National mental health policy in Canada: A contextual overview Elliot M. Goldner MD, MHSc, FRCPC

1. National mental health policy in Canada: A contextual overview Elliot M. Goldner MD, MHSc, FRCPC Division of Mental Health Policy & Services Department of Psychiatry University of British Columbia

2. Key Objectives: • To provide an historical and contextual overview of prominent mental health policy developments in Canada • To serve as a backdrop for the subsequent presentations in the symposium, i.e. discussion of current policy issues, and description of the activities of the (Senate) Standing Committee

3. What are (public) policies? • principles and positions underlying and guiding government action • attempts to address prominent public issues (often controversial) • may be expressed as local, provincial or national government action

4. Comparison with other G8 countries(data from World Health Organization Atlas Project, 2000)

5. Institutionalization • Followed European policy of establishing large hospitals, e.g., Hotel Dieu in Paris (1656), the Zuchthaus in Hamburg (1620), Bethlehem Hospital in London (1676) • First institution in British North America, the Provincial Lunatic Asylum in Saint John, NB (1854) • In Nova Scotia, the mentally ill were housed with the sick, poor and the destitute in Halifax's Poor Asylum until 1859, when another asylum was opened

6. former Provincial Lunatic Asylum, Saint John, NB, built 1854

7. Institutionalization • established to provide safe settings for physical and spiritual care; to shield residents from harm and peril (Burgess, 1898; Deutsch, 1937; Shorter, 1997) • contrary view identifies less humanitarian motivations: segregation of those with mental illness from society; self-interests of health professionals (Foucault, 1961; Goffman, 1965; Scull, 1989)

9. overcrowding, inadequately trained staff, public disregard“custodial rather than caring” (Grob, 1973; 1978)optimism regarding new treatmentsDeinstitutionalization“Dehospitalization”

10. (Lesage et al., 2000)

11. Deinstitutionalization • Deinstitutionalization resulted in the need to develop adequate services for people with severe mental illness in community settings • Yet, the creation of community-based services and supports has proven a difficult and largely unmet challenge • Linked with the growth of policy and legislation regarding the rights of patients/clients and family members

12. Canada Health Act: • Canada’s federal health insurance legislation • Aims to to ensure that all eligible residents of Canada have reasonable access to medically necessary insured services on a prepaid basis, without direct charges at the point of service

13. Canada Health Act: • 5 Program Criteria: • Public administration (section 8) • Comprehensiveness (section 9) • Universality (section 10) • Portability (section 11) • Accessibility (section 12) • Establishes criteria and conditions required for provinces and territories to receive the full federal cash contribution under the Canada Health and Social Transfer (CHST)

14. Canada Health Act: • Grey areas: e.g. universality: “all eligible residents of Canada have reasonable access to medically necessary insured services” • Recent disputes related to the provision of Lovaas Autism Treatment (LAT) for children

15. British Columbia Court of Appeal Ruling – Autism Treatment: • Auton (Guardian ad litem of) v British Columbia (Minister of Health) • The petitioners maintained that LAT was a “medically necessary service” insofar as it significantly improved the condition of autistic children. The Crown questioned the proven efficacy of LAT and rejected it as a “medically necessary service”

16. British Columbia Court of Appeal Ruling – Autism Treatment: “The failure of the health care administrators of the Province to consider the individual needs of the infant complainants by funding treatment is a statement that their mental disability is less worthy of assistance than the transitory medical problems of others.”

18. Mental Health for Canadians: Striking a Balance (Health & Welfare, 1988) Emphasized importance of mental health promotion as a balance for traditional emphasis on treatment system Conclusion: "The protection and promotion of mental health should be a matter of compelling priority for every community in Canada. Mental health issues are of unquestionable importance to our collective and individual lives. As such, they call for intense reflection and vigorous policy initiatives by all sectors in our society."

19. Ontario Health Promotion E-Bulletin (Hyndman, August 2003) • Annual expenditure: Health Canada's Diabetes Prevention Strategy = $23 million • Annual expenditure: Health Canada's AIDS Prevention Strategy = $42.2 million per year • Annual expenditure: Canada's Breast Cancer Prevention strategy = $10 million • Annual expenditure: Health Canada's Mental Health Promotion Initiative = $250,000

20. Canadian Mental Health Association’s Framework for Support (Trainor et al., 1992) Highlighted importance of services and supports outside the formal mental health service delivery system, e.g., housing, meaningful work opportunities, self-help and family supports Best Practices in Mental Health Reform (Clarke Institute of Psychiatry, 1997) Provided an evidence-based framework for mental health reform including clinical and system strategies Accountability & Performance Indicators for Mental Health Services & Supports (McEwan & Goldner, 2001) Emphasized importance of tracking system performance in the context of clear policy goals and objectives

21. Canadian Community Health Survey: Mental Health and Well-being (CCHS 1.2)Statistics Canada N = 36,984 ages 15 + • Major depression • Mania • Social Phobia • Agoraphobia • Panic Disorder 10.4% 18% Youth ages 15 - 24 32% consulted a health professional

22. Primary Care Reform (including Chronic Disease Management) Workplace Mental Health Integration of Mental Health & Addictions Services Co-ordination of Criminal Justice and Mental Health Systems