Policy Issues:Mental Health & Addictions HLTH 405 / Canadian Health Policy Winter 2012 School of Kinesiology and Health Studies Course Instructor: Alex Mayer, MPA
Announcement• HLTH DSC Bake Sale o Wednesday, 11AM to 4PM o In the ARC Video: Bake Sale Advertisement
Announcement• Briefing Note o Last week to see me (office hours: 12pm – 5pm tomorrow, KHS 301A) o 2 weeks left before due date • Do you have a topic? • Have you completed some preliminary research?
• Briefing Note Ideas o How could outcome-based physician incentives be used to promote chronic disease prevention? (Learning from the UK experience) o Incentivizing workplace wellness programs in Ontario o Banning fast food advertisements targeting children: how effective is it? (Learning from Quebec) o Promoting physician-dietitian partnerships in every FHT: what are the challenges? o Assessing the merits of health impact assessments in urban planning: an international survey of current evidence o Strengthening health promotion partnerships with First Nations Reserves o Making Canada’s Food Guidelines reflect the best scientific evidence: the political and organizational challenges
• Briefing Note Ideas o Promoting healthier food choices among youth o Reducing prevalence of binge drinking among youth o Social and health strategies to address the health challenges of house-insecure populations in a cost- effective manner o Primary care strategies to effectively keep low acuity patients from seeking emergency room care o Provincial bulk purchasing of pharmaceutical drugs: Benefits and challenges of instituting a pan-Canadian purchasing agency o Programs and regulations to prevent cellphone- related car accidents
• Briefing Note Ideas o Teaching healthy cooking and grocery shopping skills: Exploring a new health care role to increase clinical adherence with lifestyle-based treatment protocols in high-risk patients o Exploring a new partnership model with personal trainers and/or kinesiologists in primary care o Implementing harm reduction strategies in Ontario for people with high-risk addictions o Preventing the spread of communicable diseases in Canada’s penitentiary system o Reducing mental health stigma and promoting careseeking behavior among high school youth
In the News• ‚Canadians to speak out on mental health‛ - Global News (Feb 8th, 2012)• ‚Unstable Tactics: Recent deaths throw into question how police confront mental health‛ - National Post (Feb 11th, 2012)• “In an aging society, dementia may be the new impaired driving” - Toronto Star (Feb 11th, 2012)
Topics for today’s lecture:Policy Issue #2: Mental Health & Addictions• Mental health trends• Social stigma• Trauma and Self-medication• Principles of a recovery approach to mental health• Principles of harm reduction
Defining a Healthy Mental Life• More than merely the absence of physiological impairments/imbalances (CMHA): o Striking a fulfilling balance between social, physical, spiritual, economic and mental activities o Building a healthy self-concept and sense of self-worth o Ability to freely give and receive emotional affirmation o Access to nurturing relationships (e.g. family, friends) o Managing stress and coping with change effectively o Feeling a sense of belonging and connectedness to one’s community
Approaches to Mental HealthDifferent approaches to delivering Mental Health Carein Canada have evolved over time:• Reflect shifts in social values and cultural mores• Reflect shifts in social perceptions of illness (i.e. myths, prejudices)• Reflect paradigm shifts in the dominant view/definitions of mental illnessLet’s travel back in time…
Ancient Greece Individuals with severe mental illnesses thought to be vessels for angry gods (Prince, 2003). o Sufferers were abused, humiliated, treated with contempt o Early precursor of Western values towards mental illness (i.e. stigma)
Middle Ages (5th to 16th century) Many European cultures identified mental illness with supernatural affliction (e.g. demonic possession, witchcraft). o Sufferers were often tortured, burnt at the stake, hanged or decapitated to release demonic presence (Stein and Santos, 1998)
‘Age of Enlightenment’ (17th to 18th century) In Europe, dominant view of mental illness as a physical impairment that results from a ‘excess of passion’. o Sufferers were poorly treated and often left to linger in bad living conditions. In some cases, they were confined to cages or chained to walls. o Seen as ‚self-inflicted‛ and ‚incurable‛ condition.
Late 18th century: ‚Moral Treatment‛ French physician named Dr. Philippe Pinel pioneers the belief that people who behave ‘strangely’ have a medical illness and should be cared for; Advent of psychiatry. o Consequently, the ‘deranged’ are seen as less blameful than sinners or criminals – they are merely ‘sick’. o ‘Lunatic asylums’ are replaced with psychiatric institutions, which promote semi-normal, autonomous lives and seek to treat patients with respect.
19th and 20th century: Biomedical Model Advances in mapping out physiological functions of the brain lead medical scientists to explain mental illness as resulting from damage to the physical tissues of the brain, either from trauma, pathogens, or the sequelae of congenital/hereditary defects. o Leads to pessimistic view of prospect for rehabilitation.
Early 20th centuryFollowing World War I, the prevalence of ‚shell shock‛lends credibility to the idea of psychological causes ofmental illness and the notion that everyone has a ‘breakingpoint’. o Birth of modern psychiatry and clinical psychology
Late 20th century: Biopsychosocial ModelIn 1977, Engel introduces the BPS model of health, which stipulatesthat a combination of biological, psychological and social factorscombine to produce disease and disability. o Social norms, cultural expectations and traditions become integral ways of understanding what ‘qualifies’ as mental illness o Social determinants and aggravating environmental factors now understood to play a large role in mediating mental illness
Approaches to Mental Health in Canada3 Distinct Periods (like most developed countries)in the way we as a society have approached mentalillness.Pre-1900s: Moral/Humanitarian Treatment• Mental health pioneers move beyond a ‘custodial’ model of care and seek to provide patients with the benefit of moral treatment. Few institutions exist, but those that do have a high staff-patient ratio and report high success rates.
Approaches to Mental Health in Canada1900-1960s: Institutionalization• Following success of moral treatment, institutions appear all over the country.• Patients spend most of their lives in psychiatric institutions.• Paternalistic relationship between staff and their patients.• Introduction of paid work through occupational therapy.• Government and CMHA began to concern themselves with reducing stigma: o Inauguration of ‘Mental Health Week’ (1951) o Push to eliminate terms like ‘imbecile’, ‘idiot’, ‘lunatic’ from existing statutes and the public vernacular
Approaches to Mental Health in Canada1960s-present: De-institutionalization• By 1960s, institutions are overcrowded.• New research exposes the long-term developmental harms of mental institutions.• Health advocates argue that mental health should not be treated any differently than physical health (episodically, in hospitals).• Unfortunately, deinstitutionalization was not coupled with increased investments in mental health supports.
How prevalent is mental illness in Canada, anyway?
Very Prevalent• 1 in 5 Canadians will experience a severe mental illness or drug misuse disorder during their lifetimes. The remaining 4 will know someone who does.• Has overtaken cardiovascular disease as the leading cause of disability claims in Canada.
Who is Affected?• 70% of mental health issues have their onset during childhood or adolescence.• Young people (15 - 24yr.) are the most likely to experience a mental health issue or substance use disorder.• The prevalence of age-related mental illness (e.g. dementia) is on the rise due to demographic aging. By age 80, 1 in 3 Ontarians will experience dementia.
Who is Affected?• Low-income Canadians are 3-4X more likely than those in high-income group to report ‘fair’ to ‘poor’ mental health.• Males are more likely to be high-risk drinkers (25%) than females (9%), and to experience a substance dependence (2.6X more likely).• Women are 1.5X more likely to experience a mood or anxiety disorder than men.
Underutilization of Mental Health ServicesOnly a third of those who need mental health servicesactually receive them.• Individuals with Several Mental Illness: o 40-61% receive services• Individuals with Moderately Severe Mental Illness: o 24-40% receive services• Individuals with Mildly Severe Mental Illness: o 13-27% receive services
Cost of Mental Illness in Canada • Number one cause of disability in Canada, accounting for 30% of disability claims and 70% of total disability costs. • $51 Billion/year in lost productivity in Canada, including $34 Billion/year in Ontario alone. o On average, short-term disability leave for mental health reasons costs employers twice as much as leaves due to physical illness
According to the World Health Organization(WHO), depression will be the single biggestmedical burden on human health by 2020.
The Policy Challenge• Defeat mental health stigma.• Prevent the onset of mental illness among young, in the workplace, and among older Canadians.• Provide more integrated, effective and patient- centered primary care, social and health services, and community supports for people with a mental illness.
Social StigmaWhy is social stigma a health problem rather thanmerely a social problem?
Social Stigma• Both a proximate and distal cause of employment inequity, housing insecurity, poverty, lack of access to health services and poor support networks for people with a mental illness.• Main barrier to seeking care.• Aggravating factor in mediating the frequency and severity of a mental illness.
Ontario’s 10-Year Strategy• Dispel myths and misperceptions about mental illness.• Employ people with lived experience as spokespeople on behalf of people with a mental illness.• Work with CMHA to produce an anti-stigma campaign targeting children, youth and health care practitioners.
Ontario’s 10-Year Strategy• Provide anti-stigma training to first responders (e.g. health, legal, emergency teams) to improve perceptions of the service system.• Provide anti-stigma training for employers and landlords to make them aware of their legal responsibilities under the Ontario Human Rights Code and Accessibility for Ontarians with Disabilities Act.• Develop policies and mechanisms to better enforce regulations on behalf of people with a mental illness.
Prevention of Mental Illness through Continuous Care• Mental health & addictions are often the result of modifiable risk factors such as stress, anxiety, poor response to major life events/changes, lack of social support, lack of self-esteem, or the feeling that life is out of one’s control.• There are known ways of promoting coping skills in youth and adults, and delaying the onset of degenerative brain disease (e.g. Alzheimer’s) in older adults.• Services exist but continue to be offered in a disjointed, inefficient and provider-centric manner. A patient-centered model of care is needed to promote accessible, continuous care.
Ontario’s 10-Year Strategy• Healthy development approach: Work with parents and their children to promote healthy coping skills, through school-based and community-based programs.• Cross-sector training (schools, primary care, social services, first responders, etc.) for early identification and support of people with a mental illness.• Target programs to reach high-risk groups: o Children, college and university students, elderly, First Nations, unemployed and low-income groups, victims of domestic violence, newcomers, LGBT
Ontario’s 10-Year Strategy• Be aware of and promote mental health in all aspects of the delivery of government services.• Work with communities and private sector (e.g. Bell’s ‘Let’s Talk’ Campaign) to deliver education/awareness programs about mental health.• Provide wellness and mental health supports for seniors in community settings (e.g. recreational programing and seniors’ centres).• Bolster the role of primary care providers by targeting incentives, developing screening and brief intervention tools, and ensuring that FHTs coordinate with mental health and addictions treatment providers.
Given the recessionary economicclimate, Should Ontario be investingmore money in mental healthservices? Or should we try to get morevalue for what we already spend?
Medication, and Addictions• 3 out of 10 people with a mental illness will be dependent on alcohol or illicit drugs.• Substance use disorders develop when people with a mental illness, and underlying self-regulatory vulnerabilities, discover that the specific action or effect of a drug changes or relieves a painful affect state.• Given prevalence of stigma around mental illness, the prevalence of substance use suggests a desire to treat painful symptoms while avoiding diagnosis.
Medication, and Addictions• Dube et al. (2003) measured the effect of adverse childhood events (ACEs) on the subsequent development of illicit drug use and drug addiction. o ACEs included abuse (sexual, physical, emotional), neglect (physical or emotional), growing up with household substance abuse, criminality of household members, and parental discord.• A child with exposure to 5 ACEs was ~11 times more likely than a child with no exposure to report illicit drug use.
Recovery Approach to Mental Health Care• Considering the whole person, including her lived experience, to generate an individualized wellness plan that draws from a variety of community resources.• Emphasis on positive self-concepts, the patient’s autonomy, and turning attention towards her strengths and life goals (rather than her illness).• Provide evidence-based pharmacotherapy, as needed.
Harm Reduction Approach• In some cases, however, the history of trauma and the seriousness of substance use disorder may be such that there is a very low prospect that someone will overcome an addiction.• Fortunately, most harms associated with drug use are a result of bad policy. Undo the bad policies, and we undo most of the harm.
Black market caffeine• Caffeine has just been banned in Canada, following xenophobic political discourse linking coffee consumption to the arrival of new immigrant groups, who are avid coffee drinkers.• Accompanied by sensationalist (i.e. unproven) government claims about the health effects of caffeine on the human body -- tremors, psychosis, criminal behavior, immoral thoughts.• Workers (e.g. transport drivers, doctors, university professors) who rely on caffeine for work are forced to buy unregulated products from the black market.
Black market caffeine• Coffee in beverage form is too conspicuous, so dealers trade in caffeine pills and caffeine injections.• Due to the growing price of coffee beans, caffeine products are often cut with chemical fillers and other substances.• Many workers are caught consuming caffeine, stripped of their licenses, and burdened with a criminal record that all but eliminates their job prospects. Due to the stigma of addictions from employers, most become welfare recipients.
Black market caffeine• Traumatized by their dramatic socioeconomic decline and social isolation, many former caffeine users become depressed and turn to more powerful drugs for emotional relief.• The prejudice of some social service providers towards ‘addicts’ causes some individuals to lose their benefits. Without the needed resources to pursue legal avenues, some caffeine users listlessly accept their fate – to be homeless and sick.
Principles of Harm Reduction• Compassionate approach to understanding and working with people who use illicit drugs.• A therapeutic relationship based on respect, acceptance and community inclusion of society’s most abused and marginalized individuals.• Does not seek to impose naive treatment options (e.g. detox) for ideological (e.g. ‘moral’) reasons.• Rather, it focuses on safer drug use practices, celebrating small victories, and empowering clients to prevent harms to which they are routinely exposed.
Examples of Harm Reduction• Needle exchange programs.• Supervised injection facilities.• Distribution of safer crack smoking kits.• Distribution of free or subsidized condoms in high schools and universities. Other examples?
Vancouver’s Supervised Injection Site (‘InSite’)
Vancouver’s Supervised Injection Site (‘InSite’)• First opened in 2003.• Response to dual epidemic of overdose-related deaths and HIV infections in the Vancouver Downtown East Side.• Distributes safe injection kits, supervises injections, provides medical interventions as needed, offers primary care and access to counseling and detox programs (on a strictly voluntary basis).• Receives about $2M in annual funding from Health Canada and B.C. Ministry of Health.
Vancouver’s Supervised Injection Site (‘InSite’)Very effective• In 2009 alone, 484 overdoses were reported at Insite. Not one resulted in a fatality, thanks to medical supervision.• Overdose-related deaths in the Insite area have dropped by 35% since the opening of the site.• Prevents 35 cases of HIV and 3 AIDS-related deaths per year, for a net-social benefit of over $6M per annum.• Has resulted in increased referrals to detox programs.
Vancouver’s Supervised Injection Site (‘InSite’)Challenges• Though a majority of public opinion is now in favor of harm reduction sites such as Insite, some ‘law and order’ attitudes still hold back the public health gains that could be gleaned from wider adoption.• The RCMP, a critical stakeholder, has been lukewarm to the harm reduction approach.• Legal challenges from the Harper Government have thrown the future of Insite into question. However, the 2011 Supreme Court Decision that closing the site is unconstitutional was a sound victory for harm reduction advocates.
‚Nothing worth doing is completed in our lifetime;Therefore we must be saved by hope.‛ - Reinhold Niebuhr