Thursday, March 18, 2010

Troubled times for mental health: What can we do right now?


A letter to the editor published in today's edition of The Chronicle Herald:
By Stan Kutcher [pictured]

The recent series in The Chronicle Herald about the crisis in mental health highlighted a number of issues that are not new or unique to Nova Scotia. However, the question facing us in this province is: What are we going to do about it right now? Here are three immediate solutions to our problem that we could put into place quickly.

Focus on children and youth:

We know that approximately 70 per cent of mental disorders begin prior to age 25. We also know that early identification and effective treatment of these disorders is likely to lead to substantially better outcomes and may lead to long-term health cost containment.

So what can we do about this? First, we need to provide effective support to parents and communities so children receive the best early start they can. Then we need to train our teachers and all those who work with young people to learn how to identify children and youth who may be in the early stages of a mental disorder and provide seamless access to effective interventions.

This will require enhancement of human resources, of course, but this should be first developed in this age group. It is my impression that a modest increase in investment in child and youth mental health could lead to immediate short-term improvements with an additional long-term gain. The simple immediate solution: add additional human resources to child and youth mental health services.

Increase mental health care in primary health care:

The primary care sector is the foundation of our health care system. This is where the mental health needs of people are first brought for care. Yet our primary care sector is not set up to deal with such needs. Physicians require better training in the diagnosis and treatment of mental disorders, and primary care practices need to be supported with health providers who have the skills to provide ongoing psychological care. These providers do not need to be at the highest rank of the professional ladder. Rather, they need to have the competencies to counsel and support those who require mental health interventions.

Effective primary sector mental health care will not only address issues of access to care, but will also decrease the demand on specialty mental health services, leaving them more able to provide care for individuals who require more intensive interventions. The simple immediate solution: add counsellors and other trained therapists to primary care practices.

Stop investing in things that do not work:

Mental health care has long historical roots in many types of interventions for which there is little or no evidence of effectiveness or economic value. It is essential that we stop investing in things that we know do not work or for which there is little compelling evidence that they work.

While we have been moving towards greater awareness of the necessity for evidence-based care, we need to hasten progress in that domain and begin to provide funding on the basis of solid scientific evidence. If the evidence does not yet exist, then the funding could be provisional for a period of time until those who champion the intervention or program have had the opportunity to impartially determine its effect and value.

At the very least, no new programs or interventions should be applied without good, independent and most substantial evidence of their effectiveness and economic value. And all existing programs must be evaluated on what they achieve (their outcomes) not on what they do (their activities).

The simple immediate solution: base funding of mental health programs and interventions at least in part on substantive evidence of their effectiveness and cost-effectiveness and continue funding based on outcomes evaluation.

These three simple solutions may be a good place to start. Concurrently, there needs to be immediate and substantial structural change addressing how mental health services are conceptualized and how mental health care is delivered.

We need to stand back and critically and innovatively create a new system that meets the needs of people, provides care and not just services. It must be based on our national and community values and human rights, and be delivered using the best available scientific evidence by those providers best trained to provide care.

We need to also create a framework that can work alongside (but outside) the current health and mental health domains. This may be best realized by creating a Provincial Mental Health Commission (PMHC) that reports directly to the minister of health and that has as its one mandate the development of a provincial mental health strategy that is population needs-driven, innovative and based on best scientific evidence applied within values and principles that define us as caring, compassionate and considerate human beings.

The PMHC should have a sunset clause: five years. If we cannot do this in five years, we are not doing what needs to be done.


Dr. Stan Kutcher is Sun Life Financial Chair in Adolescent Mental Health and director, World Health Organization Collaborating Centre in Mental Health Policy and Training, Dalhousie University and the IWK Health Centre.

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