Mental Health & Addictions Strategy Steering Committee Meeting

1. Mental Health & Addictions Strategy Steering Committee Meeting December 11, 2009Child & Youth Services MH & A Strategy Working Group Coordinator: Joanne Phillips Lorri Carlson: Chair Colleen Molnar Rob Stephenson Sara Johnson Doug Ramsay

2. Where did the Strategy get started ? • The Regina & Area Drug Strategy Report 2003 was implemented and a stakeholders forum in 2006 recommended adding mental health issues to the strategy. • The Laurie Thompson Review conducted in March 2008 suggested that some of the solutions to the operational difficulties of the inpatient unit could be attributed to the lack of appropriate community resources for clients. • Preliminary meetings were held with representation from management & community partners; CMHA, Phoenix Residential Society & Schizophrenia Society. • Dave Hedlund did the foundational research on tiered model which came from his contact with the National Addiction organizations – CCSA & CECA.

3. The Mental Health & Addictions Strategy will . . . • Provide a vision for improved delivery of service. • Make the social determinants of health a priority. • Implement new evidence based approaches. • Promote innovation. • Encourage new investment in MH & A programs.

5. Why Now?Our Current Context • Federal Mental Health Commission is developing a national mental health strategy. • Saskatchewan Government has committed to the development of a provincial mental health strategy and a provincial Addiction Strategy. • Increased public dialogue reflects growing concerns that mental health & addictions have been under resourced. • RQHR has a strong history of working with community and is committed to capitalizing on the growth momentum.

6. What we know . . . . . • Mental health and addiction disorders are increasingly recognized as having a significant impact on health status. • While levels of well-being can be the result of genetic and biological factors or chance occurrences, much more often well-being is a result of economic and social conditions over which we could have greater control or influence. • The determinants of health/community well-being include: income & its distribution, employment & working conditions, education, social safety net, housing, food security, social inclusion, health services access, culture and early life. • Unfortunately, there are significant inequities in many of the determinants of health for a substantial portion of the population within the RQHR. • Addressing these inequities means not only are more resources needed, but also that current services need to be provided in ways that reduce barriers to access, and increase the capacity of individuals, families, and communities in the RQHR.

7. What we know . . . . . • Canada spends less than most developed countries on mental health and addiction disorders. • In 2003-2004 the national average spent on publicly funded mental health and addiction services was $172 per person or 6.1% of the provincial health budget. • Saskatchewan spends less on mental health and addiction services than most other provinces. • Mental health and addiction services spending in Saskatchewan in 2007-2008 was 179.4 million or approximately 5% of the provincial health budget. • RQHR spent $35.76 million (4.9% of the budget) in 2007-2008 on mental health and addiction services.

8. What we know . . . . . • In the RQHR there are estimated to be approximately 33,000 adults and 10,000 children and youth with mental health and addiction disorders every year. • There is a large gap between the demand for mental health and addiction services and the current system capacity. • This means that services for mild or moderate cases and activities that lower the risk for mental health and addiction problems are rarely provided. • Moreover no other service will take responsibility for the severe and chronically mentally ill, making a focus on severe cases a necessary core service provided only by the RQHR.

9. What we know . . . . . • Like most illnesses, mental health and addiction disorders range from mild to severe. • Unlike other illnesses, 50% of those who have a severe disorder also have two or more other mental health and addiction disorders. • Mental illness begins very early in life, unlike most disabling physical diseases. • About half of all lifetime cases begin by age 14, and 70 to 75% have begun by the ages of 18 to 24.

10. Stepped or Tiered Care

11. No uniform definition of stepped or tiered care • Mental health literature = steps • Addictions literature = tiers • No agreed upon number of steps or tiers • Step/Tier 1: prevention, promotion, informal • Step/Tier 2: screening/brief (>2 hours), partnerships • Step/Tier 3: low intensity (4 to 6 hours) • Step/Tier 4: high intensity • Step/Tier 5: highly acute/chronic/complex

12. Stepped or Tiered Care • Linking individual’s to what they need is a system responsibility • Available, accessible, acceptable • Match service intensity with person’s needs and strengths – requires standardized screening and assessment tools

13. Stepped or Tiered Care • Two major features to stepped care: • Service offered should be least intense or restrictive yet still likely to produce a gain • Service offered should be self-correcting and include monitoring • There is evidence to support many types of services and treatment that could be offered at each tier • However evidence for stepped or tiered care as organizational structure for delivering addictions and mental health treatment is promising but still limited

14. Tier or Step One: Prevention and informal supports • Prevention and health promotion efforts (universal or targeted) • Resources and supports to help people manage and recover on their own • Mild cases, well resourced • Pure self-help (bibliotherapy i.e. (COMH) http://www.comh.ca/ computerized CBT i.e. CLIMATEGP) • N.B. there is little evidence that this works for most people with mental health disorders (by itself that is) • Manage medication well under GP care • After care or continuing support for people who accessed services and supports at higher tiers? • Community support groups (AA, Schizophrenia Society)

15. STEP 1: Examples • FRIENDS program - a 10 hour universal CBT anxiety treatment/prevention program delivered in school * good evidence, widely delivered • Stress management, positive psychology, depression prevention (promising but some mixed evidence, US Army is starting emotional resiliency training) • Pre-school programs, home visitor, parenting groups (doing some now) • Anti-bullying, improving social support, health promoting schools • Mental Health in the workplace: Increasing evidence some programs may save money and improve efficiency • Recognizing problems (1/2,1/2,10), accessing effective treatment, healthy workplaces (http://www.gwlcentreformentalhealth.com) • Anti-stigma: increasing evidence about how to do this

16. Tier 1: Determinants and Social Determinants of Health • Addressing these “upstream” factors is not easy • HOWEVER: Programs which support families with young children may be the most cost efficient investment we can make • Increasing evidence that ACES (abuse, family dysfunction, violence, imprisoned family member) often leads to long term social, emotional, cognitive impairment – maladaptive coping – physical & mental health • Some determinants MH&A might be able to impact directly (poor coping skills, unhealthy child development, reducing barriers to access) • For factors like education or employment MH&A might be able to provide partnerships or more support to the efforts of people who are trying to change (Stay in school programs, SIAST, Adult Education Campus, job training, workplaces) • For others like food security, income inequity, housing we will need partners

18. Step or Tier 2: • Screening, brief treatment, and referrals • Typically health has focused on GPs • Alberta looking at training and partnerships with other important service providers: social services, emergency care, public health, employment programs • Brief treatments can include: education, solution focused, problems solving • MH&As Intake workers sometimes do this now but we don’t know when it works or how often • Saskatoon Mental Health has 1 FTE with intake for in person brief treatment

19. STEP 2 Examples • Many well researched screening tools (PHQ9, GAD7, AUDIT, BCFPI) • Many well developed IT/EPR systems (some are free) • Mental Health: First Aid – well evaluated, similar to 2 day SI workshop, provide basic info on recognizing & understanding common MHDs for anyone • Brief alcohol interventions • Guided self help (1-2 hours of professional involvement plus monitoring – may double effect size of bibliotherapy & computerized CBT, but many will require 4 to 6 hours)

21. Step or Tier 3 • 4 to 6 hours of service plus monitoring • For substance use this step may include identification, engagement, active outreach, risk management, basic assessment and referral • For mental health this may include low intensity treatment and monitoring • May or may not need intensive services • Groups? (1-2 hours per client from professional perspective, 8 to 16 hours from clients perspective)

22. STEP 3: Low intensity treatment • MANY effective groups (limited acceptability though) • Increasing evidence that individually delivered low intensity treatment (largely CBT) can be used for anxiety & depression • UK IATP (case management, brief CBT treatment, medication information and adherence) • Often meet first in GP office, largely telephone based (avg 25 min), avg 4.43 contacts, 2.25 hours of service, mix of professionals and trained community paraprofessionals • Collaborative Care in GP offices (with additional staff) • client education, provider feedback, case management, provision of information on treatment guidelines/protocols to providers, and use of information technology.

23. Step or Tier 4 • Comprehensive, often specialized services • Often multiple problems • Full assessment, intensive counseling, daytox, mental health and addictions, multiple problems and multiple agencies • Many MANY effective treatments at this level in the literature • Limited information about the effectiveness of our services

24. Step 5 • Highly acute, highly chronic, highly complex • Integrated care required • Residential or hospital programs

26. Prevention Low Intensity Interventions High Intensity Interventions Prevention Primary Care/Screening Primary Care/Screening High Intensity Interventions