Men­tal Health: We Have the Ev­i­dence. Where’s the Ac­tion?

Policy - - In This Issue - Ge­orge We­ber

The pub­lic con­ver­sa­tion on men­tal health has im­proved con­sid­er­ably in the past decade, with more and more peo­ple shar­ing their own men­tal health sto­ries and cor­po­rate so­cial re­spon­si­bil­ity cam­paigns help­ing to sig­nif­i­cantly de­mys­tify the stigma around the is­sue. Pub­lic pol­icy on men­tal health, how­ever, still trails the progress we’ve made in pub­lic ed­u­ca­tion. Ge­orge We­ber, CEO of The Royal, ex­plains why we need less talk and more ac­tion.

Ear­lier this year, I opened a speech at a busi­ness breakfast by ask­ing at­ten­dees to raise their hands if they knew a col­league, fam­ily mem­ber or friend who has strug­gled with men­tal ill­ness. Ev­ery per­son in the room raised a hand.

Ten years ago, at a sim­i­lar event shortly af­ter I be­came CEO of The Royal Ot­tawa Health Care Group, I asked the same ques­tion. Less than a quar­ter of the au­di­ence re­sponded. Many were ten­ta­tive, cast­ing furtive glances around the room to make sure oth­ers were rais­ing their hands, too.

A lot has changed. Men­tal health and ill­ness has be­come a con­ver­sa­tion that’s alive and well in com­mu­ni­ties and cor­po­ra­tions across Canada. The days are rare when you don’t read or hear about men­tal health in the news.

For many, it’s a fre­quent topic of con­ver­sa­tion with fam­ily, friends, and even co­work­ers.

In the last 10 years, many re­ports on how to ad­dress men­tal ill­ness have crossed my desk. I’ve seen count­less calls to ac­tion. We have the ev­i­dence. Where’s the ac­tion?

The $5 bil­lion over 10 years in men­tal health fund­ing tied to last year’s Health Ac­cord is a good start, but men­tal health fund­ing needs to be seen as a marathon, not a 50-me­tre dash.

In 2006, men­tal health saw a boost in pub­lic ex­po­sure with the re­lease of Se­na­tor Michael Kirby’s for­ward-look­ing re­port, Out of the Shad­ows at Last: Trans­form­ing Men­tal Health, Men­tal Ill­ness and Ad­dic­tion Ser­vices in Canada.

That re­port gave voice to the mil­lions of Cana­di­ans liv­ing with men­tal ill­ness and ad­dic­tions, as well as their care­givers, in a way that was dif­fi­cult to ig­nore. It laid the foun­da­tion for cre­at­ing the Men­tal Health Com­mis­sion of Canada in 2007. Since then, that com­mis­sion has done great work to bring peo­ple and or­ga­ni­za­tions to­gether to strate­gize im­prov­ing men­tal health across Canada.

In 2012, the Men­tal Health Com­mis­sion of Canada pub­lished Chang­ing Di­rec­tions, Chang­ing Lives: The Men­tal Health Strat­egy for Canada. The com­mis­sion’s lead­er­ship wrote that “We can and must de­feat the stigma that has blighted peo­ple’s at­ti­tudes for far too long and has fed the dis­crim­i­na­tion that so many have en­dured.”

The strat­egy rec­om­mended men­tal health pro­mo­tion for peo­ple of all

MOR­TAL­ITY FROM MED­I­CAL CAUSES ages, in all places; bet­ter ac­cess to care; re­duced dis­par­i­ties of men­tal ill­ness risk fac­tors; bet­ter men­tal health care for Indige­nous Cana­di­ans; and the need for gov­ern­ment at all lev­els to unite in a com­pre­hen­sive ap­proach to men­tal health sys­tem trans­for­ma­tion.

This pub­li­ca­tion has been in­flu­en­tial, and in the years since Canada has taken great strides to­ward the goal of stigma re­duc­tion. More Cana­di­ans are will­ing to speak openly about men­tal health than at any point in liv­ing mem­ory. As for the other goals, we haven’t suc­ceeded yet.

Back in 2002, Roy Ro­manow’s re­port on the fu­ture of health care in Canada noted that, “We must trans­form our health care ‘sys­tem’ from one in which a mul­ti­tude of par­tic­i­pants, work­ing in si­los, fo­cus pri­mar­ily on man­ag­ing ill­ness, to one in which they work col­lab­o­ra­tively to de­liver a seam­less, in­te­grated ar­ray of ser­vices to Cana­di­ans, from pre­ven­tion and pro­mo­tion to pri­mary care, to hos­pi­tal, com­mu­nity, men­tal health, home and end-of-life care.”

Are we there yet? No, and in men­tal health—what Ro­manow called health care’s “or­phan child”—we have barely budged. In any given year, one in five Cana­di­ans ex­pe­ri­ences a men­tal health is­sue, with a cost to the econ­omy well in ex­cess of $50 bil­lion. One in three Cana­di­ans will ex­pe­ri­ence a men­tal health prob­lem in their life­time.

De­spite ad­vances in treat­ment, Canada’s sui­cide rate hasn’t moved. Ac­cord­ing to the Na­tional In­sti­tute of Men­tal Health, the United States has seen mor­tal­ity rates from stroke, AIDS, and heart dis­ease drop sig­nif­i­cantly from their peaks in the last 50 years—the statis­tics are sim­i­lar for Canada. When will we be able to say the same for sui­cide?

The Royal, along­side the Men­tal Health Com­mis­sion of Canada and the Cana­dian Al­liance on Men­tal Ill­ness and Men­tal Health, has ad­vo­cated for a na­tional sui­cide pre­ven­tion strat­egy backed with both fund­ing and a mech­a­nism for ac­tion. This call has gar­nered much sup­port, but has yet to re­sult in a fi­nan­cial com­mit­ment.

The $5 bil­lion over 10 years in men­tal health fund­ing tied to last year’s Health Ac­cord is a good start, but men­tal health fund­ing needs to be seen as a marathon, not a 50-me­tre dash. Men­tal health ser­vice providers such as The Royal have seen a build­ing tsunami of peo­ple seek­ing help. The Royal and its peers have also had min­i­mal fund­ing in­creases for men­tal health treat­ment over the last seven years. We’ve seen a lot of announcements, but there’s a chasm be­tween words and change that ac­tu­ally af­fects the front­lines of men­tal health care.

We need to move faster. We’ve been crush­ing stigma, and suc­cesses there mean more peo­ple are seek­ing the men­tal health care they need. The chal­lenge is to find the re­sources, cou­pled with re­search and stan­dard-

iza­tion, to keep pace with in­creas­ing de­mands.

Those liv­ing with men­tal ill­ness, and those sup­port­ing them, are be­ing un­der­served by a frag­mented sys­tem that is in­ca­pable of re­spond­ing to their spec­trum of needs. We need uni­fied ef­fort from gov­ern­ment on all lev­els to change this, and the fund­ing to back it up.

Re­cently, Dr. David Clark, Bri­tain’s lead­ing ex­pert in Cog­ni­tive Be­havioural Ther­apy and an in­no­va­tor in mak­ing pub­licly funded, ev­i­dence­based psy­chother­apy widely avail­able, vis­ited The Royal and shared the keys to suc­cess for the Im­prov­ing Ac­cess to Psy­cho­log­i­cal Ther­a­pies (IAPT) pro­gram in Eng­land. His work demon­strates the po­ten­tial pos­i­tive out­comes of a na­tion­ally im­ple­mented, stan­dard­ized ac­cess-to-care strat­egy.

IAPT makes ev­i­dence-based psy­cho­log­i­cal treat­ments for de­pres­sion and anx­i­ety dis­or­ders avail­able in ev­ery com­mu­nity in Eng­land. It has also demon­strated that the ini­tial in­vest­ment to es­tab­lish ac­cess to struc­tured psy­chother­apy can in fact of­fer a sig­nif­i­cant re­turn on in­vest­ment through re­duced phys­i­cal health care costs, sav­ings on ben­e­fits and taxes, and in­creased GDP. In the last year, a num­ber of prov­inces have made ten­ta­tive steps to ex­pand ac­cess to struc­tured psy­chother­apy. As this moves for­ward, we should not for­get the hard lessons and ex­pe­ri­ences that have led to IAPT’s suc­cess.

The growth we’ve seen in pub­lic di­a­logue has hap­pened in large part be­cause of the gen­eros­ity of those liv­ing with men­tal ill­ness and their care­givers, who have taken the time and done the hard work of shar­ing their sto­ries and ad­vo­cat­ing for change.

At The Royal’s an­nual In­spi­ra­tion Awards Gala, we honour men­tal health ad­vo­cates. This year, one of our awards went to Pat Cap­poni for her work chan­nelling her lived ex­pe­ri­ence into real change.

“We have learned to­gether, banded to­gether, not in denial of men­tal ill­ness, but in de­ter­mi­na­tion to raise our voices, and our ex­pec­ta­tions of our­selves and of the sys­tem,” Cap­poni said.

These peo­ple are the guides to cre­at­ing a bet­ter sys­tem, but the bur­den of sys­temic change should not be on them alone. If the con­ver­sa­tion we’re now hav­ing about men­tal health has shown any­thing, it’s that men­tal ill­ness touches every­one.

Inex­tri­ca­bly linked to health care, and es­pe­cially men­tal health care, is re­search. The Royal is a men­tal health care, re­search, and teach­ing hos­pi­tal, and sci­en­tists at our In­sti­tute of Men­tal Health Re­search work with the goal of re­search in­form­ing prac­tice, and care driv­ing re­search. There’s a cru­cial link be­tween re­search and ap­plied health sys­tem in­no­va­tion— from bench to bed­side.

Only 4.3 per cent of an­nual health re­search spend­ing in Canada goes to men­tal health re­search, ac­cord­ing to an anal­y­sis by Dr. Zul Mer­ali, Pres­i­dent and CEO of The Royal’s In­sti­tute of Men­tal Health Re­search. An­other 1.4 per cent of health re­search spend­ing goes to sub­stance use re­search.

Men­tal ill­ness ac­counts for a mas­sive bur­den of dis­ease—at least 1.23 times that of can­cer, and more than 1.5 times if we in­clude ad­dic­tions. If we funded men­tal health re­search at 1.23 times the amount we spend on can­cer re­search, we would be al­lo­cat­ing $667 mil­lion an­nu­ally. That would be $577 mil­lion more fund­ing than men­tal health re­search cur­rently re­ceives.

Re­search is one of the big­gest keys to im­prov­ing men­tal health care longert­erm. There are so many unan­swered ques­tions about our brains and men­tal health, and with an­swers comes the po­ten­tial for trans­for­ma­tive dis­cov­er­ies that will bring hope to many suf­fer­ing in Canada and around the world. Why aren’t we back­ing these re­search ques­tions with money?

We may need to get more cre­ative in how we al­lo­cate re­search dol­lars in or­der to in­vest in the work with the high­est po­ten­tial re­turn on in­vest­ment. In this mo­ment, it is crit­i­cal that we em­power clin­i­cal re­search that will lead to bet­ter di­ag­no­sis and per­son­al­ized treat­ment. We need to put new, bet­ter tools in the hands of our care providers in or­der to face the enor­mous de­mand for men­tal health care now and in the fu­ture.

Let me be clear: I am an op­ti­mist and can see a brighter fu­ture, but I’m also a real­ist. We have made much progress in the last 10 years in terms of rais­ing aware­ness and de­creas­ing stigma sur­round­ing men­tal health. That is a legacy in which I’ve been proud to play a role.

Along­side this progress, how­ever, we need more ac­tion and less ink. We need a long-term, more sig­nif­i­cant, con­tin­u­ous fed­eral in­vest­ment in men­tal health—in­clud­ing ded­i­cated re­search fund­ing. We need ro­bust re­search col­lab­o­ra­tion, a co­he­sive and holis­tic ap­proach to health, new treat­ment modal­i­ties that in­clude early in­ter­ven­tion, in­ter­gov­ern­men­tal co­or­di­na­tion on an un­prece­dented level, and fund­ing for in­creased front­line ca­pac­ity.

And, most of all, we need an in­te­grated ap­proach that is pre­ven­tion ori­ented, at tuned and re­spon­sive to so­cial de­ter­mi­nants of health, and eq­uity-fo­cussed—es­pe­cially when it comes to Canada’s most vul­ner­a­ble pop­u­la­tions.

As CEO of The Royal, I’ve seen the mas­sive cul­tural shift sur­round­ing men­tal health. It’s ex­cit­ing, but it’s re­leas­ing a del­uge of de­mand for men­tal health care. I hope this flood will cre­ate fer­tile ground for a new era in which we fo­cus on build­ing not only per­son­al­ized in­ter­ven­tions, but also men­tal re­silience, eq­uity, and a strong sup­port sys­tem that is there when peo­ple need it most.

Ge­orge We­ber is Pres­i­dent and CEO of The Royal, one of On­tario’s four stand­alone spe­cialty men­tal health care cen­tres. We­ber has more than 35 years of ex­pe­ri­ence as CEO of sev­eral na­tional and in­ter­na­tional or­ga­ni­za­tions, in­clud­ing the In­ter­na­tional Red Cross and Red Cres­cent in Geneva. ge­orge.we­ber@theroyal.ca

The Royal photo

The Royal Ot­tawa Men­tal Health Cen­tre. One of the lead­ing edge fa­cil­i­ties in Canada.

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