To make effective investments, provinces and territories must do a better job of measuring the capacity of their mental health care systems.
The COVID-19 pandemic has sparked concern about the mental health of the population and the ability of health care systems to respond to treatment needs. Robust, valid data collected and shared nationally is necessary to help guide decision-making so that the population’s mental health care needs can be appropriately addressed. This data must address three categories – the mental health needs of the population, services required to meet those needs, and whether individuals are responding to these services as expected. Unfortunately, robust and necessary data in these domains is not currently available.
Much of the existing population-based mental health survey information collected in Canada during the pandemic has been of inferior quality, with poor study design, no capacity to differentiate between normal emotional responses from states that require treatment, and inadequate sampling of minorities and marginalized groups. This all leads to an inability to accurately determine the mental health burden in the Canadian population. In many cases, these surveys/polls have led to sensationalized headlines based on confusion between people reporting feeling stressed during a stressful situation and reporting a true state of depression or anxiety. Building on these issues, there remains an unmet need for data that can be used by governments and policy-makers to evaluate how the mental health system is responding to need for care over time. This is a problematic information gap that surveys cannot address.
Little is known about the current state of our mental health system nationally and within each province and territory. This is a problem because, anecdotally, there exists a tremendous amount of unmet need. Robust data; collected, collated and provided in a timely manner is required to inform policy-makers about: 1) the needs of the population (including unique sub-groups); 2) the types of services available, and required, to respond to the population need; and 3) whether or not efforts to respond to need are achieving the intended outcomes.
In Ontario, the Ministry of Health has invested in the measurement of the mental health system by creating the ICES Mental Health and Addictions Program. Data obtained to date has shown a doubling of mental health and addictions-related emergency department visits among youth (16 to 24 years) between 2009 and 2017. It has also shown that the prevalence of depression and generalized anxiety disorder have remained unchanged between 2002 and 2012, but the perceived need for services has dramatically increased.
Taken together, these are important findings – the actual disease burden has not increased over time, but substantially larger numbers of people are now seeking help and this help-seeking behaviour is more common in the younger demographic. Additionally, the data has identified that the provision of acute mental health care is woefully inadequate: 60 per cent of individuals who went to an emergency department following a suicide attempt did NOT see a psychiatrist within six months after the event. This real-world information about the performance of the mental health system is necessary to effectively address areas of concern that can then lead to improvements in mental health care. You cannot change what you cannot measure.
It is essential that such data be available nationwide so that the impact of the pandemic on mental health care can be better understood and in turn better direct the post-pandemic provision of mental health care. For example, over this period one of the common changes in mental health care delivery has been the widespread use of virtual appointments. This displaced the traditional site-based, face-to-face models. While there has been much speculation and some small-scale evaluations of this change, the impact of this pivot can only be determined if robust and reliable national data is collected. Data is needed to answer the following fundamental questions: for whom did virtual care work? For whom did it not work? Who was left behind? What was the overall impact (for example, rates of hospitalizations among those left behind)?
Every province and territory needs to know what is happening within their mental health systems, but very few have good capacity for performance measurement. If each province and territory were to develop better mental health system performance measurements, efforts to improve access and quality of care could be informed by evidence. For example, the scenario above describing the very low rate of psychiatric follow-up to a suicide attempt could lead to the development of interventions to improve care, and the very same data could be utilized to monitor whether the intervention worked as intended. Sharing this information across provinces and territories could help scale up effective interventions nationally and decrease risk for investment in those that are unlikely to show return.
It didn’t take a huge investment for Ontario to improve its measurement of the mental health system’s performance. It should be done across the country. The federal government can assist in this by leveraging existing resources. This might include increasing funding to the Canadian Institute for Health Information so that it could better address this measurement issue, and creating criteria within the Canada Health Transfer that would link a portion of those funds to provincial/territorial participation in the development, collection and sharing of this kind of mental health data.
Moving forward, infrastructure must also be developed to improve the measurement of multiple aspects of the mental health system. For example, in most provinces, there is no standardized access to mental health services, meaning people have to navigate a complex array of services. Establishing centralized access points (including virtual access points) can simplify the process. If the information collected at the time of assessment is standardized, we will have information about the population seeking mental health and addictions services. For the first time, we will have real-world information about the population seeking help, and will be able to tailor existing services and future investments to meet their needs.
If this sounds like a tall order, consider the consequences of not developing effective mental health system measurement capacity – any investment to address need will be like pouring water into a leaky bucket. Systems of care delivery have been built with those measurement capacities for cancer, stroke and cardiac care. It may be more complicated to do the same for mental illnesses and addictions, but the roadmap is in place. Canadians with mental illnesses and addictions deserve better than the status quo.