I was trained in a
medical model in nursing…. So many of us
spend so much time at the end of a fast flowing stream where there is a ton of
people drowning at the bottom. We spend
time trying to pull them out and figuring out how to keep them from drowning as
opposed to moving upstream to figure out what is pushing them in to start
with. —Cheryl Van Daalen
the emphasis in this report is on services for those living with mental illness. But what about preventing mental illness from
occurring in the first place?
its hearings, the Committee heard from a number of witnesses who called for
greater efforts in mental health promotion and mental illness prevention, two
approaches that address factors that may lead to mental illness. By so doing,
they reduce both the likelihood of developing mental illness and its severity
in the population.
promotion focuses on the foundations of good mental health. Broadly speaking, it emphasizes positive
mental health, as opposed to mental illness.
It addresses the determinants of mental health — the many personal,
social, economic and environmental factors that are thought to contribute to mental
health, and to the overall health and well-being of the population. Such factors include healthy childhood
development, income and social status, and education.
The prevention of
mental ilness is a related approach that addresses the risk factors associated
with mental illness — such as substance abuse, parental mental illness, and
child abuse and neglect — and the protective factors associated with good
mental health — such as self-esteem, social support, and a healthy start in
While there is a good
case to be made for both of these approaches, it is also necessary to develop
further evidence linking the various implicated determinants and good mental
health. With so many factors at play, it
is difficult to be sure of the impact of each determinant individually. Many of them fall outside the fields of
health and medical care — an additional complication for researchers. Work is under way to improve the evidence
base, but much more needs to be done.
This chapter provides
an overview of the guiding principles and strategies for mental health
promotion and the prevention of mental ilness, including the need for more and
better evidence and for research. It
reviews the role of the federal government and makes recommendations for
improving mental health promotion and mental illness prevention, particularly
with regard to preventing suicide.
central concept behind health promotion is that health is determined by many
interacting social, psychological, and biological factors that are amenable to
intervention by individuals and society.
Mental health promotion employs the same concept. Mental health is not considered merely as the
absence of mental illness, but rather as “… a state of well-being in which the
individual realizes his or her own abilities, can cope with the normal stresses
of life, can work productively and fruitfully, and is able to make a
contribution to his or her community.”
health, according to the World Health Organization (WHO), are “those factors
that can enhance or threaten an individual’s or a community’s health
status.” They can be matters of
individual choice or social, economic, and environmental factors beyond the
control of individuals. The determinants
of health recognized by Health Canada
and the Public Health Agency of Canada are:
In the Committee’s second on-line
consultation, almost three-quarters of participants (72%) believed that to
improve the mental health of Canadians, we must first address the real causes
of most mental illness and addictions — including poverty, poor housing and
other social conditions.
The health promotion
approach focuses on improving the health of the population by addressing
determinants of health that are amenable to change, recognizing that doing so
is a long-term process yielding results only in a future more distant than the
usual political or even research horizon.
The basic action strategies of health promotion were accepted by the
international community in 1986 at the First International Conference on Health
Promotion. They are set out in the Ottawa
Charter for Health Promotion:
In August 2005, these
principles were reiterated at the Sixth Global Conference on Health Promotion,
which produced the Bangkok Charter for
Health Promotion in a Globalized World.
This Charter called for political action to implement strategies for
internationally agreed-upon frameworks and guidelines for health promotion
generally, comparable frameworks have been developed for mental health
promotion. In 2004, the WHO summarized
the current thinking on mental health promotion:
1. Promotion of mental
health can be achieved by effective public health and social interventions. The
scientific evidence base in this area is relatively limited, but evidence at
varying levels is available to demonstrate the effectiveness of several
programmes and interventions for enhancing mental health of populations.
collaboration is the key to effective programmes for mental health promotion.
For some collaborative programmes, mental health outcomes are the primary
objectives; however, for the majority these may be secondary to other social
and economic outcomes but are valuable in their own right.
3. Sustainability of
programmes is crucial to their effectiveness. Involvement of all stakeholders,
ownership by the community, and continued availability of resources facilitate
sustainability of mental health promotion programmes.
4. More scientific research
and systematic evaluation of programmes is needed to increase the evidence base
as well as to determine the applicability of this evidence base in widely
varying cultures and resource settings. 
Committee has commented on health promotion in its earlier reports on the
health system. In Volume Five of The Health of Canadians — The Federal Role,
the Committee wrote “there are potentially enormous benefits to be derived from
health and wellness promotion, illness prevention and population health…” Noting that population
health strategies should be “long term, national in scope and based on
multi-departmental efforts across all jurisdictions,” it said the federal
government should continue to provide leadership and devote more resources to
them. The Committee also recognized that
population health strategies must be adapted to local conditions and their
design and implementation must involve local communities. 
There is evidence of
links between determinants of health and the health status of the Canadian
population. In Volume Six of The Health
of Canadians, the Committee advocated continued research in the area but
also noted problems with the establishment of cause and effect relationships:
In the first place, the
multiplicity of factors that influence health status means that it is extremely
difficult to associate cause and effect, especially since the effects of a
given intervention are often obvious only after many years. Because political horizons are often of a
shorter-term nature, the long timeframe for judging the impact of policy in
this area can be a serious disincentive to the elaboration and implementation
of population health strategies.
Furthermore, it is very
difficult to coordinate government activity across the diverse factors that
influence health status. The structure
of most governments does not easily lend itself to inter-ministerial responsibility
for tackling complex problems. This
difficulty is compounded several times over when various levels of governments,
together with many non-governmental players, are taken into account, as they
must be if population health strategies are to be truly effective.
Although many difficulties
are associated with developing an effective population health approach, the
Committee believes it is important for Canada to continue to strive to set
an example by exploring innovative ways to turn good theory into sound practice
that will contribute to improving the population’s health status.
In its current study
on mental health, mental illness and addiction, the Committee has previously
stressed the critical importance of combating stigma and discrimination. It pointed out that reducing stigma and
combating discrimination “requires a multi-pronged effort sustained over a long
period of time and includes: ongoing community-based education and action,
media campaigns, and forums of exchange between affected individuals and other
Canadians to enhance public awareness, and professional awareness campaigns to
reduce structural discrimination in the health care system and in the mental
health system itself.” The Committee is also aware that educational
campaigns must be complemented with policies that create environments that
support change in people’s attitudes and behaviours.
The Committee will
address the issue of stigma and discrimination in greater detail in the next chapter. Briefly, we believe that a Canadian Mental Health
Commission should be established immediately to undertake a systematic and
long-term campaign to combat stigma and discrimination (see Chapter 16).
15.3 MENTAL ILLNESS PREVENTION: RISK FACTORS AND PROTECTIVE FACTORS
While mental health
promotion addresses the determinants of health with the goal of improving
positive mental health, mental illness prevention focuses on reducing risk
factors associated with mental illness and enhancing protective factors that
inhibit its onset or shorten its duration.
A WHO report on the prevention of mental illness provides the following
…mental disorder prevention
aims at ‘reducing incidence, prevalence, recurrence of mental disorders, the
time spent with symptoms, or the risk condition for a mental illness,
preventing or delaying recurrences and also decreasing the impact of illness in
the affected person, their families and the society.’
factors are those that increase the probability of the onset, severity, and
duration of major health problems.
Protective factors are those that improve people’s resistance to risk
factors and, therefore, to mental illness.
health promotion and mental illness prevention often form part of the same set
of interventions, even though they produce “different but complementary
Some strategies for the prevention of mental ilness are similar to those for
mental health promotion — such as improved housing and access to education and
reduced economic insecurity. Other
strategies are more tightly focused — such as coping with parental mental
illness, intervening in the workplace, and improving the mental health of
As with mental health
promotion, mental illness prevention must be based on an understanding of the
causes (etiology). However, as the U.S. Surgeon
General has pointed out,
…for most major mental
disorders, there is insufficient understanding about etiology and/or there is
an inability to alter the known etiology of a particular disorder. While these have stymied the development of
prevention interventions, some successful strategies have emerged in the
absence of a full understanding of etiology.
prevention interventions, the WHO suggests a number of steps to take,
including: assessing needs; disseminating best practices; implementing
high-quality, evidence-based programs on a large scale; and developing systems
for quality assessment and improvement, ensuring those programs’
To be successful,
mental health promotion and mental illness prevention interventions must be
based on evidence. They require the
cooperation of different levels of government, service providers,
non-government organizations and affected individuals, and they also require
substantial investments — both of which will not be forthcoming unless all
stakeholders have a good idea what the probable outcomes of their cooperation
and investment will be.
need for evidence was made clear by the Office of the Auditor General of Canada. After reviewing Health Canada’s
population health projects, the Auditor General’s 2001 report said that
“choosing the ‘right’ priorities at the outset is a critical step toward
committing resources to areas that will yield the most benefit in improved
population health.” The Auditor General also expected that
priorities would be chosen “on the basis of good, evidence-based information
such as surveillance data and evaluations of population health programs.”
2004, the WHO published reports summarizing the evidence relating to the
effectiveness of mental health promotion and mental illness prevention
interventions. While good evidence was
found for some interventions, particularly at the individual level, the WHO
considered the economic data on the relative costs and benefits of
interventions to be sparse.
While the WHO argues
that plausible interventions should still be carried out in the absence of
it is clear that more data are needed on the effectiveness of mental health
promotion and mental illness prevention policies and programs.
During the course of
the Committee’s hearings, some witnesses called on the federal government to
gather and disseminate information on mental health promotion and mental
illness prevention. Ms. Christine Davis, President,
Canadian Federation of Mental Health Nurses, testified:
government must play a role in making the connections between the social
determinants of health and the promotion of mental health for children, youth,
their families and adults.
Jennifer Chambers, Coordinator, Empowerment Council, recommended
that a national mental health legal advocacy organization serve as a clearinghouse for information needed
by advocates across the country.
Israël, Psychiatrist-in-Chief; Co-director, Clinical Activities Directorate, DouglasHospital;
and Associate Professor, Department of Psychiatry, McGillUniversity,
also called for a centralized structure that would, among other things:
pool data from
epidemiological and population studies to measure and monitor population health
needs that are changing as our environment changes;
agendas and research fund allocations;
research findings once they are collected from international health policies
aimed at promoting health or preventing illness; and
preparation and dissemination of information such as public education and
called for mental health promotion and mental illness prevention to be part of
a national action plan for mental health.
As Ms. Nancy
Beck, Director, Connections Clubhouse, testified:
The plan should
focus on a population health model, paying attention to prevention, promotion,
community care, clinical care, education, research and advocacy. Health Canada’s
website has incredible resources around the topic of population health. They
have been doing research in this area for decades, but I have yet to see that
evidence put into operation.
This was echoed by Ms. Annette Osted, Executive
Director, College of Registered Psychiatric Nurses of Manitoba:
We believe that
both provincial and national action plans should include a strong mental health
promotion plan based on the determinants of mental health. It is evident that
mental illness and mental health problems have significant social as well as
physical implications. To ensure the sustainability of our health system for
future generations, more emphasis must be placed on the health, including the
mental health of our population.
Over the years, the
federal government has issued several documents that touch on the promotion of
mental health and the prevention of mental illness. In 1974, A New Perspective on the Health of Canadians
was issued by the then Minister of National Health and Welfare, Marc
Lalonde. With regard to mental illness,
the Lalonde report said:
Much needs to be done … in
informing the public and modifying attitudes towards mental illness. Much needs to be done also in preventing
mental illness, identifying positive health factors and promoting them.
The pathological processes
at work in our families, our school systems and in our society’s value system
indicate that programs of prevention directed at large population groups are
desperately needed. These programs of
prevention would have the advantage of reducing the risks of mental illness
while permitting a sharing of responsibility which would abate some of the
guilt which individuals find so intolerable.
In 1986, the then Minister of National
Health and Welfare, Jake Epp, released Achieving
Health for All: A Framework for Health Promotion. It expanded on the Lalonde report, focusing
on the broader social, economic and environmental factors that affect
health. It set out three challenges:
This was followed in 1988 by Mental
Health for Canadians: Striking a Balance, in which mental health promotion was put in terms of these three
challenges. It suggested a number of
expanding the body of knowledge concerning the nature and causes of good
mental health and prevention of mental illness;
coordinating policies to ensure a mental health perspective is brought
to bear on relevant issues; and
committing resources to community development and community-based
programs and services.
In 1994, the federal, provincial, and
territorial Ministers of Health officially endorsed the population health
approach. In Strategies for Population Health: Investing in the Health of Canadians,
they set out three strategic directions for national action:
Strengthen public understanding of the broad determinants of health, and
public support for and involvement in actions to improve the health of the
overall population and reduce health status disparities experienced by some
groups of Canadians.
Build understanding about the determinants of health and support for the
population health approach among government partners in sectors outside health.
Develop comprehensive intersectoral population health initiatives for a
few key priorities that have the potential to significantly impact population
Integrated Pan-Canadian Healthy Living Strategy represents additional efforts in health
federal/provincial/territorial initiative aims to improve the overall health of
Canadians by addressing preventable risk factors. The federal/provincial/territorial
Ministers of Health agreed to work together on the Integrated Pan-Canadian
Healthy Living Strategy in 2002. The
initial emphasis of the Strategy is on physical
activity and healthy eating and their relationship to healthy weight, but it will eventually be expanded to address other
priority health issues such as mental health.
risk factors can have a positive impact on the mental health of the
population. But this requires a strongly
coordinated effort. The Committee
believes that the approach that has been developed under the Integrated Pan-Canadian Healthy Living Strategy should be expanded to include mental health as a priority health issue;
it recommends therefore:
That mental health be included as an immediate
priority health issue in the Integrated Pan-Canadian Healthy Living Strategy.
In its submission to the
Committee, the Canadian Psychological Association suggested that a Canadian
Mental Health Guide be created. Modelled
Food Guide, it would
… help reduce stigma and
discrimination by recognizing that mental health is part of everyday life, promoting
and supporting psychological resilience, enhancing early detection and so on.
Guide would give concrete advice on topics such as:
Mentally healthy activities for all ages.
Early warning signs of psychological stress and what to do about them.
Normal reactions to life events such as death, tragedy, failure, or
Ways to improve psychological resilience.
What is normal in terms of sadness, anxiety etc., and how to recognize
when normal reactions might become an illness.
The Committee sees merit
in this proposal and therefore recommends:
That the Public Health Agency of Canada, in
collaboration with other stakeholders, prepare a Mental Health Guide for
Canadians and ensure its broad distribution.
Within the federal
government, Health Canada
and the Public Health Agency of Canada are both centrally involved in health
promotion and illness prevention. Within
the Public Health Agency of Canada, the Mental Health Promotion Unit is the
focal point of efforts to improve positive mental health and well-being in the
Canadian population. The mandate of the
Unit is to:
… promote and support
mental health and reduce the burden of mental health problems and ilness, by
development, synthesis, dissemination and application of knowledge;
development, implementation and evaluation of policies, programs and activities
designed to promote mental health and address the needs of people with mental
health problems or illness.
federal institutions are also involved in activities related to health
promotion. The Institute
of Population and Public
Health within the Canadian Institutes of Health Research (CIHR) “supports research into the complex interactions (biological, social,
cultural, environmental) which determine the health of individuals,
communities, and global populations; and into the application of that knowledge
to improve the health of both populations and individuals.” The Institute of Neurosciences, Mental Health
and Addiction, which supports research on the functioning and disorders of the
brain, the spinal cord, the sensory and motor systems, and the mind,
constitutes another example.
A further example is the Canadian
Institute for Health Information (CIHI), which manages the Canadian Population
Health Initiative; its mission is to:
foster a better understanding of factors that affect the health of
individuals and communities, and;
contribute to developing policies that reduce inequities and improve the
health and well-being of Canadians.
As well, Statistics
Canada collects and disseminates statistics on the health of Canadians. It conducts population health surveys,
including the Canadian Community Health Survey - Mental
Health and Well-being, which was designed to provide national estimates of
major mental illness and problems.
Committee believes that the federal government needs to increase its capacity
to identify national priorities for interventions in mental health promotion
and mental illness prevention, and to translate these priorities into
action. Given the overlap between mental
health promotion and general health promotion, the Public Health Agency of
Canada should continue to be the focal point for mental health promotion.
To complement the
work of the Public Health Agency of Canada, the proposed Canadian Mental Health
Commission, as outlined in Chapter 16, will include a Knowledge Exchange Centre
that works with existing agencies to foster the collection of data relevant to
mental health and illness and the exchange of information. The Committee
That the federal government commit
sufficient resources to enable the Public Health Agency of Canada to take the
lead role in identifying national priorities for interventions in the areas
of mental health promotion and mental illness prevention and to work, in
collaboration with other stakeholders, toward translating these priorities
That all mental health
promotion and mental illness prevention initiatives contain provisions for
monitoring and evaluating their impact.
That the Knowledge Exchange Centre (see
Chapter 16) work closely with existing bodies such as the Canadian
Institute for Health Information, Statistics Canada and
the Canadian Institutes of Health Research to collect and disseminate data on
evaluations of mental health promotion and mental illness prevention
interventions, including campaigns to prevent suicide.
That, in this context, the
Canadian Mental Health Commission (see Chapter 16) explore the possibility
common measures to evaluate mental health promotion and mental illness
federal policy initiatives for their probable mental health impact;
identifying clusters of
problems and/or at-risk populations that are not currently being addressed.
The Committee has
identified suicide prevention as another priority. As noted in the Third Interim Report, every
year some 3,700 Canadians kill themselves.
Although suicidal behaviour is not itself a mental disorder, it is
highly correlated with mental illness and addiction — more than 90% of suicide
victims have a diagnosable mental illness or substance use disorder.
link between suicide and mental illness was borne out by a recent study of
deaths by suicide in New Brunswick. It found that in the large majority of the
102 suicide deaths examined, the “victims had a long-standing trajectory of
persistent difficulties in terms of personal development, consisting of an
accumulation of personal, family, psychological, psychiatric and social
problems.” The study also found that there tended to be
“serious addiction problems among the suicide victims.” It observed
… in general, members of
the public can clearly recognize signs of distress and suicidal
behaviours. But for many, the next
essential step of getting a friend or family member to the appropriate services
has not yet become a natural response.
study suggests, suicidal behaviour can be addressed by promotion and prevention
interventions. This echoes A Report on
Mental Illnesses in Canada, which
Promotion of mental health
of the entire Canadian population, reduction of risk factors and early
recognition of those at risk of suicidal behaviour play essential roles in decreasing
suicide and attempted suicide.
making people more aware of the signs of suicidal behaviour, the hope is that
those considering suicide will be encouraged to seek help and that it will be
available to them, beginning with interventions by family, friends and
indicates that when communities work together to increase awareness, the
suicide rate can indeed be reduced. One
campaign that is often mentioned was conducted by the U.S. Air Force; it
“focused on removingthe shame associated
with mental health problems and on increasingsocial support, coping
skills, and help seeking.” As a result, the number of suicides was
reduced by one-third.
many provinces, territories and communities have developed suicide prevention
does not have a national suicide prevention strategy. Many believe the federal
government should work with the provinces, territories, and relevant
stakeholders to develop one. To quote the Honourable Elvy Robichaud, Minister of
Health and Wellness, Province
of New Brunswick,
area that would benefit from federal involvement is the issue of suicide
prevention and awareness. We have
recently released a research study on suicide in New Brunswick. It is clear that this is
a complex issue, and is everyone’s responsibility, not just the health and
mental health care systems.
to provide public information, share knowledge and best practices, and exchange
successful programs and initiatives would be beneficial to all jurisdictions
and the people they serve.
federal government is currently working on an Aboriginal Youth Suicide
Prevention Strategy in partnership with the Assembly of
First Nations and the Inuit Tapiriit Kanatami, with input from other national
Aboriginal organizations, provinces and territories, and federal departments. Mr. Ian Potter, Assistant Deputy
Minister, First Nations and Inuit Health Branch, Health Canada, told
the Committee that the Strategy had been announced in September 2004; $65 million was allocated to it over five
years. It is
designed to support communities in their efforts to prevent youth from becoming
suicidal, in particular by reaching out to youths who are at risk of committing
suicide and by preventing suicide clusters that are frequently observed in the
aftermath of a completed suicide.
government is also involved in research on suicide. In 2003, Health Canada and the CIHR’s Institute of Neurosciences,
Mental Health and Addiction held a conference to define a research focus
related to suicide. The participants
identified six major themes: suicide in social and
cultural contexts, evidenced-based standards, mental health promotion,
multi-dimensional models explaining suicide, spectrum of suicidal behaviours,
and a national database for suicide-related research.
In October 2004, the
Canadian Association for Suicide Prevention, a group of professionals working
to reduce the suicide rate, published a Blueprint for a Canadian National Suicide Prevention Strategy. In his appearance before the Committee, Dr. Paul Links, Professor of
of Toronto, and President
of the Canadian Association for Suicide Prevention, called for federal
leadership in developing a national suicide prevention strategy:
levels of government, various community agencies and organizations, survivors
and clients need to be involved, but it is clear that we must have federal
leadership to set out policies, provide resources and set outcome targets,
including actual reduction in suicide rates.
The Blueprint for a Canadian National Suicide
Prevention Strategy includes many of the concepts that have been touched on
in this chapter. It sets out a number of
Promote awareness in every part of Canada that suicide is our problem
and is preventable;
Develop broad-based support for suicide prevention and intervention;
Develop and implement a strategy to reduce stigma, to be associated with
all suicide prevention, intervention and bereavement activities; and
Develop, implement and sustain community-based suicide prevention
programs, respecting diversity and culture at local, regional, and provincial/
believes there is merit in advancing the Canadian Association for Suicide Prevention’s
initiative aimed at development of a national prevention strategy. The Committee therefore recommends:
That the federal government support the
efforts of the Canadian Association for Suicide Prevention and other
organizations working to develop a national suicide prevention strategy.
That the Canadian Mental Health Commission
(see Chapter 16) work closely with all stakeholders to, among other things:
standards and protocols for collecting information on suicide deaths,
non-fatal attempts and ideation;
increase the study and
reporting of risk factors, warning signs and protective factors for
individuals, families, communities and society;
support the development of a national
suicide research agenda along the lines proposed by the Canadian Institutes
of Health Research.
At the beginning of
this chapter, we asked whether it is possible to prevent mental illnesses in
the Canadian population by intervening to address their causative factors. The available evidence shows that some
interventions aimed at mental health promotion and mental illness prevention
are effective in reducing the onset of mental illness and/or its severity and
duration. Such interventions should be
pursued further and, at the same time, additional evidence of their impact must
be collected and assessed. Armed with
such evidence, governments and other stakeholders will be more ready to make
sustained and long-term investments to help improve the mental well-being of
the Canadian population.
From the very beginning of
its study of mental health, mental illness and addiction, the Committee has
heard the call for a national mental health strategy.
Many witnesses have stressed the tremendous significance of and need for such a
strategy, noting that Canada
is alone among the G8 countries not to have
one. In fact, it has been five years since the Canadian Alliance on Mental
Illness and Mental Health issued A Call
for Action: Building Consensus for a National
Action Plan on Mental Illness and Mental Health.
While it is
important to point out that there is no evidence to suggest that Canada treats
people living with mental illness significantly differently than other highly industrialized nations, nevertheless the absence of a national approach to mental health issues represents an
important national deficiency. Not having a national strategy symbolizes
neglect of mental health issues by government; it also forecloses on a
number of very concrete initiatives that would benefit people living with mental illness throughout the country.
Although many witnesses
expressed support for the concept of a national strategy or plan, their views
varied on its exact purpose and what it should contain. There were many
suggestions relating to the role of the federal government in creating such a
Phil Upshall, National Executive Director
of the Canadian Alliance on Mental Illness and Mental Health, testified that:
The Canadian Alliance on Mental
Illness and Mental Health advocates for an overarching national action plan. …
Our preferred option is a national action plan that is developed by a
distinguished blue-ribbon panel including consumers, patients and families,
which will advise the policy work of the federal, provincial, and territorial
governments. We think that this is an
essential element of a national strategy.
For its part, the British Columbia
Schizophrenia Society suggested that:
A national mental
health plan should be developed to (i) focus on standardized care for the
seriously mentally ill; and (ii) monitor outcomes across the country. A
Canadian national mental health plan should also establish national standards
for education, early intervention and family support
that will lead to improvements in treatment and care for Canadians with
serious mental illness.
the federal government should take the lead in developing a national plan that would, in the words of Tina Pranger, Mental Health
Consultant to Health and Social Services in Prince Edward Island, “provide direction to
the provinces and territories in developing, refining and supporting their own
mental health plans” and “include national
standards for service delivery.”
Others, such as Jocelyne Green, Executive Director, Stella Burry
Community Services in St. John’s, insisted on the
need for the federal government to provide “targeted and significant levels of
funding for mental health services” that the provinces could access only “if
they deliver programs in line with national standards, with no ‘ifs’,
‘ands’ or ‘buts.’”
beginning, the Committee has recognized that mental health, mental illness and
addiction issues resonate with every level of government; they affect, to all
intents and purposes, the entire population of Canada.
Strategies are required at every level — locally,
regionally, provincially, federally, and nationally.
believes it important to make the significant distinction between “national” and “federal,” and to
be clear on what a feasible national
mental health strategy
could look like in Canada.
Many tend to look on the federal government as the repository of all national
efforts and, therefore, call on it to initiate the development of national
strategies, independent of the particular sphere of activity.
health reform, however, this approach cannot work. While there is a leadership role for the
federal government in the development of a national
approach to mental health, this level of government
is not responsible for its development and enforcement. The Committee believes
that, in Canada,
any attempt to establish a national approach in health care related areas,
including mental health, must
take into account, among other factors,
the reality of which organizations
actually deliver health-related services and supports and the fiscal capacities
of each level of government.
repeating that the provinces and territories are
responsible for delivering health services, including mental health services,
to the general population. The federal
government carries this responsibility only for recognized or registered First
Nations and Inuit, Canadian Forces personnel, federal offenders, and a few others that fall under the
The federal government’s influence on the
way health care is delivered is largely
exercised through its fiscal capacity, i.e., its spending power. The provinces
and territories receive federal
grants in exchange for agreeing to respect certain conditions on how they use
these transfers. This is how federal legislation such as the Canada Health
Act works. This basic fact sets
limits to the role that the federal government can play in developing a
national strategy or a national action plan relating to responsibilities that
fall primarily within the jurisdictions of the provinces and territories.
Does this report contain the elements of a “national strategy”? The answer depends on what one expects a national strategy to contain. Some of the ground-breaking
recommendations put forward here by the Committee are, indeed, national
in scope. But this report also contains recommendations directed at all levels of government (federal,
provincial/territorial, regional and local) as well as at the providers of
mental health services and supports. To some extent, at least, the
report can serve as the basis upon which a national mental health strategy
could be developed.
As in its
previous reports on the acute care system, the Committee has made recommendations in this report on issues that fall outside the
jurisdiction of the federal government. No effective, systematic approach to
the delivery of mental health and addiction services could have been made
The Committee recognizes
that neither the provider groups nor the provincial or territorial governments to which many of the recommendations in this
report are addressed are under any obligation to respond to our
recommendations. Nevertheless, in our experience with previous health
reports, we have found that if recommendations are based on careful
consideration of the evidence, they are
often received favourably by those to whom they are addressed, jurisdictional boundaries
notwithstanding. The Committee is
hopeful, therefore, that its recommendations on mental health, mental illness
and addiction will be considered on the basis of their merit by all those to
whom they are directed.
overarching question the Committee believes of particular importance, given the
extent to which the mental health sector has been neglected over the decades,
is how to maximize the chances of this report’s recommendations being acted
upon. It has become clear that a mechanism of some sort
is needed both to undertake certain critical
tasks at a national level and also to maintain a needed national focus on
mental health issues.
The Committee’s key
recommendation to achieve this objective, a proposal to create a Canadian
Mental Health Commission, was made public by the then Minister of Health, the
Honourable Ujjal Dosanjh, on 24 November 2005, tabled in the Senate of Canada and released on the Committee’s website. Minister Dosanjh announced that
the Government of Canada, along with all provincial
and territorial Ministers of Health, with the exception of Quebec, had already agreed to the
creation of the Commission; their agreement was based on the proposal that the
Committee submitted to a meeting of the federal/provincial/territorial
Ministers of Health on 23 October 2005. Steven Fletcher, health critic for the
Conservative Party in the 38th Parliament, also expressed his
support for the establishment of a national Mental Health Commission.
Before presenting an expanded version of
this proposal, the Committee would like to comment on the significance of its
having already been endorsed and on the role the new Commission will play in
the development of a “national” approach to mental health in Canada.
The announcement that a Canadian Mental
Health Commission would be created was the culmination of several months of
consultations between the Committee and many mental health stakeholders across
the country. It was greeted with universal enthusiasm by those concerned with
mental health issues in Canada.
For example, Dr. John Service, Executive Director of the Canadian Psychological
It is our belief that the
announcement of the Commission was an historic event in Canada. It has
the potential to significantly change the way we deal with mental health issues
in this country. For the first time, we will have a pan-Canadian forum to
examine and draw attention to successes and gaps and to work with governments
and stakeholders to improve the lives of Canadians.
It is remarkable that the
federal, provincial and territorial governments came together in such a short
period of time to agree on a Commission. It is a testament to the fact that
governments recognize the extent of the need and the necessity to address the
need as quickly as possible. The governments are to be congratulated for their
willingness to collaborate and to come to an agreement.
The Canadian Collaborative Mental Health Initiative
(CCMHI) also applauded the announcement and
pointed to the potential advantages of the Commission’s structure:
A real strength of the
Commission will be the partnerships it will develop with governments,
employers, mental health stakeholder organizations and, in particular,
Canadians living with mental illness and their families and caregivers.
Advisory committees to the Commission will also play a big role in ensuring the
breadth of mental health issues in Canada are well understood and
For its part, the Canadian
Mental Health Association (CMHA) saw the establishment of a Commission on
Mental Health and Mental Illness “as a momentous step towards the development
and implementation of a strategy to address the mental health needs of all the
people of Canada.”
Dr. Paul Garfinkel, President and CEO of
the Centre for Addiction and Mental Health, stressed the importance of the
proposal’s emphasis on reducing stigma and ending discrimination:
Every day we hear from
patients and their families who delayed seeking treatment because they feared
the social stigma that a diagnosis of mental illness or addiction would bring.
In fact, research shows that two-thirds of affected people never seek
treatment. The power of stigma cannot be underestimated, and this commitment by
the Federal Government to create a national commission to help educate
Canadians about the reality of mental illness — with the ultimate goal of
eliminating all forms of discrimination against people and families living with
mental illness — will be welcomed from coast to coast.
It is no exaggeration to say that the
creation of the Canadian Mental Health Commission heralds a new era in mental
health in Canada.
For the first time, there will be a body that can help to channel institutional
and financial resources at a national level into a sector that has been systematically neglected. The
Committee wholeheartedly commends all the Ministers of Health who have
signed on to this proposal, as well as the Government of Canada for agreeing to
fund the Mental Health Commission.
While the financial resources that are
required for the Commission will come from the federal government, its
institutional structure also encompasses the other levels of government in
addition to non-governmental stakeholders. The Commission will operate at arm’s
length from government; a majority of its board of directors will come from
outside government, as will its Chair (the Mental Health Commissioner of Canada). Thus,
no single group, including government, will be able to dominate the
Commission’s Board of Directors. In this sense, it is very much a “national,”
as opposed to a “federal,” undertaking.
The creation of the Mental
Health Commission is, in the Committee’s view, one of the two key components of
what could be called a “national strategy” contained in this report. The second involves the creation of a Mental Health
Transition Fund. If agreed to by the federal government, this Fund will permit
the transfer of federal funds to the provinces and territories for their
use in accelerating the transition to a mental
health system predominantly based in the
communities in which people with mental illness and addiction live. The
rationale for this fund is set out in detail in Chapter 5; later in this
chapter (see section 16.5) we discuss how large this fund should be and how the
money should be raised.
The Committee recognizes
that many other recommendations in this report also have a national dimension, despite being directed only
at one or another level of government. For example, the investment of an
additional $25 million annually in mental health services research, as
recommended in Chapter 11, will have a national impact, although the recommendation
is directed solely to the federal government.
recommendations involving the Mental Health Commission and the Mental Health
Transition Fund, however, entail the creation of a new institution that brings
together not only the different levels of government with responsibility for providing mental
health services and supports, but also the people who actually deliver those services as well as the
people who benefit from them.
potential impact of creating of a Mental Health Commission is substantial.
Should the Transition Fund also be created, these two entities will represent a truly momentous injection of
institutional and financial resources
into a sector that has been neglected for decades. The lives of many thousands
of Canadians can be improved.
Nevertheless, the Committee hesitates to
call this report a national strategy or plan. In other countries, such plans typically specify details about how various
services should be provided and who will be responsible, and to whom, for the
Important specifics of this kind are not contained in this report; nor would it
have been appropriate for the Committee to have included them.
the national measures that the Committee has recommended in this report lay a
firm foundation for an exploration of how a mental health plan could be developed, negotiated, and
endorsed by all stakeholders. The Committee’s recommendations, implemented in full, would also move the reform
agenda forward in immediate and concrete ways, including by providing funding
for transformative change by the provinces and territories. In addition, the activities that the Mental Health
Commission will undertake on its own
(anti-stigma work and establishing a knowledge exchange centre) will
significantly alter the landscape for people living with mental illness.
Thus, there is a plan of action in this
report with a “national” dimension to the recommendations
it contains. The plan is a feasible one tailored to the realities of health
care delivery in Canada.
The Committee fervently hopes that all stakeholders will agree that its implementation promises a huge
advance for people living with mental illness and addiction.
In this section, the Committee’s proposal
to create a Mental Health Commission is reproduced as tabled in the Senate of
Canada on 24 November 2005.
Section 16.4 contains additional comments on the proposal that the Committee
feels it is important to make, including a more detailed discussion of the
tasks the Commission will undertake “in-house” (a ten-year anti-stigma campaign
and the establishment of a Knowledge Exchange Centre).
Several factors led the
Committee to recommend the creation of a Canadian Mental Health Commission:
a) Although the Committee’s
work and, importantly, recent actions by several provincial governments have
begun to focus a long-overdue spotlight on mental health, it remains that the
whole complex, pervasive problem of mental illness and addiction in Canadian
society continues to be neglected. The Canadian Mental Health Commission will
provide a much needed national (not
federal) focal point that will keep mental health issues in the mainstream
of public policy debates in Canada and accelerate the development and
implementation of effective solutions to the long-standing problems of this
Those most directly affected are people living with mental illness,
their families, friends and employers. But, given that, each year, one in five
Canadians will experience a mental illness, virtually all Canadians will be
affected, directly or indirectly, by mental illness and/or addiction. Mental
illness is truly of national concern.
No single level of government has the resources needed to deal with
the full range of mental health issues on its own. Creating a national focus
will add substantial value, especially with respect to exchanging information
and facilitating collaboration among governments and between governments and
In both public and private sector businesses and workplaces, mental
health problems and substance abuse disorders are responsible for a large
proportion of all disability, absenteeism and diminished workplace
productivity. The proportion of workplace disability associated with mental
illness and substance abuse is rising more rapidly than those associated with
other illnesses and has been estimated to cost Canadian companies about $18
billion a year in recent years.
The economic as well as the social implications are both obvious and of
In every government, whether federal, provincial, territorial or
municipal, responsibility for mental health issues is dispersed among several
departments and agencies — health, social services, housing, etc. Managing issues that span
ministerial/departmental boundaries is notoriously hard; truly effective ways
of doing so are few and far between. The
Canadian Mental Health Commission will benefit all governments by facilitating
the exchange of information on best practices on how to deal with this classic
There is, as well, no easy mechanism now available for stakeholders
in the mental health sector to exchange knowledge and distribute information
about best practices coast to coast to coast. A national Knowledge Exchange
Centre will be an integral part of the Canadian Mental Health Commission.
Canadians must become better educated about the reality of mental
illness. They must be encouraged to understand and be more tolerant of people
living with mental illness and addiction. To those ends, a national campaign is
needed to combat the stigma and discrimination associated with mental illness.
Such a campaign will be most effectively managed nationally by the Canadian Mental
The Committee considered alternatives to
the creation of a national commission. It concluded, however, that no existing
organization has a mandate that encompasses, or could be modified to encompass,
a majority of the factors set out above. For example, the mandate of the
Canadian Centre for Substance Abuse is too narrow to encompass the range of
mental health issues of concern to this Committee. Moreover, it has no role in
changing public attitudes.
While mental health falls
naturally under the purview of the Health Council of Canada, its chair, Michael
Decter, has told the Committee that it will be some years before the Council’s
extremely full agenda will be cleared sufficiently to address mental health
adequately. The Health Council’s mandate also includes monitoring the
performance of all government health care systems. The Canadian Mental Health
Commission proposed by the Committee explicitly will not have any role in monitoring any government’s performance in
dealing with mental health and addiction.
It is clear to the Committee that a new
national organization is required. It must be emphasized, however, that the
success of the proposed Commission in contributing to improvement of the mental
health of Canadians depends critically upon there being in place strong
structures and committed people at the provincial and territorial level to
translate policy, knowledge and ideas into action on the ground. This is true
also with respect to the mental health services provided by the federal
government through its various entities such as the First Nations and Inuit
Health Branch of Health Canada
and Correctional Service Canada.
The Committee’s intention is that the work
of the Canadian Mental Health Commission will complement, and not replace, that
being done by existing structures and people at the federal, provincial and
Finally, consistent with its view that
structural solutions to any problem should not be permanent, the Committee
recommends that the Commission “sunset” in ten years.
independent, not-for-profit organization at arm’s length both from governments
and from all existing mental health “stakeholder organizations”;
Make those living
with mental illness, and their families, the central focus of its activities;
Build on and
complement initiatives already under way throughout Canada, and avoid duplicating the
roles and activities of those currently working in mental health;
partnerships with governments, employers, mental health research organizations
and service providers, other health care organizations, and the spectrum of
existing national and international mental health stakeholders;
Put its emphasis
on evidence-based mental health policies and methods of service delivery;
evaluate, assess and report on its own activities, in order to ensure their
appropriateness and efficacy and to maintain the Commission’s credibility with
governments, its collaborating stakeholders and the Canadian public.
To act as a
facilitator, enabler and supporter of a national approach to mental health
To be a catalyst
for reform of mental health policies and improvements in service delivery;
To provide a
national focal point for objective, evidence-based information on all aspects
of mental health and mental illness;
To be a source of
information to governments, stakeholders and the public on mental health and
To educate all
Canadians about mental health and increase mental health literacy in Canada,
particularly among those who are in leadership roles such as employers, members
of the health professions, teachers, etc.;
To diminish the
stigma and discrimination faced by Canadians living with a mental illness, and
To discharge its mission,
the Commission will form collaborative relationships that amount to
partnerships with governments, employers, mental health stakeholder
organizations, professional associations, research organizations and, in
particular, those Canadians living with mental illness and their families. Such
relationships will be developed with existing organizations and committees such
as the Canadian Institute for Health Information, the Canadian Institutes of
Health Research, the Canadian Alliance for Mental Health and Mental Illness and
its constituent organizations, the Global Economic Roundtable on Mental Health
and Addiction, the Canadian Centre for Substance Abuse, the Public Health
Agency of Canada,
federal/provincial/territorial Committees on Mental Health and Substance
Use, and other relevant organizations and committees concerned with mental
health and addiction.
The coordinating functions
and collaborative role of the Commission will help to reduce duplication of
effort and to facilitate cooperation among all stakeholders, particularly
governments and service providers.
In order to discharge its collaborative
mandate, the Commission will establish, in addition to partnerships, a number
of advisory committees. While it will be
up to the Commission to decide on their number and composition, two advisory
committees are obligatory — one composed of representatives of all
federal/provincial/territorial governments and another of representatives from
Canada’s Aboriginal communities.
The Commission will assist governments,
employers, and service providers in a non-confrontational way, recognizing that
the circumstances in which mental health policies and services are provided in
every community are distinct. Yet every community can benefit from lessons
learned elsewhere, especially given the linkage between the most effective
mental health services and primary and community-based care — areas in which
best-practice information would be particularly helpful both to communities
seeking to improve the effectiveness of their own services and to provincial
and territorial governments.
The Commission’s activities can be divided
into six broad categories:
Development of a National
Mental Health Strategy
relating to mental health, mental illness and addiction and a framework for a
national strategic plan to achieve them, recognizing that such a plan must:
take into account existing federal, provincial and territorial mental
reflect the fact that governmental responsibility for mental
health is very much inter-ministerial in
nature (i.e., not confined to ministries of health);
information to governments, stakeholders and the public on mental health issues
(section 16.2.9 expands on the benefits of the Commission’s being a source of
information to governments on such issues);
annually to the Federal/Provincial/Territorial Conference of Deputy Ministers
of Health and the Deputy Ministers responsible for Social Services (and of
other ministries/departments as required);
Ensuring that the
specific issues on which the Commission will focus at any given time are in
accordance with the interests of its Board and its committees as they evolve
Knowledge for Application to the Canadian Context
reliable and valid measures, indicators and tools to facilitate monitoring by
governments and health authorities of the performance of their mental health
systems over time;
benchmark capacity requirements for different types of service along the entire
spectrum of mental health services.
Canadian Institute for Health Information and Statistics Canada, collecting on
a regular basis data on the mental health status of Canadians and providing, on
the Commission’s website, a comprehensive database for use by researchers and
Canadian Institutes of Health Research (CIHR) to support research into the best
structures and/or mechanisms to supply, most efficiently, the wide range of
services required by people living with mental illness and addiction;
to support research on how to measure the outcomes of mental health services so
that governments can assess the success and effectiveness of their mental
Integrative and Networking Activities
consensus-building activities relating to adoption of the best evidence-based
clinical and service-delivery practices and system-level approaches;
sharing of knowledge across jurisdictions and stakeholder groups regarding
effective approaches, developments and innovations;
integration of primary care services with other forms of service delivery, such
as secondary and tertiary treatment services, health promotion and disease
collaboration between addiction and mental health stakeholders with a view to
improving services and supports for the many individuals coping with addictions
who are also living with mental illness;
information on how services for people with concurrent disorders can be most
effectively and efficiently integrated;
employers and organizations, such as the Business Roundtable on Mental Health,
Mental Illness and Addiction, to develop programs to reduce the burden of
mental illness and addiction on those affected and on the economy.
Public Education and
national anti-stigma program to educate Canadians about the reality of mental
illness, with the ultimate goal of eliminating stigma and all forms of
discrimination against people and families living with mental illness;
communications campaigns on specific aspects of mental illness (e.g., the signs
of serious depression) aimed at specific target audiences (e.g., school-aged
Canadians on ways and means of optimizing their own and their loved ones’
population mental health and the prevention of mental illness and addiction;
activities such as conferences, seminars, and an annual awards program to
celebrate people who provide exceptional leadership in mental health.
Internet-based national Knowledge Exchange Centre for the distribution of
information about mental health;
reports and other documentation on mental health;
national and international developments in mental health policies and services
and, where relevant, incorporating this information into the website of the
Knowledge Exchange Centre;
Making the Knowledge
Exchange Centre accessible to people living with mental illness, their families
and caregivers, employers, researchers, governments and other stakeholders;
Knowledge Exchange Centre website with relevant sites operated by provincial
governments and stakeholder groups.
The Commission will both contract out
projects and undertake work itself on behalf of various Canadian and
international institutions, including both governments and non-governmental
organizations in the private sector.
It is important to emphasize that the
Commission is to be advisory and facilitative, not operational in nature, apart from its commitment to undertake
some project and research work that is consistent with its mission.
Specifically, the Commission will not:
services itself, except for its management of the Knowledge Exchange Centre and
the national anti-stigma campaign, or in association with its doing work under
contract for other institutions;
performance of any government with respect to mental health services. The
Commission will recognize explicitly that each government’s approach to
providing mental health services will reflect the particular characteristics of
The Commission will be
established under federal legislation or other appropriate authority (e.g.,
through incorporation as a not-for-profit corporation).
In structuring the Commission’s Board, two
principles must be kept in mind:
First, as set out
in the guiding principles outlined above, the Commission will operate “at
arms-length both from governments and all existing mental health stakeholder
organizations.” Therefore no single stakeholder group, including government,
may have a majority of seats on the Board;
facilitate its effectiveness, the Board should not be too large. Adequate input
from all stakeholder groups can be ensured through the judicious use of
advisory committees (including the federal/provincial/territorial governmental
advisory committee and the Aboriginal advisory committee specified above).
These two constraints, together with the
precedents established by the composition of the Boards of the Canadian
Institute for Health Information and the Canadian Patient Safety Institute,
lead the Committee to recommend that the Board of the Canadian Mental Health
Commission have nineteen members, approximately one-third from governments and
approximately two-thirds without any government affiliation or connection.
Therefore, the Board of the Commission
will consist of:
a) Five provincial
governmental nominees chosen as follows: one from the Atlantic
provinces, one from Quebec, one
and two from the Western provinces.
One member nominated jointly by the three territorial governments.
One member nominated by the federal government.
Eleven nominees at large, chosen by the seven government nominees to
represent a wide range of stakeholders involved in mental health issues,
including those living with mental illness, their families, caregivers, service
providers, the professions, employers, etc. No nominee can represent a specific
organization; each must be widely recognized as reflective of the mental health
community at large.
A non-governmental chair (the Canadian Mental Health Commissioner)
chosen by the seven government nominees.
Board members will serve three-year terms
and be eligible for renewal once. All, including the Commissioner, will be
Every government faces a myriad of issues
as it attempts to improve services to people living with mental illness. While some of these issues are specific to a
jurisdiction, many others are broadly applicable across jurisdictions. It is with respect to the latter that the
Commission can play a valuable role for all governments by providing
information on what has proven to be most effective in other provinces and
other countries (i.e., best practices), sparing each government from having to
gather and assess the information on its own.
Four such issues illustrate the point:
effectively for the transformation of the mental health service delivery system
across the continuum of provincial, regional and community-based services, it
is critical that governments have available, evidence-based information with
respect to the most effective practices elsewhere in Canada and in other industrialized
countries. In the absence of such information,
governments have little defence against pressures to adopt particular policies
and practices based only on anecdotal evidence or representing
information on and evaluated practices used elsewhere, the Commission will
provide leadership in building a natural consensus around best practices.
Primary Care and
Community-Based Service Delivery
new ways of integrating mental health services into multidisciplinary primary
care clinics and of delivering community based services are taking place across
the country. Evaluation of the effectiveness of these experiments and
developing a comparison of evidence-based best practices will be very useful to
governments and service providers alike.
Chronic Mental Illness
with a chronic mental illness need a range of services, many of which (social
housing, for example, and various types of income support and training
programs) are not provided by health departments. Given that they are usually
the responsibility of different government departments, often there is no
mechanism, or at least no easy mechanism, to coordinate the range of services
needed by a single consumer. Because no single department “owns” or has sole
responsibility for a person living with a mental illness, even an aggressive
case manager — clearly part of the solution to the problem — will have
difficulty crossing departmental lines.
That some of these services, social housing for example, have fallen out
of political favour in recent years makes solving the problem even more
will help governments in two ways:
evaluating mechanisms that have been used elsewhere to coordinate effectively
multi-department services for a single consumer, and proposing options for
governments to consider.
identifying gaps in the services required and encouraging governments to fill
d) Mental Health Human Resources
It is widely
acknowledged that a severe shortage of mental health human resources exists
across the whole spectrum of mental health service providers. It is also acknowledged that existing
training programs (and programs designed to update the skills of people
currently working in the field) need modification.
Few people are
trained in how to help those who suffer from concurrent disorders. Often someone with both a mental illness and
an addiction is treated sequentially; the treatment is frequently ineffective
because the problems are linked. The
solution to this problem requires significant change in the training of mental
practitioners and nurses need more training in how to help people living with a
mental illness and how to identify the presence of concurrent disorders. This requires changes in academic curricula,
always a very slow and difficult thing to achieve. Family members also need
training of the same kind but in community settings.
Scope of practice
rules must be modified if multi-disciplinary primary care clinics are to become
the predominant point of entry into a transformed mental health system. There is bound to be resistance to such
Assessment of the
skill set required to provide various mental health services will enable
accurate forecasts to be made of the numbers of mental health workers of
different categories required in Canada in the future.
By providing an informed, authoritative
source of national pressure, equally independent of government, advocacy
groups, service providers, and those responsible for providing training and
education programs for mental health workers, the Commission will reinforce
governments as they seek changes of the kind listed above.
As noted earlier, on 24 November 2005,
Minister Dosanjh announced that the Government of Canada, along with all
provincial and territorial Ministers of Health, with the exception of Quebec, had agreed to
the creation of the Canadian Mental Health Commission and the Government of
Canada agreed to fund the Commission. The Committee believes that it is
essential to move forward quickly, and recommends:
That a Canadian Mental Health Commission be
established and that it become operational by 1 September 2006.
That the guiding principles, mandate, method of
operation and activities of the Canadian Mental Health Commission be as
specified in sections 16.2.2 to 16.2.5 of this report.
That the composition of the Board of the
Commission and its staff be established as set out in sections 16.2.6 and
16.2.7 of this report.
That the Government of Canada provide $17
million per annum to fund the operation and activities of the Commission; of
this amount, $5 million per annum should be dedicated to a national
anti-stigma campaign, $6 million per annum devoted to the creation of the
Knowledge Exchange Centre and $6 million per annum used to cover the
operating costs of the Commission.
It is important to make a
few additional remarks on the how the Committee envisages choosing the members
of the Board of Directors of the Canadian Mental Health Commission and on the
nature of their role.
The composition of the Board
of the Commission was crafted so that it will be able to propose and advocate
for innovative policy and educational initiatives that will significantly
improve the lives of people living with mental illness across the country. In
determining the number of governmental representatives on the Board, both the
Committee and the provincial governments with which it has consulted believe it
important to include a representative from the three territorial governments,
in great measure because of their significant Aboriginal populations. The
Committee believes this is one way to ensure that the concerns of Canada’s
Aboriginal peoples are at the forefront of the Commission’s activities.
It will be crucial to establish a balance
in selecting the 12 non-governmental directors. The Committee believes very
strongly that these directors should neither be, nor be seen as,
“representatives” of any particular stakeholder group or organization.
It will, of course, be essential that the
full range of views and expertise from all stakeholder groups be heard, not
only via the various advisory committees to be created by the Commission but
also at the Board of the Commission itself. However, it is critical that Board
members not see themselves, or be seen, as representing any of the narrowly
focused interest groups that now constitute integral parts of the current
mental health system. There can be no room on the Board for the kind of “silo”
approach that is still all too common in the organization and delivery of
mental health services and supports. The Board members must be capable of
looking at the broad system as a whole and making this the centre of the
The key to the success of the Commission
will be its ability to take into account a wide cross-section of views and to
distill these into a coherent overall program that will improve the lives of
people living with mental illness and addiction from coast to coast to coast.
The non-governmental members of the Board must be carefully selected to ensure
that they bring a diversity of experience to the table but are nonetheless able
to look at what needs to be done primarily from the broad perspective of the
country as a whole.
There is no doubt that the Board will need
in its membership people with knowledge of a variety of mental health constituencies.
They must include, first and foremost, people living with mental illness
themselves as well as their families. In addition, there must be individuals
who understand and have experience of issues confronting people of Aboriginal
origin, and the special needs of children and youth, as well as service
providers inside and outside the medical professions, and experts in as many
areas of mental health as possible.
Additional input from all of these
constituencies will also be channelled into the Commission through advisory
committees that will be created. In this way, the Committee believes it will be
possible for the Commission to have access to the full range of views that will
be needed to make sure that its initiatives respond to the needs of Canadians
living with mental illness without developing a structure for the Commission
that would be so unwieldy as to prevent it from completing its mandate.
In its first report on
mental health, the Committee devoted an entire chapter to the issue of stigma
Witnesses have consistently told the Committee that a systematic effort to
reduce stigma and combat discrimination is essential to improving the situation
for people living with mental illness.
During its cross-country hearings, this
point was reiterated by Jean-Pierre Galipeault of The Empowerment Connection:
[A]ll of the
efforts in terms of mental health policy development, system reform, consumer
and family member involvement will be unattainable without making some efforts
to address the issues of stigma and discrimination.
The Committee has included development of
a sustained anti-stigma campaign as a key element of the mandate of the
Canadian Mental Health Commission. While it will be up to the Commission to
work out the details of how this campaign should be undertaken, the Committee
believes it is important to summarize the results of its own findings on this
In its first report, the Committee quoted
Professor Heather Stuart from Queen’s University, who emphasized the importance
of carefully targeting anti-stigma interventions. She told the Committee:
With respect to
anti-stigma interventions, how do we stop stigma and discrimination? We are
learning from the World Psychiatric Association work that one size does not fit
all. It is a waste of time and energy to embark on a large, public education
campaign that is designed to improve literacy as an anti-stigma intervention
because segments of the population have different views.
Professor Stuart also noted the
connections amongst a number of dimensions to anti-stigma work. She told the
Committee that the need to carefully target anti-stigma interventions also
pointed to the importance of reaching people at an emotional as well as an
intellectual level; it was also important to involve people living with mental
illness themselves in these campaigns:
When we talked
about targeting things, we were trying to target experiences. We figured out we
had to get them at an emotional level. We had to make them aware that their
whole system of beliefs was somehow ill-founded. One of the best ways to do
that was to construct situations in which people who have a mental illness
could meet people who have perhaps never met someone with a mental illness, under
controlled and constructive kinds of situations. They would talk about their
mental illness. They would convey factual information, but more important, they
would convey information at a human level. That is what made the difference.
This point was reinforced by Tara
Marttinen, who told the Committee of her experience of speaking about her own
I have spoken to a
diverse range of individuals and groups regarding my illness. Because I am
healthy, fairly articulate and approachable, people are generally more
receptive to learning about the disease, and I try to shatter those barriers of
stigma that people often have. Hence, I strongly recommend implementing a
mental health ambassadors program that is not volunteer-based. I believe this
should be a paid position and this program would eliminate some of the stigma I
think that a lot of people with mental illness have to endure.
Jean-Pierre Galipeault told the Committee
that this kind of effort has to be undertaken at the local level, and sustained
One approach is
the old grinding approach, what I am starting to call the “one-block-at-a-time”
approach. A couple of years ago a
manager of a mental health program in downtown Dartmouth asked me how can we
make sure that consumers are viewed as full citizens. I think part of the
answer is those of us who are involved in this [have]
a responsibility to assist in this regard.
I told her to take a one-block or a two-block radius of you’re the program location and hold a town
hall meeting and have consumers present and talk to the citizens in that area.
I told her to start knocking on doors, dropping off flyers, inviting people out
and letting them know how consumers contribute to the economic well-being of
that two-block community and how they contribute to the cultural mosaic of that
community. You work those two blocks for
a period of months or a year and then you spread out to two more blocks. I think it is a long, slow approach, but I
think it is part of the solution.
Several witnesses also highlighted the
importance of making resources available across the country to support this
kind of campaign. The Honourable Elvy Robichaud, Minister of Health and
Wellness in New Brunswick,
told the Committee:
is more difficult to address, and is not open to legislative protection as is
discrimination under the human rights legislation. In this area, the federal
government could play a major leadership role. Anti-stigma and social marketing
campaigns are costly and often beyond the fiscal resources available in our
province, or if we did it on our own. It might be a whole lot better if all
jurisdictions would get into the act and have something that is at least
essentially the same. Usually we can adapt to most any Canadian jurisdiction.
Further, this is an area in which the federal government has demonstrated
competence and leadership — for instance, on the tobacco
campaign — and one in which federal
initiatives would be beneficial to all provinces and territories.
Reid Burke, Executive Director, Canadian
Mental Health Association of Prince Edward Island, emphasized both the need to
sustain anti-stigma campaigns over time and the need to focus on the potential
and changing attitudes is the way to go.
It is not going to happen with one campaign. ParticipAction took 10 or 15 years and now
everybody well understands how important that is. If we want to call it “mental fitness” or
“mental wellness,” there needs to be a concerted effort in this country to put
money into social marketing that normalizes mental health. I do not think that will take away from the
devastating effects of the illness, but we need to promote hope, as well as
recovery and resilience.
The Committee was very impressed by
initiatives undertaken by the Australian government to educate people about the
realities of mental illness and to combat stigma. In particular, the Committee
believes that there is much to learn from the separate, not-for-profit, private
company that was funded by the Australian government called “beyondblue.”
The company was established in October 2000 with the objective of promoting a
better understanding of depression. It works in partnership with health
services, schools, workplaces, universities, media and community organizations,
as well as with people living with depression, and thus brings together both
expertise in depression and personal experience of the problem.
In its plan for the years 2005-2010, beyondblue notes that:
As an independent national
body, beyondblue can reach beyond
government politics and policies into states, territories and local communities
and across regional and rural Australia.
beyondblue will establish new and
expand existing programs to meet emerging national priorities for prevention,
treatment and awareness of depression, anxiety and related substance use
national strengths are greater than an individual state-based focus on
depression. It is cost-effective for all state and territory governments to
conduct their promotion, prevention and early intervention strategies for
depression and related disorders in partnership with beyondblue. The return on investment through delivery of national
programs and website provides outcomes that are greater in value than the
individual contributions made by state and territory governments.
territories already benefit from the greater understanding of depression
generated by beyondblue’s national
awareness programs, positive media and community profile, and the beyondblue website with its series of
clinical fact sheets; interactive on-line depression self-assessment; media
centre and supporting links.
Mr. Dermot Casey, Assistant Secretary,
Health and Priorities and Suicide Prevention, for the Department of Health and
Ageing, Government of Australia, told the Committee that the various
initiatives undertaken in Australia
had helped improve “mental health literacy in the Australian population by
about 10 percentage points since 1996.” He also told the Committee that:
contact data and our health service contact data show that there is a greater
proportion of the population seeking care than was the case when we did our
epidemiology study. We would conclude from that that they are now at least more
prepared to seek treatment…
A recent study of the impact of beyondblue confirmed Mr. Casey’s
assessment, and noted that:
The data are consistent
with beyondblue having had a positive effect on some beliefs about depression
treatment, most notably counselling and medication, and about the value of
help-seeking in general. These findings suggest that national awareness
campaigns may be effective in improving community mental health knowledge. The
data also demonstrate the potential value of population monitoring of mental
There are thus six points that stand out
in with regard to building an anti-stigma campaign in Canada. The
evidence strongly suggests that, to be successful, an anti-stigma campaign
Be carefully targeted to specific audiences;
Be sustained over a substantial period of time;
Both educate people about the reality of mental illness and engage
them at an emotional level;
Involve people living with mental illness as spokespeople;
Focus on the potential for recovery and highlight the positive
contributions made to local communities by people living with mental illness;
national resources that can be adapted to regional and local circumstances.
The Committee believes that these lessons
should guide the Mental Health Commission in the design and implementation of
the anti-stigma campaign with which it has been charged.
As outlined above, the second major task
that the Canadian Mental Health Commission will undertake is the creation of a
Knowledge Exchange Centre. Many witnesses pointed to the need for such a
Moreover, in October 2005, the Committee
received a detailed proposal from three distinguished academics that contains
recommendations that align very closely with the Committee’s intentions. The
following observations draw on this submission by Goering, Goldner and Lesage
and expand on the description contained in the Committee’s proposal to create
the Commission reproduced above (see section 16.2.1).
The authors call for the
creation of a “Canadian Mental Health Services Knowledge Translation Network”
that is very similar to the Knowledge Exchange Centre and related functions of
the Commission in the Committee’s proposal. The network would be
a dedicated national,
expert resource to facilitate mental health services knowledge translation,
including the use of research syntheses and best practices across the country
regarding the organization and delivery of mental health prevention, treatment,
rehabilitation and support services. …The Network would facilitate the exchange
of the best available knowledge between mental health services knowledge
producers and users across Canada.
It would facilitate the translation of mental health services research into “on
the ground” policies and practices.
Based on a scan of several organizations
in Canada (including the Canadian Centre on Substance Abuse, the Canadian
Institute for Health Information, and the Canadian Institutes of Health
Research) the authors found that “while several individuals and organizations
across Canada are engaged in mental health services knowledge translation
activities in a variety of capacities, this function is typically not their
primary focus,” and that “a national, dedicated focus for carrying out the
mental health services knowledge translation function, currently does not
The Committee agrees that these functions
can best be carried out by a “neutral source, one that is not affiliated or
driven by any current mandate or particular stakeholder interests, other than
Such an organization would produce “research syntheses, national and best
practice reports regarding the organization and delivery of mental health
prevention, treatment, and rehabilitation and support services” targeted at governments, providers, and
people living with mental illness and their families.
The authors point out that:
translation also requires expertise in determining what constitutes quality
knowledge and the ability to develop and apply optimal methodologies for
effective knowledge transfer and utilization. Expertise on mental health
service and system issues is vital given the particularly difficult and complex
issues with which this sector must grapple — stigma and discrimination, and a
low public policy profile.
This would entail both “pushing” research
results out to users and facilitating the ability of people to “pull” material
from the organization’s database, as well as allowing exchanges between both
“pushers” and “pullers.” Thus it would be possible to do the following:
“Push” research findings out to users:
available high-quality, relevant mental health prevention and services
New mental health
services research syntheses/summaries;
New national reports
on the state of the mental health system;
reports on the status of mental health of Canadians;
reports on mental health services; and
provide means of evaluating the fidelity and outcomes of programs.
Facilitate user “pull”:
existing knowledge syntheses, national and best-practice reports;
services knowledge needs assessments; and
development through the training and education of knowledge users — i.e., federal, provincial and territorial
planners, decision-makers and leaders of service providers and community
organizations, as well as advocates for people living with mental illness.
Facilitate exchange between “pushers” and
Provide a rapid
response consultation service on priority areas, based on the best available
symposia, seminars, and workshops that facilitate knowledge exchange; and
Internet-based knowledge exchange portal.
The Committee also agrees
with the authors that the Knowledge Exchange Centre should “collaborate with
existing organizations within and outside of the federal and
provincial/territorial governments to avoid duplication and ensure that its
efforts add value.”
The authors also rightly point out that
there are many tasks that the Centre should not
undertaking specific research projects;
existing knowledge, data, or information;
existing knowledge transfer tools and resources (e.g., Canadian Health Services
service for consumers seeking to access mental health services;
consumer/provider/system advocacy; and
knowledge (i.e., policy or service implementation at the provincial, regional,
local and individual levels).
The Committee believes that the Canadian
Mental Health Commission should draw on these observations as it establishes
the Knowledge Exchange Centre.
As discussed in Chapter 5, a
number of significant benefits would be realized by accelerating the transition
to a community-based system of mental health care. Research reviewed in that
chapter shows that community care leads to better mental health outcomes,
and that treatment within the community environment can improve access to care
while making the mental health care system more sustainable. It also enables
greater participation in the organization and running of the system by people
living with mental illness and their families, community organizations, and
voluntary health organizations.
Most importantly, the
provision of mental health services and supports in the community fosters
recovery by giving people living with mental illness more autonomy and
independence. They gain the ability to live in their communities with minimal
intervention by formal services; to the greatest extent possible, they make
their own decisions.
Despite these benefits, we
saw in Chapter 5 that the movement toward a community-based system has not
fully taken root. In many cases, deinstitutionalization has been undertaken
without the necessary community supports being in place. The result has been
that far too many people living with mental illness have ended up in prisons
and homeless shelters — indeed, prisons and shelters have become the asylums of
the 21st century. Alternatively, families have been burdened with
responsibility for care.
Part of the problem has been
that it has proven difficult to fund the costs of transition from institutional
to community care. During the transition period the old system must be
sustained until the new one can take its place. As explained in Chapter 5, the
Committee believes that in order to complete this transformation of the mental
health care system from an institutionally based system to one that is
predominantly based in the community, a targeted investment by the federal
government is needed in the form of a Mental Health Transition Fund.
In the Committee’s view, this
Mental Health Transition Fund (MHTF) should have two main components: a Basket
of Community Services (BCS) to assist provinces to provide services and
supports in communities to people living with mental illness, and a Mental
Health Housing Initiative (MHHI) to provide federal funds for the construction
of new affordable housing units, as well as for rent supplements so that people
living with a mental illness, who could not otherwise afford to do so, can rent
suitable accommodation at market rates.
Both of these initiatives would be subject
to the same ten-year sunset provision as the Canadian Mental Health Commission;
neither would entail new open-ended funding obligations on the part of the
With regard to the BCS,
research shows that the costs of supporting and treating people in the
community are roughly equivalent to the costs of the old institution-heavy
This means that once a new “steady state” has been achieved, it will be
sustainable with the same level of provincial government spending as was
devoted to the institutional system it will have replaced. This will allow
withdrawal of support by the federal government after a transition period. With
regard to the MHHI, it has a specific target — the elimination of discrimination
in the provision of affordable housing to people living with mental illness; it
too will end after ten years.
As noted in Chapter 5, the Committee has
been very careful in crafting its recommendations to ensure that the Mental
Health Transition Fund is a genuine transition
fund. It is designed solely to cover the costs associated with the shift from
one way of organizing mental health services to another that will cost the same
once the transition is complete. In this, it is unlike many other federal
initiatives that have also been called “transition funds,” such as the Primary
Care Transition Fund. Too often, such federal initiatives have entailed the
creation of new programs that must either be supported by new provincial money
or disbanded once the federal funding that sparked their creation has come to
an end. Such initiatives place subsequent ongoing obligations on provincial and
territorial governments to fund them.
The Committee believes strongly that the
federal government must provide the funds needed to accelerate the
transformation of the mental health care system. Therefore, the Committee
recommended in Chapter 5:
That the Government of Canada create a Mental Health
Transition Fund in order to help accelerate the transition to a system in
which the delivery of mental health services and supports is based
predominantly in the community.
That this Fund be made available to the provinces and territories
on a per capita basis, and that the Fund be administered by the Canadian
Mental Health Commission that has been agreed to by all Ministers of Health
(with the exception of Quebec).
That the provinces and territories be eligible to receive funding
from the Mental Health Transition Fund for a Basket of Community Services, as
long as these projects:
Would not otherwise have been funded; that is,
these projects would represent an increase in provincial or territorial
spending on mental health services that is over and above existing spending
on services and supports plus an increment equal to the annual percentage
increase in overall spending on health;
Contribute to the transition towards a system in
which the delivery of mental health services and supports is based
predominantly in the community.
That, as part of the Mental Health Transition Fund, the Government
of Canada create a Mental Health Housing Initiative that will provide funds
both for the development of new affordable housing units and for rent
supplement programs that subsidize people living with mental illness who would
otherwise not be able to rent vacant accommodation at current market rates.
That, in managing the housing portion of the Mental Health
Transition Fund, the Canadian Mental Health Commission should work closely
with the Canada Mortgage and Housing Corporation.
The requirement that Transition Fund
monies be incremental to current provincial/territorial spending on mental
health should not act as a
disincentive to improved productivity in delivering mental health supports and
services. The availability of new funds should not deter anyone in the mental
health system from actively working to use all public funds as efficiently as
possible. The Committee believes it important that savings derived from
productivity increases be available to health departments to invest throughout
the health care system and not exclusively on mental health and addictions.
The Committee believes strongly that the
Canadian Mental Health Commission should manage the Mental Health Transition
Fund. The Commission will be a truly national body with expertise like none
other in mental health care. It will be able to consult all stakeholders on how
best to ensure that the fund is used effectively, and it will be able to
collaborate with the provinces and territories on the design, administration
and implementation of the fund.
As discussed in Chapter 5, the Commission
would not direct how the monies from the Basket of Community Services portion
of the fund should be utilized, other than to ensure that they are used to
support the transition to community-based services (such as Assertive Community
Treatment Teams, Home Withdrawal Management Programs, Intensive Case Management
and Crisis Intervention Services) and to verify that federal money is used to increase
the amount that provinces and territories would otherwise have spent on mental
health services and supports. The Committee has deliberately left open which
specific programs would be covered under the Basket of Community Services. In
other words, it has not attempted to define a comprehensive list of services
and supports that would be eligible to receive money from the Mental Health
In Chapter 5, the Committee
explained the many reasons for adopting such a non-prescriptive approach. In
part, it is based on the recognition that the Committee does not have the
necessary expertise to undertake such a task. There is also the reality of
regional and local diversity of circumstance — needs are so varied, resources
so differently distributed that it would not be appropriate for any national
body to attempt to specify in detail which services and supports deserve to be
funded. Any examples that are given in this report are just that — examples of
the kinds of services and supports the Committee believes should qualify for
Transition Fund support.
The Committee also believes
that the fund should be distributed to the provinces and territories on the
basis of population. However, access to family and community-based health care
services is a particular challenge in the territories, where the distribution
of small populations across vast and remote regions poses huge obstacles to
community-based delivery of mental health services.
federal government recognized these difficulties at the September 2004 First
Ministers meeting on health care by creating a Territorial Health Access Fund
($150 million over five years). The Committee also acknowledges the particular
circumstances and needs of the territories. It believes that they should receive
additional funding to assist the provision of community-based mental health
care services to remote populations. The
Committee therefore recommends:
That the territories receive additional funding
from the federal government, over and above their per capita allocation from
the Mental Health Transition Fund, in order to assist them in addressing the
needs of remote, isolated and non-urban communities.
The Committee also recognizes that similar
concerns have been raised concerning per capita funding by some of the smaller
provinces. The Committee believes that in the case of Prince Edward Island, careful consideration
should be given to the possibility of adjusting the per capita funding level in
order to ensure that sufficient funds are transferred to that province to
enable it to complete the transition to a community-based mental health
As noted in Chapter 5, the federal
government, stakeholders, and Canadians in general are entitled to know that
money from the Mental Health Transition Fund is: (a) spent on community-based
mental health projects; and (b) used to increase the total amount each
jurisdiction is spending on enhancing mental health and treating mental
illness. The goal is that the Transition Fund be used to support transformation
of the mental health care system, not as a substitute for existing provincial
or territorial spending.
The Committee realizes that provinces and
territories are not in favour of having to report to the federal government or
a national organization on how they manage their health care spending.
Nonetheless, the Committee strongly believes that there should be some form of
accountability for the use of money from the Fund. Therefore the Committee
That the use of the monies from the Mental Health Transition Fund
should be subjected to an external audit, to be performed by provincial
auditors general in order to ensure that the monies are spent in a manner
consistent with the two objectives of the Transition Fund, namely:
to fund community based mental health services
and supports; and
to increase the total amount each jurisdiction
spends on enhancing mental health and treating mental illness.
Subjecting the use of money
from the Transition Fund to an external audit will also help to ensure that
these funds are effectively segregated from the rest of the health care system.
By making it easier for provincial and territorial health ministers and deputy
ministers to resist internal pressure from other spending demands of their government,
that segregation would help to prevent money from the Mental Health Transition
Fund from simply disappearing into the acute care system.
There are currently no
reliable data on what it would cost to complete the transformation of the
mental health care system from an institutional base to one that is
predominantly based in the community. An accurate assessment would require a
needs-based analysis not just in each province and territory but within the
regions of each jurisdiction, given that the services available and the unmet
needs vary greatly across the country and from community to community.
The mental health care “system” is diverse
and fragmented; most services and supports operate independently of one other.
It is thus very difficult to assess even approximately the needs and the
capacity shortfalls in the current system. Consequently, the Committee has
relied upon the work of others to establish a reasonable estimate of the size
of an effective transition fund.
In 2000, the Ontario Minister of Health
and Long-Term Care established nine regional task forces to develop
recommendations for regional and local improvements to mental health services
these included restructuring the psychiatric hospital system, community
reinvestments and the implementation of mental health reform.
The Toronto-Peel Mental Health Implementation Task Force, like the other
regional task forces, made a wide range of recommendations affecting the full
spectrum of mental health care services.
It also provided an overall costing estimate to transform the mental health
care system in that region.
The Committee’s estimate of the overall
cost of transforming the mental health system is based on the work of this task
force. Rather than attempt to cost out each and every recommendation, the
Toronto-Peel Task Force provided an overall, “order-of-magnitude” estimate of
the increases required in the base funding for mental health care services in
its region. It concluded that, to achieve an adequate transformation, the
region’s mental health system required an investment of approximately $245
million over five years.
The report by the Toronto-Peel Task Force
is one of the few detailed, systematic attempts to examine the needs of the
mental health care system in Canada
and provide an estimate of the costs of transforming that system. While the
Committee realizes that the area studied is largely urban, it combines a fairly
well serviced area, Toronto, with one of the
most poorly serviced areas in Ontario
from a mental health service and support perspective, Peel.
Furthermore, the Toronto-Peel region
incorporates a high degree of socio-economic diversity. The Task Force had to
balance the gaps and capacity needs of each part of the region. Similarly, it
would be up to each province and territory to determine where services are most
needed and where additional resources would be most effectively allocated. The
Committee believes that the costing estimate of the Toronto-Peel Task Force is
a useful base from which to calculate what the needs of the mental health care
system might be in Canada
In order to determine the overall size of
the transition fund for all the provinces and territories, the Committe
extrapolated on the basis of population from the Toronto-Peel region to the
rest of Canada.
In 2001, when the last census was conducted, Toronto-Peel constituted 30.42% of
the population of Ontario; Ontario
constituted 38.02% of the population of Canada. By extrapolation, the total
required for Canada
would be $2.148 billion.
The Toronto-Peel Task Force requested that
the recommended increase in funding be allocated over five years. The Committee
believes, for two reasons, that it would be preferable to spread the allocation
to the Mental Health Transition Fund over ten years:
First, given the
human resource and supportive housing shortage facing the mental health sector,
the Committee does not believe that the system could effectively absorb the
full transition funding in five years.
Second, it is
unreasonable to expect the federal government to be able to afford to close the
service funding gap in a period as short as five years.
The Committee believes that ten years is a
realistic time frame for transition, although it recognizes that it may not be
possible to put in place at once all the programs that are needed. Instead, it
may be necessary to begin slowly and increase the flow of funds over time.
Therefore, the Committee recommends:
That the Basket of Community Services component
of the Mental Health Transition Fund average $215 million per year over a ten
year period, for a total of $2.15 billion.
This is a lot of money, but the total
pales in comparison to the estimated $2.7 billion the province
of Ontario alone spends on mental
health care each year
or to the $14.4 billion that mental illness and substance use problems cost Canada in 1998.
As discussed in greater
detail in Chapter 5, one of the biggest problems facing people with mental
illness is the lack of affordable housing. Because people with mental illness
often have little or no income, they are often forced to live in neighbourhoods
characterized by high crime rates, drugs and violence. Among the homeless, it
has been estimated that between 30% and 40% have mental health problems.
According to data provided by the Canada
Housing and Mortgage Corporation, 15% of the Canadian population as a whole is
in need of housing that is adequate, suitable, and affordable.
At the same time, the housing situation confronting people living with mental
illness is considerably worse; 27% (approximately 140,000) are in need of
adequate, suitable, and affordable housing.
In other words, the percentage of Canadians who are living with mental illness
who need access to such housing is almost double the percentage of people in
the general population whose housing needs are not being met. The Committee
believes that this constitutes discrimination against people living with mental
According to the Canadian
Mental Health Association, between 1980 and 2000, the number of affordable
housing units created by the Government of Canada dropped from 24,000 to 940.
In many communities, adequate and affordable housing is beyond the means of
people who rely on publiclyfunded income support. For example, in British Columbia, people
on disability benefits or social assistance receive $325 for shelter costs per
month, yet average market rents in Metropolitan Vancouver are over $600 per
month; even run-down single-room-occupancy hotel rooms cost $350 a month on
The Committee concluded unequivocally in
Chapter 5 that: more affordable housing units are required; more assistance is
needed so that people can afford to rent existing apartments at market rates;
and more supportive services are needed so that people living with a mental
illness can live in their communities.
It is critical that a significant increase
in community-based supportive services for people living with mental illness be
part of any housing initiative targeted at people living with mental illness.
Otherwise, such a program cannot achieve its objectives. Therefore, all such
services must be eligible for funding under the Basket of Community Services
portion of the Mental Health Transition Fund.
The federal government has
begun to reinvest in affordable housing, primarily through the Canada Mortgage
and Housing Corporation. It recently extended the National Homeless Initiative,
which funds community supports such as emergency shelters and drop-in centres.
It also established the Residential Rehabilitation Assistance Program, which
provides assistance to low-income households, persons with disabilities and
Aboriginal people to bring their homes up to minimum health and safety
standards, as well as repair shelters for victims of family violence and
support home adaptations for low-income seniors.
In addition, through the Affordable
Housing Initiative, the federal government has agreements with the provinces
and territories to share the cost of the construction of new affordable housing
units, as well as to provide rental supplements to low-income households. The
federal government does not have any housing programs, however, designed to
meet the specific needs of people living with mental illness.
The Committee considers
inexcusable the lack of affordable and appropriate housing for people living
with mental illness. It is appalling that the proportion of people with mental
illness in need of housing (27%) is nearly double that of the population as a
whole (15%). According to the Canada Mortgage and Housing Corporation,
approximately 56,500 people living with mental illness would need access to
some form of affordable housing in order to bring down the proportion of people
living with mental illness in need of housing to the national average.
Ideally, the Committee would like to see
all Canadians have access to affordable housing; but this is not a realistic
goal in the short term. The Committee does want, however, an end to the current
discrimination against people living with mental illness; this is why it has
recommended the establishment of the Mental Health Housing Initiative as part
of the Mental Health Transition Fund. This is also why the Committee has
recommended that 57,000
new affordable housing units be developed.
The needs of people living
with mental illness are not all the same — some require supportive services
while others who are more independent have trouble finding adequate housing.
The Committee believes that a program to meet the core housing need of people
living with mental illness should establish a 60/40 mix of rent subsidies
relative to the construction of new housing units.
The Committee also believes that when the
Mental Health Housing Initiative is launched, its initial focus should be on
rent-subsidized units because of the need to act quickly to address the housing
The MHHI should be modelled on existing housing programs and “cost-shared” with
the provinces in the same way that current supportive housing projects are —
such as those targeted at people who are currently homeless.
The Committee feels so strongly that the
housing shortage must be addressed immediately, that it is recommending that
the federal government pay the full share of the rent subsidies for the first
three years. This will kick-start the program and allow time for agreements to
be reached subsequently with the provinces and territories.
More specifically, the Committee is
recommending that in years 1 through 3 of the MHHI, 80% of the people provided
with housing should receive a rent supplement of $6,020 in the first year and
$4,250 annually thereafter. The remaining 20% should move into newly
constructed units costing $75,000 per unit.
In years 4 through 7, the proportion of rent supplements to newly constructed
units should be 60/40, and in years 8 through 10 the proportion should be
The table below shows that the total cost
would be $2.24 billion over ten years at an average annual cost of $224
The MHHI would draw on evidence-based
housing policies and best practices in supported housing. Consideration should
also be given to innovative approaches by governments, health authorities and
non-profit organizations, such as aggregating their subsidies to allow
partnerships with tenants in the purchase of housing properties. Such
approaches may help to address the economic realities of escalating rents and
Costing Analysis of the Mental Health Housing Initiative
# of new units
Cost of new units
# of new rent supple-ments
Cost of new rent supple-ments
# of continued rent
Cost of continued rent
Total rent supple-ment cost
Total annual cost
# of people removed from core
Based on data provided by the Canada Mortgage and Housing Corporation. All
costs are in millions of dollars.
The Committee therefore recommends:
That the Government of Canada invest
$2.24 billion over ten years in the Mental Health Housing Initiative (MHHI)
that is to be established as part of the Mental Health Transition Fund.
That the MHHI have as
its goal to reduce the percentage of Canadians living with mental illness in
need of housing that is adequate, suitable and affordable from 27% to the
national average (15%) of people in need of such housing, specifically by
providing 57,000 people living with mental illness with access to affordable
That, over the life of the MHHI, 60%
of its funds be allocated to providing rent supplements to people living with
mental illness who would otherwise be unable to afford to rent accommodation
at market rates, and the remaining 40% be devoted to the development of new
affordable housing units.
That, in order to provide immediate
assistance to as many people as possible, during the first three years of the
MHHI, fully 80% of available funds be allocated to rent supplements; and that
during this period the federal government pay the full share of the rent
subsidies, after which the cost of the rent subsidies be shared according to
existing federal-provincial-territorial arrangements.
That innovative approaches by
governments, health authorities and non-profit organizations be supported,
such as aggregation of subsidies to allow partnerships with tenants in the
purchase of housing properties.
That, following the ten-year life of
the MHHI, the Canada Mortgage and Housing Corporation be mandated to maintain
the percentage of people living with mental illness who are in need of
housing that is adequate,
suitable and affordable at the same percentage as that of the
population as a whole.
In addition to the Basket of Community
Services and the Mental Health Housing Initiative, the Committee believes that
several other important elements should be part of the Transition Fund.
with a Specific Focus on Substance Use Disorders, Addictive Behaviour and
The Canadian Addiction
Survey, a recent national epidemiological study of substance use and addictive
behaviour across Canada,
estimated that approximately 3.5 million Canadians had a substantial problem
with alcohol consumption, 2.1 million with cannabis use, and 330,000 with other
illicit drug use.
For many, such substance use problems and addictive behaviours have devastating
consequences that result in profound harm and suffering. Morbidity and
mortality data reveal high rates of suicide associated with alcohol and drug
use, accidental deaths and disability (including motor vehicle related deaths
and disability), violent behaviour and criminal activity, physical illness and
the spread of infectious diseases such as hepatitis C, tuberculosis and
HIV/AIDS. A 1996 study by the Canadian
Centre on Substance Abuse, The Costs of
Substance Abuse in Canada, estimated that the economic cost of substance
use problems in 1992 in Canada
was $18.4 billion, including the direct costs of health care and law
enforcement and indirect costs due to loss of productivity.
Publicly funded prevention, treatment and
support services for substance use problems and addiction are provided
primarily by provincial and territorial governments as a category of general
health services. Ideally, a broad set of coordinated services and supports
would be available to address substance use problems, such as the continuum of
services described in the recent B.C. government framework, Every Door is the Right Door: A British
Columbia Framework to Address Problematic Substance Use and Addiction:
Health Promotion and Primary Prevention Initiatives, including universal and selective prevention activities;
Secondary Prevention/Early Intervention, including indicated prevention, early identification and early
Standard Treatment and Self-management with Selected
Intensive Treatment, Long-term Rehabilitation and
Programs that are designed to meet the
needs of specific populations, such as older adults, youth, and Aboriginal
peoples, are also required for optimal prevention and treatment of substance use
disorders. In addition, initiatives are required to address other addictive
behaviours such as problem gambling.
Throughout most of Canada, a
complete and comprehensive set of services and supports to address substance
use problems and addictive behaviours is unavailable. It is impossible to
obtain an accurate estimate of the total funding allocated by the provinces and
territories to address substance use and other addictive behaviours, because
expenditures for these services are blended into overall health care costs.
National figures on the number of Canadians involved in addiction treatment
programs are also not available. The Canadian Centre for Substance Abuse
estimates that approximately $400 million per year is currently being spent
across the country on substance use disorder treatment services.
A recent national epidemiological survey undertaken by Statistics Canada found
that only a small proportion of individuals with substance use disorders and
addictive behaviours receive treatment. 
The relationship between services for
mental illness (such as treatment for depression, anxiety disorders and
schizophrenic disorders) and services for substance use disorders (including
treatment for problematic alcohol use, withdrawal management services, methadone
maintenance for opiate addiction and needle exchange programs) has been the
subject of much discussion and debate across Canada. In previous decades,
services for the two types of disorder were administered separately; they
developed divergent treatment philosophies, used different terminology and
constituted different “cultures” that were often in conflict.
Mental illness and substance use disorders
are often concurrent; it is quite common for people to suffer from both.
Research has shown that 30% of people diagnosed with a mental illness will also
have a substance use disorder in their lifetime, and 37% of people with an
alcohol use disorder (53% who have a drug use disorder other than alcohol) also
live with a mental illness.
The “culture clash” between mental health
services and addiction services has created substantial problems for clients,
particularly those with concurrent disorders. As a result of conflicting
approaches to treatment, clients have often received confusing and inconsistent
information and advice. It has been common for clients to be excluded from
mental health services if they admitted to substance use problems. Similarly,
clients were often excluded from addiction treatment programs if they admitted
to the use of antidepressant medications.
Efforts to improve the
integration of mental health and addiction services are currently underway in
many parts of Canada.
Most clients welcome greater integration but some providers do not welcome the
change. Providers of treatment for addiction often express concerns about what
they anticipate to be the “medicalization” of services; mental health providers
fear, on the other hand, that their clients’ symptoms will be inadequately
addressed and treated. In many jurisdictions, providers from both groups are
receiving joint training to develop more comfort when providing treatment to
people with mental health problems, substance use disorders or concurrent
disorders. The administration of mental
health and addiction services has been integrated in some provinces and
territories, whereas in others separate administrative structures have been
was developed as a federally coordinated initiative to reduce the harm
associated with the use of narcotics, controlled substances, alcohol, and
prescription drugs. It includes education, prevention and health promotion
initiatives as well as enhanced enforcement measures. The Strategy involves a
number of federal departments together with provincial and territorial governments,
addictions agencies and non-governmental organizations, such as the Canadian
Centre on Substance Abuse. The federal government has committed $245 million
over five years, or an average of $49 million per year, to this strategy.
The Committee is convinced that the
federal government can and should do more to address substance use problems,
addictive behaviour, and concurrent disorders. Specifically, the Committee
believes that the federal government should provide an additional $50 million
for services and supports for people living with concurrent disorders. The
Committee therefore recommends:
That the Government of Canada include as part of the
Transition Fund $50 million per year to be provided to the provinces and
territories for outreach, treatment, prevention programs and services to
people living with concurrent disorders. As with the rest of the Transition
Fund, this money would be managed by the Canadian Mental Health Commission,
but in respect of this component of the fund there should be close
consultation with the Canadian Centre for Substance Abuse, as well as the
provinces, territories, and other stakeholders.
In concert with the Drug Strategy funds,
this additional federal investment represents a significant opportunity to
improve prevention and treatment services for people with concurrent disorders.
It should be noted that in 2004-05, the federal government collected almost
$1.3 billion in excise duties on alcohol; its expenditures on substance use are
less than 4% of what it collects in excise duties.
As discussed in Chapter 12,
there is enormous potential to telemental health, especially because the
process of psychiatric diagnosis is not primarily a physical one, but relies on
verbal and non-verbal communication. One of the most frequently cited benefits
of telehealth is its potential to increase access to health services generally
in rural and remote communities, and in particular to mental health services.
This is especially important for northern Aboriginal communities with no or
limited access to psychiatric services.
Funding for telemental health services
comes largely from provincial and territorial governments. All provinces and
territories have been experimenting with telemental health and some have
already embarked on program implementation, despite the high upfront costs. The
Committee believes that it important for the federal government to assist with
the deployment of telemental health initiatives throughout the country.
Over time, and once the infrastructure is
in place, the provinces and territories should find that the savings (e.g.,
reduced transportation and other costs) made possible through the
implementation of telemental health services are sufficient to fund the
operation of those services. The Committee recommended in Chapter 12 that the
federal government assist provinces with the transition towards this “steady
state” and recommends:
That the Government of Canada
provide the provinces and territories with $2.5 million per year to help them
move forward with their plans for telemental health. This money would be part
of the Mental Health Transition Fund and be administered by the Canadian
Mental Health Commission.
In Chapter 10, the Committee
documented the tremendous importance of self-help and peer support for people
living with mental illness and their families. The Committee recognizes the
financial difficulties faced by many of the organizations that provide these
services across the country. Hence, the
Committee recommended in Chapter 10 that a designated national fund be
established to provide stable funding to existing peer development initiatives,
build new initiatives and establish a network of self-help and peer support
initiatives. Therefore, the Committee recommends:
That the Government of Canada
provide the provinces and territories with $2.5 million per year for peer
support and self-help initiatives. This money would be part of the Mental
Health Transition Fund and be administered by the Canadian Mental Health
In addition to the various elements of the
Transition Fund, the Committee reiterates its support for research. Research
into mental illness and addiction is of enormous importance. It can lead to
meaningful improvements in the lives of people living with mental illness and
addiction in Canada.
That is why, in Chapter 11, the Committee recommended:
That the federal government commit $25 million
per year for research into the clinical, health services and population
health aspects of mental health, mental illness and addiction.
That these funds be administered by the Canadian
Institutes of Health Research (CIHR), through the Institute of Neurosciences,
Mental Health and Addiction under the guidance of a multi-stakeholder board
and in consultation with the Canadian Mental Health Commission.
That this $25 million be incremental to the
funding currently provided to the CIHR.
16.7 FUNDING THE FEDERAL INVESTMENT IN MENTAL HEALTH
The Committee has always
believed that the responsible course of action is not simply to recommend that
the federal government spend more money in a particular area but also to
suggest how it can be raised to pay for implementation of the Committee’s
recommendations. The Committee took this approach in its October 2002 final
report on the acute care (hospital and doctor) system. In that report, the
Committee recommended that $5 billion be raised annually through a
National Health Care Insurance Premium. While the federal government decided
not to adopt the Committee’s recommendation, nonetheless, in the September 2003
federal/provincial/territorial health accord, it did agree to contribute to the
provinces and territories essentially the same amount of money for health care
as had been recommended by the Committee.
Based on the calculations presented in
this chapter, the amount of money that is required for mental health, mental
illness and addiction supports and services is only one-tenth of the amount of
new spending that the Committee recommended be put into the acute care system.
The Committee believes that the new
revenue it is recommending be raised should be earmarked for spending on mental
health, mental illness and addiction. This revenue would still go into the
Consolidated Revenue Fund but be subject to the requirement that it be spent
entirely and exclusively on the programs recommended in sections 16.3 and
Objections have sometimes been raised to
earmarked taxes because they reduce governments’ ability to adjust their
spending as priorities change. While the
Committee is sympathetic to this objection in general, it believes that an
exception ought to be made for the money recommended for mental health, mental
illness and addiction for the following reasons:
Canadians living with a mental illness or a substance use problem have been
neglected, or at best substantially under-served, for so long, an extraordinary
signal of support is necessary from the federal government. Such a signal would
be given by its preparedness to earmark a source of new revenue specifically
A clear precedent
for earmarked taxes has been established by the federal government’s recent
decision to give a certain percentage of gas taxes directly to municipalities.
Given that mental
health and substance use issues touch the lives of essentially the entire
population, the Committee believes that Canadians will agree with the proposal
to pay a small amount to improve the lives of people living with these problems.
The Committee believes that
the proposal outlined below will be acceptable to the Canadian public. In fact,
there is considerable research evidence to suggest that taxes earmarked for a
specific purpose are likely to be more acceptable to voters than are tax
increases that provide governments with additional general revenue.
The Committee realizes that there is no
“best” way of raising the required revenue. Four tests for examining possible
sources of revenue were used:
The revenue should be easy to collect and entail minimal additional
administrative costs — that is, the method of raising funds should be very
It should be easy to explain to Canadians the nature of, and the
rationale for the chosen source of revenue.
The method proposed for raising the revenue should be politically
feasible, that is, acceptable to most Canadians.
It should be easy for people outside government to calculate how much
money was raised and to verify that it was indeed spent on mental illness and
substance use problems; that is, it should be easy to hold government
After careful consideration, the Committee
That, in order to raise additional revenue to
pay for the recommended federal investments in mental health, mental illness and
addiction initiatives, the Government of Canada should raise the excise duty
on alcoholic beverages by a nickel a drink, that is by 5 cents a
One standard drink in Canada is 13.6 g of
alcohol — a 12-ounce bottle of beer, a five-ounce glass of wine or 1.5 ounces
of 80-proof liquor.
Five cents per drink translates into 5 cents on a bottle of beer, approximately
25 cents on a bottle of wine, and approximately 85 cents on a bottle of
For the reasons explained below, the
Committee believes that this increase in excise duty should not apply to
alcoholic beverages with an alcohol content of 4% and lower; it should not
apply to light beer or other low-alcohol beer.
In fact, the Committee believes that
society would benefit from a shift in consumption from higher- to lower-alcohol
beer. Therefore, the Committee recommends:
That the Government of Canada lower the excise
duty by 5 cents a drink on beer of alcohol content between 2.5% and 4%, and
the excise duty on beer of alcohol content under 2.5% should be eliminated
In all, these changes to the federal
excise tax on alcohol would raise approximately $478 million per year. The
calculation is presented in the box at the following page.
The Committee believes that Canadians are
not likely to object to an increase of only 5 cents per drink, especially
since the federal excise duty on alcohol has not risen since 1986;
the Consumer Price Index (CPI) has risen by 64.25% since then.
In real terms (i.e., after inflation), the increase in the excise duty would be
about half the rate of inflation. In 2004-2005, the revenue from excise duties
on alcohol was $1,286,128,496.
The revenues of $478 million from the “nickel a drink proposal” would
increase this amount by 37%.
REVENUE FROM THE “NICKEL A DRINK” PROPOSAL
According to Statistics Canada, approximately 2,232,756,000
litresof beer were sold in Canada
in 2004.* The typical bottle of beer (one standard drink) contains 341 ml.
Thus, the equivalent of 6,547,671,544 bottles of beer was sold in 2004.
Based on information from the industry, approximately 82% of the beer sold
has an alcohol content greater than 4%. If the excise duty on this beer
were raised by 5 cents, this would generate $268,454,534 in revenue
annually, provided consumption remained at the same level.
If the excise duty on beer with an alcohol content of 4% and
lower were reduced by 5 cents from the current rate, this would lower
revenues by $58,929,044.
Very little beer sold in Canada has an alcohol content
of 2.5% and lower. If the excise duty on this beer were eliminated, this
would reduce revenues by about $740,000.
In 2004, the
total volume of absolute alcohol from spirits sold in Canada was 54,683,000 litres;
from wine, the total was 38,611,000 litres. One standard drink contains
13.6 g of alcohol, or 17.325 ml. If the excise duty were increased by 5
cents per standard drink, this would generate revenue of $269,246,753 from
spirits and wine, provided consumption remained at the same level.
revenue from the “Nickel a Drink” proposal would be approximately $478 million per year.
* Information on the amount of beer, spirits and
wine sold in Canada was obtained from Statistics Canada, The Control and Sale of Alcoholic
Beverages in Canada, 2004, 63-202-XIE.
It should be noted that while the current excise duty on spirits is
based on volume of alcohol, the excise duty on wine is based on volume
sold. Consequently, unless the federal government decides to change the
method of calculating the excise duty on wine (there would be some merit in
doing this, as fortified wines are taxed less on a per standard drink basis
than other wines), the revenue generated would likely differ slightly from
the calculation given.
Other important benefits could be gained
by shifting consumption away from higher-strength to lower-strength beer. There
is good evidence from Australian studies that the consumption of lower strength
beer leads to a measurable reduction in impaired driving, and that geographic
regions with higher proportional sales of lower-strength beer also have less
alcohol-related violence and fewer hospital admissions related to alcohol
In 2001, the Australian federal
government, persuaded by the evidence that reducing taxes on lower-strength
beers was good for public health and safety, introduced differential excise tax
rates for beer as follows:
(not exceeding 3% alcohol/volume): $15.96 per litre of alcohol;
(>3%, <=3.5% alcohol/volume): $17.33 per litre of alcohol;
(exceeding 3.5% alcohol/volume): $22.68 per litre of alcohol.
The combination of less alcohol per drink
and lower tax rates per unit of alcohol resulted in substantial retail price
advantages for lower-strength beer. As a result, about 40% of the volume of the
Australian beer market now consists of low- to mid-strength beer, between 2.5%
and 3.8% alcohol.
The Australian experience suggests that
there could be multiple benefits for Canada were it to introduce
A 5-cent (nickel)
excise duty increase on a standard drink of alcohol with the proceeds earmarked
for mental health and substance use problems; and
reduction in taxes on lower-strength beer.
These benefits would include:
health and substance use services funded from the approximately $478 million
per year that would be raised by the increased excise duty;
the manufacture, marketing and sales of products with a lower alcohol content;
reduction in the harms associated with alcohol due to a shift of consumption to
products of lower strength.
The Committee has anticipated a variety of
possible objections to its recommendation for a “nickel a drink” increase in
the alcohol excise tax. Our responses to them are as follows.
To those who say
that government should not increase any tax, we say that there is no free good
or service. We say also that services must be improved now for Canadians living
with a mental illness or a substance use problem;
To those who may
say it is wrong to raise money based on alcohol consumption to help provide
services to people living with a mental illness, we think this a
misunderstanding of our proposal. Because we are recommending increased federal
expenditures of nearly $500 million per year out of the Consolidated Revenue
Fund, we need to recommend a way to replenish that fund with an equivalent
amount. We insisted that our revenue-raising proposal meet the four tests we
set out earlier in this section. The Committee believes that our proposal
satisfies all four tests.
revenue-raising proposal is not linked to our expenditure proposal in any
causal way. The only connection is that the amounts of money are equivalent.
Indeed, the Committee has deliberately avoided raising questions here about the
nature of a causal link, if any, between mental health and substance use
disorders. Rather, the Committee has simply made a recommendation to the
government that is both economically
sound and, in our view, politically feasible.
The total annual cost of implementing the
Committee’s recommendations is outlined in the following table.
million per year)
Mental Health Commission
Mental Health Housing
Basket of Community Services
Concurrent Disorders Program
The $17 million budgeted for the Mental
Health Commission is broken down as follows:
program: $5 million per year. This investment would be supplemented by the
Commission’s solicitation of public service announcements using the same
communications materials developed for the paid social marketing campaign. In
all, as much as $8 million a year, a significant communications undertaking,
would fund the anti-stigma campaign.
Exchange Centre: $60 million over ten years, an average of $6 million per
year. The Committee has prepared and will submit to the federal government a
detailed ten-year budget for the Knowledge Exchange Centre. Costs will be
higher in the initial years as the information infrastructure required for the
Centre is constructed, and will decline gradually as a stable operating
environment is established.
Operation of the
Commission: $6 million per year. This includes the basic operating costs of the
Commission, its Board, and the advisory committees and working groups it will
create, as well as the Commission’s contribution to joint projects undertaken
with other governments and non-governmental organizations. The Committee has
prepared a detailed budget, based on the operation of the Health Council of
Canada, for submission to the Government of Canada.
Given that the anticipated revenue
generated from the “nickel a drink” proposal would be $478 million per year, a
shortfall of $58 million per year is left between the Committee’s
recommendations and its proposed source of revenue. The Committee believes that
the cost estimates for the construction of new housing units may be high,
so the discrepancy between revenues and expenditures may disappear once the
programs are in place.
Should a shortfall persist, the
Committee’s preference would be that it be made up from general revenues.
Failing that, there are several other ways to bridge the potential gap:
The housing costs
could be spread out over 15 rather than 10 years. This would reduce the average
annual cost by $62 million, from $224 million to $162 million.
Mortgage and Housing Corporation has a large annual surplus from its mortgage
insurance program. By 2009, it is estimated that CMHC will have $4.5 billion
more than is necessary in capital reserves for that program. Some of these
funds could be spent on the housing needs of people living with mental illness.
palatable option from the Committee’s perspective would be to leave in place
the excise duty on beer with an alcohol content of 4% and under. Were this tax
to remain, revenue would increase by approximately $58 million.
As noted earlier, the Committee believes
that implementing the recommendations contained in this chapter — together with
all those made throughout this report — will allow, for the first time,
national resources to be channelled into fostering the mental health of
Canadians. They will also establish a solid basis for maintaining a national
focus on mental health issues and pave the way for the further development of a
national approach to mental health, mental illness and addiction in Canada.
 6 May 2005, /en/Content/SEN/Committee/381/soci/14mn-e.htm?Language=E&Parl=38&Ses=1&comm_id=47
 Canadian Institutes of Health
Research, Institute of Neurosciences, Mental Health and Addiction. (April 2003)
“About INMHA.” http://www.cihr-irsc.gc.ca/e/8579.html.
See also Chapter 14 for a more detailed discussion of INMHA’s activities.
 Standing Senate Committee on
Social Affairs, Science and Technology.
(November 2004) Report 3 —Mental
Health, Mental Illness and Addiction: Issues and Options for Canada, Chapter 4, Section 4.2, p.
 Government of New Brunswick,
Department of Health and Wellness. (April 2005) Research Project on Deaths by
Suicide in New Brunswick
between April 2002 and May 2003, p. 7. http://www.gnb.ca/0055/suicide-e.asp.
 Health Canada. (2002) A Report on Mental Illnesses in Canada,
Senate Committee on Social Affairs, Science and Technology. (November 2004)
Report 3 —Mental Health, Mental
Illness and Addiction: Issues and Options for Canada, Chapter 4, Section 4.2, p.
 As indicated in Chapter 3,
the Committee has not been able to devote as much attention to substance use
issues as it intended when it embarked on its study of “mental health, mental
illness and addiction.” The Committee recognizes that in previous decades,
services for the two types of disorder were administered separately; they
developed divergent treatment philosophies, used different terminology and
constituted different ‘cultures’ that
were often in conflict. However, the limitations of this report with
respect to substance use issues means that the Committee has been unable to
examine fully the similarities and differences in approach in the mental health
and substance use fields. Although some examples are drawn from the substance
use sector, the main thrust of this chapter concerns the implementation of
mental health initiatives at the national level. It would clearly not be
appropriate for the Committee to assume that conclusions it has reached after
carefully considering the mental health evidence necessarily apply with respect
to substance use issues. Some may apply, but the Committee has attempted to
avoid any unwarranted assumptions in this regard. There is, however, an
important recommendation in this Chapter that the federal government inject an
additional $50 million per year in concurrent disorder programs (see section
 It is worth reiterating that,
although the range of supports and services that are part of the mental health
“system” extend well beyond the sphere of health departments, the services and
supports that are the responsibility of health departments are nonetheless
clearly critical ones.
 See Chapter 13, “The Direct
Federal Role” for a full discussion of the role of the federal government in
delivering mental health services to the client groups for which it has direct
 See Chapter 13, “The Direct
Federal Role,” and Chapter 14, “Aboriginal Peoples of Canada,” for further
discussion of the importance of this recommendation.
 Standing Senate Committee on
Social Affairs, Science and Technology. (November 2004) Report 1 — Mental
health, mental illness and addiction:
Overview of policies and programs in Canada, Chapter 3.
 Standing Senate Committee on
Social Affairs, Science and Technology. (November 2004) Report 1 — Mental
health, mental illness and addiction:
Overview of policies and programs in Canada. Chapter 3.
 Jorm, A., Christensen, H.,
and Griffiths, K. (2005) The impact of beyondblue: the national depression
initiative on the Australian public’s recognition of depression and beliefs
about treatments. Australian and New Zealand Journal of Psychiatry,
Vol. 39, p. 253.
 Goering, P., Goldner E., and
Lesage, A. (October 2005) Proposal submitted to the Committee by Research in
Addictions and Mental Health Policy Services, Canadian Mental Health Services
Knowledge Translation Network.
 Ontario Ministry of Health
and Long-Term Care. (1999) Making it Happen.
 Toronto-Peel Mental Health
Implementation Task Force. (December 2002) The Time Has Come: Make it Happen —
A mental health action plan for Toronto-Peel.
 Many regions had difficulty
accurately determining the level of current funding, and what information they
did collect indicated a wide regional disparity of per capita funding levels
for mental health care within the province
 Toronto-Peel Mental Health
Implementation Task Force. (December 2002) The Time Has Come: Make it Happen —
A mental health action plan for Toronto-Peel, p. 314.
 Provincial Forum of Mental
Health Implementation Task Forces. (2002) Final Report—The Time is Now: Themes
and Recommendations for Mental Health Reform in Ontario, p. 62.
 The $14.4 billion is the total
of $6.3 billion in direct health care costs and an estimated $8.1 billion in
indirect costs related to premature death and productivity loss. See: Standing
Senate Committee on Social Affairs, Science and Technology. (November 2004)
Report 1 — Mental health, mental illness and addiction: Overview of policies and programs in Canada,
 See Chapter 5, “Toward a
Transformed Delivery System.”
 According to the Canada
Housing and Mortgage Corporation, “core housing need refers to households which
are unable to afford shelter that meets adequacy, suitability, and
affordability norms. The norms have been adjusted over time to reflect the
housing expectations of Canadians. Affordability, one of the elements used to
determine core housing need, is recognized as a maximum of 30 per cent of the
household income spent on shelter.” See: Canada Housing and Mortgage Corporation.
(undated) Affordable housing. http://www.cmhc-schl.gc.ca/en/corp/faq/faq_002.cfm.
Canada Mortgage and Housing
Corporation. (7 October 2005) Letter to the Standing Senate Committee on Social
Affairs, Science and Technology.
 Canadian Mental Health
Association. (April 2005) Meeting the mental health needs of the people of Canada:
A Submission to the Senate Standing Committee on Social Affairs, Science and
Canada Mortgage and Housing
Corporation. (22 November 2005) News release: National renovation and homeless
Canada Mortgage and Housing
Corporation. (7 October 2005) Letter to the Standing Senate Committee on Social
Affairs, Science and Technology.
 This figure represents a
rounding-up of the estimate of 56,500 that was provided by the Canada Mortgage
and Housing Corporation.
 The federal government
currently has cost-sharing agreements with the provinces and territories for
rent supplements and the construction of new affordable housing units. See: Canada Mortgage
and Housing Corporation. (7 October 2005) Letter to the Standing Senate
Committee on Social Affairs, Science and Technology.
 The cost of newly constructed
units is based on the federal government contributing half of the costs to a
maximum of $75,000. It is likely that the actual cost of new units will be
 Canadian Centre on Substance
Abuse. (November 2005) Brief to the Standing Senate Committee on Social
Affairs, Science and Technology.
 Canadian Centre on Substance
Abuse. (1996) The Costs of Substance Abuse in Canada.
 British Columbia Ministry of
Health. (2004) Every Door is the Right Door: A British Columbia Framework to
Address Problematic Substance Use and Addiction.
 Canadian Centre on Substance
Abuse. (2005) Addiction Treatment Indicators in Canada.
 Statistics Canada. (2004) Canadian Community
Health Survey 1.2.
 Skinner, W., O’Grady, C.,
Bartha, C., and Parker, C. (2004) Concurrent substance use and mental health
disorders: An information guide. Toronto:
Centre for Addiction and Mental Health.
 Receiver General of Canada, Public
Accounts of Canada,
2004-05, section 4.7. This amount does not include GST collected on the
sale of alcoholic beverages.
 See Chapter 12, “Telemental
Health in Canada,”
for a more detailed discussion of telemental health.
 Health Canada. (2000) Straight Facts about
Drugs and Drug Abuse, p. 30.
 The excise duties and taxes
were changed for alcohol (beer, spirits and wine) were changed in 1991 with the
introduction of the GST. This change in rates was “revenue-neutral”; that
is, the excise tax and duty rates were increased to produce the same combined
sales and excise tax and duty revenues as under the old federal sales tax