CHATHAM—When Katrina Stone first walked into the brand-new mental health clinic on the main street of this historic southwestern Ontario town five years ago, she was in crisis.
She had already lived through four sexual assaults and six suicide attempts. She was struggling with post-traumatic stress disorder, years of self-harm and an addiction to alcohol.
She was also pregnant with a child she didn’t think she wanted. She was 18 years old.
“I was having flashbacks and nightmares,” she said. “There was a lot of self-hate and blame for things that had happened.”
Within moments of stepping through the clinic’s doors, Stone became an early adopter of the innovative new “hubs” model.
“When I walked in to Access Open Minds … something was different,” Stone said. “They got me on the right path …I got to meet a lot of people who were very sympathetic and they all felt very friendly… I started being able to conquer it.”
If you are thinking of suicide or know someone who is, there is help. Resources are available online at crisisservicescanada.ca or you can connect to the national suicide prevention helpline at 1-833-456-4566, or the Kids Help Phone at 1-800-668-6868.
Thousands of young Canadians with mental health challenges are now being treated in these one-stop mental health centres that bring a battery of specialists under one roof to offer medication, therapy, addiction treatment, and housing and career support.
Hubs tackle one of the most common complaints among Canadian youths seeking mental health help: Most of the time, the services they need are spread out among multiple healthcare providers, each focused on a speciality without an understanding of the larger challenges.
At hubs, accessing a range of services means crossing the hallway instead of the city or region.
“Let’s say you have anxiety or depression,” said Dr. Ashok Malla, lead investigator for the Montreal-based Access Open Minds initiative, one of two hub organizations that run the Chatham facility. “You’ll get a person who is qualified to deal with that. But at the same time, you might also be struggling with looking for work … The employment counsellor is available right there.”
Dr. Joanna Henderson, executive director of Youth Wellness Hubs Ontario (YWHO), which has 10 centres operating across the province and also co-runs the Chatham site, said the model is addressing the traditional challenges of treating youth mental health care.
The model is relatively new in Canada.
YWHO, Access Open Minds and B.C.-based Foundry have together launched more than 30 centres in nine provinces and territories in the past six years, with funding from the Graham Boeckh Foundation, a charity devoted to promoting innovation in mental healthcare.
The early results point to streamlined bureaucracy and faster access to care for many young patients whose mental health challenges have been exacerbated by long waits and inefficiencies.
Access Open Minds was created as part of a project at McGill University’s Douglas Research Centre. Set to complete its initial run in 2022, the project has tested the effectiveness of the model to bridge the gap between child and adult mental health services.
Since 2016, The Chatham-Kent site has served 1,400 youth with 36 per cent of them identifying as LGBTQ+, six per cent as Indigenous and 11 per cent as having lived in foster care.
The hub model of integrated care now exists in hundreds of clinics in at least nine countries.
A 2012 international review of patient trials of collaborative care — a similar model also based on assembling teams of providers for a patient — found they showed “significant improvement in depression and anxiety outcomes,” compared to more traditional forms of treatment.
By targeting underlying issues and resolving them early, the model promises to save the health system money by reducing the number of youth flocking to emergency rooms.
Access estimates its model can save up to $4,500 per patient per year, with a return-on-investment in healthcare savings of 10:1.
Alongside provincial investments at YWHO and Foundry, similar projects are in early development in Alberta, Manitoba, New Brunswick and Newfoundland and Labrador.
Ian Boeckh, president of the hubs-funding Graham Boeckh Foundation, calls the Canadian roll-out “very ambitious.”
“We see something that really has that potential to transform the mental health care system for youth…We can start to think of this scaling to every community in Canada.”
The hub model is also migrating to Canadian campuses as universities and colleges work to meet rising demand for mental healthcare amid expanding waitlists for counselling.
The University of Alberta has integrated an Access Open Minds centre into its counselling.
Today, a student there can reach out to the counselling centre, students’ associations or academic departments and get a referral into the Access network. From there, they are assigned campus-based services to meet their care plan, similar to off-campus hubs.
An internal review published by Access in 2019 found the University of Alberta network had consistently succeeded in meeting its goal of a 72-hour response time, except in cases where student schedules didn’t line up with availability.
The interior of the Chatham hub appears as a kind of streetscape, with a row of themed counselling and meeting rooms inspired by youth who were consulted on the design.
There’s the Harry Potter room, the Zen Garden, the Movie Room and the Cottages, each designed to reflect a different mood. Practitioners sit in comfortable chairs next to their clients, rather than behind desks.
“The idea was just to be a nonjudgmental, calm, welcoming sort of vibe when you walked in,” said Charles Langford, 19, a member of Access’ national youth advisory council.
Before any new Access centre is built in a community, the organization assesses the area, its cultures and its service gaps. At the four sites that specialize in Indigenous youth, cultural practices and perspectives on wellness are integrated into treatment.
“The model is extremely flexible, based on what the contextual needs are,” Malla said. “What works in Cree Nation or a Mi’kmaq community will not work in Edmonton.”
Stone said she worried her visit to the Chatham centre would be the latest unsuccessful round of counselling.
“Just literally walking into the building was different,” Stone recalls. “It wasn’t so office-y.”
Stone was first assessed by the clinic’s intake staff and assigned to Janice Kirkwood, a youth case manager and specialist in both trauma and substance abuse.
In the past, either the psychiatrists and counsellors did not seem to understand her struggles, or the interactions ended with broken promises. This was different, she said.
“I felt like I was talking to a friend, rather than just a counsellor,” Stone said. “She actually didn’t mind spending time with me, and not putting me on a clock.”
When Stone was experiencing seizures from stress and her driver’s license was suspended, Kirkwood made house calls. When an hour-long session would end and Stone had more to say, Kirkwood stayed put.
Life is much better for Stone these days.
Now 23, she works at a local birth clinic as a doula, inspired by the woman who guided her through her own childbirth. With Kirkwood’s help, she got medication, referrals to housing and victim compensation programs, vocational training and advice on personal budgeting.
Stone still sees Kirkwood from time to time. There’s still work to be done, she said.
There are triggers that take her back to the darkest moments in her life. And the suicidal ideation hasn’t gone away altogether.
“I still have nightmares occasionally, and there will be triggers that I still face on a daily basis. But [Kirkwood is] teaching me a lot on how to cope with those things,” Stone said. “I obviously still have those bad days…but I feel proud, finally.”
Youth, parents, psychiatrists, counsellors and researchers say mental health care could be dramatically improved in Canada by reforming a set of key policy and professional practices.
Here’s a sampling of ideas based on more than 200 interviews and a review of more than 100 academic studies and papers:
Early Intervention and Post-18 Care
Detecting and treating mental health at an early age can address problems before they upend lives and dramatically reduce the long-term cost of care to the public purse.
But Canada has largely failed to act on that knowledge.
London, Ont., is home to one of the only facilities in Canada focused on early intervention for depression and anxiety in young people -The London Health Sciences Centre’s (LHSC) First Episode Mood and Anxiety Program (FEMAP).
“Sixteen to 25 is so pivotal, and inform[s] people’s educational career and relationship endeavours for the rest of their life,” said FEMAP founder Dr. Elizabeth Osuch. “You see these people who have a mood and anxiety problem that is highly treatable… It is just a crying shame if they can’t get back on that normal path, because their whole lives will be different.”
A lack of coordination in Canada’s mental health system places many young people in the expansive crack between youth and adult care systems, she said. Without a smooth transition that early intervention provides, too many young lives are knocked off-course for good, she said.
That might have been Tandra Lepine’s story. Upon turning 18, she aged out of youth mental health care support which meant she could no longer see her counsellor, who specialized in children. Worse, she lost coverage for her costly prescription medication.
At 19, living without treatment in a small Manitoba town, she found herself wandering down to the community bridge a couple of times a week to stare down at the water, wondering.
“I felt very alone. I felt worthless,” Lepine recalled.
If you are thinking of suicide or know someone who is, there is help. Resources are available online at crisisservicescanada.ca or you can connect to the national suicide prevention helpline at 1-833-456-4566, or the Kids Help Phone at 1-800-668-6868.
She eventually moved to London and, at age 23, was referred to FEMAP by local crisis workers.
“I actually felt cared for,” Lepine, now 26, said. “I was made to feel like my existence mattered.”
Her psychiatrist also helped her restart her medication, filing an Exceptional Access Program form to waive her prescription costs. Years later, she continues to see him regularly, as existing patients are not dropped when they age out of FEMAP’s target range.
In November, the LHSC announced that work was underway on a second FEMAP location, set to open in early 2021 as part of a $4 million fundraising effort to reduce wait times, expand services and double the program’s clinical staff.
To date, close to $2.8 million has been raised, but money remains a stumbling block.
The program still has no hospital budget. It is run on philanthropic donations collected through the hospital’s foundation.
The lack of public funding for the country’s youth mental health crisis defies a proper long-term economic analysis, Osuch said.
“You can have someone partially or completely disabled from these illnesses, if they’re not treated.”
Psychiatric Standardization
Psychiatry needs reform if we’re going to have an impact on youth mental health, said Benoit Mulsant, head of psychiatry at the University of Toronto.
Too often, he said, psychiatry is seen as a subjective process guided by the clinician’s personal intuition and experience, rather than defined by a clear set of measurable tools more common in other areas of medicine.
“You want your accountant to use a calculator,” Mulsant said. “Why wouldn’t you want a psychiatrist to use a tool to diagnose you?…We don’t have the kind of standardization of care that exists in other areas of medicine. We are reinventing the flat tire with every patient.”
FEMAP’s Osuch said this uncertainty creates a culture of skepticism among patients.
“I can send the same exact patient to six different psychiatrists, and I can get very different diagnoses,” she said. “It makes people think ‘oh, these illnesses are not real, because we can’t measure them.”
“They’re very real. We just don’t have the technology yet.”
Psychiatry should take a page from Cancer Care Ontario, said Paul Kurdyak, lead mental health researcher at the Institute for Clinical Evaluative Sciences.
He points to the agency’s founding in 1995 as the catalyst for incredible progress in fighting the disease, chiefly due to its focus on standardizing care.
Without the same kind of approach in psychiatry, policy makers have an obscured view of how to deploy resources.
“The province of Ontario actually spends quite a bit of money [on mental health],” Kurdyak said. “But they don’t have a sense of value for money.”
National Suicide Strategy
One of the key measurements of success in youth mental health work is suicide numbers. On that score, experts say Canada has a long way to go.
With the 47th-highest suicide rate in the world, Canada is among the top-third of all countries. For youth suicides, Canada is fifth among more than 30 nations in the Organisation for Economic Co-operation and Development.
In Indigenous communities, especially in the far north, suicide is a widespread crisis. If Nunavut were its own country, its suicide rate would be the highest in the world.
As one of the few Western nations without a national suicide strategy, Canada’s approach to measuring and treating the problem is failing young people, said Peter Szatmari, a physician and mental health researcher with CAMH, SickKids Hospital and the University of Toronto.
“The emergency room is separate from community organization, separate from schools, separate from social support systems. None of the systems are working together for kids. Currently, they’re all funded differently. While they work well in their sphere of influence, they don’t work well between their spheres of influence,” he said.
National suicide strategies, appearing in more than 40 countries over the past four decades, are associated with significant drops in suicide rates, including nine per cent in Finland and 18 per cent in Scotland, both over 10 years.
The World Health Organization has described them as “essential” to reducing suicides.
Canada has a federal suicide framework, adopted in 2016, which prioritizes awareness campaigns, destigmatization, increased statistical reporting and accelerated research efforts into suicide prevention.
But many health experts, including Szatmari, say a framework of suggestions doesn’t go far enough.
“Strategies provide clear roadmaps, with goals, timelines, resources, assigned responsibilities and a robust plan for their evaluation,” a 2016 editorial in the Canadian Medical Association Journal said.
“A framework is not a strategy. It does not bring necessary resources to bear, nor does it mandate the federal and provincial–territorial actions and multisectorial partnerships required to underpin effective suicide prevention across Canada.”
In a statement, the Public Health Agency of Canada (PHAC) said it works collaboratively with different levels of government and organizations on “initiatives that promote positive mental health.”
“Suicide prevention and mental health promotion are a shared responsibility across sectors and jurisdictions—from national initiatives to community-based programs,” the statement reads.
Though Canada lacks a federal strategy, some provinces have taken the reins.
In 1997, Quebec established the Help For Life strategy, pouring resources into reducing access to the means of suicide, encouraging more responsible media coverage and investing in awareness, research and crisis intervention.
By 2012, Quebec’s suicide rate had fallen to 13.7 per 100,000 people, from its 1999 high of 22.2. Among teenagers and young adults, the province saw a 50 per cent drop in suicide rates.
Other regions with suicide prevention strategies include Alberta, New Brunswick, Manitoba and Nunavut, each of them implementing them with varying levels of success.
For Canada to translate its disparate regional strategies into federal action, it would need commitment from each province and territory.
Ian Dawe, mental health director at Trillium Health Partners in Mississauga, said that when resources are properly marshalled for public health crises, “we’re actually pretty good at changing numbers that were seen to be intractable… This is suicide’s time.”
With files from Emma Renaerts / University of British Columbia School of Journalism
This story was also published in the Toronto Star.
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