Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue No. 47 - Evidence - October 18, 2018
OTTAWA, Thursday, October 18, 2018
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:31 a.m. to continue its study on issues relating to social affairs, science and technology generally (topic: study on child and youth mental health).
Senator Chantal Petitclerc (Chair) in the chair.
[Translation]
The Chair: Good morning and welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
My name is Chantal Petitclerc, a senator from Quebec. I am pleased to be chairing the meeting this morning.
[English]
Before we give the floor to our witnesses, whom we are pleased to have with us, I would invite my colleagues to introduce themselves.
Senator Seidman: Judith Seidman, deputy chair of the committee, Montreal, Quebec.
Senator Eaton: Nicole Eaton, Ontario.
Senator Ravalia: Mohamed Ravalia, Newfoundland and Labrador.
Senator Manning: Fabian Manning, Newfoundland and Labrador.
[Translation]
The Chair: Today we are continuing our study on child and youth mental health. These are preliminary meetings.
[English]
This is the third preliminary meeting on this study. It’s been very valuable. When it comes to youth and mental health, it has many faces, challenges and silos. We are very much looking forward to your insights and expertise in order to help us with recommendations for the federal government.
I will introduce our first of two panels today. On the first panel, we have Madam Calla Barnett, President of the Canadian Centre for Gender and Sexual Diversity. We are also happy to have with us Karen Cohen, Chief Executive Officer of the Canadian Psychological Association.
[Translation]
Welcome, everyone.
[English]
I will ask you to start with your opening remarks. Try to keep them under seven minutes.
[Translation]
We’ll start with you, Ms. Cohen.
[English]
Karen Cohen, Chief Executive Officer, Canadian Psychological Association: Good morning.
The CPA, the Canadian Psychological Association, is the national association for the science, practice and education of psychology in Canada. We are very pleased that this committee is looking at child and youth mental health. In 2006, it was the same committee that published Out of the Shadows at Last: Transforming Mental Health, Mental illness and Addiction Services in Canada. This report was truly a watershed moment for advancing the mental health of Canadians.
We have come a long way since the report was released: the Mental Health Commission was created and Canada’s first national mental health strategy was released. Mental health is top of mind, and stigma and discrimination are decreasing.
Budget 2017 included $5 billion over 10 years for mental health. Although CPA is highly supportive of this commitment, we believe that long-term, sustainable and predictable funding tied to improving access to evidence-based services is required to realize parity between physical and mental illnesses in Canada.
Page 5 of the report makes an important point:
Statistics prove that medication alone is not as successful as a combination of both psychotherapy and medication. Other forms of therapy are not available to those of us on fixed income or incomes that do not allow for the sometimes high cost of therapy through psychologists, social workers and alternative therapists.
Unfortunately, despite our mental health accomplishments over the past 12 years, this statement is still true today.
According to the Mental Health Commission of Canada, an estimated 1.2 million children and youth in our country are affected by mental illness, yet fewer than 20 per cent will receive appropriate treatment. By age 25, approximately 20 per cent of Canadians will have developed a mental illness.
At any given time, approximately 12.6 per cent of children between the ages of 4 and 17 experience clinically significant mental health problems which can lead to serious consequences such as poor school performance, substance use and self-harm. Children with significant problems can be identified as early as age 4 to 7.
The strongest evidence for return on investment in mental health involves services and supports for children and youth — services that reduce conduct disorders and depression, deliver parenting skills, provide anti-bullying and anti-stigma education, promote health in schools and provide screening in primary health care settings for depression and alcohol misuse.
Reaching children where they live, learn and play is critical. This means reaching them in schools, where psychologists play an important role in the prevention, early intervention and treatment of mental health problems. Psychologists in schools bring specialized experience in developing and evaluating prevention and intervention programs, as well as in assessing and diagnosing psychological and cognitive disorders. When treatment is needed, school psychologists can apply evidence-based interventions.
To ensure that school psychologists can deliver these services, an appropriate ratio of psychologists to students must be maintained. Generally, the ratio should not exceed one school psychologist for every 1,000 students. When scope of practice includes comprehensive prevention and treatment services, such as assessments, teacher and parent consultations, crisis response and psychological treatments, this ratio should not exceed one school psychologist for every 500 to 700 students. When psychologists are assigned to work primarily with student populations who have significant special needs, such as those living with severe emotional, behavioural or developmental disorders, the school psychologist to student ratio should be even lower.
Integrating mental health services into primary care is also an important step, because this is often where parents and families first bring their health concerns. Staffing primary care settings with psychologists and other mental health providers can ensure a stepped care approach that is timely and responsive.
Earliest development impacts the whole lifespan, including mental health later in life. The substantial neurological, physical, cognitive and behavioural development that occurs in the first few years of life is heavily influenced by experience. Parents and caregivers can shape these experiences, providing an optimal target for earliest interventions to support lifetime mental health.
Support for families and infants can include: informational campaigns that are as simple and inexpensive as signs in locations families typically frequent, such as supermarkets or bus stops, identifying specific, easy ways parents can encourage optimal development; home visits, already employed in Canada, have been found to be effective in reducing emergency health care use, as well as negative cognitive, mental health and behavioural outcomes; and mental health supports for parents, particularly parents experiencing challenges.
Despite efforts geared at health promotion and illness prevention, some people will develop psychological problems and disorders for which they will need treatment. Access to effective intervention for mental health problems should be available to all Canadians and not depend on income level or access to privately secured health care insurance.
If mental health staffing ratios in Canada’s public institutions is not realistic or maintained, children and families who cannot afford to pay for treatment in the private sector end up on long wait lists, depend on medications alone or do not get help at all.
If we want a health care system that delivers cost and clinically effective care, then we must revision the policies, programs and funding structures through which health care is provided.
CPA urges all levels of government to invest in evidence-based mental health solutions. Canada has fallen behind other countries like the United Kingdom, Australia, the Netherlands and Finland, which have established mental health initiatives that include covering the services of psychologists through public health systems. These initiatives are proving both cost and clinically effective. These initiatives provide care people need by the regulated health providers trained to deliver it. Thank you.
The Chair: Thank you very much. Now to you, Madam Barnett.
Calla Barnett, President, Canadian Centre for Gender and Sexual Diversity: Thank you very much. As President of the Canadian Centre for Gender and Sexual Diversity, I’m here to talk about specifically mental health in LGBTQ2SIA youth. That’s lesbian, gay, bisexual, transgender, queer, two-spirited, intersex and asexual.
We are an advocacy and education organization. We work in the schools across Canada. We also work with the federal public service and other organizations seeking training. Some of the training is offered for free, others are charged. It depends on the situation, and we’re always happy to negotiate.
We work with youth very specifically on a wide scale. Last year we put out something called the Pink Agenda. It highlights our priorities in various intersectional areas of LGBTQ2SIA advocacy against discrimination. The three main highlights we have for mental health issues are that we need more resources, more training and more funding, and not just in the schools. The training, especially, we need for the psychologists, psychiatrists and social workers working with our LGBTQ2SIA youth because they don’t necessarily have access to the information they need to be effective in dealing with a suicidal trans-child. Queer and transgender suicide is very much a prevalent issue. I just read a study by Veale et al. explaining that for every four cisgender suicides there are 16 transgender suicides. It’s pervasive in our communities.
The second issue is we need to ban conversion therapy. Conversion therapy is therapy wherein a child suspected of being LGBTQ2SIA is placed usually at a camp and taught to be straight or cisgender. The methods for doing this are generally quite abusive and can affect the mental health of that youth. As we all know, we’re born this way — the queer and transgender community — and sending them somewhere where they’re told they’re bad all day, every day will have detrimental effects on these young people for the rest of their lives.
Finally, we advocate for access to free mental health services and mental wellness programs across the country. Those are our main three issues. I would like to highlight that Ontario, Manitoba and, most recently, I think on September 25, Nova Scotia, have introduced some sort of ban on conversion therapy. We applaud these efforts and hope to see them go further.
Thank you very much. They’re brief statements. I’m more than happy to answer your questions.
[Translation]
The Chair: Thank you to our two witnesses.
[English]
We have questions, I’m sure many of them. We will start with the deputy chair.
Senator Seidman: Thank you very both for your presentations.
If I might dig down a little bit further on the statistics that you presented — is it Professor Cohen or Ms. Cohen?
Ms. Cohen: I have a PhD.
Senator Seidman: Dr. Cohen, the Public Health Agency of Canada’s 2016 progress report on the federal framework for suicide prevention summarized some of the statistics in Canada. We know that suicide is the second leading cause of death among children and youth aged 10 to 19. Of course, I think accidents are the first cause, which makes sense, sadly. As much as 90 per cent of the 4,000 people who die by suicide in Canada each year were living with a mental illness — 90 per cent. If we could look more specifically at children and youth who die by suicide, if you have those stats, what proportion of them were affected by mental illness?
Ms. Cohen: Are you asking me if that proportion is also around 90 per cent?
Senator Seidman: Right.
Ms. Cohen: I don’t have that data readily at hand. I would suspect it would be similar to what we would find, but I can certainly get it for you.
Senator Seidman: Okay. That would be great.
Do we know, for example, gender differences among those youths from 10 to 19 years? The gender differences, if any, among rates of suicide, attempted suicide, and self-harm? There are three categories.
Ms. Cohen: I can try to get that data for you too.
Senator Seidman: Okay.
Ms. Cohen: The only gender differences I’ve been aware of are at a different end of the age continuum, older men, but I can look into that for you as well.
Senator Seidman: And are you aware of any other risk factors, such as socio-demographic factors or other things that would help us try to understand if there are important differences in the population? I’m looking for population statistics.
Ms. Cohen: When we prepared a paper several years ago for committee, one of the things we suggested is because of the very high proportion of people who end their lives by suicide have problems with mental health and mental illness, the time to provide intervention obviously is much earlier. One of the great challenges we face across the country — and I think Calla alluded to this as well — is the fact that there are some real barriers and some real economic barriers to getting mental health help.
Senator Seidman: Exactly, and also age-specific barriers, as we’ve heard.
Ms. Cohen: Yes. Part of the age-specific barriers relate to the other point we made, which is we have to reach children where they live and where they are, not necessarily in tertiary facilities like hospitals, but in schools and communities and in primary care practices where often the funding for mental health help or the availability of mental resources are too sparse.
Senator Seidman: I wish to ask you specifically about something you said in your presentation. You said evidence-based mental health solutions are important. I bring this up now because you’re talking about schools in primary care settings — and so did you, Ms. Barnett. The importance of delivering services in those settings — getting to these kids before we face these huge crises. You said Canada has fallen behind other countries like the U.K. and Finland and you named some others.
Are there evidence-based mental health solutions? How have we fallen behind? What is it exactly you’re referring to here?
Ms. Cohen: I can speak to the more programmatic things that the U.K. and Australia have done. The U.K. has their increasing access to psychological services program. They started with sentinel conditions of depression and anxiety and making that kind of care available. These are developed cognitive behavioural approaches to depression and anxiety. They train therapists, supervised often by psychologists who evaluate their outcomes. They collect data on the efficacy of these programs — up to 90 per cent of sessions, as I understand it. I believe it’s about 45 per cent of folks who go through the programs, then go off disability of the ones who have been on it. They have a lot of measures indicating it’s effective. They’ve been doing this under the public purse. That is easier to do in the U.K. than Canada because it’s one national health service, whereas we have multiple so it’s hard to coordinate. It was something about which our association has talked to Health Canada and the Public Health Agency of Canada for some time, particularly at the time when government was contemplating its targeted transfers for mental health that we think about doing something a little bit more systematic.
Australia took a different approach. They do it through primary care that is nationally funded, whereas tertiary care is state-based. I believe what they were able to do is have psychologists, trained social workers and OTs available again through the public system in primary care.
They deliver a certain number of covered sessions to people who need it. That is overseen through referral by a family doctor. They’ve done a better job at facilitating access to publicly funded treatments.
Certainly Quebec and Ontario have announced some intention with the targeted transfers of what they’re going to do with mental health, and that’s terrific. I believe in Ontario it is geared to children and youth. They’re going to be using what they call structured psychotherapy, which I understand is basically cognitive behavioural kinds of interventions. These are commonly used for things like depression, anxiety, anger management, all kinds of issues. It’s just that other countries have been able to scope it, scale it and particularly make it accessible in a more funded way.
Senator Eaton: Thank you very much for both of your presentations. I have questions for both of you.
Dr. Cohen, this school idea seems like such a logical way to start. Have the school boards shown any interest in having a greater number of psychologists evaluating kids firsthand when they go to kindergarten and pre-kindergarten, watching them? Has there been a big move by schools to take this on?
Ms. Cohen: Multiply all the provinces and territories by the number of school boards. There probably is a different state of situation from school board to school board. What we hear from our members who work in schools are a number of things. Often there’s not enough of them. Children are waiting maybe a year to 18 months for an assessment.
Senator Eaton: Which is too long.
Ms. Cohen: If a child has a learning disorder or developmental problem and they’re not assessed in a timely way, what happens? Well, that’s a year or 18 months when maybe they are made fun of or not having social success because they’re not getting help for a problem that has been identified. Certainly a shortage is one issue.
Another has to do with how the roles and jobs of psychologists are profiled when there are not enough. Are they just testing kids, or are they actually intervening to do something to assist kids?
I know locally I’ve often heard from colleagues who work in pediatric psychology that even in the private sector here, you can wait two to three months to see someone. Parents will do that; they want their children assessed and helped quickly.
Senator Eaton: What you’re basically saying to me is schools have not yet seen this as an opportunity to start helping people at a very young age? They have not yet devoted the resources to hiring more psychologists?
Ms. Cohen: Or they may not have enough. I guess that’s the challenge. I know certainly what our profession has experienced is that when the public institutions face pressures, whether it’s a hospital, school or correctional facility, it ultimately impacts their salaried human resource, which includes psychologists. I’ve heard administrators of institutions say people can get that in the community. Well, they can’t get it in the community covered by our health insurance.
Senator Eaton: You made the excellent point that children should be served where they work and play.
Ms. Barnett, do you have something to add? Then I have a question for you.
Ms. Barnett: I do. It’s a bit anecdotal, but I’m the child of a master of social work and grew up in social work community. I also have a daughter with ADHD who has been through the school system in terms of getting access to psychological help.
Here in Ottawa, in the French public school board, they have two psychologists for the entire school board. That’s everyone from the age of 4 to the age of 17 across this city. I don’t know what that number is, but what it means is they prioritize by urgency. My daughter getting suspended every day for two weeks because she has ADHD and couldn’t control herself takes a back burner to a suicidal teen, but that can create issues for my daughter later on. Everything got sorted out — they were incredible — but it took an incredible effort on my part as a parent. Part of the issue is getting parents more involved in the child’s mental health.
Senator Eaton: Or getting the school more involved from the very beginning.
Ms. Barnett: Perhaps, yes, but in my case they were involved.
Senator Eaton: But they didn’t have enough resources?
Ms. Barnett: Exactly.
Senator Eaton: You said that very often for transgender and gay children, psychologists don’t have the information they need to spot a child who could be suicidal.
Ms. Barnett: Right. It’s a little more complicated than that.
Senator Eaton: Elucidate for me. I’m asking you the question.
Ms. Barnett: Absolutely. It’s not just about spotting suicidal tendencies; it’s about how to support that child if they are suicidal or depressed. What might be happening for that child is real, true fear that they’re going to be rejected by their families. What’s happening for that child is they’re being told they’re too young to make those decisions for themselves and that they’re forced to be someone they’re not. They’re afraid they’re going to be rejected by their teachers and their schools. Maybe if they’re from a religion that’s not Christianity, there’s a different religious aspect to what they’re going to face.
There is real shame that not every psychologist is trained to deal with, such as body dysmorphia, not believing your body is yours, which is a common issue for trans youth who are suicidal. What that means —
Senator Eaton: They don’t identify with their bodies.
Ms. Barnett: They don’t identify with their bodies. What’s in their head and what’s in their body don’t match. Even if they’re accepted, even if everybody is okay with who they are, even if they’ve come out and everything is okay, they are still depressed.
Access to training like that is not commonplace for mental health professionals across the country. Many mental health professionals have that training but it’s optional. It’s a choice. That’s something we could discuss more, especially in the schools.
Senator Eaton: Do I have more time? No?
The Chair: We can put you on the second round.
Senator Manning: Welcome to our guests. I have many questions in a short period of time.
You mentioned earlier, Dr. Cohen, the initial distribution of $5 billion over 10 years, which was committed last year by the federal government. In fiscal year 2017-18, it was $100 million that was distributed on a per capita basis to the provinces and territories, which represents about 2 per cent of the total $5 billion.
In your view, is the level of investment — we’re looking at nine more years. Where would the priority areas be? Do we need to step it up? At that rate, if we stay at the same amount, we’re only going to spend $1 billion out of the announced $5 billion and spending the extra amount. I wonder if you could touch on that.
Ms. Cohen: There are a couple of issues related to that. The CPA is a member of the Canadian Alliance on Mental Illness and Mental Health. One of the things they’ve been advocating for is the proportion of the health budget that’s spent on mental health needs to increase. Typically it’s been about 7 per cent. It should be 9. The targeted transfers, as I said, are a terrific start, but I think the provinces need to be able to count on the sustainability of that funding. I think the solutions need to be tailored to the jurisdiction. Different jurisdictions may have different issues when it comes to the mental health of their populations.
One of the concerns CPA has had historically, though, is we talk about mental health as if it’s a unitary thing. We have a Mental Health Commission. We would never have a physical health commission. That would sound preposterous. We behave as if there’s one mental health problem and there’s one mental health solution. There is not.
Even what Ontario and Quebec are advocating for now — as I mentioned in Ontario, structured programs for children and youth — are not going to solve the mental health needs of every person living in Ontario, which is why I think the primary health care approach has some appeal. A primary health care service can staff itself according to the needs of the people and the patients that it serves.
That wasn’t a terribly fiscal response, I guess, but maybe a little bit more complicated.
Senator Manning: That’s fine. Ms. Barnett, I’m not sure if I caught exactly what you said. One of the issues you have is access to free mental health care or access to health care?
Ms. Barnett: Free mental health care.
Senator Manning: Can you elaborate on that somewhat for us? How do we address that situation? Do you have suggestions on how we address that?
Ms. Barnett: Well, there have been a lot of suggestions made by Dr. Cohen in terms of putting psychologists in the schools and reaching children where they are. Other issues come from provincial health-care plans, which used to cover certain mental health services and no longer do. That choice has been made. I know there’s been a significant change recently in Ontario around how mental health is structured.
All the social work agencies are scrambling to meet reporting requirements that had just changed and they had just gotten used to in the first place. Lots of money is being cycled through the changing governments in provinces, which leads to less money being spent on service and access, and more money being spent on reporting and accountability.
In addition, it’s also about the private insurance and health care plans that aren’t available in the universities. Young people in university have coverage, but they have three sessions of coverage. That is not enough. Three sessions with a psychiatrist is barely enough. Ten sessions may be enough. Then you have psychiatrists who choose to bill at a higher level if you have insurance, and when that runs out, they bill you at a lower level. There are a whole bunch of things happening that make it difficult to access health care financially. I will leave it at that.
Senator Manning: I am concerned about the access regardless of where you live in Canada. I come from a small rural community in Newfoundland and Labrador. I know of children who have mental health issues. There is a stigma related to that, especially in a small community and a small school. The federal government announces a fair amount of money for the program. The delivery of health care in most cases is provincial jurisdiction.
Could either one of you tell us whether something is being done in Ontario, Quebec, Manitoba or wherever that we should be emulating in other provinces with respect to the delivery of mental health care? My concern is across the country, it is up and down, especially when you go to coastal or rural communities away from the major centres. I will leave it at that.
Ms. Barnett: I don’t know what is going on in every province in terms of access to care in rural areas. I know that in Ontario, for example, they have recently set up mental health care services on reserves for Indigenous people to access that are run by Indigenous people for Indigenous people. That is a good step in the right direction.
On the other hand, there have been recent changes making it more difficult. I don’t think Ontario is necessarily something to emulate, although there are definitely good programs.
Ms. Cohen: I think there has been a fair bit of talk of scaling up programs that work in one jurisdiction to another. For a time the council of the federation was looking at team-based care that spread across jurisdictions.
I think each jurisdiction has its own unique needs. It may have constraints on whether something applicable in one will have legs in another.
The Mental Health Commission has an advisory group we are a member of on e-mental health. I think a lot of attention is being paid now in remote areas as to whether we can deliver care other than face-to-face. There are services for children and youth that make use of a lot of new technologies and delivering services and supports. I think those are promising. I think they still need to be evidence-based and delivered or overseen by people licensed to deliver that care.
I certainly agree with Ms. Barnett on the importance of cultural competence when we deliver care. Any provider needs to understand the issues specific to the population or people with whom they are working.
In 2016, we came out with a statement opposing the use of reparative therapy and how it does more harm than good and has negative outcomes. In it, we affirm the importance of children and youth being able to, when they have mental health problems, whether or not it is related to any kind of LGBTQ issues, meet with a therapist who is affirming and has a positive approach to the issues.
Senator Ravalia: Thank you very much. My first question is for Ms. Cohen. Again, I am from a small community in Newfoundland and Labrador. In our school system, we’ve had to disproportionately rely on the work of guidance counsellors to deal with these issues. They then determine which child gets an appointment with a psychologist or which child goes to a primary care model because access to psychiatric services is virtually zero.
Do you have any evidence to suggest that the guidance counsellor model works? Do they need additional specified training because of their own vulnerability and risk of burnout? Do you think this may be a model that could, in a cohesive and relatively financially neutral way, improve access for these vulnerable children?
Ms. Cohen: That is an interesting question. There are several ways to look at it.
One of the things we have been talking about is it is important at the gate to have a reliable screen so that you are giving the right child or right person the right care. You can accomplish that by putting your most trained resource at the gate; that tends not to be the way we do it, but that is one way to do it. You are getting an effective triage so an anxiety disorder is not misdiagnosed or a learning disorder is not missed.
That said, in programs such as the ones in the U.K., the folks who deliver it and screen for its use are very supervised and supported in that delivery. I think you probably could make use of guidance counsellors as long as their work was embedded in sufficient training and direction when problems are encountered.
You will be hearing from the Canadian Mental Health Association later today. They have a program called BounceBack; you may want to ask Dr. Smith about it. I believe it’s a model where providers deliver the service but they have access in their screening and intervention to more specialized providers like psychologists.
Senator Ravalia: Do you have access to some of the literature from the U.K. that could be made available to us, please?
Ms. Cohen: I can look into that for you, yes.
The Chair: Do you want to add to that, Ms. Barnett?
Ms. Barnett: No.
Senator Ravalia: I have a question for Ms. Barnett as well.
Similarly, we have seen a rise of vulnerability amongst our LGBTQ kids in rural communities. Not only do they face the potential of being ostracized within their families but also within their church groups and so on. There has been specific media attention paid to a community in Newfoundland and Labrador that went through such a crisis.
In particular, the most vulnerable are our trans children. In our own setting, because we have had excellent counsellors, we’ve created this concept of a safe space where these children have the opportunity for one-on-one counselling and referral to appropriate services.
Do you have any examples of whether that exists across the board or whether there is an opportunity for us to protect these extremely vulnerable youth?
Ms. Barnett: Safe space is pretty common across the board. We talk about safer spaces and brave spaces. No space is 100 per cent safe because someone can always say the wrong thing. That is a really good concept, especially for young trans children. In high school, that might be different for them. They might not trust it even though it exists.
I think it sounds like a great idea. I’m not sure what is being implemented in other schools. I like that idea. I would recommend that those counsellors, though, have trained in terms of LGBT outreach and intersectional issues that LGBT youth face. By that I mean if you have a young person of colour who is a trans woman, then you will have an entirely different set of issues than with a white trans woman, for example. They would have to be trained for that to be truly effective.
They would also need to be trained in safe talk. These are basic trainings. Safe talk is training to determine whether or not one is suicidal. We get that training for our program coordinators at CCGSD. Some basic knowledge for people in those positions to be able to appropriately support the youth coming to them so that youth might be able to come and say these things and get it off their chest and not be judged for it. But then what? That is where the next step is.
Senator Munson: Thank you very much for being here.
Sometimes when I come to these meetings I say to my assistant, “I’m not going to ask a question today. I’m just going to listen.” Then a witness says something that startles me. You said, “Ban conversion therapy camps and teaching people to be straight.” I’m startled — maybe I should know better. In this country, could you tell me where these camps are? Who’s doing this to Canada’s children?
Ms. Barnett: Well, there have been camps. The camps may be gone now. I knew there was one near Toronto. That’s gone because of the ban that happened in Ontario. It does happen in churches and in other religious organizations. It’s not all the churches. Some churches are particularly welcoming; other churches are still figuring it out; other churches still prefer to help people not be gay.
Nobody does it maliciously or to harm. They do it because they think they are helping. You are faced with a community group that you belong to that and has said they love you and, all of a sudden, you are bad and wrong. I am talking about it from the perspective of a child here. You can’t get out of it. You’re stuck. Even if it’s not a camp, it’s your family, your church and your school. Everyone is banding together to tell you the way you are is wrong — but they love you. That mixed message can create a problem.
Senator Munson: That’s a mental health issue. Do we have psychologists who have the empathy and understanding of dealing with what a 15-year-old might be going through, who innocently went to a church camp and heard all the things you just described, to personally be able to have the courage to say, “Here is what has happened to me. I don’t feel this way.” Are we dealing with this in real time in this country?
Ms. Barnett: Not as a concerted effort. There is advocacy and then you see provinces bringing in bans. I’m not sure what’s being done on the mental health side of things in terms of training. Maybe you could speak to that, Ms. Cohen.
We are trying. We have been going province by province because those mandates are there. I guess this is why we are here. If there were a federal position on conversion therapy coming from Health Canada, that may help. That might help to prod the provinces into enacting legislation around it.
As far as what mental health professionals are doing, I will let Dr. Cohen speak to that.
Ms. Cohen: I can only speak to ours. We’re a national association of psychologists and our membership is divided up into sections. We have one on sexual orientation and gender identity. There are researchers and practitioners within the profession who specialize in this area and become involved and develop the training programs and recommendations for best practice in terms of treatment. Not all psychologists will work in this area, just as all psychologists don’t work with adults, or people with disabilities, or whatever. It can be a very specialized field.
I think there is wisdom, guidance and research in this area about how to do it in a way that is evidence based. It’s the evidence that is very clear that reparative therapies do no good. They do more harm than good.
Senator Munson: This has to do with autism and mental health. If we have a chance for a second round, perhaps I can get into that: the whole idea of mental health issues with those with intellectual disabilities, which is a serious issue.
The Chair: We will put you on the second round.
[Translation]
Senator Mégie: I have a question for Ms. Cohen. Is this shortage due to the fact that psychologists do not choose to work with children with mental health problems? Is it the absolute number of psychologists that is low or is it a lack of political will on the part of the educational community? You said that we need professionals who work with young children in their environment. The school environment is ideal for reaching these young people, but there aren’t enough psychologists. What are the possible causes of this shortage of specialists?
Ms. Cohen: I understood your question very well, but I will speak in English.
[English]
I think there are a lot of factors into why there are some human resource challenges when it comes to psychologists working in schools. They’re complex. I don’t think there is only one factor. There are four times as many psychologists as psychiatrists in the country but there is an access problem, because psychiatrist services will be covered by the provincial health care plans and the psychologists’ will not.
As public institutions face budget pressures and decrease their salaried resource, professionals like psychologists, or occupational therapists, or physiotherapists go to work in the private sector and they don’t come back because they’re doing fairly well. There aren’t the incentives to bring them back into the public sector even if the institution could hire them again.
The other piece concerns conditions of work. In my remarks I said you can’t give someone 10 cents and say go buy a loaf of bread. If you want to have sufficient resources in a school, you can’t have one psychologist for 5,000 students because they will succeed in not being able to contribute very much.
[Translation]
Senator Mégie: Yesterday, one of our witnesses spoke about a web platform that could help make up for the lack of resources. Young people who feel depressed can use this platform to obtain advice. Have you consulted these platforms, and how effective are they? Is there a negative aspect for young people who consult them?
Ms. Barnett: I’m not familiar with the platform. I didn’t know it existed. This tool gives young people the possibility to seek help. My concern is that, without a person present, it isn’t always possible to see the problems young people hide. Take for example a 13-year-old boy who says he feels depressed. He is offered the web platform. However, this boy doesn’t suffer from depression but has bipolar disorder. We can’t always know what’s going on in a young person’s head. This tool can help to find resources and determine who needs help in person. It can be a sounding board, even if there isn’t an answer as such.
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Ms. Cohen: There is a researcher out of, I believe, the University of Regina who works on delivering web-based therapies. There’s a lot of evidence they are effective for some people with some kind of problem at some time. I could echo what Calla said. It’s not a one-stop shop solution. Do they have a use? Asbolutely. Are they going to work for everyone at any point in time? No, they are not.
Senator Omidvar: I have a number of questions. In the interest of time I will try the first one and see how far we get.
Ms. Barnett, I’m like Senator Munson. I think I’m going to sit here and soak it in and learn and then someone asks something that piques my curiosity and interest. I am interested in this conversion therapy you talked about. I looked online and found that Manitoba, Ontario and Nova Scotia have a ban; Vancouver has a ban. Alberta is considering a ban.
Malta has a national ban with a fine of $15,000 and a year in jail. The U.K. is considering a ban. Should the federal Government of Canada consider a ban on conversion therapy and should it be a recommendation in our report? Keep in mind the federal government doesn’t actually deliver these services.
Ms. Barnett: Yes. It’s a human rights issue. That seems pretty self-explanatory to this room. It is a human rights issue. I believe because conversion therapy and forcing children into conversion therapy violates the rights of the child for safety and security. Yes, I believe the federal government can implement a ban. I believe it should be the recommendation of this committee.
Senator Omidvar: I agree completely that providing primary care to children and youth in schools is an optimal way of going forward. The challenge becomes an issue of resources. I may not come from a small, rural community like some of my colleagues. I am from Toronto, but I can tell you anecdotally I know parents whose children have been on a waiting list for 18 months to get an assessment. Parents will then choose to pay themselves. I know how much that can cost, up to $3,000 to get an assessment which doesn’t do anything, it just gives you an assessment. Then you have to go further and find a psychologist, et cetera. This is not a level playing field for anyone.
Is it possible, within the new funding that the federal government has provided for mental health services that Senator Manning referred to, to target it particularly for expenditures in the school system, in primary care? The federal government can do this if persuaded. It is able to say this much money will be spent in this way without getting lost in the maze of transfer payments.
Ms. Cohen: That is an interesting question. Way back when we were meeting with the Public Health Agency and Health Canada, we had commissioned a study a number of years ago on how Canada could learn from what has been done in other countries and better target funds to make psychological care more accessible, we had been advocating for a more centralized approach for how this money could be spent. The constitutional reality of this country is complex, because health care is provincially and territorially delivered, how many parameters can be around those targeted funds?
One realistic place to put it would be in schools for children and youth. Another reasonable case might be primary care. I imagine it would be challenging for the federal government and the provinces to reach that understanding of how they will best use it.
Senator Omidvar: I am a bit concerned — perhaps you can help me out, Dr. Cohen — that more access to care is better, but when that access to care leads to an unhealthy reliance and addiction on medication for children. Again, anecdotally I have heard stories. You go to a psychologist and they will put you on medication and you can zoom out.
I want to have comfort that your profession understands addiction and understands the danger of prescription medication and that when the addiction starts early in life, it is that much harder to kick.
Ms. Cohen: Psychologists have PhDs not MDs. In Canada we do not prescribe medication. In some U.S. jurisdictions psychologists have prescriptive authority, but not in Canada. I couldn’t agree with you more. There are many ways to address mental health problems. The two sentinel treatments when it comes to mental disorders are medications and psychological treatment. Psychotherapy, cognitive behavioural therapies, interpersonal therapies, there are all kinds of evidence-based therapies. In Canada neither of those interventions are covered. We don’t have a pharmacare plan and we don’t cover psychotherapy, which is mainly delivered by psychologists. Some psychiatrists do psychotherapy but it is mainly psychologists, social workers and other trained counsellors who are delivering it.
I couldn’t agree with you more that there are other things to try first. There are other things that work. The evidence will tell you that when it comes to anxiety disorders, for example, psychological treatments are indicated over and above medication. Part of the challenge is that people go to the funded door and our health providers give what is available to them to give.
The Chair: I have a quick question for you, Ms. Barnett. In terms of the community you represent, you talked about the challenges of accessing professionals and the cost when it comes to health or intervention and treatment. What about the expertise when you finally reach out to professionals? Do we still have a gap in terms of their education and ability to serve the community that you represent?
Ms. Barnett: Yes, there is definitely a gap. There are definitely social workers, psychologists and psychiatrists with an incredible amount of expertise in order to support the LGBTQ2SIA community. Not everybody has that ability. Some people think they do and they don’t. Some people know they don’t. It is kind of the luck of the draw. With the funding systems the way they are, it is hard to switch psychiatrists or psychologists once you have been assigned one. There is not a database of experts on LGBTQ2SIA issues in terms of psychiatry, psychology, social work and counselling. One particular area is street-involved youth. There are a lot of trans folk and queer kids on the street. They will walk in and get a counsellor that will either understand their issues or not. It is just whoever happens to be on call that day in the walk-in clinic.
There is a lot of work to do.
Senator Munson: I put autism on the table. I think we can ask that question of other witnesses.
We are always talking about children but parental barriers are important, too. What are the parental barriers? What is most common that is preventing children from getting the help they need? Is it stigma, financial situation, poverty, their own mental health? We talk about schools and millions of dollars from governments, and so on. It starts with the parent.
Ms. Cohen: When we were doing a bit of research among our membership for your presentation today, one of the messages we got from our membership of pediatric psychologists is you are absolutely right, reaching parents and giving them the supports they need is incredibly important. There are programs that have been adopted in Canada. One I am aware of is the Triple P parenting program out of Australia which has been excellent to give parents the skills they need to support the mental wellness of their children. Those are population level things that I think is in the purview of the federal government and are critically important.
In terms of barriers, no matter how much we devote to health promotion and illness prevention there will be people, children and adults among them, who need help. The barriers to getting that help are all of the above. It could be demographic or resources in that area.
Senator Seidman: I want to zero in on something I think this committee is concerned with. We are a federal jurisdiction.
Youth mental health is a very complex and huge area. We’re trying to begin our study with a bit of exploratory work, so we can narrow it down and really focus on something that can make a difference to this field.
We’re trying to get our witnesses, such as you, to put forward to if you could identify a specific gap in knowledge or aspects of the youth mental health issue that we, as parliamentarians, could focus on and really pursue in order to improve child and youth mental health.
You focused a lot on accessibility and delivery of services. It’s frustrating as a parliamentarian, because I so empathize. We have heard this over and over: accessibility and delivery of mental health services. I’m trying to find an angle as a federal legislator that would allow me to pursue that.
Now I’m biasing you as I ask you this question, but please look at the broader aspect here. If you could provide us with some insight, that would be great.
I might start with you, Ms. Barnett.
Ms. Barnett: Yes, I’ve been thinking about that for days. As far as access is concerned, it’s probably only through recommendations at Health Canada that Parliament can make any kind of wave in terms of financial access, what’s covered and statements about the rights to accessing health care. Considering mental health as a part of standard health care in Canada is a really big deal.
We’ve been talking about conversion therapy. Something I would be happy to hang my hat on is rights-based legislation around ending conversion therapy across the country.
Senator Seidman: In fact, including mental health in the Canada Health Act, right, because it’s right now not really part of the Canada Health Act? Mental health is not —
Ms. Barnett: Yes.
Senator Seidman: That’s great.
Ms. Cohen: I would add that the health promotion or population health level to provide resources to parents around parenting programs and those kinds of things are probably easier to do as a federal government. But I agree with you about the Canada Health Act. I would go further and say it’s challenging. We talk about having a public health care system. We don’t really. We have a public medical care system. We pay certain kinds of providers to deliver care in certain venues. That’s what we do.
It’s Canada, and health care has evolved. We started with Medicare. We have hundreds of thousands of health-care providers who are not physicians, and their services are simply not covered.
I do think there’s a systematic problem to fix. For example, in the study we commissioned, we found out that family doctors in Canada — about $356 million for family doctors to do counselling and psychotherapy. This is not part of their core skill set necessarily, but that’s where the money and funding is accessible. Some go out and get specialized training, which is wonderful, but we have social workers, psychotherapists and psychologists who are trained to deliver this, and there is this huge gap.
I’ll end with saying when there was talk about targeted transfers for mental health, looking at the what the U.K. is doing, there was an opportunity to do something centrally, rolling out across the country, collecting data in a systematic way so we know it’s effective. That might be another approach to take.
Senator Seidman: These recommendations in a study that you have — you referred to a study.
Ms. Cohen: Yes, it’s called An Imperative for Change. We commissioned it in 2013-14. I’d be happy to share it with you.
Senator Seidman: That would be great if you could send it to the clerk of the committee.
The Chair: Thank you to both of our panellists. It’s been informative and insightful.
We will now welcome our second panel regarding this study on youth mental health.
For the next panel we have with us, and we are pleased to have you with us, Dr. Patrick Smith, National Chief Executive Officer from the Canadian Mental Health Association. We also have with us from HealthCareCAN Dr. Zul Merali, representative, President and CEO The Royal’s Institute of Mental Health Research.
We will start with you, Dr. Merali.
Zul Merali, Representative, President and CEO, The Royal’s Institute of Mental Health Research, HealthCareCAN: Good morning, honourable senators. Thank you for this opportunity to speak to today.
My name is Dr. Zul Merali. I am President and CEO of The Royal’s Institute of Mental Health Research, affiliated with the University of Ottawa. I am joining you as a representative of HealthCareCAN, a national voice for health care organizations and hospitals across Canada.
We know mental illnesses such as depression can develop at a very young age. More than half of adult depression manifests before the age of 14, and over 70 per cent of adults with depression report having symptoms by the age of 18. Not only is the scope of mental illness significant in our country, affecting more than one in four Canadians, but the fact it starts early and is often chronic and recurrent means that prioritizing child and youth mental health is extremely important.
A focus on early intervention and prevention would yield the biggest bang for our buck, so to say. In terms of mental health investment in our country, intervening early would not only improve the life trajectory for many youth, in terms of education and social connectedness, but would also have a significant downstream effect benefit for the Canadian economy as a whole. This week alone, for instance, 500,000 Canadians will not go to work due to mental health-related issues. If we can begin to systematically prevent mental health problems early in life, we can help ease the growing social and financial burden and level of lost productivity due to mental illness that it imposes on the workplace and the Canadian economy.
Only one in three that need help will actually seek help; however, as stigma around mental illness continues to dissipate, more and more people are now coming forward and asking for help. As it stands, however, our country’s health care system has nowhere near the capacity needed to treat the number of individuals who are struggling. Furthermore, about half of those who do get help do not respond adequately to the treatments we have for them.
We know that if we can detect mental illness early, then we can intervene early. The fact that our current mental health treatments don’t work very well — we need much greater investment in research. We need to find better and more innovative ways of treating mental illness.
The reality is there will never be enough resources to meet all the needs of our country, unless we take new approaches to deal with the demand. As one focuses on prevention and early intervention strategies that are informed by research, like we did for polio and like we do for cancer, such needs to happen for mental illness. Through these strategies, we can provide better access to treatment and, importantly, ensure that those treatments are evidence-based.
On this front at The Royal, we recently created an international network through the Government of Canada’s Networks of Centres of Excellence program, a program called Frayme, which focuses on gathering and sharing best evidence and practice-based knowledge about integrating youth services and putting those learnings into more impactful models of care.
As we develop more evidence-based care, we also want to ensure that our treatments are more holistic and easily accessible and that our health care models equally prioritize physical and mental health.
One particularly successful model that we can look to for guidance is Foundry out of British Columbia, where centres have provided a one-stop-shop for youth aged 12 to 24 across mental health care, primary care, social services and other supports.
It is not only important to provide young people with access to effective, cutting-edge treatments when they fall ill, but it is equally important to try and keep individuals well, by recognizing those at risk and dealing with early symptoms to prevent detrimental outcomes associated with mental illness occurring in the first place.
We can do this partly by harnessing some cutting-edge technologies and artificial intelligence. For instance, there are very few antidepressants available to the youth; there are many for the adults but not for the youth. Those who are prescribed have often undesirable side effects that young people don’t particularly like, such as weight gain and sexual side effects. Research indicates, however, that we can effectively alter brain activity in other ways too by using non-invasive technologies, such as repeated transcranial magnetic stimulation, whereby you can change brain activity in a non-invasive way. This rTMS technology has proven to be effective quite rapidly to alleviate symptoms of depression, particularly in those individuals who are treatment-resistant. However, our current provincial plans do not cover such treatments.
Another cutting-edge approach to prevention is being led by Dr. Zachary Kaminsky who holds a DIFD-Mach Gaensslen Chair in Suicide Prevention Research at The Royal. He has developed algorithms that use artificial intelligence to predict suicide risk based on analytics around Twitter messages that they send.
Such an approach can be seen as a decision-making aid to identify those who are at risk very early so intervention and suicide-prevention strategies can be mobilized, particularly amongst Canadians between the ages of 15 and 34 for whom suicide is one of the leading causes of death.
Finally, through all our approaches to prevention and treatment, we must keep a strong focus on personalized interventions. Just as there are many types of cancer, we know through research there are several subtypes of mental illnesses such as depression.
At The Royal’s Institute of Mental Health Research, we are currently working to establish a first episode depression research and intervention centre, which will harness some of the latest brain imaging technologies to subtype depression in individuals, and figure out which treatment best works for individuals based on the subtyping of the illness. We want to test, for example, the efficacy of drug therapy versus rTMS, repeated transcranial magnetic stimulation, versus talk therapy. We want to see who should be getting those treatments and who is going to best respond.
To conclude, it has been incredibly encouraging in recent years to see public dialogue and government policies pushing for greater access to mental health care, particularly as it pertains to vulnerable groups such as children and youth.
Now, if we are able to direct increased investment towards mental health research, we can ensure the strategies and resources that are being rolled out are effective and evidence-based, and in many cases able to prevent mental health crisis from occurring in the first place. Thank you.
Patrick Smith, National Chief Executive Officer, Canadian Mental Health Association: Thank you, Madam Chair. Thank you for inviting me here today. I’m Dr. Patrick Smith, national CEO of the Canadian Mental Health Association. CMHA/ACSM is a Canada-wide organization that serves more than 1.3 million Canadians directly. We serve all Canadians because all Canadians have mental health. We are in over 330 bricks-and-mortar locations across the country and serve rural and remote communities from those bricks-and-mortar locations to many, many more communities across Canada.
CMHA is Canada’s most established and most extensive community mental health organization working to prevent mental illness, support recovery and resilience and promote flourishing.
Today my remarks will emphasize what we see as key challenges and opportunities for action in child and youth mental health.
There is no doubt the growing attention to mental health is starting to break down stigmas around mental illness. The Government of Canada has shown strong leadership in this regard, infusing $5 billion into mental health over the next 10 years. However, it’s important to recognize that even with that investment Canada spends the lowest percentage of our health-care budget on mental health. We’re at 7.2 per cent. The $5 billion still keeps us at the bottom. Countries like the U.K. spend 13 per cent of their health-care budget on mental health.
It’s important to recognize that has real implications. That’s not just one year. That’s year over year over year. The gaps are significant. I’m a clinical psychologist trained in the States — a recovering American and have been here for well over 20 years and don’t plan to go back. It’s astonishing to know that social workers, psychologists, specialized peer support workers, they’re all here in Canada, but we’re all sitting on the sidelines of a publicly funded medical care system.
I’m head of the Addiction Psychiatry Program at UBC, at the University of Toronto, and I concur in terms of the need to invest in more research. There’s way too much we know already works that we are not implementing in Canada. I think that’s where we need to focus. I am confident we’re all here today because of some awareness of that situation.
For 70 per cent of people living with mental illness, onset does occur between the ages of 14 and 24. In 2016, 12,000 youth in Ontario waited 18 months to access a psychiatrist. Many more waited to access psychologists and social workers, and many didn’t even line up because you have to pay out-of-pocket or have private coverage.
Suicide is the second-leading cause of death in young people and the leading cause of death in Indigenous youth. These figures suggest the depth and scale of the challenge we are facing.
We must determine effective funding, resourcing and programming solutions. For our efforts to be meaningful in the short term and sustainable in the long term, we must also attend to the inequities that negatively impact child and youth mental health in the country. I will offer a few examples.
Our most recent reports on child poverty indicate that poverty affects upwards of 1.2 million children. These rates are far more severe for Indigenous children, 50 per cent of whom experience poverty. Several recent studies of low-income communities in different parts of Canada link poverty to things like anxiety and depression.
Persistent gender inequality, including sexual violence, has a considerable impact on the mental health of girls. The rate of sexual assault is 18 times higher for girls and women aged 15 to 24 than for Canadians aged 55 and older. Girls who experience sexual assault have higher incidences of depression, self-harm, anxiety and eating disorders.
We also know mental health disparities exist for LGBTQ and transgender youth, in particular, struggle. Indigenous youth is the fastest growing segment of the population, yet they experience the highest mortality rates. In addition to higher rates of death by suicide, Indigenous youth in Canada experience higher rates of problematic substance use and addiction because of the effects of early childhood trauma, generational trauma and separation from family.
The impact of social media on children and youth has also come into focus. As recent research in child and adolescent psychology has shown that social media can have a deleterious effect on psychological well-being and development. International studies show that 23 per cent of youth who experience cyberbullying report reduced self-esteem and higher rates of withdrawal, anxiety and depression. Alongside these challenges, children and youth in Canada must navigate a complex array of available providers and services and youth often must undergo multiple assessments, if they do get access to care. This complexity is challenging for any busy family, and even more challenging for families experiencing racial, social and income inequality.
Moving forward on child and youth mental health demands a multidisciplinary cross-sectoral approach that increases public investment while harnessing Canada’s capacity for research and innovation.
First and foremost, Canada must address chronic inequality and underfunding in mental health. The reality is this level of deferred maintenance will not be solved in one budget and it will not be solved even in one sitting government. We need to address the inequalities and we need to do as the Honourable Norman Lambin the U.K. did when he introduced parity of esteem legislation. He said the first thing we have to do is stop justifying the unjustifiable. It’s just speaking the truth about how big the gap is.
Imagine if we found out in Canada that in one community, in Kamloops, just the way it evolved organically, we had fifth and sixth grade only and 30 kilometres down the road we had a community that only had kindergarten and junior high. We wouldn’t scratch our heads, put a task force together or try to figure out what to do. If that was the case across Canada, with everything the developed world knows about the needs of a Piaget developmental model for education, we would just put in that developmental model, make sure kids have access to second, third fourth grade and so on.
That is the situation in Canada, not just for kids, but especially for kids. What’s available in communities is as diverse as that would be in education. What we need to do is address that recognizing the federal and provincial, territorial jurisdiction.
The other important thing the federal government can do — and I concur with all speakers today who have emphasized mental health promotion and mental illness prevention — is take a settings-based approach. Where do people spend their most time? We’ve seen amazing results when corporate Canada has stepped up to the plate and invested in workplace mental health. It’s time to do that on a dramatic scale for schools.
Programs like Not Myself Today and Social and Emotional Learning, both adapted for schools, is something the federal government can do immediately, and it will have the biggest impact on child and youth mental health in Canada. Thank you.
The Chair: We have a list of senators with questions. We will begin with the deputy chair, Judith Seidman.
Senator Seidman: Thank you for your informative presentations. Dr. Merali, Canada has a federal framework for suicide prevention that was implemented in 2016, and it includes three strategic objectives: to reduce stigma and raise public awareness, to connect Canadian’s information and resources and to accelerate the use of research and innovation in suicide prevention. Because of what you presented to us, I’m addressing you about this first.
I know you come with two organizations in your current work life. One is The Royal’s Institute of Mental Health Research and the other is representing HealthCareCAN. I’d like to know if either of those two organizations were involved in developing the Suicide Prevention Framework, and is it an ongoing partner in its implementation? In your viewpoint, do you think there’s adequate engagement in meeting the objectives; and if not, what role the federal government could play in furthering those objectives?
Mr. Merali: We have scientists who were involved in the development of the national strategy. But in terms of your second question about the implementation of the framework, I think that’s where more can be done, in the sense we can set up frameworks to facilitate engagement and involvement of people toward those strategic objectives.
However, because in Canada we are so provincially oriented in terms of the implementation side, things get lost in translation.
I wear a strong research hat. My view is we need to figure out a better way. My learnings are from what we have done in the past, where there has been a major crisis. For example, look at polio, which we don’t hear much about these days. In the 1950s, when access to care was very different, we wanted to see how can we build enough wards to house the iron lungs that would keep people alive. That was our access to crisis care. The solution was not to create more wards with iron lungs, the solution was a vaccine that completely alleviated the problem.
We need to think outside of the box and find other ways so we have effective treatments. Maybe we are not implementing those in the most effective way right now, but even those are incremental. We need to do a quantum change. That will only come through research.
In terms of our national framework, we have not had mechanisms to energize and mobilize those three pillars we talked about.
Senator Seidman: Dr. Smith, I would like to hear from you as well. I would like to hear more about the last comment of Dr. Merali. You nodded your head.
Mr. Smith: The mechanism is part of it. We submitted to the Finance Committee a specific recommendation on this. We have 87 branches, divisions and regions and 336 bricks and mortar locations across Canada. Over 220 of those are actively involved with their communities, grassroots, on the ground, working on suicide prevention in the schools and in their communities.
We work with the Mental Health Commission of Canada. We are aware of the Roots of Empathyand some of the recommendations they are making. The mechanisms are there, if they are funded. Our only Centre of Excellence in Calgary is the national Centre for Suicide Prevention. It is a CMHA branch and works effectively with the branches across Canada with schools and communities. That is why we have made the recommendation. Those branches have been working in those communities for years. We don’t see this as being the Roots of Empathy approach, picking five or six pilot sites and trying to figure out what to do with that.
We have been involved with the Canadian Association for Suicide Prevention, CASP. All three former chairs are currently employees of the Canadian Mental Health Association across the country. We have the blueprint; we know what we need to do. It focuses on raising awareness.
If we look to other jurisdictions like the U.K., the Time to Change campaign for raising public awareness, their federal government invested $34 million Canadian over the first four years alone to measure and track public attitudes with specific segments of the population. We, as you know, have been doing our Mental Health Week campaign, our #GetLoud campaign. We have been doing that with no funding for 67 years. That is another part of an integrated solution where we have put forward, for the first time, a recommendation for nominal funding to help us do that.
Senator Eaton: Gentlemen, is mental health getting worse? Are there common triggers over the last 20 years that weren’t there before or did we just not keep statistics and data?
Mr. Smith: It is complex, but I think it is a bit of both. The reality is if you had a cottage with a leak in your roof and that caused water damage in your basement and you pumped the water out but you weren’t addressing the deferred maintenance on your cottage, over time the cost of fixing that cottage will increase.
When I talk about the year over year of 7.2 being with the lowest of all G7 countries, it is the basic foundation of mental health provision in other countries that we don’t have here. When stage 1 cancer isn’t treated, it does go to stage 2 and 3. It does get worse and more difficult to treat.
Senator Eaton: I think mental health is mostly a provincial jurisdiction, is it not?
Mr. Smith: Yes.
Senator Eaton: I think the federal government disbursed $100 million of the $500 million promised. Should they direct it? Should they say, “This is what you should do?”
Mr. Smith: We have said all along yes. If it is about specific funding of services, I can see the provinces saying, “No, we know what we need.” All mental health disciplines, other than psychiatry, are not funded and included in the publicly funded package. That can’t be left up to the provinces in the hope that they get it right. That is a fundamental, systemic problem across Canada. People scratch their heads when they are coming from another country. New Zealand, Australia, every G7 country wonders how they would respond to their mental health challenges in their country if social workers, psychologists, addiction councillors, specialized peer support workers, very focused primary care clinicians trained to do just what we need them to do were not publicly funded. They wonder how has Canada gotten as far as we have.
Senator Eaton: The money should be publicly directed?
Mr. Smith: Yes, absolutely.
Mr. Merali: It is absolutely right that it should be directed. We have to find more effective ways of fostering this partnership. The broken piece of the system is that although we put the resource here, the federal government is interested in putting resources towards mental health. The provincial buy-in is not consistent across the country, and that is a challenge.
You are beginning to see some uptake in the sense that now, for example, some of the provinces have agreed to provide psychological services, CBT, through this mechanism of the enhanced federal funding. Although I would have hoped to see a much bigger engagement by the provinces, I think that pressure needs to be kept on. It is a national problem right now.
Senator Eaton: Neither one of you answered. Perhaps there isn’t an answer to this. Are there common triggers?
Mr. Smith: Yes.
Senator Eaton: Housing, violence; are there common triggers that a child growing up in a certain way is more likely, because of his surroundings, to develop mental illness?
Mr. Merali: Yes there definitely are. You mentioned some of those already, especially the issues of childhood neglect and abuse which are critically involved in the geology. There are also common factors about the stressors and changes that young people face early in life that have long-term implications. I think that is there.
The earlier question you asked was about whether there was an increase in the mental health prevalence. The prevalence rate as we measure it today has not significantly changed. If you look at the trajectory of our rate of sucide across Canada. If you look at cancer, it has gone down; heart disease has gone down, even AIDS has gone down. If you look at suicide, it is not only a straight line, it is trending upwards in the sense that something is not right. It is a canary in the mine situation.
Suicide is the very epitome of things going wrong but there is a pyramid underneath that needs to be addressed. Although the prevalence rates are not necessarily increasing, it is clear that some of the underpinnings that you are talking about, the early stressors in life, are increasing. Furthermore, technologies are there via 24/7 connectedness, through iPhones and iPads, lack of time and sleep for young people; too much screen time, certainly has an impact, amongst other things.
Senator Eaton: Thank you very much.
Senator Munson: I have a different question to both doctors.
Dr. Smith, you said our system also struggles to support youth in transition to adult mental health. I would argue there is a two-tier mental health system in this country. I know of a young man who is 15 or 16 and saw a psychologist. Things were working out, so it was there for him when he was 22 or 23. This young man wanted to go see a psychologist. He had the money, the wherewithal. He had the $100 or the $150 for the first session. After three or four sessions, he felt good about himself and had the mental health ammunition to deal with issues. But I would argue there are tens of thousands of Canadians who don’t have the wherewithal to get to that.
I will throw that question out to you and then ask the doctor about algorithms, artificial intelligence. While the doctor is answering here, perhaps you can give us an idea how it is working at the Royal and how it works to predict suicide risk based on Twitter messages. I find that fascinating.
Mr. Smith: I concur that it’s a two-tier system. It’s set up that way, again, if the only clinicians that we support are doctors and nurses. They are not the most effective and they are the ones who tell us, “We have 25 people in the waiting room. We shouldn’t be having to do the psychotherapy, the CBT. Other countries rely on these.”
If you won the lottery and you work at Starbucks Canada, where they moved their coverage from $400 to $5,000 per employee, then, yes, you can get access to counselling and psychotherapy. It shouldn’t be up to the employment lottery.
As we are struggling to try to figure out how to bridge that gap — and we have to start somewhere — I think the federal government can have the biggest impact on changing the settings and really focusing on social and emotional learning and a settings-based approach in schools. That is something in the federal government’s purview. It could invest, and as we see in Not Myself Today in workplaces, it works. The Department of Finance of the federal government uses that program, as do Health Canada and the Public Health Agency of Canada. Let’s put that in our schools for the teachers and the kids. That can have a dramatic impact immediately.
Mr. Merali: In terms of the predictive analytics looking at the Twitter chats, I think the objective was to see whether we can get a signal early on whether someone will be developing a strong suicide ideation. Using artificial intelligence and looking at those chats, our researcher Zachary Kaminsky has been able to develop algorithms that can detect very early — weeks ahead — whether someone will be escalating toward a higher suicide ideation. The idea is, can we use this technology to try to figure out who might be at risk and what can we do about it? That is a challenge because there are privacy issues involved and there is the jurisdiction and who can talk to whom.
In essence, just like you get targeted messages when you go on your website, for example, if you were to look at an ad for an Alfa Romeo, often when you get on your web you will often see an ad for an Alfa Romeo. In the same way, if you can identify people at risk early on, can we send targeted messages of help, where to go and what to do, instead of those types of commercial ventures?
I think the providers, the Googles of today, are interested in giving positive, helping messages through that platform. If you can find ways of harnessing that and maybe of informing their therapists so they can do some intervention, that could be a unique way of doing that.
Using predictive analytics and artificial intelligence is getting more and more evolved. For example, we could do the same thing at the workplace. You could fill out a short questionnaire — five minutes long — anonymously. We have developed a risk calculator that will tell you how at risk you are of developing depression over the next four years.
Senator Munson: My time is up but I guess it would take the psychologists to gain the confidence of the young person to take a look at his or her Twitter account.
Mr. Merali: It’s public. Your Twitter chats are public.
Senator Munson: The chats are, that’s right. Thank you.
Senator Ravalia: Thank you for your very insightful presentations.
My first question is to Dr. Smith. If we were to raise our funding to 13 per cent, what would it take to keep psychologists in the public system as opposed to the drift toward private, where we really need them? Would a fee code or something similar to the public Medicare system assist all our health care professionals who are engaged in the delivery of mental health services?
Mr. Smith: We often look at other jurisdictions to see what happened when they did that. The U.K. didn’t always put 13 or 14 per cent of their dollars toward mental health; it’s recent. They just opened it to say, “We have only been reimbursing physicians and nurse practitioners. Let’s go out on a limb and reimburse psychologists and social workers.”
It’s the same pot of money. Fewer GPs are charging a higher dollar. They found out there were longer-term savings in more focused work for the GPs. GPs did what they were trained to do. They also found — and Norman Lamb will be at our conference next week to talk about this — they were closing units in jails that used to house mental health clients. What we can tell you is what we would assume could happen, but we can also ask what happened in other jurisdictions when they made these simple changes. That is usually a better predictor of what will happen, namely, what happened with them? What happened in Victoria, Australia, when they did this? What happened in the U.K. when they did this?
When we don’t treat stage 1 cancer, we all know that it goes to stage 2 and then to stage 3. By the time it goes to stage 4, it’s not as easy to treat and it’s way more costly. It’s the same thing with the iron lung. It does save. The untreated mental health probably exacts more of a financial toll on Canada, and not just within the health system.
Yesterday, I presented at the Criminal Justice and Mental Health Conference. The criminal justice system is calling themselves the emergency room for mental health in Canada because we don’t have publicly funded — as Dr. Cohen said earlier — primary mental health care.
Psychologists will stay in the publicly funded system as long as they are paid. They don’t need a lot of money, just some reimbursement.
Senator Ravalia: My question to Dr. Merali is specifically related to research. You talked about transcranial magnetic stimulation. Have studies been done in youth and children with respect to this modality? If access were available, are there any concerns about adverse effects?
Mr. Merali: The answer is yes to the first question.
It has been tested on youth and it is effective. I am not quite sure about children but for youth, certainly.
In terms of the adverse effects, there are no reported adverse effects with this modality of treatment except for something like a headache. Other than that, there are few side effects, if any, with this modality. It is an exciting area of treatment. Often youth, as I said, don’t want to be taking medication because of the side effects. They might want to try something else.
In the past, RTMS needed about a 30- or 40-minute session of coils being placed outside your head, which the treatment provided. Now we have honed it down to a point where you only need a 3-minute session. It is almost like a cup of coffee and you are done, but it needs to be done on a repeated basis.
Senator Dasko: Thank you for your presentations. Dr. Smith, I want to ask about the figure of 7.2 per cent funding towards health care. The Americans would spend less, would they not, in terms of publicly?
Mr. Smith: No. Even the Americans in the publicly funded system, the state hospitals, et cetera, spend more on mental health than Canadians.
Senator Dasko: In terms of per capita spending as opposed to percentage of the share of health care, are we still at the bottom of the list of per capita spending, or are we somewhere in the middle?
Mr. Smith: No, I would say we are at the bottom. We are recognized as having leadership. You will know that the Honourable Ginette Petitpas Taylor has recently stepped up to the plate to chair the Alliance of Champions for Mental Health and Wellbeing. People are looking to Canada because there are some really great examples of leadership from Canada. They also recognize the specific gaps for primary mental health care here we don’t find in any other developed country.
Senator Dasko: Right. Per capita spending is also very low. I think that is the key figure; namely, how much are we spending on a per capita basis.
Mr. Smith: Yes.
Senator Dasko: When you talk about a role for the federal government, I very much appreciate your comments. Your organization focuses on prevention. I think that is a important role for the federal government.
Could you articulate a bit more regarding your idea about spending on programs in schools? When I think about the federal government, we don’t think about the schools because the federal government is far from the education system, which is provincial and local. How does that happen? How would it happen?
Mr. Smith: Again, internationally, there is real awareness that building in resiliency skills for kids will have a bigger impact on a population level than serving their needs after they have developed all these mental health issues.
Senator Dasko: Sure.
Mr. Smith: The Public Health Agency of Canada has done pilot funding of things that are more generalizable in other countries like social and emotional learning and social and emotionally aware kids. The Public Health Agency of Canada funds us in Nova Scotia, for example, to develop that. It’s getting picked up across Atlantic Canada. Those are things that could be scaled up across all jurisdictions, provinces and territories. I think it would mean targeted funding from the Public Health Agency of Canada to say we believe in this. We have already seen the results, and we believe in it enough to scale it up and have it available to kids everywhere.
I am a clinical psychologist. I am trained to treat people who have problems. I’ve worked at CAMH; I was founding vice-president there, clinically the largest mental health hospital in Canada. I am also aware of the power of population mental health promotion and knowing we have to stem the tide. We will never treat our way out of the mental health crisis that we see ourselves in, especially with years of not investing in the services.
I do think from a bang for your buck perspective, if you will, those programs are well-established in transforming workplaces. Schools are workplaces too. Transforming that for the people who work there but also for the students.
As an aside, psychological health and safety standard for workplaces is what drove the demand for that across Canada in workplaces. They are developing the standards for university campus settings for students and teachers. We are currently adapting the Not Myself Today program for university campuses.
Senator Ravalia: This is a specific research-related question. You alluded to treatment-resistant depression, which for practising clinicians is a huge challenge. I know in the U.S., particularly the western states, there has been some research directives in the use of hallucinogenics in treatment-resistant depression. Are we doing any of that work in Canada?
Mr. Merali: That is a very good question. Yes, we are, not in hallucinogenics per se. I think the drug we have pioneered at the Royal in the Canadian context is the use of ketamine, which used to be known as a safe anesthetic agent. If you use it at a very low level, it is proven to be effective in 60 per cent of the individuals who have failed about five different drug treatments in the past. They are treatment-resistant for sure. A low dose of ketamine, which must be infused, alleviates the symptoms of depression rapidly. What is unique about this approach is that instead of waiting weeks or months it typically takes antidepressants to kick in, ketamine works within hours.
What is even more exciting is that not only does it alleviate the symptoms of depression in general, but in particular, it alleviates suicide ideation. We are currently testing to see when people come in with high suicide ideation, we don’t let them go home. Essentially they will be hospitalized and they will be on track for ECT, which is electroconvulsive therapy. Instead, when people come in, we are trying to give them ketamine to get the same type of outcome, and it does.
We will be launching a multi-centred clinical trial to test ECT versus ketamine. It will be much more effective. People can probably go home the same day. Of course, there has to be other backup treatment plans in place.
New and innovative ways of trying treatments is important because so far it was taking long for the antidepressants to kick in and not everyone was responding; more than half were not responding. Actually, only 33 per cent respond well to current antidepressants. We have to make advances on that front.
Senator Ravalia: Thank you.
The Chair: Thank you very much. I want to say thank you to both our witnesses. It has been valuable for our research as we embark on our youth mental health study. Thank you for being here and sharing your knowledge and expertise.
(The committee adjourned.)