This document provides an overview of a university course on Canadian health policy relating to mental health and addictions. It includes topics that will be covered in an upcoming lecture, potential topics for student briefing notes, and news articles relevant to mental health issues. Briefing note topics focus on policy issues around mental health, addictions, and chronic disease prevention. The lecture will cover trends in mental illness, approaches to mental health care, stigma, trauma, self-medication, principles of recovery and harm reduction.

1. Policy Issues:
Mental Health & Addictions
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies
Course Instructor:
Alex Mayer, MPA

2. Announcement
• HLTH DSC Bake Sale
o Wednesday, 11AM to 4PM
o In the ARC
Video: Bake Sale Advertisement

3. 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?

4. • 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

5. • 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

6. • 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

7. 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)

8. Mental Health & Addictions

9. 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

10. 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

11. Maslow’s Hierarchy of Needs

12. Approaches to Mental Health
Different approaches to delivering Mental Health Care
in 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 illness
Let’s travel back in time…

13. 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)

14. 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)

15. ‘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.

16. 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.

17. 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.

18. Early 20th century
Following World War I, the prevalence of ‚shell shock‛
lends credibility to the idea of psychological causes of
mental illness and the notion that everyone has a ‘breaking
point’.
o Birth of modern psychiatry and clinical psychology

19. Late 20th century: Biopsychosocial Model
In 1977, Engel introduces the BPS model of health, which stipulates
that a combination of biological, psychological and social factors
combine 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

20. Approaches to Mental Health
in Canada
3 Distinct Periods (like most developed countries)
in the way we as a society have approached mental
illness.
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.

21. Approaches to Mental Health
in Canada
1900-1960s: 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

22. Approaches to Mental Health
in Canada
1960s-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.

23. How prevalent is mental
illness in
Canada, anyway?

24. 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.

25. Major Clinical Diagnoses in Canada
Condition 1-Yr. Prevalence
Anxiety Disorder 12.2%
Major Depression 4.1 – 4.5%
Alcohol Dependence 3%
Dysthymia 0.8 – 3.1%
Bulimia 1.5% (women)
0.1% (men)
Anorexia 0.7% (women)
0.2% (men)
Bipolar Disorder 0.2 - 0.6%
Schizophrenia 0.3%
Suicide 24% of deaths (15-24 yr.)
16% of deaths (25-44 yr.)

26. 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.

27. 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.

30. Underutilization of
Mental Health Services
Only a third of those who need mental health services
actually 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

31. Underutilization of
Mental Health Services

32. Underutilization of
Mental Health Services

33. 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

34. According to the World Health Organization
(WHO), depression will be the single biggest
medical burden on human health by 2020.

35. 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.

36. Social Stigma
Why is social stigma a health problem rather than
merely a social problem?

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

42. 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.

43. Given the recessionary economic
climate,
Should Ontario be investing
more money in mental health
services?
Or should we try to get more
value for what we already spend?

44. Trauma, Self-Medication,
and Addictions

45. 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.

46. 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.

47. 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.

48. 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.

49. What do I mean by this?

50. 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.

51. 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.

52. 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.

53. 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.

54. 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?

55. Vancouver’s Supervised
Injection Site (‘InSite’)

56. 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.

57. 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.

58. 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.

59. ‚Nothing worth doing is completed in
our lifetime;
Therefore we must be saved by hope.‛
- Reinhold Niebuhr

60. Have a great week!