For historical reasons, some mental health services, particularly those not provided in hospitals or by physicians, have never been included as fully insured services under the Canada Health Act. The policy legacies associated with the development of universal medicare in Canada included an emphasis on hospital-based treatment and a privileged position for doctors – GPs and psychiatrists – over other mental health care providers (Mulvale, Abelson & Goering, 2007; Dyck, 2018). For example, the services provided by psychologists are largely private, and paid for through private health insurance as part of employment benefit packages, or OOP payments (Romanow & Marchildon, 2003).
As a consequence, in part, of this policy legacy, GPs provide the majority of primary mental health services in Canada. GPs also serve a referral function to community services, and each province and territory includes a range of community mental health and addictions services in its publicly funded insurance programme: these include case management, help for families and caregivers, community-based crisis services, and supportive housing (CIHI, 2018e). The Commonwealth Fund Survey of Primary Care Physicians in 2019 found that 61.4% of GPs felt well prepared to care for patients with mental illness (e.g. anxiety, mild or moderate depression), and only 19% felt prepared to care for patients with substance use disorders (e.g. drug, opioid or alcohol use) (CIHI, 2019h). These findings have been echoed in other studies, for example, revealing that patients perceived that their GPs had limited knowledge of mental health and addictions, and that primary care professionals felt they needed more knowledge and experience in order to provide high-quality mental health care (Wener & Woodgate, 2017).
There are limited comparable data across Canada on access to mental health services, or measures of mental health and well-being. PHAC has compiled national statistics on mental health and well-being to populate a Positive Mental Health Surveillance Indicator Framework, and disaggregate indicators by age, sex, province, urban/rural, and other variables. Recent estimates from CIHI suggest that nearly 10% of Canadians who visited the ED for mental health or substance use concerns were frequent visitors (four or more in a year), and 12.7% of individuals who had been hospitalized in a year for a mental health condition had three or more hospitalizations in a year (CIHI, 2019e).
These data suggest that there are major challenges in accessing mental health and addictions services in the community. Moreover, estimates suggest that although provinces and territories have increased their spending on mental health in the past decade, as a proportion of total health spending, mental health spending is lower in Canada than in other countries, at 7% in Canada compared with 15% in France, 13% in England, 11% in Germany and 8% in Australia (CIHI, 2019i).
Like almost all other OECD countries, Canada’s mental health outcomes in term of mental and behavioural disorders have not improved appreciably since the implementation of deinstitutionalization in the 1960s (OECD, 2018). In 2006, the Standing Senate Committee on Social Affairs, Science and Technology recommended that a national commission be established to develop a pan-Canadian policy for mental health care and addictions (Senate, 2006). One year later, the Mental Health Commission of Canada (MHCC) was established by the federal government with the endorsement of all provinces and territories except for Quebec. In 2009, after extensive consultations with governmental and nongovernmental stakeholders, the MHCC released its first major report setting out a mental health strategy (MHCC, 2009). Since then, the MHCC has produced public reports, and contributed to training, capacity-building and public awareness about mental health in Canada.