on mental health and mental illness. This roundtable provided preliminary information on the prevalence, economic burden, stigma and discrimination associated with mental illness in Canada. It also highlighted the role the federal government could play in the development of a national approach to mental health, mental illness and addictions. Following the roundtable, the Committee decided that due to the complexity of the matters, a wholly separate process should be initiated in order to adequately study and report on mental health and mental illness in Canada.

The terms of reference for the Committee’s study are as follows:

1. 1. Conduct a study on mental health and mental illness in Canada;
2. 2. Consult broadly with stakeholders, including but not limited to, federal and provincial departments and agencies, non-governmental organizations, universities, business sector, professional groups and individuals;
3. 3. Document the incidence of mental health problems and mental illnesses by age, sex, region, etc.;
4. 4. Document the economic burden of mental health problems and illnesses to various sectors of the Canadian society, including businesses, education and health care systems;
5. 5. Review mental health strategies implemented in other countries;
6. 6. Consider, and make appropriate recommendations on the role of the federal government in the fields of mental health promotion; mental illness prevention; access to needed mental health services and providers; support to families and caregivers, and mental health related disease surveillance and research;
7. 7. Consider, and make appropriate recommendations on how mental health services should be integrated into the health care system, for example: primary health care and home care.

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1. 8. Consider, and make appropriate recommendations on the development of a national action plan on mental health and mental illness in Canada.

The Committee’s work plan proposed a study with two distinct phases. The first consisted primarily of gathering information on mental health and illness, including site visits in Toronto, Montreal, Eastern and Western Canada. The Phase One report was intended to discuss myths and realities and highlight the main issues.

Fourteen distinct roundtables were scheduled during Phase One. They included:

1. • Roundtable One: Mental Health Problems and Illness from Personal Experiences - an examination of the impact of mental health problems and illnesses on patients, families, friends and workplace settings, a look at stigma and discrimination, experience with respect to access and information on detection, prevention, treatment and social integration.
2. • Roundtable Two: Refresher on Mental Health and Mental Illness - defining key concepts, causes (etiology), consequences, co-morbidity, correlation and interactions between various genetic, social and environmental determinants, and interdependent relationships between physical and mental health.
3. • Roundtable Three: Prevalence and Costs - an examination of the iincidence of mental health problems by age, sex, region, the economic burden and the impact on quality of life.
4. • Roundtable Four: Mental Health and Addiction (Concurrent Disorders) - an examination of the link between substance use/abuse and mental illness, the prevalence of concurrent disorders, specific population issues (e.g.: homeless, Aboriginal peoples), collaborative work and implications for research, policy and treatment.
5. • Roundtable Five: Mental Health in the Workplace - an examination of economic burden, lost productivity and disability, disability tax credits, private insurers and the 2002 Statistics Canada Public Service Employee Survey.
6. • Roundtable Six: Stigma, Discrimination, Myths and Public Awareness - addressing stigma and discrimination, myths, realities and public awareness.
7. • Roundtable Seven: Childhood Disorder: Dealing with Autism, Attention Deficit Hyperactivity Disorder, FAS/FAE - the impact on parents, early diagnosis and intervention, access and continuity of care.

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1. • Roundtable Eight: Adolescent Disorders - dealing with eating disorders, stress, depression, addiction, suicide, the impact on parents, early diagnosis, intervention, access and continuity of care.
2. • Roundtable Nine: Adult Disorders - addressing schizophrenia, bipolar disorders, depression, suicide, concurrent disorders (addiction and mental health), gender differences and the co-morbidity of mental and physical health problems.
3. • Roundtable Ten: Seniors Disorders - addressing depression, dementia and Alzheimer’s disease among seniors, concurrent disorders, addiction and mental health, gender differences, access to and continuity of mental health services, and family/caregiver stress.
4. • Roundtable Eleven: De-Institutionalization and Rehabilitation – addressing de-institutionalization, psychiatric rehabilitation, forensic services, employment supports, education and housing.
5. • Roundtable Twelve: Mental Health Promotion, Mental Illness Prevention and Disease Surveillance – dealing with the role of the federal government, provincial perspectives and non-governmental organizations.
6. • Roundtable Thirteen: Delivery of Mental Health Services – addressing the role of physicians, psychiatrists, nurses, psychologists, social workers, hospitals, community services, and
7. • Roundtable Fourteen: Research and Information Dissemination

"2.0. Report 1: Overview of Policies & Programs ",
 

The work of the Roundtables was then consolidated into three reports released publicly November 23rd of 2004, along with a web site, on-line questionnaire and a commitment to further consultations with the public beginning in June of 2005. The final report is expected to be released prior to year end.

In Phase Two, the Committee plans to address issues raised during Phase One, review public policy with respect to mental health and mental illness in selected countries (Australia, New Zealand, England and the United States), and consider potential options for Canada, including the creation of a national action plan on mental health. Phase Two will result in a final report detailing recommendations, planned for completion in the Fall of 2005.

2.0. Report 1: Overview of Policies & Programs

2.1 Summary

Designed as a "fact-based" document based on public testimony and a literature review. The four parts of the report provides historical background,

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an overview of service delivery, a look at the respective roles of federal and provincial/territorial governments and an assessment of policies and programs.

Part 1: The Human Face of Mental Illness and Addiction

A look at four individuals whose concerns reappear throughout the study.

1. Personal Stories

Loise suffers from bipolar disorder and talked of a non-integrated system, which required her to see many different health care providers, repeating her story at each level while still having difficulty obtaining the necessary assistance from psychiatrists and institutions.

Ronald spoke about his wife who suffers from schizophrenia and is unwilling to find help in part because of the stigma. Ronald also raised concerns about the lack of information and support for family members. He noted the value in self help groups that assist disabled individuals re-enter the work force.

Murray relayed a tragic story of his son who suffered from paranoid schizophrenia and was killed in a traffic accident when he wandered off hospital grounds. Murray expressed frustration that early diagnosis and intervention was not easy to obtain. He talked about the financial and emotional strain on the family and expressed frustration with privacy legislation, intended to protect the patient but making it impossible for the family (in this case the primary care givers), to access medical records. He felt that government funding, due to pressure from lobby groups, goes to other diseases first.

As the father of a 31-year-old son living with autism, David expressed concerns over the lack of suitable care facilities, and the strain created on the family (emotional and financial). David believes that mental illness is not treated with the same urgency as other diseases.

1. Other Testimony

Stories from letters and e-mails, public testimony and from first hand experience during site visits repeated a number of concerns, of which stigma was foremost. They felt the public was unwilling to deal with "crazy people" and this lead to feelings of low self-worth. There was also a perception that medication was sometimes used as a "chemical straight jacket" for the comfort of the mainstream community.

Key requirements repeatedly included the need for early intervention, the provision of adequate services including housing and post-discharge support, (and the ability to access them) along with better co-ordination across the

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system. Opinions were also gathered from those responsible for caring for individuals with mental illness. This care invariably falls on the parents and families who, in return, become the principal advocates. Of major concern to these families was the strain of learning "the system," the financial burden of the care and the social and emotional isolation. For aging parents, the foremost concern was the question of who would care for the children when they no longer could. The survivors of suicide requested a comprehensive suicide prevention strategy that would include early identification of suicidal behavior and crises management.

A third facet of the consultation was with the people providing mental health services. Their primary concerns were related to access. They talked of limited resources and uneven distribution of services and support, particularly in remote communities. Arguments were made that teachers and schools could be a significant tool for early diagnoses and access to treatment, but resources are too thin. They talked of 18 month waiting times for children with ADD or ADHD, unless the family could pay for private consultation, thereby creating a two-tier system. It was thought that the system should integrate the care of physical and mental illness, and that "appropriate incentives" needed to be developed in order to attract sufficient numbers to mental health professions.

The Committee then looked at both the negative and positive aspects of work. In some workplaces, the stigma of mental illness caused the creation of what the Committee dubbed "workplace secrets." Some workers were unwilling to admit problems to the employer even if an assistance program was available. It was felt that better education of managers and co-workers would be required to break the stigma. Conversely, when employees were able to get help and remain in the workplace, financial and emotional gains could be made.

The federal government has direct responsibility for mental health care for a few specific populations, namely veterans, inmates at federal institutions, and First Nation and Inuit peoples where a range of special needs were identified.

1. Stigma and Discrimination

Throughout the interviews and testimonials the Committee heard of the effects of stigma and discrimination, frequently caused by stereotypes like "people with mental illness are dangerous and should be avoided," and "people with mental illness have brought their problems upon themselves and are to blame for their disabilities since they arise from weak character."

The media plays a role in spreading and perpetrating these dangerous stereotypes. Movies, music, books and even news broadcasts spread images of "homicidal maniacs who need to be feared" and "childlike individuals who

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must be protected by parental figures". These negative stereotypes are even found in children’s programs.

The stereotypes of people living with mental illness can be so strong that the individuals begin to believe it themselves. This self-stigmatization leads to further difficulties such as low self-esteem, isolation and hopelessness. Many people will attempt to hide their illness and may not seek help.

There is also a stigmatization of mental health providers with media portrayals tending to convey the idea that helping others is an unworthy vocation requiring little skill or expertise, frequently belittling psychiatrists.

The study identified two forms of discrimination, direct discrimination defined as a person in a powerful role withholding opportunity. For example 1/3 to 1/2 of individuals with mental illness are denied or dismissed from jobs. Families are also targets for discrimination due to misconceptions about the family’s role in the cause of mental illness. In addition, there were complaints that some physicians and emergency room technicians did not listen to or respect patient’s views.

When stigma affects service protocols it is referred to as structural discrimination. For example, while physical and mental health are inextricably linked, mental health programs and research are given lower priority than those services that focus exclusively on physical health care issues.

The Committee felt strongly that education regarding stigma and discrimination needed to have an experiential component; doing more than promoting facts.

The Committee identified four areas in which change is needed to help reduce stereotypes which lead to prejudice and discrimination. (1) A National Strategy placing physical and mental illness on equal footing. One proposal would see an amended Canada Health Act to include psychiatric hospitals. (See analysis for possible negative consequences.) (2) Policy Reform to ensure mental illness is on par in terms of benefits with other chronic diseases and reforming billing system so doctors can provide more effective treatment. (3) Reducing violence committed by persons with mental illnesses. (4) Involving the media such as the British and Australian attempts to have media promote more positive messages.

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Part 2: The Prevalence & Consequences of Mental Illness & Addiction

A look at the prevalence and economic burden associated with mental illness.

1. Prevalence and Cost

In order to plan and organize the delivery of needed services and supports and to develop sound public policy on mental health, it is essential to properly assess the prevalence and economic burden of mental illness and addiction. Unfortunately, the depth and scope of studies are limited and number comparisons are sometimes difficult. Prevalence numbers differ depending on the period of time for which they refer. For instance, point prevalence refers to a certain point in time, period prevalence refers to a length of time (often one year), and lifetime prevalence is of course an event occurring throughout a lifetime. With many hurdles to overcome, it is nonetheless essential to get an idea of the numbers of Canadians affected.

Numerous statistics were cited with some of the more cogent numbers reported below.

1. • Canadians 15 years and over (1 in 10 experienced symptoms during the past year);
2. • Children and Adolescents (15% at any point in time)
3. • Seniors (3% reported symptoms);
4. • Canadian Forces (prevalence of depression over one year 7.6%, over a lifetime 16.2%);
5. • FAE/FAS and dual diagnoses (1-3% of Canadians have moderate or severe developmental disabilities).
6. • The studies also examined specific populations such as Aboriginal people, homeless people and inmates. The studies found higher rates of mental illness, addiction and suicidal behavior in Aboriginal communities and prisons and a mere 14% of homeless people reported no mental illness or substance abuse.

With such high numbers for prevalence of mental illness, substance abuse disorders and suicidal behavior, what are the economic ramifications for society? The Committee cites a study1 that estimates the total burden to be in the area of $14.4 billion in Canada with mental illness and suicide accounting for 10.5% of the total burden of disease worldwide. Unipolar major depression ranks second only to ischemic heart disease in terms of the number of years lost due to premature death or disability. (DALY) Alcohol abuse in Canada is estimated to cost $7.5 billion, and although no studies

1 The Economic Burden of Mental Illness in Canada, Statistics Canada, 1998.

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were available for Canada as a whole, the cost per each suicide in New Brunswick (direct and indirect) was estimated at $850,000.

The Committee concludes by stating that the database within Canada are inadequate and are "a major impediment to determining the need for appropriate and adequate treatments and services."

1. Mental Illness, Addiction and Work

The workplace can both alleviate and aggravate the symptoms of mental illness. Work related stress can be a detriment to positive mental health, but the workplace can also be a critical component to recovery.

Employment can help an individual recover from a mental illness by providing structure and social connections; whereas the loss of a job results in financial dependence, low self-esteem, loss of personal relationships and social marginalization.

Some of the barriers to employment for mentally ill individuals are early onset and discrimination. An onset of an illness early in life makes it difficult for the individual to obtain qualifications for employment. Employers may discriminate against the mentally ill or show a lack of flexibility making it difficult for mentally ill employees. Some studies suggest unemployment in severe cases of mental illness may be as high as 90%. This compares to 50% unemployment in physical or sensory disability and 7% in the general public.

There is no single source of information to determine the prevalence of mental illness and addiction in the workplace; however, there is some information from specific employment sectors.

1. • The manufacturing sector reports addiction among employees at twice the national average;
2. • High rates of depression and anxiety exist in the information technology sector;
3. • Hospital workers are experiencing higher rates of stress;
4. • 45.7% of physicians were in advanced state of burnout;
5. • 40% of workers in jobs with high demands but little latitude for decision-making indicated high levels of stress.

For a company, concerns regarding employee performance can be divided into two categories. Presenteeism is when individuals are present, but function less than full capacity. Absenteeism is, of course, the employee not showing for work. Presenteeism and absenteeism contribute to lost productivity, and companies lose an estimated 19% of profits to lost

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productivity. Mental illness is the leading cause of absenteeism and presenteeism. It is therefore in the best interests of the company to address issues of mental illness and addiction in the workplace.

It is predicted that mental health insurance claims may climb to more than 50% of all claims in next five years. There is no Canadian survey providing information on total cost to employers for Short Term Disability (STD) and Long Term Disability (LTD) due to mental illness. Some facts were available:

1. • Since 1994, depressive disorders alone have doubled as a percentage of STD and LTD claims, and have grown 55% across all categories of disability-related absences from work.
2. • Mental illness and addiction were the leading cause of STD claims, and 73% of respondents in a Watson Wyatt Worldwide survey confirmed that these disorders were also the leading cause of LTD claims.
3. • Between 640,000 and 1,075,000 full-time employees in Canada are currently on disability leave with mental illness as their primary or secondary diagnosis.

It is also important to note that the disability plans must be designed to provide protection for the ill, but still afford sufficient incentive to return to work, which can be beneficial to recovery. A balance is important to ensure the benefits paid are sufficient to help the individual, but does not penalize the individual from seeking employment (e.g. cutting off payments for securing part-time employment).

As part of the study on disability, the Committee noted that the Workers Compensation Board (WCB) is reluctant to fill claims because mental disability is difficult to define or to prove the genesis.

Federal Income Security Programs are ill-suited to assisting the mentally ill. The largest single disability program, the Canada Pension Plan Disability program CPP(D) fails in a number of ways:

1. • Many applicants have limited work history and do not qualify because of a stipulation they must have received work income in 4 of the last 6 years
2. • Applicants must be "permanently unemployable" and mental illnesses tend to be cyclical in nature
3. • Applicants are penalized for looking for work
4. • It is difficult to get on the program, especially for those with mental disorders who can’t "push the system."

Employment Insurance programs are also deficient. In many cases employees conceal their illness due to stigma or are not in a position to claim Employment Insurance benefits because they did not previously disclose their illness. The unpredictable nature of the illness makes it difficult to

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qualify, for example the minimum number of hours worked requirement is often impossible to accommodate if you have a severe and persistent illness.

The employer can play a critical role in the well-being of its employees, by implementing Employee Assistance Programs and policies of "accommodation." The study points out that 60% to 80% of medium to large companies have Employee Assistance Programs, which can be effective if properly implemented and promoted within the company. Policies of accommodation call for equitable treatment for individuals with disabilities (such as flexible hours). Workplace "accommodations" are a more effective alternative to drugs used for avoidance, sick leave and/or wage replacement, and the employee continues to contribute and does not become a burden on society.

While the employer can have a direct impact on the well-being of their employee, the Committee suggested that governments should share the responsibility with employers for shouldering the economic burden of mental illness and addiction in the workplace through incentives for corporations investing in mental health programs. The Committee also encouraged government support for initiatives that promote businesses run by individuals with mental illness and addiction.

A look at the integration and funding of mental health and addiction services.

1. Mental Health Service Delivery and Addiction Treatment in Canada: A Historical Perspective

The history of mental health service throughout the centuries involves advances from ancient Greece where illnesses were seen as angry gods to the 1800’s when Philippe Pinel and William Tuke advocated "moral treatment." In Canada the history can be divided into three phases.

1. • Before 1900: characterized by cruel incarceration until the building of "moral" institutions.
2. • 1900-1960: large institutions, lack of effective treatment, overcrowding, understaffing and emphasis on custody rather than therapy. Institutions moved away from Pinel and Tuke’s model.
3. • 1960–present: de-institutionalization, anti-psychotic medication, service delivery moved toward general hospitals, long term stays replaced by short term.

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The 1970’s and 1980’s saw the introduction of Community Health Services and Supports with more funding for community care, but integration between hospitals and community clinics was poor. Throughout the 1990’s there was an increased emphasis on home visits, outreach services, mobile crises, self-help groups and more assertive community treatment teams.

The history of the provision of addiction treatment can be categorized in five phases:

1. 1) Late 1940’s – lack of attention to treatment. Persons with addictions were considered to have lack of "will power."
2. 2) Up to mid 1960’s - advent of Alcoholics Anonymous (AA), addiction became known as a treatable disease.
3. 3) Mid 1960’s – detoxification centers, outpatient programs, short and long term residential facilities and aftercare services.
4. 4) 1980’s – addiction research/education/treatment in a system outside the general health system. Treatments were specialized for different individuals.
5. 5) Early 1990’s to present day – integration with mental health and health services.

1. Mental Illness and Addiction Policy and Legislation in Canada: Review of Selected Provincial Frameworks

Although there are large variations from province to province reform is occurring in most jurisdictions. Some of the commonalities in each province include:

1. • A shift from hospital to community-based services to create a more balanced approach to the delivery of mental health/addiction services;
2. • Specified, protected funding for an integrated mental health and addiction treatment system, including community, hospital-based and community-based tertiary care;
3. • A single point of accountability where responsibility for the operation of an integrated system is at the local/regional level;
4. • Mechanisms for the meaningful involvement of individuals with mental illness and addiction and communities in decision-making.

The Committee identified some common problems with the provincial frameworks:

1. 1. Fragmentation and lack of integration.
   1. − Less of a "system" and more of a "complex array of services."
   2. − No integration of mental health, addiction and health systems.

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1. − Still focused on institutional care
2. − No continuity in support
3. − Under-funding
4. − Human Resource shortages
5. − Lack of accountability
6. − Stigma

In addition, many of these problems were amplified when caring for children, individuals with concurrent disorders, seniors and forensic psychiatry services.

1. 2. Community Services and Supports
   1. − An increased need for case management to supply three types of services, namely relapse prevention, clinical services and rehabilitation.
2. 3. Uneven Regional Distribution and Quality of Service
   0. − Rural communities are under-served.
3. 4. Primary Health Care Sector
   0. − Family physicians lack knowledge, skill and motivation
   1. − Cannot screen disorders or navigate referral pathways
   2. − Need to move to a system of "shared mental health care"
4. 5. Human Resources
   0. − The lack of psychiatrists and psychologists, particularly in rural areas will result in long waiting lists.
5. 6. Unmet needs
   0. − Many who require assistance do not receive it. (Survey found only 32% of adults and 25% of youth requiring services were served.
   1. − Stigma, scarce resources and low awareness cause needs to be unmet.
6. 7. Early Detection and Intervention
   0. - Early detection sharply improves outcome of treatment but is rarely available.
   1. - In children, early detection can prevent school failure, poor employment opportunities and poverty.

It is the province’s responsibility to enact legislation that provides for protection of the health and rights of individuals seeking mental health care as well as the rights of the public. It is important that the provision of service must reflect a balance between the rights of the individual and the role of society to care for the individuals. The Uniform Mental Health Act suggests the following principles be adapted:

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1. • A system that promotes voluntary admission and treatment with informed consent is preferred to compulsory service;
2. • Where there is no alternative to involuntary detention and treatment which limits a person’s liberty or right to make decisions, these limitations must conform with the Charter;
3. • A range of appropriate treatment options, including the least restrictive and intrusive alternatives are utilized;
4. • A duty of confidentiality of information in the medical file/record is heightened by the vulnerability of mentally-ill persons and the potentially severe consequences of improper release;
5. • The patient has the right to view, for purposes of accuracy, documents gathered for the purpose of his/her medical treatment;
6. • If a person’s rights and freedoms are affected by legislation, an independent body or a court can review the decision to determine whether or not the decision was reached fairly.

1. Mental Illness and Addiction Policies and Programs:

The federal government’s role in over-seeing mental illness and addiction policies involves a direct responsibility to veterans, the military, inmates in federal institutions, certain landed immigrants and refugees, R.C.M.P. and First Nations on reserves and Inuit. The government also has an indirect role to oversee the national interest of all Canadians, which is achieved primarily through funding and standards.

First Nations and Inuit programs were reported to be inadequate and non-integrated and people might be better served if government would delegate to Aboriginal communities.

Correctional Services Canada (CSC) is responsible for service and programs within Canada’s federal institutions. The programs they oversee are psychological services, mental health services, methadone maintenance treatment and suicide and self injury programs.

Veterans and active members of the Canadian Forces have access to a number of federal programs and new treatment facilities, education forums and research into post-traumatic stress disorder are being initiated as part of a "Canada Mental Health Strategy" developed by the Canadian Forces in response to a 2002 mental health survey of armed force members. That survey found a high incidence of anxiety and depression.

Federal Public Servants also have a number of programs at their disposal including EAP (Employee Assistance Program), WHPSP (Workplace Health and Public Safety Program) and CISM (Critical Incident Stress Management

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Services). The government however, is not seen as a role model employer in the prevention of mental illness with studies showing that public employees take more "mental health" days than private sector employees.

A step forward in federal interdepartmental coordination came with the partnership of formerly separate health care providers including the Department of National Defense, R.C.M.P., and Veteran’s Affairs. By consolidation of costs the government should see a forecast savings of $17.6 million for 2003-2004.

The federal government is directly involved in addiction policy through its Drug Strategy. Canada’s Drug Strategy involves programs designed to reduce the health, social and economic harm associated with substance abuse. The drug plan has developed critics for its fragmented approach.

In addition to services and funding the federal government controls service through legislation such as:

1. • The Charter of Rights and Freedoms
2. • The Criminal Code
3. • The Controlled Drugs and Substances Act
4. • The Tobacco Act
5. • The Canadian Human Rights Act

According to the Committee, the Canada Health Act excludes services in psychiatric institutions from its definition of comprehensiveness. This omission reinforces stigma, and hampers inter-provincial billing. In addition, the Health Act should include home care and prescription drugs prescribed outside of hospitals. Secondly, there is no dedicated federal funding for mental health care and addiction treatment. Thirdly, the National Homeless Initiative requires long-term supporting facilities and transitional housing for the chronically homeless. In addition, there is a requirement for affordable housing for discharged psychiatric patients and greater intensive support services.

Canada is the only G8 country with no national strategy which results in fragmentation and overlap of services and long waiting lists. Additionally, Canada has no suicide prevention strategy or system to monitor substance use disorders. The National Action Plan should address four main issues:

1. 1. Education and Awareness
2. 2. National Policy Framework
3. 3. Research
4. 4. Surveillance

It is important that all tiers of government, as well as voluntary organizations, be involved in both the design and implementation of a plan.

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Part 4: Research and Ethics

1. Research into Mental Health, Mental Illness

and Addiction in Canada

The primary funding agency for mental health, mental illness and addiction research in Canada is the Canadian Institutes of Health Research. The CIHR’s research includes biomedical, clinical, health services and population health research.

The Institute of Neurosciences, Mental Health and Addiction (NIMHA)), is a branch of CIHR that supports research "to enhance mental health, neurological health, vision, hearing and cognitive functioning and to reduce the burden of related disorders."

Additional federally funded groups conducting research into mental health and addiction include SSHRC (Social Sciences and Humanities Research Council), and NSERC (Natural Sciences and Engineering Research Council).

Currently, the federal government has no guidelines on how much to spend on research, and how the money should be allocated. Proposals aimed at assisting in where the funding is allocated include targeting the relative burden of illness, comparing research funding patterns in other jurisdictions, and examining morbidity and mortality, disability or economic burden.

In addition to federal government funding for research, other agencies contributing to research include the pharmaceutical industry (the largest contributor), provincial funding agencies and NGO’s.

Research is the cornerstone of advancement of mental health care. Although a great deal of important research is underway, there are numerous stumbling blocks; the lack of communication between researchers; the lack of a comprehensive database and delays in knowledge transfer from the lab to the field.

1. The Question of Ethics

The ethical issues in treating mentally ill are numerous and varied and guidelines should include practice in the best interests of the patient, respect for the patient as an individual, assurances that patients used as research subjects are treated fairly.

It is important that ethical questions be addressed when considering access to services and supports, consent and capacity issues and privacy and confidentiality laws.

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It is also necessary to consider the ethical questions involved with the care of special populations. Children have special consent and disclosure issues, seniors often receive inadequate care because they have physical as well as mental health needs. Forensic patients face issues of confidentiality when their caregiver is also expected to testify.

In the future, with the advancement of genetics it may be possible to predict who may develop disorders. The stigma of disease today may translate into a stigma of the genetically imperfect.

Do the benefits of research outweigh the rights of an individual? Using human subjects in research may be a benefit to the research, but what if it causes medical or mental strife for the subject? Current research strategies such as placebo-controlled studies, washout studies and challenge studies may all involve risks to participants. Currently CIHR and Health Canada are studying a harmonized national policy regarding genetic testing.

2.2 Analysis

The Senate Committee’s First Report is philosophically consistent with CMHA’s "New Framework for Support,"2 and it was evidently influenced significantly by CMHA’s submission to Phase1.3 Both reports served as the "foundational" documents for this analysis. Observations and issues:

1. • The "human side" of mental illness presented common complaints heard in CMHA Branches and Regions on a daily basis: service is frequently poor with problems of access, coordination, integration and continuity of care. The "consumers of service" are frustrated, families lack hope and professionals are over-extended. There is no comprehensive "system" and the patchwork of services is in critical condition. Public policy development and concerted advocacy require to be among CMHA’s top priorities.
2. • Stigma and discrimination remain a significant problem; however work in New Zealand4 suggests that a comprehensive and sustained approach, with both educational and experiential components might in fact shift public attitudes. The project has four components; advertising, public relations, a national policy and an experiential "curriculum." Personal experience appears to be the best approach and people who have "been there" are usually the best teachers. CMHA’s "Good Cause" award should increase the organization’s visability and could be used to leverage future participation by Federal and

2 The New Framework for Support, Third Edition. Canadian Mental Health Association

3 Access to Mental Health Services: Issues, Barriers & Recommendations for Federal Action, June 2003

4 http://www.likeminds.govt.nz

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1. Provincial/Territorial governments in a comprehensive and perhaps sustained public education campaign.
2. • The statistics on prevalence and cost are consistent with CMHA data and references, however, many of the statistics are "suspect" in terms of the rigor behind the research. Others are confusing or are presented without context to the period of time to which they refer. While the Health Canada Report on Mental Illness in Canada and the Stats Canada report, Canadian Community Health Survey on Health and Mental Well-being are currently the most definitive record, a new and careful academic compilation of the myriad of Canadian statistics on mental illnesses, including their definitions, is required.
3. • The Senate report’s emphasis on the value and importance of work along with the need to address workplace stressors has been identified as a priority within several of CMHA’s Divisions and Region’s.5 This experience in initiating and evaluating workplace service innovations provides CMHA and consumer organizations with an opportunity to further influence the thinking of policy makers and perhaps expand current services.
4. • The Senate report’s summary of the historical development of services is brief and misses key federal factors which have driven mental health reform. Pharmaceuticals for example are presented as the primary driver of institutional down-sizing. While drugs were indeed a significant factor, the Canada Assistance Plan of the mid 1960’s funded community clinics in general hospitals but refused funding to institutions that allocated more than 10% of its beds to psychiatry. The effect was to create psychiatric units in general hospitals across the nation while mental hospitals were downsized. The Senate Committees proposal for greater funding to psychiatric hospitals might inadvertently have the effect of reversing this trend. Current "best practice" calls for decentralized, regionalized and integrated service, principals quite inconsistent with the re-vitalization of psychiatric hospitals.
5. • There is nothing new in the Senate report regarding government policy and service delivery, with every province initiating some form of "reform," generally in a patchwork fashion. (The exception may be New Brunswick). These provincial initiatives have a number of common features, emphasizing institutional downsizing, community services (housing, assertive outreach, crisis intervention,) and decentralized and regionalized governance. Future presentations by CMHA should include an orientation to the philosophy and rationale underpinning the New Framework For Support.
6. • The Senate report does not however, adequately highlight where government policy and service delivery are inconsistent across the

5 Workplace Wellness: www.cmha.calgary.ab.ca; Mental health Works http://www.ontario.cmha.ca ; Ontario Coalition of Alternative Businesses: www.icomm.ca

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1. nation. These variables include income support arrangements, the integration of addiction services, primary care (physician services), support for consumer initiatives, programs of employment "accommodation," criminal justice diversion and access to the latest in pharmaceuticals. The most significant limitation in most provinces is the lack of a comprehensive multi-year strategic plan that is sustained through changing governments and administrations. A National Action Plan could help drive initiatives by articulating an organizational and service model reflecting the best in evidenced based practice.
2. • What is new in the report is recognition that there may be a need for a National Action Plan and therefore a role for the federal government in promoting mental health services, including suicide prevention. This proposal is consistent with CMHA policy and advocacy. It is also consistent with the efforts of the Canadian Alliance on Mental Illness and Mental Health (CAMIMH) who have called for a National Action Plan that would (1) establish a national data and collection system (2) implement a national research strategy (3) establish national standards for service and (4) provide and target necessary resources. While some provinces, particularly in the west, might be expected to vigorously oppose further federal intervention in what is understood to be essentially a provincial responsibility (health care), such an attitude fails to consider a modern view of mental health services as detailed in CMHA’s New Framework For Support. Such a plan could go beyond CMHA’s June 2003 brief to the Senate that recommended better collaboration, a Human Resources Plan and National Programs of medications, home care standards and family support. In addition, such a plan might provide a model of service delivery as previously noted, along with a commitment to designated funding, surveillance (information), education, research, and service for specific populations (Aboriginal people, the Armed Forces, the RCMP, federal prisoners and the homeless).

3.0 Mental Health Policies and Programs

3.1 Summary

This section examines mental health policies and programs in other countries in order to provide a reference point and a source of policy inspiration for the development of Canada’s own system. Due to a lack of resources, the Committee did not undertake field studies but instead relied on written material. The Committee selected countries with health care systems similar to the Canadian model.

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Part 1: Mental Health Care in Australia

In Australia, the responsibility for health care is, like Canada, divided between the national and sub-national governments (Commonwealth and Territories). The Territories in Australia are more dependent than Canadian provinces on funding from the national government.

The Commonwealth is responsible for policy in public health, research and national health information management. It operates the national – publicly funded "Medicare" insurance plan and regulates private health insurance industry. The Commonwealth government is also responsible for financing and regulating nursing homes and it funds and administers (jointly with the territories) community based and home based care. The funds for all programs are derived from general taxation as well as a 1.5% levy on taxable income that is dedicated to health care.

State and Territories responsibilities to healthcare include the management and delivery of publicly insured health services, public acute and psychiatric services, and community programs such as school health, dental care, maternal and childcare. They are also responsible for the regulation of health care providers, and the licensing and approval of private hospitals. The funding for these programs come from grants from the Commonwealth government as well as general tax and user fees.

The Australian Medicare program covers physicians and hospitals, some community based care and home programs and prescription drugs. Although coverage is extensive, some user charges may be required, and doctors are permitted extra billing. The health care spending is 70% public and 30% private. The government is the primary public insurer of prescription drugs and physician services and fund 50% of hospital expenditures. 25% of State and Territory budgets go to health care. The Commonwealth funds the States through block grants that are tied to specific conditions.

The private health care in Australia consists of private insurers and for-profit hospitals. Private insurance plans may cover the same benefits as the public plan as well as supplement Medicare. Citizens are not able to opt out of the public system and private health insurers are not allowed premium discrimination based on sex, age, or state of health and are solely community rated. Some private for-profit hospitals exist but only for (less complicated forms of elective surgery.)

1. Mental Health Strategy

Australia adapted a series of five-year plans known as the National Mental Health Strategy. The strategy was designed to address issues that arose from a policy of de-institutionalization that took place in the 1960’s, however,

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few alternative community services were developed to assist in the closing of the large institutions.

The first of the five-year plans under the National Mental Health Strategy, which ran from 1993-1998, involved:

1. • Expanding the proportion of acute psychiatric inpatient care provided in general hospitals rather than separate psychiatric hospitals;
2. • Including integrated mental health services within the mainstream organizational arrangements for general health services;
3. • Ensuring that each State, Territory and area/region had a plan for the mix of services available to its population;
4. • Reducing the size of, or closing, existing psychiatric hospitals and at the same time providing sufficient alternative acute hospital, accommodation and community based services;
5. • Increasing the number and range of community based supported accommodation services and ensuring an adequate range of services to meet consumer needs.

In 1998, the second National Strategy five-year plan was implemented. Its themes were:

1. • Promotion and prevention;
2. • Partnership in service reform and delivery;
3. • Quality and effectiveness.

Australia has been seen internationally as leading the way in health promotion, prevention of mental illness, early intervention and stigma reduction. The chief accomplishment of the Strategy was considered to be the "integration of mental health assessments and interventions in mainstream delivery." Unfortunately, some studies still show that only 38% of Australians who need help access the system.

1. Costs

In 1999-2000 the predicted total costs of mental health services were $2.6 billion (AUS). From 1992 to 2000 the percentage of total spending directed to mental health services remained stable but expenditure on psychiatric drugs increased by 402%. Lost productivity due to mental illness was estimated at $5 billion (AUS) a year.

A monitoring system was implemented to track expenditures in order to ensure that dollars saved from institutional down-sizing would be reinvested in communities. Over the first five years of the strategy spending on community services grew by 87% and resources released from institutional downsizing were reinvested in alternatives that provided approximately half of the additional funds used to expand community services.

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Since the implementation of the Strategy’s five-year plans, spending on mental health has increased by 46%. Detractors argue, however, that mental health spending is still only 6.6% of the total health spending.

1. Service Delivery

From 1993 until 2000, community based units known as "community care units," or "psychiatric hostels" have had their number of beds increase by 68%, now accounting for 1/4 of the reduction in beds at psychiatric hospitals. The ambulatory care service workforce also saw significant increase in their numbers, soaring 90% since the start of the strategy.

A number of non-government organizations (NGO’s) in Australia provide services such as home based outreach, residential rehabilitation, and self-help and recreation programs. The role of the NGO varies however, between state and territories and no defining model for NGO’s was developed.

Since the start of the National Mental Health Strategy, the number of people in the workforce (including general practitioners, psychiatrists, mental health nurses, occupational therapists, psychologists, and social workers) increased by 15%. However, workforce shortages continue to be reported, especially in rural areas. A new program intended to improve services rewards doctors for spending more time with individual patients.

The private sector in Australia provides 21% of the total psychiatric beds. It also employs 12% of the national mental health workforce and treats 50% to 60% of all people seen. The access to private sector care is uneven, with the majority of locations centered in capital cities.

Care of the indigenous people is considered inadequate. Some of the issues concerning proper care are a health system with no culturally appropriate resources and health care professionals who do not understand the culture.

1. Addictions and Substance Abuse

The care of those suffering from addictions and substance abuse issues falls within the public health system, and not within mental health. The focus on combating addictions and substance abuse problems is addressed with three program pillars: (1) Supply Reduction (namely drug policing) (2) Demand reduction (education) and (3) Harm reduction (treatment).

1. Promotion and Prevention

Promotion of Mental Health issues, known as "mental health literacy," is accomplished through education, private awareness groups and the National Media Strategy. Education of mental health issues in Australia is aimed at

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schools and the media. Publicly funded, private awareness groups like "Beyondblue" promote awareness of depression and, the National Media Strategy is designed to educate the media by working in journalist schools.

Australia has a framework for suicide prevention called LIFE (Living is For Everyone). The goals of this framework are to reduce deaths by suicide across all age groups, enhance resilience and resourcefulness, to increase the support available to individuals, families and communities and to provide a "whole community" approach to suicide prevention through education.

1. Prospects for Future Reform

The year 2003 marked the beginning of the next of the series of five-year plans under the National Mental Health Strategy. The intended future reform is reflected in the key principles of this new plan:

1. • All people in need of mental health care should have access to timely and effective services, irrespective of where they live;
2. • The rights of consumers, and their families and caregivers, must shape reform;
3. • A recovery orientation should drive service delivery;
4. • Investment in the workforce is essential.

Part 2: Mental Health Care in New Zealand

The New Zealand government is responsible for over-seeing the health care system, while delivery of services is shared between public, volunteer and for-profit sectors. The New Zealand Health care system is primarily funded by taxation. In 1999 – 2000 the health sector was funded by 75% taxation monies, 15.7% consumer (user-fees), and 6.3% private health insurance. No mental illness coverage was provided by private insurance. Public hospitals are responsible for secondary and tertiary care, while private hospitals provide elective surgery and long-term care.

In 2000, the New Zealand government created 21 district health boards. Each board is tasked with providing health services in their region and is given a three year funding package.

Mental health strategy in New Zealand is based on two documents, the first released in 1994 and entitled "Looking Forward: Strategic Directions for the Mental Health Service" and the second, developed in 1997 entitled "Moving Forward: The National Mental Health Plan for More and Better Services." The key goals of the strategy are:

1. 1. To decrease the prevalence of mental illness and mental health problems within the community;

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1. 2. To increase the health status of and reduce the impact of mental disorders on consumers, their families, caregivers, and the general community.

In 1996 the Mental Health Commission was established to implement the strategy, and in 1998 released "Blueprint for Mental Health Services in New Zealand" with seven strategic directions.

1. 1) Implementing community-based and comprehensive mental health services;
2. 2) Encouraging Maori (aboriginal) involvement in planning and delivering;
3. 3) Improving the quality of care;
4. 4) Balancing personal rights with protection of the public;
5. 5) Developing a national alcohol and drugs policy;
6. 6) Developing a Mental Health Services infrastructure;
7. 7) Strengthening Promotion and Prevention.

1. Costs

From 1993-1994 and again from 2001-2002, the government of New Zealand has increased funding for mental health services by 127%. A full 64% of that funding went to community based services with resources guaranteed to the year 2007.

Critics charge, however, that even with the increased spending some regions are short of achieving their goals and workforce shortages have hampered development.

1. Service Delivery

By the year 2000 all acute psychiatric services, with the exception of one, were integrated into general hospitals with all 10 psychiatric institutions closed. The system currently supports hospital based rehabilitation wards, a range of supported accommodation, vocational training options, day programs and drop-in centers. Most adults who receive mental health services have a clinical case manager and/or a community support worker.

Some of the identified problems with health services in New Zealand are access to general practitioners and user fees. For some people, especially Maori and rural residents, access to a general practitioner is difficult.

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To address the issues concerning care of the Maori population, the Maori Mental Health National Strategic Framework was released in 2002. The framework was designed:

1. • To provide comprehensive clinical, cultural and support services to at least 3% of Maori, focused on those who have the greatest mental health needs.
2. • To ensure that active participation by Maori in the planning and delivery of mental health services reflects Maori models of health and Maori measures of mental health outcomes.
3. • To ensure that 50% of Maori adults seeking wellness, will have a choice of mainstream or specialized Maori community mental health service.
4. • To increase the number of Maori mental health workers, including clinicians, by 50% over 1998 levels.

1. Promotion and Prevention

In 2002 the Ministry of Health released "Building on Strengths" to outline a five year plan to promote wellbeing and to "reduce inequalities in mental well-being by improving the social, economic, cultural, political and physical environments in the country." The document included a list of five priority actions:

1. 1. Reorient health services to reduce inequalities between socioeconomic groups.
2. 2. Strengthen community action in mental health promotion activity.
3. 3. Create safe and supportive environments within action that creates cohesive cities, communities, workplaces, school, and homes.
4. 4. Develop personal skills by emphasizing mental health protective factors such as resiliency, social support and life skill development.
5. 5. Build healthy public policy through improved research and evaluation to identify and address mental health promotion needs.

In an effort to combat stigma and discrimination, the New Zealand government instituted a five-year project in 1996 called "Like Minds, Like Mine." The overall aims of the project were to enable consumers to gain equality and respect and to enjoy the same rights as others, to change public and private sector policy to value and include consumers and to create greater understanding, acceptance and support.

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1. Future Reform

Currently, work is being done on the 2nd National Mental Health Plan, which will soon be before Cabinet. In addition, studies are being conducted on how to keep the "Blueprint for Mental Health Services" current and significant.

Part 3: Mental Health Care in England

In 1948 the government of England established the National Health Service (NHS), which has become the most centrally managed health care systems in the world. The NHS is responsible for management, delivery and financing of the health system. The NHS covers physicians, hospitals, prescription drugs, dental care and optical services as well as specialist services. In England, private health insurance is also available to cover the same benefits.

The National Health Service receives 82% of its funding from the public sector. The NHS is principally funded through general taxation and national insurance contributions (from employers and employees). User charges account for less then 3% of total funding.

The Health care system is divided into three tiers. The uppermost tier, the Department of Health, is responsible for developing policy and systems. Tier two, is a system of 28 Strategic Health Authorities (SHA). The SHA control the management and performance of local services. Each SHA is also responsible for up to 30 Primary Care Trusts (PCT) which make up the third tier of the system. The PCT manages health services at a local level.

In the 1960’s, England began a policy of de-institutionalization, but unfortunately insufficient community care programs were established to properly care for the newly discharged. In 1998 new policies were introduced including the report "Modernizing Mental Health Services: Safe, Sound, Supportive" which emphasized "assertive outreach teams" and the "National Service Framework (NSF) for Mental Health" that set detailed standards for services for adults over a 10 year period.

In 2000 the National Institute for Mental Health in England (NIMHE) was set up to implement the NSF-MH framework. Its task included assisting in "training, disseminating expertise and propagating best practice." The NIMHE has 8 regional offices that apply programs around an integrated community approach. The NIMHE also make use of Local Implementation Teams (LIT).

Further support for the NSF-MH came in 2001 with the "Policy Implementation Guide" and published proposals for reforming the Mental Health Act.

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1. Costs

The overall costs for mental health problems in England are estimated at around 77.4 billion pounds (including estimates for premature mortality costs). Missed employment opportunity losses were estimated at over 23 billion pounds per year. Mental health care budgets make up 12% to 13 % of hospital and community health services budgets, a portion of the total spent. Expenditures on mental health care seem to be insufficient to support current proposals and critics of the system believe that "decision-makers are faced with a choice to scale back the reform agenda or obtain more resources.

1. Service Delivery

Specialist mental health trusts have recently been structured in order to create a single local provider of mental health services. They vary in size of budgets, number of employees, number of inpatient beds, number of sites, range of geographical areas covered and client groups served.

A substantial proportion of mental health services are provided by primary care settings. Nine out of ten adults with mental problems and 1/4 of those with severe mental health problems receive all their care from primary care. 30% of general practitioner consultations concern mental health problems.

Recent initiatives include the development of a "graduate primary care giver" to assist general practitioners help patients with mental health concerns and assertive outreach teams have been deployed to ensure service users remain on a specified care plan.

Problems in recruitment and retention have led to critical staff shortages. Although local experience varies, some areas have seen serious staffing issues that threaten implementation of new programs.

Concerns of racism are a concern in that minority groups are six times more likely to be detained under the Mental Health Act than white people. Additionally the rates of diagnosed psychotic disorders are estimated to be twice as high among African Caribbean people and they are three to five times more likely to be diagnosed and admitted with schizophrenia. South Asian woman born in India and East Africa have a 40 per cent higher suicide rate than those born in England and Wales.

1. Promotion and Prevention

A campaign was launched in 2001 called "Mindout for Mental Health," intended to tackle the issues of stigma and discrimination and a five-year program called "Changing Minds" was developed to educate the population on mental health concerns. Critics charge that most programs have focused on education and awareness and have not achieved behavioral change. Newer promotions designed by NIMHE intend to change focus by looking at

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international evidence as to what works, targeting key audiences, delivering consistent messages, publicizing consumer contributions to society and sustaining the campaign over time.

In 2002 The National Suicide prevention program was developed. The program, to be delivered by NIMHE is an in-depth strategy comprised of six main goals:

1. 1. To reduce risk in key high-risk groups;
2. 2. To promote mental well-being in the wider population;
3. 3. To reduce the availability and lethality of suicide methods;
4. 4. To improve the reporting of suicidal behavior in the media;
5. 5. To promote research on suicide and suicide prevention;
6. 6. To improve monitoring of progress towards the "Saving Lives: Our Healthier Nation" target for reducing suicide.

1. Future Reform

Halfway into a ten year NSF program and critics are calling it a "patchwork system." There also continues to be a criticism that mental health is not a priority of the health care system.

Part 4: Mental Health Care in the United States

The United States is unique among the countries studied. It is the only country where the private sector is responsible for providing health care coverage and delivery of health care services. The private sector in the United States provides 55% of the financing, the federal government 33%, with State and local governments picking up the remaining 12%.

The National Government administers and operates the Medicare program, an insurance plan that covers people over the age of 65, as well as some people with disabilities. Medicaid is a partnership between the federal and state governments and covers medical expenses for people with low incomes. The State Children’s Health insurance Plan (SCHIP) covers medical care for children. 24% of the population use public health care insurance.

The mental health system in the United States has been criticized as being a "patchwork relic," or a non-system. Mental health problems are treated by a variety of caregivers who generally work in diverse, relatively independent, and loosely coordinated facilities and services.

Approximately, 15% of adults and 21% of children use the "system" that is comprised of four major sectors.

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1. 1. The specialty mental health sector consisting of mental health professionals such as psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers who are trained specifically to treat people with mental disorders.
2. 2. The general medical/primary care sector consisting of health care professionals such as family physicians, general internists, pediatricians, and nurse practitioners in office-based practice, clinics, acute medical/surgical hospitals, and nursing homes.
3. 3. The human services sector consists of social services, school-based counseling, residential rehabilitation, vocational rehabilitation, criminal justice/prison-based services, and religious counselors.
4. 4. The voluntary support network sector, which consists of self-help groups, such as twelve-step programs and peer counselors, is a rapidly growing component of the system.

These different facilities are both private and publicly operated, with public facilities like state and county medical hospitals serving those without insurance. An estimated 84% of the population has some private insurance coverage, but coverage for mental illness varies by plan. In addition, with many different public and private service providers, each sector in mental health service has different types of care and patterns of funding.

Like the other countries examined for this report, a program of de-institutionalization took place in the 1960’s, with the aim to cut state mental hospital populations. The program successfully cut the number of beds in these hospitals from a high in 1955 of 550,000 to a mere 40,000 today. Unfortunately, only ½ of the planned Community Health Centers planned to care for the released populations were ever completed. The money saved from the closure of the large institutions was not reinvested into community support services resulting in homelessness, sick people in prisons and a host of other problems.

States utilize the Medicaid program to pay for mental health care, funded up to 75% by the federal government.

1. Costs

The estimated indirect cost of mental health illness and disorders including values for lost productivity, mortality costs and lost production is $79 billion. In 1996 the United States spent $99 billion for treatment. 57% of the monies came from the public sector while 43% were private billings.

Many with private health insurance have no coverage for mental illness and plans that offer mental health coverage place restrictions on the length and amount of mental health care that will be covered. There have been attempts to legislate parity for insurance plans between mental health care and other

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health care but these attempts have met with limited success, with providers finding "loop-holes" in the legislation.

1. Service Delivery

The four levels of mental health care (general/primary care facilities, specialty care facilities, the human services sector and the voluntary support network) all provide services but consumer resources both permit and limit access to service. The high rate of unemployment among those suffering from mental illness is in part caused by a disincentive to work because Medicaid coverage will be lost.

The lack of affordable housing causes many people to cycle between jails, institutions, shelters and the streets. 7% of inmates suffer from serious mental illness, and frequently do not receive treatment. Additionally, many will lose insurance benefits and income supports they will need upon release.

Inadequate access to care in many rural areas combined with lower, incomes and stigma may result in a delay of treatment and greater chronicity. Minorities are often misdiagnosed because of a lack of understanding of beliefs, languages or value system and many children receive no care, ending up in child welfare or juvenile justice systems.

1. Promotion and Prevention

A major initiative launched by the United States government in the 1990’s, is the National Strategy for Suicide Prevention (NSSP). The aim of this strategy is to:

1. • Promote awareness that suicide is a public health problem that is preventable;
2. • Develop broad-based support for suicide prevention;
3. • Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and suicide prevention services;
4. • Develop and implement community-based suicide prevention programs;
5. • Promote efforts to reduce access to lethal means and methods of self-harm;
6. • Implement training for recognition of at-risk behavior and delivery of effective treatment;
7. • Develop and promote effective clinical and professional practices;
8. • Improve access to and community linkages with mental health and substance abuse services;

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1. • Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse in the entertainment and news media;
2. • Promote and support research on suicide and suicide prevention;
3. • Improve and expand surveillance systems.

1. Prospect for Future Reform

The President’s "Freedom Commission on Mental Health" published a final report in 2003 that listed six goals they believed should be met to improve the mental health system in the United States:

1. 1. Americans understand that mental health is essential to overall health;
2. 2. Mental health care is consumer and family driven;
3. 3. Disparities in mental health services are eliminated;
4. 4. Early mental health screening, assessment and referral to service are common practice;
5. 5. Excellent mental health care is delivered and research is accelerated;
6. 6. Technology is used to access mental health care and information;

Part 5: Mental Health Care in the Four Countries Studied

In all four countries studied, de-institutionalization was a common theme. It was brought on mainly by new drug treatment options, changed attitudes and the principal that treatment would be more effective in the community. It was also seen, that in most situations, the systems could not handle the closure of the institutions. Facilities were not established that could provide care.

Most countries instituted their mental health strategy concurrent with the process of de-institutionalization in Canada however, no national strategy exists.

1. Costs

All four countries studied experienced increased spending on mental health after the implementation of a mental health policy. It was also noted that most counties were moving to decentralize operations.

1. Service Delivery

A shift to community care brings concerns over the adequacy of care. There is a need for coordination and integration of service delivery. There is a view that overcoming fragmentation must be initiated from the top down as well

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as from the bottom up. Another positive step is the adoption of individualized care plans that are consumer centered and controlled.

In most countries, the primary caregivers are the first line in mental health care, with more severe cases going to specialized institutions. To improve this system, the knowledge level of the primary caregivers, in identifying or diagnosing mental health illness and in accessing the mental health system, must be improved. Second, funding for the primary caregivers must be addressed so that they are adequately compensated for care given and third, communication and coordination between primary and secondary care systems must be enhanced.

Some common themes that were observed in the comparison of the four national systems were the under-servicing of rural areas, the inadequate and inappropriate treatment of minorities, and the need for long term sustained funding.

1. Future Reform

Some of the lessons learned in this study which should be followed in any future system of reform are:

1. • The advantages of a long term, integrated planning process;
2. • "Big Bang" reforms that attempt to do everything at once are unlikely to succeed due to the complexity and range of services.

3.2 Analysis

The Senate Committee’s Second Report details information on mental health care in four countries, relying largely on published materials. The summary of their review provides a partial analysis of their findings however utilizing CMHA’s Framework for Support as the foundational document for an additional analysis, several conclusions can be drawn:

1. • All nations have similarities in their "reform" initiatives with an emphasis on de-institutionalization and community supports. There is also consistency on what is considered to be organizational and program "Best Practice" and those are detailed succinctly in a Canadian study.6
2. • As a general rule, reform began in the early 1960’s with the advent of new pharmaceuticals and a new philosophy emphasizing integration and human rights.

6 Federal, Provincial Advisory Network, Best Practices in Mental Health Reform, 1997.

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1. • No nation has a model system. However, Australia has adopted the most strategic and sustained approach to reform and appears to be achieving the best results, albeit with a small percentage of the population.
2. • The United States has a decentralized piecemeal approach to service delivery and like other nations has never fully met its commitment to community support services following institutional downsizing. However, the Committee’s report fails to recognize "pockets" of best practice and innovation in several States (Wisconsin, Massachusetts, Connecticut, Maine, Rhode Island, and Vermont). The most common feature of successful programs in the United States has been the development of comprehensive community supports (income, housing, crisis intervention, recreation, assertive outreach and pharmaceuticals) prior to institutional downsizing.
3. • In all of nations, many of the former psychiatric hospital patients who received inadequate community support, ran into conflict with the law and were incarcerated in prisons.
4. • Indigenous people (Aboriginal) in all countries have higher rates of illness and social problems and mainstream mental health services appear to be largely ineffective.
5. • Public and private expenditures on mental health services cannot be used for comparison purposes between jurisdictions. They are defined differently and encompass different types of service in every location. What appears to be evident however, is that no jurisdiction funds services in a manner consistent with the prevalence and burden of mental illnesses and substance abuse.
6. • All of the countries in the study have a National Action Plan to reduce their suicide rate and ironically, the Australian, New Zealand and American plans were influenced to a great extent by initiatives in Alberta. To date, Canada has no National Action Plan on suicide prevention.

4.0 Issues and Options for Canada

4.1 Summary

The third part of the Standing Senate Committee’s report deals with options for Canada. The report is intended to outline major issues, present potential policy options, address some issues and launch public debate.

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Part 1: Delivery of Services and Supports

The Committee advocates a mental health and addiction treatment system that is seamless, accessible and offers high quality, coordinated integrated service. The system should be focused on two principles of care. First, the system must be patient centered and second, focused on recovery.

Currently, the mental health and addiction system is organized around service providers and not the patients or clients. The Committee would like to see plans tailored to individual needs, providing a detailed description of services and supports an individual requires for recovery. Funding would follow the patient, and providers (not the patients) would coordinate multiple services. In addition the system must deal with the cultural, linguistic and geographical barriers that limit access for some populations.

Question: What mechanisms must be put in place to deliver services and supports in a culturally appropriate manner?

Currently, separate groups provide mental health care, addiction treatment, support services and disability benefits. In addition, programs span federal, provincial and regional agencies creating difficulties with coordination of services.

Question: How can the burden of coordinating and integrating services and supports be shifted to the system itself and away from affected individuals and their families?

To provide a seamless service delivery system, existing organizations must learn to work together. This may involve a reduction in their autonomy in favor of interdependence. Incentives may be needed to promote integration and deliver a genuine "system" of mental health service.

A strong mental health system would provide reliable mechanisms for early access, diagnosis and detection of illness. The earlier the diagnoses, the earlier the patient can receive treatment and the better the results.

Question: To put more emphasis on early detection of and intervention in mental disorders among children and adolescents, what would be required in terms of: school mental health programs, mental health screening for high school aged children, and screening for dual diagnosis and concurrent disorders?

It was seen in the Committee’s study, that a majority of Canadians do not seek or receive professional help when needed. Some solutions for improving access to the mental health system include legislating greater equity between physical and mental illnesses, and/or appointing "mental health advocates" to assist individuals in accessing needed support.

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Part 2: Specific Population Groups

1. Children and Adolescents

The responsibility for care of children and adolescents is currently divided among many groups such as hospitals, child welfare, schools, young offender, addiction services and special education service groups.

Question: How can we best achieve a seamless, well coordinated, network of services and supports to address the prevalence of mental disorders among children and adolescents?

Question: What services and supports could be provided in an efficient and cost-effective manner in the school system?

1. Aboriginal Peoples

There are two major federal departments, Health Canada and Indian and Northern Affairs that are currently responsible for the care of First Nations people on reservations and Inuit people. Additionally, provinces and territories are responsible for care of Aboriginal people off reserves. The division of care increases the complexity of coordination and hampers continuity of care. To improve service to Aboriginals, more Aboriginal mental health and support specialists working in community built systems are required. Aboriginal peoples should be supported in the development of their own solutions, rather than having solutions imposed on or provided for them. Such a change would foster the development of more culturally appropriate, and therefore effective, services and supports.

1. Seniors

With a rapid growth of an aging population, new standards of care must be designed to deal with the complexity of mental health care for seniors. Depression, dementia, delusional disorders and delirium are most common, but these illnesses are compounded by other co-morbidity or concurrent disorders. There is a need for health care providers specialized in care for seniors. Also, the system now provides only limited support for family members who act as primary caregivers.

Question: What could the federal government do to alleviate the burden that now falls on the shoulders of thousands of family caregivers?

Question: What are the needs of elderly parents who are the primary caregivers of adult children with mental illness and addiction?

Speak out Bravely; Listen Compassionately 36

1. Individuals with Complex Needs

Those individuals with complex needs, including concurrent disorders, dual diagnosis, some inmates or homeless, often require help from several different sectors. To improve service to these individuals, greater collaboration between sectors is required.

Part 3: The Workplace

1. Employers

Some of the issues facing mental health care in the workplace are caused by the often chronic and cyclical nature of many illnesses which may require treatment on and off for many years. Employers can play a vital role in dealing with mental illness and addiction among workers, in terms of disability management, accommodation policy and return-to-work programs.

Some suggestions the Committee heard for employers to improve conditions for employees with mental illness were to reform insurance programs to be more suited to mental health issues; to revise Employee Assistance Programs (EAP) to provide sufficient therapeutic sessions, better accommodation plans for people recovering from illness (i.e. flexible hours), and to ensure that employers and management become aware of issues of mental illness.

Question: What specific changes in policy are required to ensure that disability insurance is not a disincentive for someone affected by mental illness or addiction to return to work?

1. Workers Compensation Board

In recent years, there have been a growing number of claims to Workers Compensation Boards for occupational stress. Some W.C.B. offices are reluctant to provide mental health related benefits.

Question: What is the extent to which disability benefits related to mental health disorders should be paid by workers’ compensation versus health care insurance?

1. Federal Income Security Programs

Some of the problems for persons with mental illness facing a claim for the Canadian Pension Plan Disability Program (CPPD), are the requirements of previous work experience (4 of last 6 years employed) and the requirement to be "permanently unemployable".

Question: Should the federal government change the CPP(D) in order to provide partial or reduced benefits to enable individuals with mental disorders to retain a portion of their benefits while still working part-time?

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Question: For Employment Insurance claimants, should individuals subsequent to leaving employment be found to be affected by mental illness and addiction be exempted from the requirement to fulfill the total number of insurable hours?

1. Federal Government as an Employer

Question: How effective is the federal government as an employer in accommodating individuals with mental illness and addiction? What needs to be improved so that the federal government can lead by example in its role of employer?

Part 4: Specific Issues

1. Combating Stigma and Discrimination

To properly combat the issues of stigma and discrimination, a national anti-stigma strategy is required. This strategy should consist of:

1. • Public awareness campaigns
2. • A role for the media to change public opinions
3. • Social contact (education through interaction)
4. • Education for members of the media
5. • Increased awareness among health care professionals.

1. Suicide Prevention

Canada currently has no national strategy for prevention of suicide. A specific strategy should be implemented and include:

1. • Public awareness campaigns
2. • Population health strategies
3. • Prevention programs
4. • Equitable access to counseling and treatment
5. • A measure to reduce lethal means of suicide
6. • Training of service providers and educators in early detection
7. • Research and education.

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Part 5: Human Resources

1. Supply of Mental Health and Addiction Human Resources

There is an obvious need for more monitoring of health resources in Canada. Currently, there is no data on the supply of human resources. This lack of information creates obstacles to planning.

A human resource strategy needs to be developed that ensures the right skills are delivered, and culturally appropriate services are available to all communities. There is a need to assess and resolve issues of geographic distribution of personnel.

1. Primary Health Care Sector

Question: If primary health care providers are to be the primary gatekeepers for a patient’s entry into treatment for mental illness and addiction, what needs to be done to improve mental health care at the primary level?

An improved primary health care system would include greater mental health training for family physicians and nurse practitioners, adjustments to physician’s fees to better accommodate the type of care needed by patients with mental disorders and better collaboration between physicians and psychiatrists.

1. Community Support Workers and Police Officers

Question: What types of training are currently available to, and required of, a community mental health support worker in Canada? Should there be more uniformity in the training and education of community mental health support workers?

Question: What should be done to improve the training of police officers to enable them to deal more effectively with individuals with mental illness and addiction? How can we increase the safety of those involved in the intervention and help to ensure that law enforcement officers use the least amount of force when apprehending someone who is experiencing a mental health crises?

1. Supporting Caregivers

Question: Do families living with someone affected by mental illness or addiction have adequate access to the resources they need to help their loved ones?

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Part 6: National Information Database, Research and Technology

"The Committee believes strongly that excellence in mental health services and addiction treatment depends on a strong commitment to develop a national information database, fostering research on how to manage health information generally and that related to mental health and addiction in particular, and to using information and communications technology appropriately. This would greatly help to inform and guide decisions, the setting of policies and priorities, and improve outcomes for individuals with mental illness and addictions."

1. Canadian Community Health Survey

The 2002 Canadian Community Health Survey (CCHS) provided, for the first time, prevalence rates for some mental illnesses, substance use, suicidal ideation and pathological gambling. The Committee feels that the CCHS should be repeated on a regular basis and its base should be expanded to cover a wider range of mental disorders, age groups and population sub-groups.

Question: What can be done to improve the information available on prevalence of mental disorders among Aboriginal peoples, the homeless and the prison population?

1. National Information Database

Canada currently lacks a national information base on the prevalence of mental illness and addiction. We also lack the information system required to measure the mental health status of Canadians and to evaluate policies, programs and services in the fields to mental health, mental illness and addiction.

1. Research

The funding dedicated to research into mental health, mental illness and addiction does not reflect the burden of mental illness and substance abuse on the Canadian economy. Estimates suggest that if funding were to be provided in relation to the economic burden of disease, then CIHR’s (Canadian Institutes of Health Research) support for mental illness and addiction would have to increase from its current base of $33 million to at least $80 million per year." It must be determined what factors should be taken into account when determining the allocation of funds.

Question: Is the research funding from provincial governments sufficient? What about the level of research funding from mental health organizations? Are pharmaceutical companies investing sufficient funds in this area?

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1. Knowledge Transfer

All too frequently, published research discoveries in mental health, mental illness and addiction (medication, psychotherapies, etc.) remain with researchers in their laboratories and have limited impact on service delivery and patients’ outcome.

Question: What are the reasons behind the resistance to adopting evidence-based state-of-the-art medications and therapies? How can this resistance be overcome?

1. Research Involving Human Subjects

It is imperative that research be conducted ethically and never at the expense of human rights. There must be guidelines and rules to protect individuals that volunteer to aid research, but not be so stringent as to eliminate any group from participating in a program for the benefit of all.

1. National Research Agenda

A national research agenda should be developed to coordinate fragmented research and to promote balanced research. Further, this national agenda should be built on input from Canadian expertise.

1. Information and Communications Technology

Modern technologies should be developed to assist in the efficient delivery of mental health and addiction services. These new technologies could include the development of electronic health records which would improve timeliness of care by allowing speedy access to relevant client data. Electronic health records could also improve integration of provincial and territorial health infrastructures and reduce the need for clients to repeatedly provide personal and health data. Major steps toward such a plan have been taken by the federal governments’ Canada Health Infoway Inc.

The Committee is also interested in the possibility of developing of a Tele-mental health service, which would provide distance health care through videoconferencing. This technology would help to improve access to mental health care for those in rural or remote areas.

Question: What is the potential for Tele-medicine in the field of mental illness and addiction?

In reference to the development of an Internet based system for information access, the Committee recommends: "the creation of a national portal for the Canadian public that would provide comprehensive, trusted health related information to support self-care decision-making. The portal should build on the success of the Canadian Health Network and be linked strategically to provincial and territorial website services to ensure the consistency of health-related information."

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1. Privacy

It is important that there be a continuation of efforts to promote a harmonized approach to protecting health information. In addition to safeguards, personnel accessing electronic health records must be accountable for the use of those records.

The question of family and caregiver access to personal records must be addressed. In some circumstances, allowing family access to personal medical information can improve the quality of care for the affected individual and the care of the patient must take precedence over privacy concerns.

Part 7: The Role of the Federal Government

Improvement needs to be made in both the federal government’s direct and indirect roles in mental health services. In its direct role of supplying mental health services, there must be a coordination of an overall framework to address the currently fragmented approach. There also needs to be population specific strategies and the development of a mental health initiative to address the needs of the people under federal responsibility. In its indirect role, the federal government has no defined position for mental health in the public health system. There are no funds dedicated directly to mental health care, and there must be improvements to address issues of access to prescription drugs and home care.

The federal government develops policy and approves funds while the provincial and territorial governments are responsible for the delivery of services. To improve the system these various levels must work together. The report hypothesizes that "A high degree of intergovernmental consultation and collaboration is essential to achieve uniformity, to develop and maintain standards, bring harmonization and establish a national mental health initiative across the country"

1. National Action Plan

Canada needs to develop a comprehensive national action plan on mental health, mental illness and addiction to ensure successful reform and restructuring. Canada lacks national leadership in mental health, mental illness and addiction, a serious deficiency that, in the view of many, has left a large void.

The lack of strong leadership has created a "piecemeal" approach to mental health, mental illness and addiction services. A national action plan should set standards for prevention and promotion, child and adolescent care as well as care of inmates, seniors, women, landed immigrants and Aboriginals. A

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successful national action plan would be developed through consultation with all levels of government as well as non-government organizations.

Question: Should the national action plan be developed by an incremental approach or through the simultaneous reform of several large-scale systems? Should Canada have a single, national, action plan? Should each province and territory have its own action plan but with a common vision?

Question: What elements should be included in a national action plan?

Question: How can we ensure that individuals affected by mental illness and addiction and their families participate fully in the development of a national action plan?

Part 8: Financing Reform and Fostering Performance and Accountability

1. Level of Funding

Funding directed towards mental health illness is, in relation to physical illness, very low. Inadequate funding results in serious gaps in service. Thorough review is required to assess what an adequate level of funding would be.

Question: What, if any, should be the relationship between the funding for mental health, mental illness and addiction and the prevalence and economic burden of these illnesses?

In its review of mental health programs in other countries, the Committee heard, as part of funding issues, how New Zealand had developed detailed targets to which to build capacity (number of beds, workers etc.). Should Canada develop a similar set of targets to help determine how much funding is needed?

Question: Would dedicated funds better ensure the funding for mental health, mental illness and addiction as predictable, sustainable and equitably allocated?

1. Performance and Accountability

"There is a significant lack of accountability mechanisms in the current mental health and addiction system. The respective roles and responsibilities of the various levels of government and the multiple service providers are not clearly set out."

Question: Should quality assurance programs be put in place? How should quality be defined and, equally importantly, how should it be measured?

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Question: Is the National Health Council, the appropriate structure to assess, and report on, the performance of the mental health/addiction system and to improve accountability?

4.2 Analysis

The Senate Committee’s Third Report and the related questions clearly reflect a bias consistent with CMHA’s "New Framework for Support"7. Again it is evident that the Committee was influenced by CMHA’s submission to Phase One".

Observations and issues:

1. • Proposals for individualized service plans are medically oriented (patient centered and focused on recovery). While medicine is an important part of recovery, the more significant factors are encompassed within the determinants of health. CMHA might better serve its constituents by focusing on these determinants than examining individualized funding models that tend to focus on a narrow area of clinical service. The literature suggests that coordination and integration can best be achieved through a system of specifically assigned service managers (case managers).
2. • The issues of early intervention can be informed by CMHA’s learnings in the Early Psychosis Intervention: A Framework for Strategic Planning project. Community awareness, clinical access and family and client information are all important dimensions and need to be reflected in a comprehensive approach.
3. • For the past decade almost every report and study on Aboriginal relations reiterated the same conclusions. Efforts to address this group’s significant health and social deficits will continue to fail as long as society continues to "do for." Empowerment of Aboriginal people, along with improved resources for education, employment and addictions should be strongly supported in CMHA policy.
4. • Parents of children with mental illnesses require some comfort knowing that as they age and die, their children will still be cared for. A comprehensive mental health system that builds on the "health determinants" can do that. Tax credits for families who care for their disabled members might be a worthy consideration.
5. • Private health plans and most Family and Employee Assistance Plans are inadequate in terms of coverage for any form of extended psychological service and a federal initiative could legislate change as

7 The New Framework for Support, Third Edition. Canadian Mental Health Association

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1. was attempted with some success in the United States. CMHA and other organizations have experience with workplace initiatives and "accommodations" designed to assist employees and/or to provide opportunities for new employees. A federal study endorsing these initiatives could assist with this knowledge transfer.
2. • Canada and Alberta in particular, have suicide prevention initiatives that are modeled around the world. The profile of the Centre for Suicide Prevention in Calgary might be enhanced if it became a National initiative. The impetus of a federal government National Action Strategy might lead to funding partnerships between the private sector and the federal, provincial/territorial governments. Provincial governments are currently duplicating effort.
3. • Physician billings for mental health related matters and the prescribing of pharmaceuticals is now one of the most significant costs in most provincial health plans. The efficacy of this approach is questionable and several new models of primary health care are being attempted in communities across Canada. Physician payment arrangements have been changed and multi-disciplinary teams have begun working in partnership with physicians, supplementing medications with psych-social supports. A federal study of these pilot initiatives could facilitate learning transfer.
4. • A CMHA BC study8 on police interventions recommends improved family collaboration, access to information, dispute protocols and improved police training. However, programs of diversion in Toronto, Edmonton and Calgary suggest that officer training may not be as significant a requirement as once thought. The availability of treatment options for the officer to utilize at their discretion may be a more significant factor. While research results are preliminary, a national review of diversion initiatives might demonstrate service and cost effectiveness, helping to stimulate similar resources across the nation.
5. • Tele-health services have huge potential in a country as vast as Canada and several provinces including Newfoundland and Alberta have almost a decade of experience. Alberta has a particularly rigorous evaluation protocol and research data supporting the benefits from both a cost and therapeutic perspective. The results of this experience should be examined and promoted on a nation-wide basis.
6. • Provincial comparisons of mental health spending are difficult due to the inconsistency in definitions, reporting and recording. One study9 reported that the Canadian provincial average was 11% of heath care spending while the "burden of illness" was 15%. But what is the right amount? It may also be difficult to argue for "more" when we know we spend poorly in many areas. For example, the lack of early intervention leads to chronicity and long term care and frequent

8 Study in Blue and Grey, MacNaughton, Dec 2003

9 Huebner, Gardiner & Adair, Best Practices in Mental Health Systems, University of Calgary, 2002

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1. hospital re-admissions due to a lack of community supports increase cost at the most expensive cost centre. A more judicious approach might be to argue for long term strategic plans with clear goals, well developed multi-year funding projections and outcome measures.
2. • Health outcome measurement is at a preliminary stage and mental health outcomes are even less adequately developed, with most programs focusing on outputs. While the National Health Council might serve as a resource to develop models and assist in the training of evaluators, service evaluation it would seem, is best integrated into the existing general health care infrastructure.
3. • The 2004 Federal/Provincial First Ministers "Health Renewal" meetings identified "community mental health services" as a high priority and this interest could be nurtured and encouraged to concrete action.

5.0 Challenges, Opportunities and Key Messages

The Senate Committee initiative has already provided CMHA with a significant opportunity to inform national thinking on future directions for mental health services. The CMHA influence on Phase One appears to have been very substantive.

However, the "results" of advocacy efforts will be judged by whether we truly see change. Phase Two of the Senate process will provide CMHA with an almost unprecedented opportunity to influence the public and to motivate governments to action. It also presents its challenges. They include:

1. • Presenting the Committee and public with a consistent message nation-wide;
2. • Influencing Committee thinking with passionate and cogent arguments;
3. • Stimulating public interest sufficiently that they will participate in the consultation process, hopefully validating and reinforcing the CMHA message;
4. • Motivating the media to cover both the proceedings and the recommendations in the final report in an attempt to "catch" the attention of political leaders;
5. • Designing and implementing a sustained political action campaign following the release of the report.

While CMHA’s June 2003 brief to Phase One of the Senate process was detailed and well documented, it contained many messages. If we are to capture public, media and government attention we will need to articulate a key message or messages that are easily understood. While these messages

Speak out Bravely; Listen Compassionately 46

need to be developed through a nation-wide consultation within CMHA Divisions and Branches/Regions, there appears to be a growing consensus on a single message: the need for a Pan-Canadian Action Plan for Mental Health, Mental Illness, Addictions and Suicide. That plan might include:

1. • A recommended model of service delivery detailing the best in evidence-based practice to ensure consistent core services and result oriented programming.
2. • A recommended set of national standards of service for all programs including home care.
3. • Leadership in fostering intergovernmental, interdepartmental and intersectoral collaboration in order to improve efficiency and maximize on the use of resources such as national education campaigns, research and suicide prevention.
4. • Partnership with the provinces and educational facilities in developing a long range human resources plan in order to ensure an adequate supply of appropriately trained service providers.
5. • Resources to facilitate access to the latest in pharmaceuticals in order to maximize on treatment outcomes.
6. • Facilitation of a national information and statistical system with rigorous privacy provisions in order to provide the necessary information for planning and service delivery.
7. • Ensuring the provision of evidence-based services to mandated populations (Aboriginal people, the Armed Forces, the RCMP and federal prisoners) in order to provide the same standard of care as is available to the general population.

6.0 Next Steps

If CMHA is to maximize on the opportunities afforded by the Senate initiative, it will be imperative to harness the organizations nation-wide potential to:

1. • Distribute Speak Out Bravely; Listen Compassionately across the nation in order to inform, stimulate thinking and receive feedback.
2. • Agree on the over-arching policies and content of the Phase 2 submission;
3. • Prepare a draft National brief and ensure wide internal distribution, and consultation prior to submission.
4. • Encourage all Divisions and Branches/Regions to coordinate any request to appear before the Senate hearings with national CMHA. All local requests should honour the Senate criteria of focusing on specific innovations while avoiding any duplication of the national CMHA

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1. message. For direct input, Local members and clients should be encouraged to complete the on-line submission (See appendix B).
2. • Following the release of the Senate Committee report in the fall of 2005, National CMHA with the support of all Divisions and Branches/Regions would use whatever means at their disposal to influence government action on all of the recommendations formally endorsed by CMHA. (An "influence map" is attached as Appendix C in order to stimulate ideas as to where members might exercise their influence.)
3. • In so doing, Speak Out Bravely and Listen Compassionately, then celebrate the successes.

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7.0 Appendices

7.1 Appendix A: Definitions

Concepts as defined by the Committee:

1. • Mental health and mental illness
2. • Mental disorders are defined, including mood disorders, anxiety disorders, psychiatric disorders, eating disorders, personality disorders, pervasive development disorders, attention deficit, disruptive behavior, cognitive and substance use disorders.
3. • Substance use and addiction including abuse and dependence, and how dependence may be either physical, psychological or both.
4. • Co-morbidity, where the same individual has two or more disorders (in the context of this report, a mental and a physical illness)
5. • Concurrent disorders (mental illness and substance use disorders), and dual-diagnosis (mental health problem/illness and developmental disability)
6. • Services and supports are defined as well as the primary, secondary and tertiary care.
7. • Case management, inpatient/outpatient services, community supports, mental health crises/emergency response and individual and family initiatives.
8. • Chronic Disease Management which provides an emphasis on community based care and aims to foster independence, fulfillment and self management (the individual develops knowledge to deal with illnesses or disorders on their own).
9. • Concepts of promotion in the format of awareness and understanding of issues (referred to as mental health literacy and intended to reduce stigma).
10. • Concepts of prevention are divided into primary (averting potential problems), secondary (early detection/ intervention) and tertiary (minimizing disability or avoiding relapse).

APPENDIX A 49

1. • Surveillance of mental health care, which is a program for collection, interpretation and analysis of health related data, is also included in the discussions. Sadly, they note there is no current surveillance program in Canada

Finally, the terms used to describe individuals with mental illness are discussed, the more common being patients, clients, consumers, and survivors.

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7.2 Appendix B: On-Line Questionnaire

The Standing Senate Committee on Social Affairs, Science and Technology

This questionnaire is also available online at the following address:

www.senate-senat.ca/SOCIAL.asp

1. OVERVIEW

a) Please describe briefly your experience with mental health and addiction services.

b) What was your most positive experience?

c) What was your worst experience?

2. HEALTH SERVICES AND SUPPORT SERVICES

a) Canadians use a wide variety of mental health and addiction services and support services, such as housing support, educational or vocational training services, income support, disability benefits, social support services and so on. These services are offered by many levels of government, different organizations and professionals. Many Canadians suffering from mental illness or addiction problems find the number and variety of services confusing and difficult to access. What changes would you like to see made so that it would be easier for you to gain access to the mental health and addiction services and support services you need?

b) If you could change the way mental health and addiction services and support services are delivered, what are the three most important things that you would recommend?

3. SCHOOLS

a) Some people have suggested that for children and adolescents, schools would be a good place to provide access to mental health and addiction services. Do you think that this is a good idea or a bad idea? Why?

APPENDIX B 51

b) If you agree that for children and adolescents, schools are a good place to provide access to mental health and addiction services, what kinds of mental health services or addiction services do you think should be available in schools?

4. EMPLOYMENT

a) Having a job is important to everyone, including people affected by mental illness or addiction. What do you think employers can do to make it easier for individuals with mental illness or addiction to get a job or to return to work after being on sick leave because of a mental illness or addiction problem?

5. FAMILY CAREGIVERS

a) Families are often the most important source of support for people affected by mental illness or addiction. They provide their loved ones with a place to live, with care and with financial assistance. In your view, what could be done to make life easier for families which have a family member who is affected by a mental illness or addiction problem?

b) What support services do family members need? For example, do they need information on mental illness and addiction, someone who can look after the person with a mental illness or addiction problem for short periods of time so that the family member can get a break, financial help, etc.?

6. STIGMA AND DISCRIMINATION

a) Discrimination affects individuals living with mental illness and addiction in many different ways. They are often denied many of the rights others take for granted. The list of areas where they may be treated differently is a long one, and it includes: access to housing, employment opportunities, having an adequate income, availability of insurance, admission to post-secondary education, eligibility for disability benefits, criminal justice matters and parenting rights. Do you know of instances of discrimination against individuals living with mental illness or addiction? If you do, can you give us some details about the discrimination?

b) Do you have any suggestions for how this problem of discrimination can be solved?

7. OTHER CONCERNS

a) Are there particular concerns related to mental illness or addiction you would like to share with the Committee, other that those you have mentioned in your answers to questions 1-6? Please be as specific as possible. The more detailed the information you give us, the more helpful it will be to us.

APPENDIX B 52

7.3 Appendix C: Policy Influence Map