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Response to the Discussion Document ‘Every Door is the Right Door: Towards a 10-Year Mental Health and Addictions Strategy’

August 1, 2009

CMHA Ontario provides feedback for the discussion paper, “Every Door is the Right Door: Towards a 10-Year Mental Health and Addiction Strategy.” The desired future state of a new mental health and addictions strategy for Ontario is an integrated, person-centred mental health and addiction services system. The transformation needed from today’s organizational structures and relationships is substantial and will require a fundamental reshaping of the current service delivery system. (August, 2009)

Preface

CMHA Ontario welcomes the opportunity to provide feedback on the discussion paper, “Every Door is the Right Door: Towards a 10-Year Mental Health and Addiction Strategy.”

CMHA Ontario is a not-for-profit, charitable organization committed to improving the mental health of all Ontarians.Our vision is ‘Mentally Healthy People in a Healthy Society’. Our mission is to develop and provide public policy advice that promotes mental health and improves the lives of people living with a mental illness. It is this from this perspective of better mental health for all that we provide our feedback.


Introduction

CMHA Ontario is fully supportive of the need and opportunity expressed by Minister Caplan and his advisory group for developing a new 10-year mental health and addictions strategy for Ontario. While our current policy frameworks have served us well over the past decade, much has changed in this province that demands we develop a fresh and forward looking approach. We believe that the new strategy must build on the strengths of our current mental health and addictions systems but it should not be bound by its current structures or approaches. The discussion paper released by the MOHLTC on July 13th is a start to the development of a 10-year strategy, an excellent start, but we believe many issues remain to be addressed and the current proposals should be considered a work-in-progress.


A New Vision for Ontario

The discussion paper begins with a new vision that reflects our much changed environment and provides a broader focus than previous government mental health and addiction strategies. For example:

  • This discussion paper reflects the whole Government’s commitment to an integrated mental health and addictions strategy.
  • This paper reflects the whole Government’s approach to addressing mental health and addictions and not just health care services.
  • The discussion paper broadens the vision set forth from care and treatment to promoting health and well-being.
  • The focus emphasizes reducing the incidence and burden of mental health and addictions for all Ontarians.

This new vision is laudable and CMHA Ontario fully supports it. Realizing such a vision is highly complex and requires fundamental change in government policy development and implementation, integrated funding strategies, new inter-organizational and inter-professional relationships with each other and with those individuals with lived experience and, finally, changing public awareness and expectations. It is a tall task to accomplish but one that isdoable and worthy of the time and investment required by all of us.

In this submission we will provide our insights and advice for the next phase of the strategy’s development and ultimately towards its implementation.


Making Every Door the Right Door

The discussion paper addresses the current fragmentation in our systems that exist for those seeking care and services. The seven proposed directions outline the fundamentals of the new strategy and CMHA Ontario concurs with the importance of these directions.

The discussion paper is grounded in the concept that every door is the right door. As the paperpoints out, there is a compelling need for enhanced access, improved navigation and better cultural/linguistic competence. We do not do these things very well at present. As such, the rationale and intent of the concept is understandable. From a service delivery perspective, it is likely achievable but it will be difficult to develop appropriate skills and training across the many service delivery entry points to make it feasible.

However, the strategy is much broader than service. In the context of the overall strategy, the meaning of every door is the right door is less clear and needs much greater clarity as to how the intent can and should be carried out in the proposed broad and multi-sectoral implementation. By way of example:

  • The discussion paper rightly notes that only a minority of individuals seek care and the current capacity of the system to respond even at this level is limited. How does this concept address the capacity issue and how does it help the over 60% of persons who never open any doors?
  • The discussion paper speaks to a strategy that goes well beyond services to changing public and professional attitudes, community resilience and healthy communities. These initiatives are not services per se but rather reflect values and beliefs; understanding and awareness; social action and community advocacy. The concept of every door is the right door is not the most applicable frame of reference in the context of the broader strategy.
  • The range of touch points referred to in the strategy are many and varied from schools to community centres; religious institutions to sports programs; and hospitals to in-home services. It is most certainly very important to raise awareness and understanding of mental health and mental illness to support prevention, recognition and access to services. But to expect individuals working in these settings to be have more than a preliminary ability to intervene may not be realistic.

In considering the next phase of development for the strategic framework, it is worth noting that a recent reportout of the United Kingdom, “A Future Vision for Mental Health”, takes a somewhat different approach to identifying the breadth of what is required in a comprehensive mental health strategy.1 According to this report the four concepts of key importance are:

  • Mental health and well-being is everybody’s business.
  • Good mental health holds the key to a better quality of life.
  • People should get as much support to gain a good quality of life and fulfill their potential from mental health services as they expect to receive from physical health services.
  • A new relationship is needed between mental health services and those who use them

Although the UK report speaks to mental health and does not include addictions, the basic principles on which it is based appear equally valid for addictions. The concepts in the UK report are very powerful and change the fundamental viewpoint from which we act. For example it states that, “good mental health benefits us all”and that,”every citizen has a right to good mental health.”The report also states that, “we believe that ‘investing to save’ in the public’s mental health will accrue benefits, not just to individuals and their families but to whole communities and to taxpayers.”And finally, the UK report states that “the standard and quality of mental health care should be as high as that of physical healthcare.”

Ontario’s draft discussion document is philosophically consistent with the UK report. The important difference is the framing of the mission. Where the Ontario model focuses substantially on the needs of those living with a mental illness or addiction, the UK report begins with a set of values and beliefs for society as a whole. This latter approach makes mental health and addictions a responsibility of all of government and society and not just those serving an identified target group. The UK report approach binds us all together and embraces social inclusion and social responsibility in a more empowering way. It does, of course, also speak to service provision and need.


Desired Outcome

The desired future state of a new mental health and addictions strategy for Ontario is an integrated, person-centredmental health and addictions services system. The transformation needed from today’s organizational structures and relationships is substantial and will require a fundamental reshaping of the current service deliverysystem. Today’s community mental health services are focused primarily on adults (18 to 65 years) with a serious mental illness. While it is changing, primary care in Ontario is still delivered mostly by fee-for-service physicians in solo or group practices. Children’s mental health services operate through different policies, practices and organizations than the adult system. As well there is the institutional/community gap to be bridged and a need to find a better way to serve the elderly. Similar disconnects are found in the addictions services system.

Before we can address the ‘how’ of reaching desired outcomes of a transformed mental health and addictions system, the overarching rationale for the change must be specified. The discussion document does not put forward an argument for what is needed or intended by bringing mental health and addictions together within a single strategy and system.

Excluding Ontario, six other provinces have combined mental health and addictions branches, units or departments at the provincial level, although many of these provinces maintain separate strategies and separate services.2 BC and Alberta are moving to more structural integration at the policy, planning and service delivery levels. There has been no evaluation of the impacts of integration of mental health and addictions at the provincial level in Canada, and the U.S. results have been mixed.

The most common reason for integration has been to more effectively address the high prevalence of concurrent disorders. Recent studies suggest that the prevalence of concurrent disorders may be less than first thought and that the benefits of integration cannot be generalized to all potential users.3 Therefore the strategy must answer several key questions:

  • Is it only concurrent disorders that we are concerned about?
  • Is the purpose of integration more values driven or to achieve cost effectiveness?
  • What aspects of mental health and addictions would be better integrated and what parts may be better planned and delivered separately?

The strategy must first enunciate its intent and specific goals and objectives regarding the integration of mental health and addictions. The stated policy and strategic directions can then guide the action strategies and plans at the community and service delivery level.

Mental health and addictions services, in many instances, have developed with different cultures and philosophies that must be melded to create a new, integrated culture at all levels. Ontario’s experience with integration, mainly hospital restructuring, has shown the time and effort required for successful change management. The strategy must look at a number of options and specify the policy directions. For example:

  • Does integration mean single sites with cross training of professionals and peer support workers?
  • Is integration to be more about e-health solutions?

Without greater understanding of the desired outcomes, it will be difficult to move forward.

CMHA Ontario is supportive of the emphasis placed in the discussion paper on population based health promotion and prevention. A very important element of this strategy is addressing stigma and discrimination. The literature shows addressing stigma requires multi-faceted, targeted and sustained action to even begin to change attitudes and beliefs. The discussion paper talks about all parts of the health system and all other sectors being involved in this endeavour. The literature indicates that the most successful efforts have been centrally led and supported; routinely evaluated and targeted in message and approach. It is questionable whether a diverse and highly distributed approach will lead to success.


Implementing a New Strategy

A transformed system, once clarified, begins not at the point of service delivery but at the organization of government’s own actions and must be carefully managed and coordinated through every step of the process from policy development through to service delivery. There is some cogent literature addressing this matter. An article in Public Administration Review entitled “The Whole-of-Government Approach to Public Sector Reform,”4 discusses the current approaches in use for the holistic health strategies proposed in the discussion paper. There are many examples of how this has been achieved, including new cabinet committees, inter-ministerial or inter-agency collaborative units, intergovernmental councils, lead agency approaches, cross-sectoral projects or programs and super networks.

The UK report, “A Future Vision for Mental Health”, calls for “a champion at the heart of government”and recommends a “Cabinet Minister to take oversight of all government departments’ activities and spending on mental health and well-being, championing government action to improve mental health.”While this approach has considerable potential and should be considered in Ontario, it is essential to look beyond the coordination of policy and government funding allocations to on-the-ground implementation.

The issue of whole-of-government or horizontal government has been addressed in a recent Senate Committee Report.5 The report comments that such an endeavour will “require a profound structural change in the government’s approach to the development and implementation of public policy.”The Senate Committee recommends the establishment of a Cabinet Committee preferably chaired by the prime minister. The report goes on to acknowledge that implementation requires both expert knowledge and connectivity expert knowledge to support the Cabinet Committee and connectivity to ensure appropriate links horizontally and vertically.

These are considerations for Ontario’s Mental Health and Addictions Strategy, as well. At present, there is no single body or process in Ontario that can direct and monitor the implementation of not just the service system’s transformation but the strategy in its entirety. This will be addressed later in our response.

The discussion document notes that only about one-third of people needing mental health and addiction services access available services. For many of these individuals, the basket of services required is not provided in an integrated, coordinated or timely basis. Canada and Ontario spend far less than other jurisdictions on mental health and addictions. To be successful, the strategy rightly calls for more comprehensive and accessible care for all Ontarians. The strategy must be accompanied by a multi-year investment plan if the desired outcomes are to be realized. The current economic realities may preclude immediate and substantial investments but significant future investments are essential. There are very real capacity issues in the system today with long wait times for many services.

Stopping stigma and discrimination is another important goal for Ontario. The UK report notes that “changing attitudes and behaviour is the work of generations”. Government led anti-stigma campaigns have been carried out in Australia, New Zealand, the UK and Japan.6 These campaigns have been government coordinated and funded at significant and sustained levels. Heather Stuart, a leading Canadian expert on reducing stigma, supports the approach of face-to-face interactions with consumers (as the draft strategy recommends), but does caution that this approach has, “been most successful in improving knowledge and attitudes (but not necessarily behaviours).”Results of any efforts in Ontario must be evaluated to ensure the desired outcomes are achieved.

Creating healthy communities holds considerable promise of change and progress. It is on this goal that the need for coordination across governments, human services sectors, providers, consumers and the general public becomes most evident. CMHA Ontario commends the Minister and the Minister’s Advisory Group for making it quite evident that supporting recovery is complex and requires a holistic approach. “People with lived experience should have the same opportunities as other Ontarians to have income, employment, housing, education and lifestyles that lead to better health.”This statement represents the very essence of what the strategy must address.

Building community resilience is closely aligned with creating healthy communities. CMHA Ontario fully supports this direction but cautions that impact will only be achieved with proper planning and evidence-based services and programs. Although action is implemented at the community level, there is a very considerable risk to leaving the task to communities without strong and consistent provincial direction and leadership.

Our addendum provides more specific commentary on the proposed strategic directions and priorities discussed in “Every Door is the Right Door”.

Through the dedication and encouragement of the Minister of Health and Long Term Care, his cabinet colleagues, the Minister’s Advisory Group and many others, the process has begun to develop a 10-year strategic plan to improve mental health and well-being for all Ontarians. The work to date is to be commended and its further development and refinement encouraged and supported.


Recommendations for the Next Phase

In the next phase of the Minister’s Advisory Group’s work, CMHA Ontario recommends a number of areas for consideration and refinement.

Clarity of Purpose

Ontario, like several other jurisdictions, has sought to better integrate mental health and addictions. While there are compelling reasons to do so in some instances, the literature does point out that such integration may not always be beneficial. The strategy needs to define what is intended by this integration and the results expected to benefit the individuals living with a mental health and/or addiction issue, their families and the community. This is essential as it will drive the whole process, including strategic objectives, priorities and investments, etc.

It is also important for the strategy to better clarify the priorities for action and include a timetable and funding strategy within the 10 years it covers. The discussion paper moves back and forth between healthy public policy (government-wide), health care policy and more specifically mental health and addiction services policy. All these areas need to be addressed in the strategy but there is a lack of prioritization and, more importantly, a lack of connectivity to ensure the whole strategy is leveraged by its parts. Competing incentives and conflicting policies from lack of integrative thinking have been a detriment to success of other transformational exercises in the past and must be addressed.

Governance and Accountability

The complexity and comprehensiveness of the proposed strategy is hampered by the lack of any single point of accountability for it. This is true today in our more fragmented system, and without concrete plans and processes for the strategy’s implementation, this serious gap will continue into the future and put the whole strategy at risk. It is unlikely and unnecessary that we can hold a single individual or organization responsible and accountable for all aspects of the strategy but a transparent and understandable series of (linked) accountabilities is a must.

The UK report suggests some mechanisms as to how the UK should improve accountability. Since the UK system is very different than ours we cannot merely adopt their recommendations, but their thinking serves to highlight some of the considerations involved. At the top, in both jurisdictions, is government. As noted previously, their report recommends a cabinet minister be appointed as champion with monitoring responsibility for all activity and spending across the government related to mental health. Their report goes on to recommend new public service agreements for mental health and well-being that specify the expected action across government and their corresponding local health and social care agencies and organizations. In the long term, it calls for legislation explicitly preventing discrimination against people with a mental illness and positively promoting full participation as equal citizens.

At the July Summit it was heartening to see the number of cabinet ministers committed to making improvements in mental health and addictions in their areas of responsibility. Equally encouraging is the Select Committee of the Legislature’s dedication to making a difference for all Ontarians in a non-partisan and informed way. Translating all this interest into a coordinated and comprehensive government strategy remains the challenge. It will require sustained action that goes beyond an inter-ministerial committee whether political or bureaucratic. Accountability by the legislature, governing party and bureaucracy is needed over the life of the strategy to address aligning legislation, regulations, policy and funding.

Moving out from Queen’s Park to communities will also need a transparent chain of accountability. While some of the services rest with the LHINs, these service agreements cover only a fraction of the services and people involved. New structures, processes and/or alliances will be needed to weave the pieces together at the provincial, regional and local levels. It is CMHA Ontario’s intention to work with other partners and stakeholders to develop options with government on this matter.

Funding the Strategy

CMHA Ontario believes that everyone involved with the strategy development and implementation understands the limits the current recession places on government expenditures; but the need for investment – significant investment – in realizing the strategic plan is a requirement, not an option. The facts are clear and irrefutable. While some efficiencies might be feasible through better coordination, these are more than offset by the fact that Canada spends far less than other jurisdictions. Add to these financial pressures additional investments to serve those with moderate mental illness and/or addictions, reduce stigma , labour issues and on and on, and more funds must be targeted to strategy implementation. How these investments are made is also an area for the new strategy to address. There is a need for strong provincial leadership and policy guidance to ensure these investments reflect the strategy’s intent and desired outcomes.

Finally, the investments and the strategy must be accompanied by ongoing monitoring and evaluation.

Research

The most recent series of investments were accompanied by funded research to evaluate the impacts of the investments. This has proved very successful as a learning tool for the government and the field. It is imperativethat the strategy be accompanied by a parallel research program to ensure the impacts are producing the intended results on clinical, operational, service system and societal levels. These investments should be designed as integral to the strategy.


References

  1. The Future Vision Coalition, “A Future Vision for Mental Health,”July 2009, available at www.futurevisionformentalhealth.org.uk
  2. CMHA Ontario, “Mental Health and Addictions Brief: Internal Discussion Document,”April 2009.
  3. Brian Rush et al., “On the Integration of Mental Health and Substance Use Services and Systems: Main Messages,”Canadian Executive Council on Addictions, December 2008, available at www.ccsa.ca
  4. T. Christensen and P. Laegreid, “The Whole-of-Government Approach to Public Sector Reform,”Public Administration Review, November/December 2007.
  5. Standing Senate Committee on Social Affairs, Science and Technology, “A Healthy, Productive Canada: A Determinant of Health Approach,”Final Report of the Senate Subcommittee on Population Health, June 2009, available atwww.parl.gc.ca
  6. H. Stuart, “Fighting Stigma Caused by Mental Disorders: Past Perspectives, Present Activities, and Future Directions,”World Psychiatry, 7(3); 2008: 185-188.

ADDENDUM

Detailed Response to the Proposed Strategic Directions and Priorities for Ontario’s Mental Health and Addictions Strategy

1. Act Early

1.1 Help Ontarians self-identify and manage their health

It would be beneficial to incorporate the language and strategies of mental health literacy in order to support acting earlier.

In order to help Ontarians to self-identify and manage their health, the strategy should consider the recommendations prepared by the Canadian Alliance on Mental Illness and Mental Health on mental health literacy.1

Stigma can preclude self-care initiatives

Canadians have a good understanding of the early signs of mental illness and are able to recognize mental disorders.However, the fear of stigma can shame people from seeking care, even when they recognize that they are in need. Fighting stigma and eradicating discrimination in all publicly funded services can enable people to seek help by eliminating the shame.

The Canadian Alliance on Mental Illness and Mental Health (CAMIMH) cautions that mental health literacy initiatives can be disempowering if they focus exclusively on professional perspectives of understanding mental illness, as this framing of what constitutes mental illness can be stigmatizing to individuals and may deter them from seeking help. Widening the lens through which people understand mental illness to include diverse perspectives and multiple determinants is important.2

Self-management of health requires access to the determinants of health including income, supportive environments, and social inclusion

Being able to take personal action to reduce health risks through healthy eating and active living requires access to the determinants of health, including adequate income to afford proper nutrition and recreation; and safe neighbourhoods to support options for physical activity. Social networks can develop when people are given opportunities for social partnership and civic engagement and are free from violence and discrimination. Place-based approaches and healthy public policy can enable people to achieve the personal and material resources required to manage their health.

Effective self-management requires links to primary health care and specialized services and supports

People require access to appropriate services close to home. Ontarians living in rural and northern communities in particular face challenges in accessing mental health services and supports.

1.2 Build strong collaboration between family health providers and mental health and addiction services

Access to family physicians continues to be a challenge for Ontarians with mental health concerns and mental illness

Ten percent of Ontarians reported having no access to a regular place for family health care, while many with a regular place of care reported difficulties in accessing care when required.3

People with mental illnesses and mental health concerns report unique difficulties in accessing primary health care. A likely contributing factor is that family physicians feel they lack the knowledge, skills, training and/or resources to provide mental health care.4, 5

There are a range of collaboration and partnership models between family health care and community mental health agencies

Models of coordination range from collaborative mental health care initiatives that support family health providers through training, supervision and education, to the co-location of community mental health agency staff in a range of family health care settings. In one Ontario city, a community mental health agency has fully integrated primary health care and mental health services and supports through the development of a community health centre onsite for people with serious mental illness.6

Broader health system planning is required

In Ontario, the planning, monitoring and funding for community health centres (CHCs) and community mental health agencies fall under the jurisdiction of Local Health Integration Networks. Other Ministry of Health and Long-Term Care units hold the mandate for health human resources, regulation of health professionals, family health teams, nurse practitioners and physician remuneration. A broader health system planning approach is required to address these inter-jurisdictional issues within the health system.7 Funding to develop integrated service delivery approaches is also needed.8

1.4 Recognize the important role of peer-based programs in early identification

Peer-based programs are also important strategies to help keep people well

Peer-led programs such as warm lines do more than fill a gap by providing support for people waiting to enter specialized services by keeping well through support, empathetic listening and referrals. These peer support initiatives were recognized by the Mental Health Implementation Task Forces across Ontario as a key component of a comprehensive mental health service delivery system.

1.5 Build stronger links with other sectors, including social services, education, employment, seniors’ services, housing, settlement services, labour and justice

Intersectoral approaches require leadership and incentives to direct and monitor the process

Intersectoral linkages are most successful when there is clear leadership in policy directions or champions, common goals, a clear delineation of roles and expectations, and shared understanding of benefit.

Building stronger links across sectors requires dedicated funding

Recent evidence shows that system change and integration in community mental health occurs when dedicated investments are targeted towards coordination and integration activities.9

The community mental health sector needs to be further enhanced in order to collaborate across sectors

Findings from the System Enhancement Evaluation Initiative found that enhancements in one part of the mental health system increased case finding, thereby creating additional demand for mental health services and supports.9. The community mental health system will need to be enhanced to increase capacity if more people with mental health needs are identified, and identified earlier by programs in other sectors. Without these investments, it is likely that wait times will increase.

Act Early References

  1. Canadian Alliance on Mental Illness and Mental Health, “Mental Health Literacy in Canada: Phase One Draft Report, Mental Health Literacy Project,”May 2007, available at www.camimh.ca
  2. Canadian Alliance on Mental Illness and Mental Health, “National Integrated Framework for Enhancing Mental Health Literacy in Canada: Final Report,”July 2008, available at www.camimh.ca
  3. Canadian Institute for Health Information,”Experiences with Primary Health Care in Canada,”July 2009, available at http://secure.cihi.ca
  4. Standing Senate Committee on Social Affairs, Science and Technology, “Mental Health, Mental Illness and Addiction: Overview of Policies and Programs in Canada,”Interim Report, Report 1, November 2004, available atwww.parl.gc.ca
  5. National Physician Survey, “National Physician Survey: Second Year Medical Resident Questionnaire,”College of Family Physicians of Canada, Canadian Medical Association and the Royal College of Physicians and Surgeons of Canada, 2007.
  6. T. Doey, P. Hines, B. Myslik, J.E. Leavey and J.A. Seabrook, “Creating Primary Care Access for Mental Health Care Clients in a Community Mental Health Setting,”Canadian Journal of Community Mental Health, 27(2); 2008: 129-138.
  7. D. Macfarlane, “Current State of Collaborative Mental Health Care, Canadian Collaborative Mental Health Initiative, June 2005, available atwww.ccmhi.ca
  8. M.A. Gagne, “What Is Collaborative Mental Health Care? An Introduction to the Collaborative Mental Health Care Framework,”Canadian Collaborative Mental Health Initiative, June 2005, available at www.ccmhi.ca
  9. SEEI Coordinating Centre, “Moving in the Right Direction: SEEI Final Report,”Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, March 31, 2009, available at www.ehealthontario.ca

3. Transform the System

Transformation requires resources

Effective coordination of services requires time and money. Service providers report that lack of adequate funds to support their involvement in planning and implementing change and innovation restricts their abilities to participate in system change . Recent evidence from the System Enhancement Evaluation Initiative found that the dedicated funding to system redesign led to new and better collaborative program models.16

Appropriate funding formulas for community-based services

Funding for mental health services and supports must account for both the episodic and long-term nature of many mental illnesses. A funding formula premised on acute inpatient service utilization data will not account for the comprehensive and phased service needs necessary to support individuals in their recovery.17

3.1 Increase public awareness of mental health and addiction services and supports

Increasing awareness without capacity to respond will generate frustration

Improving Ontarians’ awareness of mental health services and supports is an important step, and programs such as ConnexOntario should be leveraged to inform Ontarians of the services that are available in their communities. However, increased public awareness will not translate into access to services in communities that lack capacity. Without adequate availability of a comprehensive continuum of services and supports, people may face long waiting times to access the services they need and are requesting.

3.4 Integrate mental health and addiction services with other health and social services

Ontario’s chronic disease prevention and management framework should be applied to the prevention and management of co-morbid mental illness and chronic physical conditions.

People with serious mental illnesses often have poor physical health, lack access to physical health care, and are at high risk of developing chronic physical conditions such as diabetes and heart disease. In addition, people with chronic physical conditions are at higher risk of depression than the general population. Collaboration between sectors can improve the situation.

Ontario’s chronic disease prevention and management strategy has the potential to improve prevention and management of these co-morbid conditions. People with mental illnesses need to be recognized as a high-risk population within provincial and LHIN chronic disease strategies. Dedicated funding can improve both the mental health sector’s capacity to deal with chronic disease and the physical health care system’s capacity to address the physical health care needs of people with serious mental illnesses.

Ontario’s Depression Strategy should also be approved, funded and integrated with chronic disease strategies to better address depression in people with chronic physical conditions.

Improved access to primary health care for people with serious mental illness must be a priority. The provincial government and the LHINs must provide resources and support for the community mental health and primary care sectors to improve system planning and service design to foster collaboration. Collaboration requires provincial policy directions and funding.

CMHA Ontario’s think tank report, “Diabetes and Serious Mental Illness: Future Directions for Ontario”has many recommendations to address co-morbidity.18 See also CMHA Ontario’s policy paper, “Recommendations for Preventing and Managing Co-Existing Chronic Physical Conditions and Mental Illness”.19

3.6 Increase capacity to detect and manage concurrent disorders

Increasing capacity to manage concurrent disorders requires more than screening.

Screening for mental illness and addictions will indeed increase capacity to detect concurrent disorders. Screening will not, however, increase the system’s capacity to manage concurrent disorders. Screening is not effective unless there are appropriate services available. The treatment needs of people with concurrent disorders vary widely. It is important to recognize that integration of services does not necessarily increase capacity. There is a need for more research about the types of integration that are effective for particular sub-populations and combinations of problems.

3.7 Recognize the long-term, changing nature of mental illnesses and addictions

Services and supports for people with serious mental illnesses must be designed around recovery, not disease management

Application of the Chronic Disease Prevention and Management framework to mental illness can provide more coordinated care. However, it is important to recognize that care is only one aspect of recovery. The recovery approach to serious mental illness has re-oriented the mental health system from a focus on clinical care to a system based on preventing and restoring all of the losses associated with mental illnesses. In contrast, the chronic disease management model was designed to improve clinical care in order to reduce, manage and prevent symptoms. People with lived experience of mental illness have worked hard to shift the system from a focus on treatment and management to recovery. If mental illnesses are linked to a chronic disease framework, it will be important that the meaning and value of recovery remains clear, and the broader foundations for support that promote recovery remain in place.

3.8 Tailor services to local needs

Culturally safe services should be available across the province

Building cultural competence and culturally safe practices should be built into the mental health and addiction system in Ontario to ensure that services are tailored to meet the diverse needs of Ontarians. Culturally safe practices ensure that the diverse needs, experiences and understandings arising from migration, ethno-racial background, age, language, gender, sexual orientation, and geographic location are accounted for, respected, and addressed in service planning and delivery.20

Respect local needs while sharing promising practices

New models of service delivery, created by local partnerships, are fostering more coordinated approaches to providing a continuum of care that is relevant, appropriate and responsive to local needs and capacity. These innovative strategies in areas of the province should be available to be shared and potentially replicated or customized to other regions within Ontario. Evaluation and knowledge exchange are the fundamental building blocks for developing a responsive and effective system of services and support.

Transform the System References

  1. SEEI Coordinating Centre, “Moving in the Right Direction: SEEI Final Report,” Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, March 31, 2009.
  2. Addictions Ontario, Canadian Mental Health Association, Ontario, Centre for Addiction and Mental Health, Ontario Association of Patient Councils, Ontario Federation of Community Mental Health and Addiction Programs and Ontario Peer Development Initiative, “Brief on the Proposed Health Based Allocation Model,” January 2008, available at www.ontario.cmha.ca
  3. CMHA Ontario, “Diabetes and Serious Mental Illness: Future Directions for Ontario, April 2009, available at www.ontario.cmha.ca
  4. CMHA Ontario,”Recommendations for Preventing and Managing Co-Existing Chronic Physical Conditions and Mental Illnesses,” August 2008, available atwww.ontario.cmha.ca
  5. Mental Health Commission of Canada Task Group on Diversity, “Understanding the Issues, Best Practice and Options for Service Development to Meet the Needs of Ethno-cultural Groups, Immigrants, Refugees, and Racialized Groups,” February 2009.

4. Strengthen the Workforce

4.2 Develop a competency-based addiction and mental health workforce

Mental health workers should be able to recognize and respond appropriately to the high risk of physical illness in people with serious mental illness

Mental health workers should be able to recognize people who are at high risk of physical health conditions due to their mental illness. For example, early stage diabetes is undetected in a high proportion of people with serious mental illnesses.

Pre-diabetic conditions are recognizable with minimal training; and early intervention can make a significant difference in the incidence and impact of diabetes in people with serious mental illness. CMHA Ontario convened a think tank in March 2009 with sponsorship from the Ministry of Health and Long Term Care, wherein a number of practical strategies to address this situation were recommended.21

4.3 Enhance the competencies of workers throughout the health and community service sector

Health care workers must have competencies in providing physical health care to people with mental illnesses

Physical health issues in people with serious mental illness are often missed when symptoms are attributed to mental health problems. Eliminating stigma by providers and demonstrating competency in diagnosing and treating the physical health needs of people with mental illness is also required.

4.5 Improve recruitment and retention

Challenges in health human resource recruitment and retention is a reality in the mental health and addiction workforce, as salaries available to these programs are not competitive with those being offered in institutions and with family health teams. This situation is exacerbated in the addiction sector which has not seen the same expansion as mental health. Fair pay and benefits for professional and peer support workers is essential.

Strengthen the Workforce Reference

“Diabetes and Serious Mental Illness: Future Directions for Ontario,”April 2009, available at www.ontario.cmha.ca


5. Stop Stigma

5.1 Eradicate discrimination in all publicly funded services

Distinguish stigma from discrimination

Stigma is a negative stereotype and an attitudinal barrier. Stigma differs from discrimination. Discrimination is unfair treatment due to a person’s identity, which includes race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, age, marital status, family status or disability, including mental disorder.22 Under the Ontario Human Rights Code, every person has a right to equal treatment with respect to services, goods and facilities, without discrimination due to the identities listed above. Overt discrimination often takes the form of individual acts of differential treatment of one person by another. Covert or systemic discrimination is often invisible and embedded into organizations and society at large, and seeks to exclude or impose restrictions upon groups of individuals.

It is not probable that integrating mental health and addiction services into the broader human services system will be enough to eradicate discrimination.

Further, Ontario is in the midst of developing standards and an implementation plan for reducing systemic barriers in the public (and private) sector, for people with disabilities.23 This includes increasing access to goods and services for including individuals with a mental disorder. The new mental health and addictions strategy should incorporate and build on existing initiatives in Ontario that can support its goals.

5.3 Champion respect for people with mental illnesses and addictions

People with mental illness who are from racialized communities face additional challenges

It is important to recognize and understand that people with mental illness face stigma and discrimination not only because of their mental disorder, but also because of the other aspects of their identity. A person’s identity influences the way they understand and communicate their mental health status, how they perceive and are perceived by mental health providers, and how they use and respond to treatments. Thus, a commitment to equity and respect for diversity must also include addressing the impact of these intersecting identities that people with mental illness face on a daily basis.

Stop Stigma References

  1. Ontario, Human Rights Code, 2006, available at www.e-laws.gov.on.ca
  2. See Accessibility Directorate of the Ministry of Community and Social Services at www.mcss.gov.on.ca

6.Create Healthy Communities

A response by CMHA Ontario in collaboration with the Wellesley Institute

Healthy communities and community resilience are interdependent strategies

CMHA Ontario and the Wellesley Institute are pleased that the Minister and the advisory group have recognized the critical importance of healthy communities and community resilience in promoting and maintaining positive mental health and supporting recovery. Initiatives that create healthy communities should also address strengthening community resilience; building community resilience impacts and depends upon healthy communities and supportive social and physical environments. As interdependent strategies, both require community- and system-level approaches to planning, monitoring and implementing community development and change.

Healthy communities and community resilience benefit all Ontarians, including those with a mental illness

Mental health can be enhanced regardless of a diagnosis of mental illness. This concept is fundamental to an understanding of how mental health promotion can be targeted to people with mental illness. Canada’s foundational work as set out in Mental Health for Canadians: Striking a Balance rejects the notion that mental health and mental illness are opposite endpoints on a single continuum by advancing a two-continuum model of mental health and mental illness.24 The two-continuum model asserts that mental health and mental illness reside on their own continua, with minimal and maximal degrees of mental health and mental illness represented at the ends of each of their respective continua.

The goal of promoting mental health through healthy communities and community resilience for people with mental illness is to ensure that individuals have power, choice and control over their lives and mental health, and that their communities have the capacity to support recovery.

6.1 Provide opportunities for secure and adequate income

Adequate income is associated with better mental health and reduced hospitalizations. Exclusion from economic supports, including adequate social assistance rates, keeps persons with serious mental illness entrenched in poverty. Income supports need to be raised to a level that is in line with the real cost of living.25

6.2 Promote employment in supportive, inclusive workplaces

Accommodation of people with mental illness in the workplace is a legal expectation and should be recognized in the strategy as an obligation

Employers have a duty to accommodate people with disabilities, including individuals with mental disorders, in the workplace. The employer must do everything possible, to the point of undue hardship — to meet that obligation.

The Ontario Human Rights Commission’s Policy and Guidelines on Disability and the Duty to Accommodate contain the Commission’s policy position on disability, accommodation, and undue hardship, as well as practical guidance on compliance with the Ontario Human Rights Code.

More information on accommodation and enhancing inclusion in the workplace can be found on the website for Mental Health Works, a CMHA Ontario initiative that helps organizations to manage their duty to accommodate employees experiencing mental disabilities.26

6.4 Provide opportunities for effective, flexible, relevant education and employment support

People with serious mental illnesses also need to have a full and fair chance for education and employment support

Individuals with mental illness are often relegated to minimum wage jobs.27These types of jobs are often non-standard types of work, such as part-time, temporary work or contracts.28 With few benefits and limited room for advancement, these types of jobs that been shown to have negative impact on mental health, as they are particularly vulnerable to fluctuations in the economy and exploitive conditions. Supported education and employment support initiatives can assist people with serious mental illnesses to have meaningful participation in the workforce. These programs help participants identify and develop their employment and educational goals in a positive, supportive environment. Programs may include skills training, teaching, job coaching, employment planning, competitive work placement with support and follow-up services, career counseling, assistance with resumes and interview practice.

These initiatives must be coordinated across ministries and the private sector to assist vulnerable populations to sustain long-term competitive employment.

6.5 Promote healthy lifestyles, including self-care and exercise

Support for people with serious mental illness to live healthier lifestyles must recognize the barriers they experience

Supporting people with serious mental illness to increase physical activity, eat healthy foods and take care of one’s health requires recognition that there are significant barriers to leading healthier lives. The high rates of poverty in this population affect people’s access to healthy foods and enjoyable physical activities. The side-effects of medications can result in lethargy, cravings for less healthy foods and weight gain. Living conditions, such as boarding homes, may limit people’s choice of foods. Interventions to support healthy living must recognize and address these barriers.

Peer support and mental health social/recreational programs can play a key role in supporting healthy lifestyles for people with serious mental illnesses.

Mental health services must be supported by policy directions and funding to integrate healthy living strategies into these services. Peer support workers and social /recreational programs can also play a role in supporting healthy lifestyles. Public health services should be encouraged to partner with peer support and social/recreation programs to address healthy living.

Promoting healthy lifestyles is dependent upon equitable access to the social determinants of health

Supporting Ontarians to lead healthier lives requires addressing the barriers that preclude people from making healthy choices. Healthier food options can be unaffordable to low-income Ontarians and living in a neighbourhood lacking green space, sidewalks or that feels unsafe can act as a barrier to physical activity. Providing opportunities for secure and adequate income, employment in supportive and inclusive workplaces, and safe housing and environments all address social determinants that can enable people with the resources they require to make the choices to lead healthier lives. Programs such as Minding Our Bodies can provide opportunities for people with mental illnesses to become physically active while building social networks.29

Self-care is supported by access to primary health care

People with mental illnesses face challenges in accessing primary health care and are less likely to receive preventive health checks. Several initiatives in Ontario are helping to reduce barriers to health care, including the Chronic Disease Prevention and Management Framework, collaborative mental health care initiatives, and co-location of community mental health and primary health programs.

Healthy Communities References

  1. J. Epp, Mental Health for Canadians: Striking a Balance, Ottawa: Health and Welfare Canada, 1988.
  2. Community Social Planning Council of Toronto, University of Toronto Social Assistance and the New Economy Project, and Wellesley Institute, “Sick and Tired: The Compromised Health of Social Assistance Recipients and the Working Poor in Ontario,”February 2009, available athttp://wellesleyinstitute.com
  3. For information on accommodation in the workplace for people with mental health disabilities, see www.mentalhealthworks.ca
  4. J. Cook, “Employment Barriers for Persons with Psychiatric Disabilities: Update of a Report for the President’s Commission,”Psychiatric Services, 57(10); 2006: 1391-1405.
  5. 28. “Time for a Fair Deal: Report of the Task Force on Modernizing Income Security for Working-Age Adults,”St. Christopher House and Toronto City Summit Alliance, 2006, available at www.torontoalliance.ca
  6. See Minding Our Bodies: Physical Activity for Mental Health, a program to promote active living in people with serious mental illness, atwww.mindingourbodies.ca

7. Build Community Resilience

A response by CMHA Ontario in collaboration with the Wellesley Institute

7.2 Support social inclusion through families, friends and community activities

Social inclusion and social capital are both important for mental health and wellness

This strategic priority focuses on the elements of social capital that support social inclusion. Social capital refers to the social networks that exist within a community. These include bonding among individuals through social ties and relationships, as well as bridging between groups.

Social networks are however just one dimension of social inclusion. A socially inclusive society is one where all people feel valued, their differences are respected and they are able to participate to meet their needs.30 Supporting social inclusion also focuses on the structures in society that permit or preclude people from living in dignity as engaged and involved members in the social, economic, political and cultural systems in Ontario. Social inclusion requires establishing structures that ensure freedom from overt and covert discrimination and create equitable access to resources and opportunities for social partnership and civic engagement.

Building a socially inclusive society involves many of the objectives outlined in the discussion paper, including the eradication of discrimination in publicly funded services, providing equal opportunities for income, employment, housing, education and lifestyles regardless of mental health status, and supporting social networks. The recommendations laid out in the Roots of Youth Violence report describe the many structures required to build social inclusion and should be considered in creating healthy communities and building community resilience.31

Social inclusion of people with serious mental illnesses can reduce stigma and discrimination

Opportunities for people with serious mental illnesses to be involved in communities and to contribute to society can also reduce stigma and discrimination. When people with serious mental illness are included in the community, community members are more likely to develop positive perceptions of people with mental illness.

7.3 Enable communities to realize the potential of groups at risk

Social and economic inequities, and specific conditions such as poor housing, education, income and living conditions have a negative impact on health. The overall goal of a health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes. A positive and forward-looking vision of health equity is ensuring equal opportunities for good health for all. The impact of achieving this goal would extend far beyond enhancing individual and collective well being, but would also contribute to overall social cohesion, shared values of fairness and equality, economic productivity, and community strength and resilience.

There is evidence that general health promotion programs tend to be taken up by the more educated and affluent, with the unintended consequence of widening health disparities in access to services.32 This highlights the importance of customizing and adapting health promoting strategies to the specific needs and situations of vulnerable communities.

Place matters, affecting the quality of life for all residents. The attention now being paid to locality reflects the fact that many of today’s policy challenges are resistant to sectoral interventions designed and delivered down by government.

Place-based approaches seek to improve the social, cultural, economic and/or physical environment within a defined boundary, in order to improve overall health, including mental health; and reduce the differences in health among the people living within that area. Placed-based approaches use the setting of a local area in which to carry out health promotion activities.25 The four principles underlying a “place-based approach”include: tapping local knowledge (lived experience of residents, participatory action research), finding the right policy mix (combining universal policies and targeted programs), governing through collaboration (developing horizontal and vertical government partnerships) and recognizing local government and providing them capacity to inform public policy and serve as an optimal access point for citizen input.33

This model is asset-based since it emphasizes finding and supporting local strengths. Its solutions are tailored to the specific needs of each community, and it encourages community-building amongst local residents. As the body of knowledge on the relationship between place and health increases, the need to consider place as a key factor in the development of health policies and programs becomes more obvious, particularly for community-level interventions.27

Community-level initiatives should be developed in collaboration with communities and in support of local assets. Asset and place-based approaches are advocated for both locally and internationally as ways to develop plans to improve conditions in local communities and work collaboratively in their implementation.34 The development of ‘community hubs’, created by the co-location of multiple local health and social-service agencies, also provide central spaces where communities can come together for priority-setting, policy development, and other community activities.

However, place-based approaches alone are not enough. Healthy public policy is also needed to strengthen mental health and well-being by promoting equity and inclusion, and reducing discrimination. Public polices in all sectors influence the determinants of health. Healthy public policy puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept responsibilities for health. Mental health impact assessments are being adopted in Europe to support policy-makers to assess the potential impact of new social policies on mental well-being.35

Build Community Resilience References

  1. CMHA Ontario, “The Gold Standard: A Sense of Belonging,”Network, Spring-Summer 2007, available at www.ontario.cmha.ca
  2. R. McMurtry and A. Curling, ”The Review of the Roots to Youth Violence. Volume 2: Executive Summary,”Queen’s Printer for Ontario, 2008, available atwww.rootsofyouthviolence.on.ca
  3. Victoria Health Promotion Foundation, “People, Places, Processes: Reducing Health Inequalities through Balanced Health Promotion Approaches,”Victoria, Australia, April 2008, available at www.vichealth.vic.gov.au
  4. Canadian Policy Research Network (CPRN), “Place-Based Based Public Policy: Towards a New Urban and Community Agenda for Canada,”March 2005, available at www.cprn.com
  5. T. Hancock, “Act Locally: Community-Based Population Health Promotion,”Report for the Senate Sub-Committee on Population Health, March 2009, available at www.parl.gc.ca
  6. World Health Organization, “Mental Health Action Plan for Europe: Facing the Challenges, Building Solutions,”WHO Ministerial Conference on Mental Health, 2005, available at www.euro.who.int

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