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Policy breif

A country with the second-largest land-mass in the world, Canada is a high-income country with an advanced economy, while Ontario makes up the largest province in terms of population, with nearly 40% of the population located there (Marchildon 2013, p. 1, 3). As such, social trends affecting Ontario may be good indicators of trends that may be prevalent across the wider country, while the simple fact of being so heavily concentrated also makes Ontario an inherent priority for successful management of national healthcare. This is especially true since Canada has a publicly-financed healthcare system, with 70% of healthcare expenditures being funded through tax revenues (Marchildon 2013, p. xvi). While a number of health issues may represent imminent concerns, mental health and addiction represent a significant health concern, especially because they stand to affect many Canadians at some point in their lifetimes, with over 2 million Canadians per year seeing providers about mental health or addictions (CIHI 2019; HQO 2018, p. 36). However, as with other health issues, there is a litany of factors that may render this issue, and these factors may also manifest these issues in a variety of ways. According to a 2017 report by the Centre for Addiction and Mental Health (CAMH 2017), the vast majority of mental health and addictions issues are more likely to affect men than women, except in the case of opioid addictions (p. iii). Interestingly, however, the agency also reported that – at least for substance abuse disorders – age was closely correlated with rates of use; that is, the highest levels of use were reported for 18- to 29-year-olds, with declining levels of abuse after these ages (CAMH 2017, p. iii). Other important risk factors include education levels, which showed declines in use with increasing education, and region, with certain issues being more prevalent in different parts of Ontario (CAMH 2017, p. iii-iv). A rather interesting risk factor correlation reported was that individuals with higher levels of income were more likely to report alcohol use, nonmedical prescription opioid use, and texting while driving. A more recent report from Health Quality Ontario (HQO 2018) suggests that the delivery of care may be a more pressing issue; specifically, the report points out the concerning trend that many Canadian children are receiving their first mental health care in emergency departments (p 37). Among those children who visited EDs for mental health care, 4 of 10 had received no prior care (HQO 2018, p. 37). While this was a slight improvement over the prior year’s rate of 5 of every 10, it is still a substantial number that indicates that there may be deeper challenges with the delivery of mental health care in Ontario. A similar sort of rhetoric is reflected in Marchildon’s (2013) report, which, despite being from years earlier, explains that Canada has historically lagged in supporting mental health care; as a result, much of this form of care is delivered by family physicians, who themselves report being frustrated with the quality of care they deliver to such patients (p. 115). The basis for this, per Marchildon, is a historical proclivity to fail to insure mental health services, particularly when they are not provided by physicians or hospitals. This is a somewhat deeply rooted issue, as it stems from the policy legacy upon which universal healthcare in Canada was stablished – a legacy that specifically emphasizes hospital-based care (Marchildon 2013, p. 115). This also included putting physicians in a privileged position compared to other professionals like psychologists, the latter who tend to be funded by alternative payment arrangements because they are not generally covered by insurance (PHAC 2015). However, somewhat ironically, this has wound up placing more of a burden on physicians, who may not be as adequately equipped to deal with mental health issues in such an extensive capacity as they are depended upon. Interestingly, despite covering addiction, the HQO (2018) report fails to address one of the most imminent issues in public health – at least within the scope of mental health and addictions. However, this issue still has very real and significant implications for addictions; that is the issue of opioid use. The failure to address this issue distinctly within the scope of addiction implies that opioid addiction has not become as prevalent as the simple use of opioids. Indeed, the report distinguishes the two rather subtly, and highlights the “opioid crisis” facing Canada by mentioning how the rate of “opioid poisoning” has nearly tripled between the years 200 and 2017 (HQO 2018, p. 16). In this context, HQO advises focuses on how increased rates of opioid poisoning have caused a spike in emergency room visits. Thus, it is interesting to note the stark similarity between this issue and that of failure to adequately support mental health in general, thus spurring a dependence on emergency services. It also intuitively follows that, as incidents of opioid poisoning (and thus opioid use) increase, the propensity for opioid addiction increases alongside it. Furthermore, HQO (2018) suggests that rates of “new starts” of opioid patients has decreased; this is the rate of people who fill an opioid prescription who had not filled such a prescription in the prior six months (p. 16). While this sounds like an improvement, they also critically point out that most of the overdoses, and especially fatal overdoses, are attributed with people using drugs from “street sources” (HQO 2018, p. 16). Thus, the problem of opioid addiction in itself could actually be more prevalent than is being reported, since those who are more likely to need it illegitimately may also be more likely to use illicit sources to acquire it. Incidentally, the report also highlights differences in opioid abuse rates across regions, with the Erie St. Clair region exhibiting the highest rates of opioid new starts at nearly twice the rate of Central Toronto (HQO 2018, p. 16). Also worth noting in this context is that the United States has had a rampant issue with opioids, and due to the geographic proximity Canada shares with the US, the US “exerts considerable cultural and economic influence on the daily life of Canadians” (Marchildon 2013, p. 2). Thus, it is possible that the nature and origin of opioid issues in Canada also partly stems from beyond those factors directly observable within Canada. However, one somewhat related issue that has gained much more prevalence (and somewhat uniquely within Canada) is cannabis use, which has rapidly increased, with more than 50% of users assessed as having “moderate to high risk of cannabis problems” (CAMH 2017, p. ii). Analysis Without a doubt, one of the biggest issues facing mental health and addiction services as a whole is inadequate support for these services. This is a multifaceted issue, and arguably one of the most central factors in it is the lack of coverage of these services when they are not provided by hospitals or physicians specifically. While perhaps this notion served some greater purpose in the original construction of Canada’s universal healthcare system, it now seems to entail more of a disparate burden, forcing physicians to deal with bulk of such issues when these types of issues are really better left in the hands of specialists. While most physicians are no doubt equipped to deal with most basic mental illnesses, they are far less likely prepared to manage these conditions over a long-term, particularly when they must also be responsible for more generalized health concerns, such as basic physiological functioning. The overutilization of emergency departments for mental health issues also tends to suggest that screening for mental health issues is not currently adequate. It seems unlikely that so many Canadian children are suddenly presenting with mental health issues in emergency departments after having exhibited no prior symptoms. Rather, it is more likely that initial symptoms were somewhat subtle, and failure to screen for issues led to their generally being ignored. Of course, part of this also likely stems from how mental health is handled primarily by physicians. Because physicians are generally not expected to manage mental health in such a meticulous way, they are probably not as disposed toward issuing such screenings when they must also ensure the integrity of a number of other physiological systems. Thus, the improvement of screening also seems inherently tied to the integration of alternative providers of mental health services. At the very least, freeing physicians of the burden of having to monitor and maintain mental health conditions may free up their attention to better emphasize screening. However, this also confers a substantial cost burden onto the government, as covering mental health issues may open a compendium of new costs as the actual scope of mental health issues in Canada becomes better recognized as people actually engage these services more widely. At the same time, it is possible that health quality in Canada as a whole may improve slightly, as physicians will be able to devote their time and resources to better accommodating issues on which they are more thoroughly trained, and may facilitate greater mental health and addiction outcomes by directing affected patients to appropriate providers, instead of basically being forced to accommodate them. Recommendation In no small way, the lack of coverage of mental health issues in Canada’s healthcare system represents a significant barrier to successful care in multiple contexts. By virtue of this, people are not receiving as efficient care as they should be, leading to deficient mental healthcare provision where issues are recognized, and more generally leading to failure to recognize issues until they have manifested potentially severe consequences (e.g.: emergency department utilization). While funding mental health will not stop all of these issues from occurring, it would put a significant damper in these trends. While such an effort would require a substantial initial cost outlay, it would potentially greatly improve mental health outcomes, particularly since these outcomes may be complicated by unforeseen future developments. For example, problematic use of technology was a mental health concern identified by CAMH; and while the long-term implications of this in itself are not particularly clear, it is clear that having a framework in place that facilitates successful accommodation of mental health issues is a critical first step to addressing this and any other issues that may arise. After all, if specialists are not prepared for such novel developments, then how is it more practical to assume that generalists will be? Thus, the most important priority for the government is to implement a means for such issues to be addressed in the proper context, which can only occur if mental health services become covered with the same health plan that the general Canadian public depends on.

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