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OTTAWA, Thursday, October 25, 2018

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:30 a.m. to examine and report on issues relating to social affairs, science and technology generally; and for the consideration of a draft agenda (future business).

Senator Chantal Petitclerc (Chair) in the chair.


The Chair: Good morning, everybody. Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.


I am Senator Chantal Petitclerc from Quebec, and it is a pleasure to be chairing today’s meeting.


Before I give the floor to our witnesses, I would like my colleagues to introduce themselves.

Senator Seidman: Judith Seidman. I’m the deputy chair of the committee, and I’m from Montreal, Quebec.

Senator Eaton: Nicky Eaton, Ontario. Welcome.

Senator Ravalia: Mohamed Ravalia, Newfoundland and Labrador. Welcome.

Senator Dasko: I’m Donna Dasko, senator from Toronto, Ontario.


The Chair: Today we are continuing our study on child and youth mental health.

We are pleased to have with us today Dr. Francine Lemire, Executive Director and Chief Executive Officer of the College of Family Physicians of Canada. We also have Dr. Daphne Korczak, who represents the Canadian Paediatric Society, joining us by video conference from Toronto.


Welcome to both of you. Thank you for making the time, and thank you for your contribution to this study.

I will ask that Dr. Korczak begin with her opening remarks. Please keep in mind that we ask you to keep your opening remarks to seven minutes. Please proceed.

Dr. Daphne Korczak, Chair, Mental Health Strategic Task Force, Canadian Paediatric Society: Thank you, and good morning. I’m proud to speak here today representing the Canadian Paediatric Society in my capacity as Chair of the Mental Health Strategic Task Force. I’m a paediatrician, a child and adolescent psychiatrist, and Director of the CLIMB Depression Program at SickKids.

As Canada’s national association of paediatricians and paediatric health experts, the Canadian Paediatric Society, or CPS, represents more than 3,300 child and youth health specialists from coast to coast to coast. We have built our reputation by providing evidence-based, thoughtful guidance to clinicians, policymakers and parents to advance the health of children and youth.

Members of the CPS are at the front line of paediatric health care across the country. We are a part of children’s lives, monitoring their growth and development, and getting to know their families. Our cumulative experiences and insights are extremely valuable in the advancement of mental health care and services for Canada’s children and youth. Indeed, improving the mental health of children is one of the five main priorities of the CPS 2017-22 strategic framework.

My remarks today will focus on the disparity between the way we see and treat physical and mental health conditions. I would like to leave you with four concrete recommendations that I hope you will take forward to help strengthen child and youth mental health and mental health care services across Canada.

In our society, we treat childhood mental illnesses and medical illnesses differently — very differently. Depression, for example, is a mental illness that often begins in adolescence and can cause a great deal of suffering and impairment for children and families. Children and adolescents with depression withdraw from friends and family, and from school and activities. They have difficulty concentrating and trouble sleeping, and they are filled with negative thoughts about themselves. Depressed youth may feel that their lives are worthless. They may become hopeless and experience thoughts about death or ending their lives at a very young age.

As you are aware, suicide is the second leading cause of death among Canadian children and adolescents. In fact, more adolescents in Canada take their own lives than the top 10 medical causes of death put together in this age group. The majority of young people who die by suicide have an underlying mental illness, most commonly depression.

Unfortunately, chronic, serious or even life-threatening physical illnesses are also not uncommon in childhood. These include asthma, diabetes and cancer. But in contrast to these physical illnesses, young people with mental illness, including depression, are more reluctant to seek help for their struggles. They find it difficult. They can find it even embarrassing to discuss their symptoms. Some adolescents and families will choose to delay treatment or even refuse treatment. Many wonder if accepting professional help or taking medication might be a sign of weakness or an indication that they are flawed as individuals or as parents.

I don’t recall children or families with asthma, diabetes or cancer expressing the same degree of self-doubt, shame or treatment hesitation that I have seen when working with children and youth with depression. These are important barriers to care, and we have a responsibility to do better. I would therefore like to put forward the following recommendations using the framework of prevention, early detection, intervention and treatment.

With respect to prevention, we must address bullying, including cyberbullying, abuse, neglect and the academic frustration that comes from undetected or unsupported learning disorders. These stressors are frequently the precipitants for mental health disorders and suicide attempts.

With respect to early detection, we must address the stigma associated with mental health problems that prevent children and families from coming forward for help and from accepting help early.

For these reasons, my first recommendation is to invest in public education and publicly funded resources to support and address and respond to bullying, improve academic support, address physical, sexual or emotional abuse, increase awareness and decrease the stigma of having a mental health disorder for children, youth and families.

My remaining recommendations focus on treatment. As with most health problems, early intervention is associated with better outcomes. The longer a child with mental health problems goes without treatment, the more likely it is that the symptoms and impairment at home, school and with peers will become entrenched and more difficult to treat.

As you have heard, children and youth with mental health conditions frequently have difficulty accessing services. Services are fragmented and often not publicly funded. While it is true that many children cannot access the treatment they need, it is also true that sometimes some children receive the wrong treatment, treatment that is not evidence-based or not effective in improving their distress.

Thus, my second recommendation is to expand access to evidence-based, publicly funded treatment for child and youth mental illness, including psychological treatments, school-based mental health and developmental services.

My third and linked recommendation is to ensure that children’s mental health services have the clinical coordination and the clinical oversight necessary to deliver the right treatment to the right child at the right time and in the right setting. This requires stepped-care approaches and monitoring of child mental health outcomes. It requires multidisciplinary teams that work together to integrate care based on research knowledge and evidence.

My fourth and final recommendation is to improve existing mechanisms for service coverage and delivery, particularly in remote, rural areas and for adolescents who are most at risk, including First Nations, Inuit and Metis individuals, those in the child welfare system, among others.

Real progress on improving mental health for children and youth in Canada must be inclusive, accessible and reflective of the diversity of Canada’s people and communities. Priority should also be given to closing the gap between Indigenous and non-Indigenous communities, as called for in the TRC.

Thank you for the opportunity to appear in front of this committee today and for your dedication to this important study on child and youth mental health. I look forward to answering any additional questions you might have.

Dr. Francine Lemire, Executive Director and Chief Executive Officer, College of Family Physicians of Canada: Thank you. I have not rehearsed. As you can tell, I need to save my voice, and I hope I meet the time requirement.

As you have mentioned, I am the Executive Director and CEO of the College of Family Physicians of Canada. I practised for close to 25 years in Corner Brook, which is a small town of 20,000 on the west coast of Newfoundland.

In my capacity as CEO of the college, the college represents 38,000 members, and we are the professional organization responsible for establishing the standards for training, certification and maintenance of certification of family physicians.

A 2016 analysis by UNICEF ranks Canada 27 out of 29 countries on child health and wellness, despite the fact that we’re doing better on housing and environment, in which we are 11, and material well-being, in which we are 15.

Data from the Canadian Institute of Health Information reveals a disturbing trend that has seen emergency visits for youth for mental health assessment and services increase by 63 per cent over the past 10 years. In Ontario, 12,000 children and youth are currently waiting for access to mental health services, with wait times of up to 18 months. I think we can agree that this is not right and that, together, we ought to do better.

Family doctors care for 60 to 70 per cent of children in Canada and are frequently the first health care professionals approached with questions or concerns. Most commonly, children present with behavioural and learning issues, attention deficit disorder, depression, anxiety, poor eating habits, grief, gender and sexual identity questions, early sexual activity, conflict with parents and recurring illnesses. While family doctors are equipped to manage some of these issues, often other health care providers are required, either through community-oriented resources or, in acute and complex cases, resorting to psychiatrists and child psychiatrists.

Standardized assessment tools play a key role in facilitating identification of issues and enabling physicians to diagnose and manage them. All family doctors receive training in mental health care and are expected to maintain their competence through continuing professional development and experiential learning. It is fair to say that having enough firsthand exposure to child and youth mental health care during core residency training is not always possible. This said, an important dimension of family medicine and family practice is community adaptiveness. This includes pulling in the help of other providers in our community.

We know that upstream determinants, such as a positive social environment, absence of adverse childhood experiences, healthy eating and exercise, may contribute significantly to the development of good mental health or absence of mental health issues in these crucial early stages of life. When it’s available, a family physician’s involvement in longitudinal ongoing care of a child allows for an opportunity to provide preventative care, education and support that addresses these factors. However, it will be difficult to establish this kind of relation-based care if, in fact, children seek their care through episodic care and seeing different providers, as sometimes we see in walk-in clinics. They have a role to play, but we want to foster that ongoing relationship.

Despite the capacity of our colleagues in other specialties to treat mental health issues for patients of all ages, wait times for such specialties can stretch to over a year, which is too long at any age. Similarly, the availability of community-based mental health support may vary greatly. The fact that psychological and counselling services are not always covered under provincial plans may limit access. In this regard, there is a good alignment between that of my previous colleague and myself. At least we’re not divergent in those opinions.

Issues of awareness and stigma must also be considered as well. Stigma can make it less likely for individuals in need of assistance to seek help, and a lack of awareness of supports can prevent outreach that would result in significant benefits.

We will also make some recommendations. First, increase access to psychology and counselling services. These services allow for crucial support close to home, without escalation to a high-stress hospital environment. We need to broaden the availability of these services in an equitable manner, to increase coverage in provincial plans and to have better communication between community resources and primary care practices. The federal government has made some strides in this direction by announcing additional mental health funding as part of a series of bilateral agreements with provinces. This is helpful, and we need to continue in this direction.

Second, invest in education and high-quality screening tools. The federal government can make this a priority in education and funding. It will be important to include research funding for education of family doctors, the development of standardized, validating instruments for screening, case funding and diagnosis of children with mental health issues, and the use of electronic methods for distance learning and care. For example, the Centre for Effective Practice released a screening tool for anxiety and depression in youth last year. Facilitating the creation of such tools would help equip our members to better tackle these issues with their patients, and we will be pleased to help to disseminate these tools.

Third, encourage inter-professional practice and remuneration methods that facilitate whole-person care. Looking after children and youth with complex problems, connecting with parents in appropriate ways and coordinating care does take time. Broadening the alternative remuneration methods, such as capitation or blended models of funding, would help encourage more in-depth care. High-functioning interprofessional teams would also lead to less fragmented and more accessible care. We know this is not the purview of the federal government, and yet your voice could help support the uptake of these remuneration models. Our organization has created and championed the Patient’s Medical Home, a vision for the future of family practice provided by inter-professional teams, centred on the needs of patients, their families and communities.

Just this week, we released a guide on mental health, and copies are available for you. This guide contains suggestions applicable to patients of all ages. This work has been done in conjunction with the Mental Health Commission of Canada, and I invite you to review this as part of this exploration. There are several recommendations, and I particularly appreciate the ones that speak to simple strategies in the organization of one’s practice to reduce stigma, such as: how to organize your reception area to provide some privacy for patients as they come in with mental health issues; having signs in your waiting room that speak to the fact that mental health is part of health and that patients should not feel afraid about discussing those issues with their health care providers; and texting patients to remind them of the date and time of their follow-up appointments for those who have difficulty keeping appointments. These are just some of the strategies that are discussed in that document.

Third, we recommend developing innovative solutions to increase consulting specialist access. The Canadian Foundation for Healthcare Improvement is piloting innovation, allowing rapid connections between primary care providers and consulting specialists in a variety of fields. One example of this is eConsult, which allows communication electronically between primary care providers and other specialists; and another example is RACE, which stands for rapid access to consultation expertise. Both of these models have been shown to enhance access by primary care providers to specialist care.

Early identification of all health issues, including mental health support and guidance throughout the patient’s journey, is where our family doctors excel, providing compassionate, comprehensive medical care. We hope that with the government addressing some of these recommendations, together we can provide improved access to high-quality mental health care services to children and youth in Canada, and we look forward to working together towards that goal.

Thank you very much.

The Chair: Thank you very much to both of you.

As we turn to questions, I would like to remind my colleagues that we have five minutes for question and answer, and please direct questions to the witness that you want an answer from first. Especially with the video conference, that will help make it smooth.

Senator Seidman: Thanks to both of you for your presentations this morning. I have so many questions and I have to try to figure out how to focus them. You have really provoked and evoked enormous feelings when one considers some of the things that you have said to us.

I am startled to hear that Canada ranked 27 out of 29 on child health and wellness in a UNICEF analysis in 2016. I find that very hard to process. I’m also startled by the numbers that you provided in terms of waiting times for care. Dr. Korczak, you spoke about prevention, and so did you, Dr. Lemire, and the need or demand to invest in education, high-quality screening and innovative solutions to dealing with this problem.

I would like to ask you about services or a particular problem in serving what we call the transitional period, youth ending their paediatric years and moving into adulthood. That is around the age of 18 or so, when they are in the process of leaving high school. We have heard that there is a huge gap in accessibility of services to these young people. First, their problems might be somewhat different, but also paediatric services and child services no longer serve them. When I think of that group in particular and the kinds of problems you’re presenting to us, I think of the idea of prevention, and we need to get in there as early as possible.

Could you tell me something about that particular problem in our system, for that transitional period? I’ll start with you, Dr. Korczak.

Dr. Korczak: It’s a good question, and the transitional age youth group is an important problem. It is, of course, the group that has been identified typically as having a mental health problem and is already being followed, and even still we know that many in this age group will not transition well. Probably around half or so will not transition well to the adult system.

There are differences in culture between the two systems, with focuses on family and the child in the adolescent health system and focuses on autonomy and individual independence in the adult health system. There are some differences in culture that can be difficult to navigate.

There are also differences in service provision. It can be about coordination, criteria or catchment. There are many different ways in which barriers show themselves between the paediatric and adult health care systems, so we do need innovation in this area.

There is a growing movement to talk about children and youth — youth being up to the age of 25, not necessarily looking at 18 as a hard cut point — and growing awareness that that transitional age group probably does require some specialized bridging skills among providers.

Paediatricians are particularly aware of these kinds of services and problems, and I think anyone in general paediatric health care is aware and would love to see more solutions around that 18-to-25-year-old group. I emphasize that for many of the children who are experiencing that disruption in care, these are the identified kids, and we know that only one in five or so are even identified.

Senator Seidman: I might like to hear from you, Dr. Lemire, especially since you represent family physicians who really have a lot of contact and, maybe, more continuity with young people.

Dr. Lemire: The college has a joint committee with the Canadian Paediatric Society that has been going on for many years, and the topic or the issue that you’re raising is raised whenever we meet. I won’t pretend to have the answer here today. I think there is no question that this is an issue. It is an issue for mental health, as well as any chronic illness a child develops. What happens when that child is looked after by a paediatrician or child psychiatrist and they reach that age of transition of 18 to 25?This is not unique to mental health. It applies to all chronic illnesses.

There is evidence to support the idea that children who have a family physician, where the family physician is involved on an ongoing basis with that family, tend to have an easier time navigating the system around those transition periods. That connection is sometimes not maintained if the magnitude of the mental health issues are such that that child needs to be seen on a more regular basis by a psychiatrist, so fostering ways of maintaining that contact and ensuring that the family physician is in the loop can probably help with that navigation around that transition.

We are also promoting collaborative approaches to mental health care, shared mental health care, where psychiatrists come into the family practice and where family physicians and other providers can refer within primary care those patients with whom we are having a bit more difficulty. I would suggest that shared care approaches could also facilitate transitions of care. Those are potential avenues that we need to pursue.

Senator Ravalia: Thank you to you both for those excellent presentations. I not only come to you from the perspective of a senator, but also as a practising family physician in my previous life in a rural community.

Within central Newfoundland, we had developed a shared care model where family physicians worked closely with clinical psychologists, school guidance councillors and psychiatrists in the region to develop a model of care that enhanced accessibility and follow-up.

I believe that, in general, our system is broken. The suggestions you have made today are excellent.

Do you have any examples of shared care models internationally that you feel might be an area that we could explore and pursue and hope to transpose into our Canadian fabric? This question is for both of you. Did you want to start, Dr. Korczak?

Dr. Korczak: I think shared care is an example of collaboration. It is one example of collaboration, and it can work very well. It has been used in Canada and in other countries as well.

The models do differ. There are shared care models in which different specialists are co-located, meaning that the mental health professional, whether it’s psychologists, psychiatrists or other mental health providers, are actually located in the same office or within the same geographic area. That is the co-located model. There is a more integrated model in which they are not necessarily co-located, but there are regular case conferences and things like that.

There are several different models. There have been models in the U.K. and Australia looking at different approaches. In general, those are favourable, positive and in the right direction toward something that is sometimes known as a stepped care model, which is when there is a pyramid or tiered approach to providing services so that, as problems become more acute, they are able to move up the system of acuity in terms of provision of services.

I think there is a role for the federal government with respect to infrastructure and initiatives for these kinds of strategies. We have to ensure that outcomes are measured in these kinds of initiatives and that strategies are transportable so that solutions that may have been shown to work in one community — an urban community, for example — actually do work in another community, culture or setting before implementing them broadly. There is a measurement component to that that is very important.

The general approach is to ensure that all Canadians will have access to the same information, that all Canadians have access to the same prevention interventions and the same stepped models of care, and that those models are coordinated and flexible. I think that sometimes those collaborative integrated care models really do provide the most coordinated, flexible models of care.

Senator Ravalia: Thank you.

Dr. Lemire: I have little to add to that. I could not describe international models myself, although I am aware that the document produced by our college and the Canadian Psychiatric Association in 2011 was informed by international models, Australia and the U.K. being such examples.

Although we can be informed by international models, we can also be informed by some innovation going on in this country right now, as we speak. The challenge is how can we scale up those pockets of innovation that we know exist in the country, have shown good results and have been evaluated? How can we move that up and spread that?

Two examples: There is a child psychiatrist in Ottawa who has created a shared care model for children and youth, with good results. Can we get informed about this and scale this up?

There is a model, again in Ottawa, where family doctors and psychologists work in primary care.

The Chair: If I may, do we have the name of this doctor?

Dr. Lemire: I would have to pull that out of my memory. I would be happy to send it to you.

The Chair: We will reach out. Thank you.

Dr. Lemire: It is not in my notes here. There is the model of a family health team where family doctors work collaboratively with psychologists. A pilot done during the transition fund era showed positive results and was positively evaluated. How do we scale that up? Better care and better outcomes, lower costs.

The Chair: Thank you.

Senator Eaton: Thank you both for your presentations.

I want to talk about family involvement. Yesterday I heard a horrendous story of a child who tried to commit suicide in the shower, and her parents sent her to school the next day where she did manage to commit suicide outside in the woods next to the school. This is being very blunt, but do families need training and support? If I have a child who has been diagnosed with a mental illness, say depression, what do I need, as a mother, to help support what you are doing professionally to help my child? Dr. Korczak, would you like to start?

Dr. Korczak: I think that is a very important question. It is a key question.

I should preface by saying that suicide has been a difficult problem to solve. Where there have been studies that show positive results, meaning a decrease in suicidal ideation and self-harm behaviours, typically these have involved families in treatment approaches. In the literature, involving the family does seem to be a key component to an effective youth suicide prevention strategy.

In Canada, we have no completed, randomized controlled trials of youth suicide prevention interventions. We have just launched the first one at SickKids. It is jointly funded by SickKids and CAMH. Almost exactly as you have pointed out, the key mechanism of improvement that we think is important is addressing family conflict. It does seem to be an important factor in child and youth distress. We have only just launched that study. It involves a brief, intensive treatment program, individual and family-based treatment, weekly for six weeks, for children who have come to the emergency department with acute suicidality or self-harm. We will have to see what our outcomes show.

It was developed on the in-patient psychiatric unit at SickKids because of the very issue that you raised, namely that parents come often unaware that their child is so distressed, often shocked when they get a phone call from the school or from the guidance counsellor, the friend, the camp or wherever, and often feeling just as anxious and as overwhelmed and as frightened as the children and adolescents do, so we have incorporated them in our treatment program. I think you are exactly right.

Dr. Lemire: No magic solution there. I concur with my colleague that this is certainly an issue. There is no question that when one sees a child with a mental health issue, we are actually seeing a family, and we need to be mindful of that. That requires time, energy and being attentive to that reality.

I would add that the situation that you describe — obviously, we can’t go into details about it — is disturbing. We often find that social determinants of health become a factor. The socio-economic environment of a family that is dealing with that child with mental health issues and also having trouble making ends meet, all those elements become a factor.

Senator Eaton: Have you found that there are commonalities with families and children with mental health?

Dr. Lemire: I could not comment on that besides what I have just mentioned. I think the social determinants of health are an added umbrella of difficulties in terms of the context that it will bring to the diagnosis and treatment of children and families with those issues.

Senator Eaton: What about something called “copycat suicides” in schools? If one child commits suicide, will that give permission to other children? Or if a celebrity like Robin Williams or an Anthony Bourdain commit high-profile suicides, does that make suicide respectable?

Dr. Korczak: I am not sure I want to say a lot about that. That is a complex issue of whether we see suicides in clusters or that sort of thing. There are some recommendations around reporting suicide for the media and how we are mindful of it.

I think when young people are experiencing distress to that extreme level, and they really are feeling quite desperate and not sure where to turn, we do see extreme behaviours. Unfortunately, sometimes we find out about the distress too late. This is really the role of publicly funded education awareness and decreasing stigma. This where we need to be acting so that people and youth who see their peers so distressed and feeling hopeless and stuck in those situations know what the avenues are to seek help, what to do and alternatives from doing something so unsafe and frightening.

Senator Eaton: Thank you.

The Chair: Thank you. Do you have a bit to add to that?

Dr. Lemire: Little other than to say — and we have witnessed this is some of the unfortunate events in the U.S. in the past year, not in relation to suicide but other causes of death — that if there is a suicide in a school, as bad as that is, intervening then in a proactive manner with the other children in that school becomes very important. That is where community partnership between what is happening in primary care, other community services, providers and guidance counsellors in the school becomes very important in a proactive manner.

Senator Omidvar: I am sorry, Dr. Korczak, that I missed part of your presentation. Thank you so much to both of you for being here.

I have begun to think that suicide is definitely not normal, but with the higher rates it seems to be becoming more normalized.

I want to ask you a question about the gender variation in rates of suicide based on age. When kids are younger, 10 to 14, it seems that it is young girls who are choosing more to commit suicide, but in the older cohort, 15 to 24, it is more young men. Can you speak to this shift? Can you tell me whether your members or the sector in general offers programs based on the difference in gender to these different age cohorts?

Dr. Lemire: I cannot speak to this. I will defer to my colleague.

Dr. Korczak: To be clear, adolescent girls in general are more likely to engage in self-harm and report suicidality and make suicide attempts, but across all age groups, adolescent boys are more likely to die by suicide. Girls are also more likely to seek help for suicidality than boys. We sometimes think about this or it is discussed as the gender paradox. Whereas girls are more likely to attempt suicide, boys are more likely to die by suicide. That has been consistent across years and across age groups.

A few studies have looked at gender differences in the response to school-based or community-based youth suicide prevention and interventions. For the girls and boys, but for the children that present to a hospital with a suicide attempt, it is devastating but it allows an opportunity for what we call secondary prevention, that is, intervention at that point. For the children who die — and it does tend to be more boys than girls who die in the community without seeking help — what we need here are primary prevention approaches or prevention for universal groups perhaps targeted to high-risk groups but certainly for children who have not come and sought help.

A few studies have looked at gender responses, but those that have also tended to find that girls are more likely to respond positively to those interventions than boys. So for school-based and community-based interventions, girls tend to report those as more positive experiences that are more helpful to them. Boys have tended to respond more negatively. However, the studies are very few, and none are Canadian, that I am aware of.

I think that means we need to intervene earlier. Certainly, we need to intervene earlier for boys, likely much earlier in childhood. The models that boys have currently for learning how to express their emotions and how to handle strong emotions, whether those models are at home or at school, haven’t been helpful in achieving good overall mental health. We need treatments that work, we need prevention strategies that work, and we need better ways of identifying the individuals who need them. To do this, we would have to prioritize youth suicide prevention research and programs.

Senator Omidvar: Normally we ask questions around which is a similar jurisdiction to us and what we can learn from it, but I will turn it around a little. Do you know which country in the world has the lowest rate of youth suicide? If you can share that information with us, then we can look to see what that country is doing and learn from it.

The Chair: Do you have that information?

Dr. Lemire: I don’t know. Dr. Google could help us, in all likelihood.

The Chair: We will find out.

Senator Omidvar: Dr. Korczak has something.

Dr. Korczak: Off the top of my head, I couldn’t tell you. I can tell you that Canada sits in the middle of the pack when we look globally and that the gender difference is pretty much the same across all countries, with the exception of rural China, I think, in which it is the opposite. Which has the lowest suicide rate, I don’t know. We also have to be mindful that suicide rates are based on reports of how death occurred. Those are important factors, too.

Senator Omidvar: Let me ask the question in a different way then. Do you know what our standing is amongst like-minded, like-constructed jurisdictions? I think of the U.K., Australia, the U.S., Europe and New Zealand. Are we still in the middle of the pack?

Dr. Korczak: Yes.

Senator Omidvar: Thank you. We should get that list.

The Chair: We will.

Senator Dasko: Thank you for your comments, both of you.

I have a question of Dr. Lemire. You mentioned that the Canadian Foundation for Healthcare Improvement has partnered with some jurisdictions and has discovered some ways to enhance access. What does it take to scale up? You mentioned scaling up would be the challenge. These are innovations that have been discovered, tried and partnered with, and proven to be successful. Would it help for more money to go to that foundation to continue to partner across the country with health care organizations, or is it a matter of health care practitioners taking up these ideas? What are the barriers to scaling up and taking the knowledge we have learned from these partnerships and building on them?

Dr. Lemire: I would say all of the above. In relation to eConsult, the Canadian Foundation for Healthcare Improvement is currently involved in helping scale up eConsult. eConsult started in the Champlain LHIN and is now being spread in Ontario, Quebec and other provinces. The Canadian Foundation for Healthcare Improvement has created the environment and provided some funding to enable a link between regional health authorities, provinces and some champions in each of those areas to enable this to happen.

In some instances, it requires some funding. Part of the funding is to create the infrastructure to enable those links to take place, as well as the involvement of what we often refer to as the pentagram partners. By that I mean the practitioners, the decision-makers, the regional health authorities, the universities, patients and communities. To get innovation to scale up, you need all of those partners to work together. In relation to eConsult, that is happening right now in Canada.

Senator Dasko: Sometimes we ask what the federal role is. This is a federally funded organization that is promoting health innovation. Do you think that is a model that can be successfully used?

Dr. Lemire: The impression we have about what the Canadian Foundation for Healthcare Innovation is doing — in relation to this and a few other examples, palliative care being an example — has been positive. I would suggest that that is an important avenue.

Senator Dasko: Thank you.

Senator Mockler: I would like to link with Senator Omidvar’s question regarding other countries. What would be those statistics across the regions of Canada? If that is available, can you provide that through the clerk?


In 2017-18, the territorial, provincial and federal ministers of health agreed on a common policy statement, shared with health stakeholders, to improve access to mental illness and addition services.


People tell us that the system is broken. People tell us that we should invest more money into it. People tell us, and my experience, it is fair to say, coming from New Brunswick, is that we have quality professionals across the base and quality professionals from coast to coast to coast.

There is an initiative by the government whereby they have committed $5 billion over 10 years. That commenced in 2017-18. In this regard, the FPT ministers of health, which are the engine, endorsed what they call the Common Stated Principle on Shared Health Priorities. There is no doubt that you have seen that program, which is leading into the next 10 years. However, the initial distribution of this $5 billion over 10 years committed by the federal government and accepted by the FPT ministers — $100 million during the fiscal year 2017-18 was distributed across Canada, per capita as per the Constitution of Canada, to the provinces and territories. This amount represents, however, only 2 per cent of the total $5 billion. The question we need to be enlightened on by you professionals is this: In your view, is this level of initiative for that program of initial investment appropriate? Why, or why not? And in your view, what are the priority areas for the remaining funds by which we can influence the stakeholders and providers of our health care system to address the issue we are talking about this morning?

The Chair: To whom are you addressing the question?

Senator Mockler: To both professionals.

The Chair: Maybe Dr. Korczak can start.

Dr. Korczak: I’m sorry. I am trying to understand. The question was about whether children’s mental health funding is sufficient and what the priority areas are; is that correct?

Senator Mockler: Yes. That is part of a common statement of principle that has been shared by health authorities and health providers in Canada through their FPT — federal, provincial and territorial — ministers of health.

Dr. Korczak: Yes, I understand. Most of us would agree that, in comparison to other health conditions, children’s mental health has been chronically underfunded. Children’s mental health research, which is necessary for the advancement of knowledge, has been exceptionally underfunded compared to other areas of health research. From that perspective, several organizations, researchers and clinicians would agree.

In terms of priority areas, there are several. It is important to look at the system of health care provision as a whole, as I mentioned, under the umbrella of prevention, detection and treatment. The system would be more efficient if it were more coordinated. While there are costs to be had in providing publicly funded psychological services, there are also costs to be saved by preventing acute health outcomes. We don’t have a national suicide prevention strategy. We have spoken about suicide a few times.

It is also true that we see better outcomes in research trials than we see once those same methods or interventions are disseminated into the community and generally implemented. Why is that? We know that treatments can work, but when they are disseminated, they don’t work as well. What we have to do is ensure that we are getting the right children to the right treatment, and we have to ensure the right treatment is being overseen and that children who are not responding are moved to the next level of care. There is efficiency to be had where treatment is coordinated and flexible, where there is oversight, and where there is rigorous training and measurement of outcomes.

Having said that, I do think that more emphasis on children’s mental health, research and funding is likely to reap benefit with respect to cost savings at the long-term and acute-care end.

Dr. Lemire: As a few additional points to what Dr. Korczak has mentioned, in terms of the stats on suicide, you can get that in some of the early reports of the Mental Health Commission of Canada, and I think that the highest rate certainly is in our Indigenous communities. There is no question there. But provincial breakdown, that’s available there. I don’t know it by heart, but the Mental Health Commission Canada, the early documents have that.

I will say I’m not sure if that amount of money is enough. What I felt very good about is, in fact, some money was earmarked for mental health care specifically with some expectations that each province and territory would actually do something about it. So is the amount enough? I’m not sure. But the fact that something has been earmarked I think is important.

The kind of investments that are required are, again, in one of those Mental Health Commission of Canada documents. The work around the investment required was quite robust. I was on the Mental Health Commission at that time. I would refer us to that.

I would suggest, in addition to what Dr. Korczak has said, that community-based care, because that is the laboratory where the seeds of many of these problems take place, is where we need to make investments. Investing in the coordination of care, and investing in transitions, not only transitions in terms of age between child and youth and adult, and also transitions between primary, secondary and tertiary care, and transitions within the community, that partnership between the school and community-based care, between primary care and community resources, is really key to moving forward on this.

The Chair: Thank you. It is time to end this meeting, but Dr. Lemire, you mentioned two programs in your introduction, eConsult and RACE. If there is anything you can share with the clerk, we truly would appreciate it. I thank both of you for the time and expertise that you shared with us. It has been truly valuable.


With that, honourable senators, we will continue our meeting in camera.

(The committee continued in camera.)