Four decades of mental health policy in Ontario, Canada

Governance of mental healthcare: Fragmented accountability

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

A Fresh Approach to Reform? A Policy Analysis of the Development and Implementation of Ontario's Mental Health and Addictions Strategy

Background:

Open Minds, Healthy Minds, Ontario's Comprehensive Mental Health and Addictions Strategy commits to the transformation of mental health and addictions services for all Ontarians.

Objective:

We analyzed the formulation and implementation of this Strategy to address the question: What are the prospects for transformative change in Ontario's current approach to mental health and addictions?

Methods:

Qualitative policy analysis using interpretive description of key documents of the policy process, drawing on policy network and horizontal governance theory.

Results:

Three features set this policy process apart from previous reform efforts: (1) expansion of the state pluralist network to those outside of health, (2) extension of the policy network approach into the Strategy's implementation stage and (3) the combined presence of political and policy leadership.

Conclusions:

There is reason for optimism that the approach of the Strategy has increased the prospects for the transformation of Ontario's mental health and addictions system.

Right to Appeal, Non-Treatment, and Violence Among Forensic and Civil Inpatients Awaiting Incapacity Appeal Decisions in Ontario

Background: Mental health legislation in Ontario, Canada, permits inpatients to refuse treatment while appealing their incapacity finding to the Consent and Capacity Board (CCB). Lack of treatment during this period poses safety concerns, as inpatients who remain untreated are at higher risk of engaging in violent behavior. The present study explored the relationship between non-treatment and violence among forensic and civil inpatients awaiting their CCB hearing at the largest psychiatric hospital in Canada. Methods: We investigated the electronic health records of 285 inpatients whose CCB applications were heard between 2014 and 2016 to better understand violent outcomes among inpatients and determine whether application timelines differed between forensic and civil inpatients. Results: Three key findings were observed. First, forensic inpatients had more episodes of violence requiring seclusion and restraint during the application timeline compared with civil inpatients. Second, forensic inpatients waited longer than civil inpatients for their appeal to be heard at the CCB. Finally, unwillingness to accept PRN medications and comorbid psychiatric conditions were potent risk factors for violence among all inpatients during the appeals process. Conclusions: Compared with civil inpatients, forensic inpatients waited longer for CCB appeals. They also scored higher on one measure of violent behavior. These findings provide context for the ongoing challenge of clinicians tasked with providing care for inpatients appealing findings of incapacity under mental health legislation in Ontario. We argue for a more streamlined approach to processing appeals for both forensic and civil patients. Better standardization or even revision of current mental health legislation may help eliminate clinical disparities between patient groups.

Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: a population-based linked administrative database study

BACKGROUND

Involuntary admissions to psychiatric hospitals are common; however, research examining the trends in prevalence over time and predictors is limited. Aims To examine trends in prevalence and risk factors for involuntary admissions in Ontario, Canada.

METHOD

We conducted an analysis of all mental health bed admissions from 2009 to 2013 and assessed the association between patient sociodemographics, service utilisation, pathway to care and severity characteristics for involuntary admissions using a modified Poisson regression.

RESULTS

We found a high and increasing prevalence of involuntary admissions (70.7% in 2009, 77.1% in 2013, 74.1% overall). Individuals with police contact in the prior week (risk ratio (RR) = 1.20) and immigrants both experienced greater likelihood of being involuntarily admitted, regardless of control for other characteristics (RR = 1.07) (both P < 0.0001).

CONCLUSIONS

We identified numerous modifiable and non-modifiable risk factors for involuntary admissions. The prevalence of involuntary admissions was high, linearly increasing over time. Declaration of interest The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This study was conducted using funding entirely from public sources. P.K. has received operational support via an Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Services Research Fund Capacity Award to support this project. The Institute for Clinical Evaluative Sciences (ICES) is funded by the Ontario MOHLTC. The study results and conclusions are those of the authors, and should not be attributed to any of the funding agencies or sponsoring agencies. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. All decisions regarding study design, publication, and data analysis were made independent of the funding agencies.

Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014

OBJECTIVE

Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors.

METHOD

In this population-based study, we used linked health-administrative databases to measure annual rates of mental health-related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions.

RESULTS

Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health-related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( P_trend = 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( P_trend = 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( P_trend < 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, P_trend < 0.001 and 5.6 to 6.0, P_trend = 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions.

CONCLUSIONS

The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

A Critical Analysis of Debates Around Mental Health Calls in the Prehospital Setting

Paramedics, health care workers who assess and manage health concerns in the prehospital setting, are increasingly providing psychosocial care in response to a rise in mental health call volume. Observers have construed this fact as “misuse” of paramedic services, and proposed as solutions better triaging of patients, better mental health training of paramedics, and a greater number of community mental health services. In this commentary, we argue that despite the ostensibly well-intentioned nature of these solutions, they shift attention and accountability away from relevant public policies, as well as from broader economic, social, and political determinants of mental health, while placing responsibility on those requiring services or, at best, on the health care system. We also argue that the perspective of paramedics, who are exposed to, and interact with, individuals in their everyday environments, has the potential to inform a better, structural and critical, understanding of the factors driving the rise in psychosocial crises in the first place. Finally, we suggest that a greater engagement with the political and social determinants of mental health would lead to preventing, rather than primarily reacting to, these crises after the fact.

Assertive community treatment in the Netherlands: outcome and model fidelity

OBJECTIVE

The implementation of assertive community treatment (ACT) varies widely. To date, the association between model fidelity and effect has not been investigated in Europe. We investigated the association between model fidelity and outcome in the Dutch mental health system.

METHOD

In a prospective longitudinal study, ACT model fidelity and patient outcomes were assessed in 20 outpatient treatment teams. Patients with severe mental illness (n = 530) participated in the study. Outcomes were assessed 3 times using the Health of the Nation Outcome Scales (HoNOS), the Camberwell Assessment of Need Short Assessment Schedule (CANSAS), and the number of hospital days and homeless days during a 2-year follow-up period. Data were analyzed using multilevel statistics.

RESULTS

High ACT model fidelity was associated with better outcomes on the HoNOS and less homeless days. Among all of the ACT ingredients, team structure was associated with better outcomes. No associations were found between ACT model fidelity, number of hospital days, and CANSAS scores.

CONCLUSIONS

Our evidence supports the importance of model fidelity for improving patient outcomes.

The development and introduction of an in-patient student law services for persons with serious mental illness: a case study

There is a need to provide legal assistance to persons who suffer with serious mental illness for legal problems over and above problems associated with mental illness. This paper describes a single-case study of the development and introduction of a pilot of a hospital-based, legal service, in partnership with The University of Western Ontario Faculty of Law. The data sources included direct observation and documentation. Law students provide legal services reflecting the application of a therapeutic jurisprudence approach. Interprofessional education and training occurs with law, medical, nursing and other students, and professionals on the principles and scholarship of therapeutic jurisprudence, mental illness and legal rights. A programmatic organizational template, the program logic model, was used to conceptualize the activities, and process, short-term, long-term and ultimate objectives, and indicators. The four core activities were: (1) patient access point to law students; (2) supervision of law students at the London Health Sciences Centre; (3) intake and access to other services, and (4) teaching and additional training of law and other students, physicians and other health caregivers. The development, issues and challenges of the introduction of an in-patient student law service is described.

Process and Outcome Evaluation of an Emergency Department Intervention for Persons with Mental Health Concerns Using a Population Health Approach

PURPOSE

To evaluate an emergency department's use of a mental health triage and mental health crisis counsellor for persons presenting with mental health concerns.

METHOD

Mixed method (qualitative and quantitative), multiple measures.

RESULTS

Significant pre- and post-intervention reductions for wait time, security incidents and hospital admissions were found. Follow ups with a community agency, medications and a psychiatrist increased post-intervention, while follow ups with detox decreased post-intervention.

CONCLUSIONS

The qualitative and quantitative findings are congruent with other studies supporting the use of properly implemented mental health triage and crisis counsellors to improve the care of persons with mental health concerns.