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Changing Directions, Changing Lives: Canada Launches a National Mental Health Strategy

Posted By Ajantha Jayabarathan, Thursday, June 14, 2012

Collaborative Care Policy Month

"If necessity is the mother of invention, then adversity must be one of the fathers….”

In the early 1990s, there was the widespread recognition at the grass roots that mental illness and addictions greatly contributed to human suffering. This was evident in communities, in the workplace, in family doctors offices, during inpatient and outpatient visits at hospitals and in long term care facilities. And everyone did their best within the existing system of health care. When issues were identified, a referral for consultation with mental health professionals, private or publicly funded, was usually arranged and the process was no different than being sent to a cardiologist for issues identified with the cardiovascular system.

However, there was something very different about seeking and receiving care when it involved mental health and addictions. I believe many people, their families, health care providers and managers of health services were aware of a myriad of issues that contributed to this difference, and the complexity of the problems were daunting.

However, all journeys start with the first steps, and in Canada, the formalizing of what came to be called "Shared Mental Health care” embodied these initial incremental efforts. Family Doctors in rural communities and smaller centers have long managed complex medical issues through "shared care” with specialists. The process involved "getting to know one another” at doctors lounges or during minor league baseball. Smaller communities lend themselves to more opportunities to meet and greater ease of networking resulting in partnerships that grow over time and through shared experiences.

A small group of psychiatrists and family doctors in Toronto, Ontario started to experiment with the idea of psychiatrists coming to the family doctors office for an afternoon to help deal with issues rather than the traditional referral letter arriving in their mail. It became evident that this simple change was yielding great benefits to the doctors and their patients.

Dr. Nick Kates and Dr. Marilyn Craven , approached their National organizations, the Canadian Psychiatric Association and the College of Family Physicians of Canada, and presented this model to them. This resulted not only in these two professional organizations deciding to form a working group to develop this model further but also brought individuals with a systems level view to the table. The group was influenced by Global initiatives such as the

  • "Declaration of Alma-Ata" in 1978,
  • "Health for All by 2000”, which emphasizes the role of primary care,
  • "World Development Report 1993: Investing in Health" which emphasized concentrating on economic benefits of "single item” interventions, and
  • "The World Health Report 2008 − Primary Health Care: Now More Than Ever".

A literature review of Shared mental health care/ Collaborative care practices was completed by Drs. Roger Bland and Marilyn Craven and was an important milestone as well as a foundational piece for the future directions of this journey.

What ensued in the next ten years was a rapid acceleration of this journey.

The first position paper , "Shared Mental Health Care in Canada” was published in 1997 and generated widespread interest and awareness of this model. Canada’s Primary Care Reform was underway in the early 2000s and provided two Federal grants that funded shared mental health care pilot projects across the country and the development of the Canadian Collaborative Mental Health Initiative ( . CCMHI developed Collaborative care toolkits and a charter that expanded this model to include people and their families, nurses, pharmacists, dieticians, occupational therapists, social workers and psychologists. Annual provincial conferences on Shared mental health care were held which invited presentations from groups that had implemented these models in their clinical settings and placed a focus on evaluation, research and knowledge exchange in this area.

Provincial funding-incentives promoting collaborative networks of practice and learning gave system level support to this model across the country.

The Canadian Armed Force Initiative, RX 2000 considered this model for their strategic planning. The Canadian Medical Protective Association acknowledged collaborative models of medical practice in support of practitioners who were now working differently within these emerging initiatives.

An important milestone was achieved when the Royal College of Physicians and Surgeons of Canada adopted training guidelines for psychiatry residents in Collaborative mental health care

At this time, the Federal government had formed the Mental Health Commission of Canada to develop a Mental Health Strategy for the country. The establishment of CHEER in 2011 ( Collaborative Healthcare exchange, evaluation & research) within the framework of the national strategy heralded the widespread recognition of the merits and value of this model of care at all levels of the system of health care. Dr. Nick Kates and Dr. Francine Lemire from the Canadian Psychiatric Association and the College of Family Physicians of Canada are the Co-chairs of CHEER.

The Mental Health Strategy for Canada, Changing Directions, Changing lives, was just released in May 2012. The six strategic directions in the strategy aim to transform the system of health services by integrating mental health and addictions related services from the grass roots of health promotion to management of chronic and severe mental illness and addictions across the lifespan of humans. It extends the expectation that the needs of families, communities and workplaces must be considered and supported as this journey of change transforms us individually and collectively.

The timing of the 12th Collaborative Mental Health Conference held in Halifax during June of 2011 was such that several of these major developments were incorporated into the content and presentations at the conference. During this time, the Minister of Health and Wellness, Maureen MacDonald, with her grass roots experience as a social worker, was resolved to develop a provincial mental health and addictions strategy to address the complex myriad of difficulties in providing and receiving mental health and addictions care in Nova Scotia.

She selected an advisory committee of diverse members to develop recommendations for the provincial strategy. The committee held consultations across the province, studied existing literature and commissioned reports to better understand and identify gaps in the current system. "Come Together", was the culmination of over two years of work and had 61 recommendations intended to snap together to address the complex gaps identified. It called for a cross jurisdictional approach within government and the districts within the province, reducing inefficiencies and waste of resources, strategic investment of new funds to develop early detection and management of issues within primary care, within families, school, communities and workplaces.

Collaborative care was presented as a means by which meaningful partnerships and working relationships could be forged in addressing system wide, deep seated issues that urgently needed change. The response from the government was to accept all the committee's recommendations . In "Together We Can”, Nova Scotia has started its own journey towards health and wellness through collaborative care based processes that are intended to lead to improved access to high quality care that is sustainable for our province.

And as I write the final words of this article, we are poised to release the recorded content from the ground breaking Collaborative Mental Health Care conference held in Halifax in June 2011, to a global audience. You are welcome to go to, and follow the links to the "First Online Collaborative Mental Health care conference”.  The content is sure to inform and inspire you!

This journey started due to necessity and as expected has met much adversity along with way. It has known the sweetness of success as well as the bitterness of initiatives that have gone awry. We have all continued to learn through engagement in this journey and the evolution of Collaborative care itself has been a rewarding process to shape and observe. And…what a ride it has been to get to the tipping point of this transformation!



Dr "AJ" Jayabarathan is a family physician in Halifax. 
She was recently awarded Nova Scotia College of Family Physicians 2012 Award of Excellence for her advocacy for "Excellence in Advocating for Accessible Quality Mental Health Care for All Nova Scotians".
AJ will present a plenary session at CFHA's October 4-6, 2012 Conference in Austin, TX.  She is a regular blogger with CFHA, including posts here, here, and here.




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