A.  Background

Mental health intersects with each of the areas included in this study: income supports, education, training and employment, housing and communities. Poor mental health increases people’s vulnerabilities to poverty and needs to be taken into account in any poverty-reduction efforts.

With the exception of certain groups of people (First Nations people living on reserves, serving members of the Canadian Forces, eligible veterans and inmates in federal penitentiaries),[192] the provinces and territories are responsible for the delivery of mental health care services in Canada. In addition to funding and administering primary and supplementary health care services for these specific groups, the federal government’s role in health care includes setting and administering national principles for the system under the Canada Health Act as well as providing financial support to the provinces and territories.[193] Several federal departments fund initiatives related to mental health.

Health Canada is responsible for funding health care for First Nations peoples on reserve and in Inuit communities and invests over $300 million annually for mental health initiatives provided by community health organizations, First Nations treatments centres and independent mental health counsellors, who deliver services including mental health promotion, addiction treatment, suicide prevention, crisis response services, mental health counselling benefits, treatment and after care, and support for residential school survivors and their families.[194] In 2016, funding for mental health for First Nations and Inuit communities was increased by $69 million, delivered in accordance with the First National Mental Wellness Continuum Framework[195] and the National Inuit Suicide Prevention Strategy.[196]

The Public Health Agency of Canada’s (PHAC) role related to mental health includes the promotion of health, the prevention of chronic disease, the strengthening of intergovernmental collaboration on public health, as well as the facilitation of national approaches to public health policy and planning. PHAC has partnered with the Mental Health Commission of Canada and other key experts to identify, organize, as well as to present data on positive mental health outcomes and protective and risk factors. PHAC’s Mental Health Promotion program[197] leads and supports national activities which promote positive mental health. Among other activities, the program: coordinates federal/provincial/ territorial action on mental health promotion; collaborates with stakeholders and partners to generate evidence-based knowledge to assist in the design of policies and programs; and develops public education and awareness activities on positive mental health. PHAC coordinates with provinces and territories to implement the Age-Friendly Community Initiative[198] in communities across Canada. The initiative is intended to facilitate the development of policies, services, and structures in communities to create physical and social environments that are “age friendly” and help seniors to live healthily, safely, and socially connected.

ESDC administers the Housing First model,[199] which integrates the need for housing with other supports and services often needed by homeless persons, such as mental health and addiction counselling services. It also administers income support through employment insurance sickness benefits and the Canada Pension Plan-Disability program for those with severe or prolonged mental disability.

In 2012, Statistics Canada released its Canadian Community Health Survey on mental health,[200] which included information about the percentage of Canadians suffering from mental health issues. The survey included details about the symptoms associated with mental health, the age and gender of individuals suffering from mental illness, as well as the health care services provided in this regard. However, the issue of poverty was not explored.

B.  What the Committee Heard

1.   Mental health in Canada

The Committee learned that mental health and substance abuse disorders are the leading cause of disease burden globally, and in Canada.[201] Officials from Statistics Canada shared findings from the Canadian Community Health Survey on mental health, which found that many people experience a mental health problem at some point in their lives and 10% of Canadians met the criteria for a mental health disorder within the 12 months prior to the survey. Among those with mental illness, 3% are considered to be seriously or severely mentally ill.[202] Witnesses explained to the Committee that women have higher rates of mental disorders than men, while men have higher rates of substance abuse disorders.[203]

a.   The cost burden of mental illness

There are significant costs to governments and employers associated with mental illness. The Committee learned that of those entering the Ontario Disability Support Program, 45% have mental illness or addiction disabilities.[204] Among claims for the Canada Pension Plan Disability program, 30.9% are for mental disorders, and this percentage is increasing.[205] Employers incur costs, as 500,000 Canadians are absent from work each week due to mental illness.[206] Because of the impacts of mental illness on the labour market, one witness suggested that governments that are planning labour policy measures factor in the costs associated with the mental health consequences of unemployment, particularly long-term unemployment.[207]

b.   Link between mental illness and poverty

The Committee was interested to learn that almost 20% of Canadians with an annual income of less than $20,000 reported a mental health disorder, nearly double the rate for people in higher income groups.[208] Those who had difficulty covering basic expenses were more than twice as likely to have a disorder as people who reported their income was sufficient. Witnesses spoke of the cycle between mental health problems, employment and poverty:

We know that poverty compromises the ability of Canadians to be well and to recover. Poverty exacerbates the symptoms of mental illness and can bring them out. At the same time, mental illness can sometimes make it difficult to sustain employment and therefore leads to poverty. It's a vicious cycle.[209]

The Committee also learned that disorders were three times more likely among those whose main source of income was social benefits, compared to those with employment income.[210] “[P]eople with mental illness have lower incomes, are less likely to work, and are less likely to have adequate housing compared to people with other disabilities or to people without disabilities.”[211] The link between poverty and mental illness was explained by Michael Creek of Working for Change:

I can't imagine any person I've talked to who has lived in poverty who hasn't experienced some sort of mental health difficulty through that whole process. It's just impossible for it not to happen. You become so dehumanized in the process of poverty that all of these mental health issues or addiction issues rear their ugly head. I'm a survivor of cancer, and I can tell you that poverty caused me more damage than my cancer treatment or other illnesses I've faced. In itself, poverty could be described as an illness also.[212]

c.   Vulnerable populations and mental health

The Committee heard that those more vulnerable to mental health disorders include lone parents, unattached singles, youth, Indigenous peoples, people with low incomes, people with a history of homelessness, and people who had experienced childhood abuse. The Committee was interested to learn that immigrants have rates of mental disorder half that of those born in Canada.[213]

While much of the need for mental health supports and services is found in the more vulnerable populations in Canada, witnesses told the Committee that there is insufficient provincial and territorial programming to adequately reach some of these groups.[214]

i.  Youth

The Committee learned that mental disorders often emerge early in life. Experts estimate that more than 1.2 million Canadian children and youth, approximately 20%, are affected by a mental health disorder, causing burdens for families, schools, and the justice system.[215] Several witnesses believed that the percentage of youth affected by mental health disorders was considerably higher than 20%.[216] The Committee also heard that approximately 75% of adults with mental health disorders began their mental health challenges in childhood or adolescence. Witnesses explained that failure to address mental disorders early in life has lifelong consequences, as 60% of young adults who experienced a mental health problem in childhood had negative outcomes in adulthood, such as failing to complete high school and failing to obtain or maintain employment, compared to 20% of adults without childhood mental health problems.[217]

In their submission, the Kingston Action Group for Basic Income Guarantee linked the increasing rates of anxiety, depression and suicide attempts on Canadian university and college campuses to the stresses of high debt loads, the lack of employment, and the precarious nature of work among those who do have employment.[218]

The Committee heard that mental health problems are two to three times more likely among children living in low-income households, due to lack of parental skills and nurturing, lack of cognitive stimulation and exposure to multiple risks factors including poor and crowded housing, poor nutrition, and unstable parental adults, who often have mental and substance abuse disorders and family instability.[219]

The Committee heard sobering testimony related to the effects of traumas, such as parental violence, violence by others in the community, and sexual assault, on the mental health of children and were reminded that “these traumas are associated with being in poverty.”[220] Witnesses stated that the consequences of these traumas extend into adulthood. Almost 14% of adults who had experienced maltreatment in childhood had a mental or substance abuse disorder, more than double the percentage of those who had not experienced childhood maltreatment.[221]

The Committee also heard that there is a damaging cycle linking poverty and mental disorders in children and youth:

Many children and youth with mental health problems are exposed to poverty, and there is a dynamic and bidirectional association between child and youth mental health disorders and poverty. While we often think of poverty as a determinant of poor mental health, it's important to acknowledge that poor mental health can contribute to poverty.[222]

Due to the early onset of mental illnesses, the Committee was informed that treating mental illness early in life resulted in better outcomes, allowing for more stable childhoods and easier transitions into higher education, employment, and adulthood. Witnesses also told the Committee that if mental illness was left untreated until older teenage years or young adulthood, the social costs related to extra burdens on the educational, judicial, and welfare systems accumulate.[223]

However, witnesses described several challenges in accessing mental health services for children and youth. Ellen Lipman of McMaster Children’s Hospital explained that in the case of Hamilton, children’s mental health services are shared between the Ministry of Health and the Ministry of Children and Youth Services, complicating access to services. Wait times for consultations, assessments, and treatment for child psychiatric services are almost nine months or longer.[224] A further barrier for youth and their families is the social stigma which, while somewhat less than in previous decades, still inhibits youth and their families from seeking help with mental health problems.[225] The Committee heard that people with mental illness experience stigma and discrimination that is considerably worse than that faced by people who suffer from substance abuse.[226]

ii. Indigenous peoples

The Committee also heard testimony concerning the mental health problems faced by Indigenous peoples. Witnesses described the historical social dislocation that underlies many of the present-day challenges related to Indigenous social and mental health. They also heard that peoples' sense of autonomy, control, and self-determination was lost with the forcible change from the Inuit’s nomadic lifestyle, which also shifted the cultural roles of Inuit men as hunters and providers for their families.

Among Inuit communities, multiple challenges, including profoundly inadequate housing conditions, have contributed to family violence, suicide, mental disorders and substance abuse. The majority of Inuit communities lack access to mental health programs and 70% of Inuit communities do not have shelters for women and children suffering from family violence.[227]

The need to address mental health disorders before children reach adulthood is particularly pressing for Indigenous communities. Among Inuit people, a recent survey reported that 52% of Inuit women and 22% of Inuit men had suffered sexual abuse as children. Further, the Committee heard that 50% of Inuit are aged 25 or younger, while in Nunavut 45% of young children live in poverty.[228]

The Committee was reminded of the alarming statistics related to suicide among Inuit peoples, and that the suicide rate was as high as 239 per 100,000 in Nunatsiavut, compared with the national suicide rate of 11 per 100,000 for the general Canadian population.[229]

d.   Link between mental health and unemployment

The Committee learned that there is a strong link between unemployment and damage to mental health. One witness explained his research findings that the trauma of unemployment increases as the period lengthens, with those experiencing prolonged unemployment (defined as unemployment longer than six months), having poorer mental health due to “elevated levels of anxiety, frustration, disappointment, and alienation.”[230] Statistics Canada also pointed to this link, as their survey indicated that those who were permanently unable to work had higher rates of mental or substance use disorder than others.[231]

The Committee was interested to learn that unemployed individuals with higher levels of education are particularly negatively affected by prolonged unemployment. It was explained that this was likely because those with highly paid employment often had a strong sense of identity based on their work and that job loss caused them to lose their sense of identity.[232]

It was also observed that employment is not only important for monetary benefit, but other aspects of employment contribute to good mental health, such as providing structure to a day, social engagement, and the purpose and meaning that people derive from work.[233] The value of contribution, either through employment or non-paid work, was also noted by Tracy O’Hearn of the Pauktuutit Inuit Women of Canada who explained that individuals in Inuit communities seeking to build sustainable livelihoods and support their families did so based on their own measures of success such as hunting, child and family care, and which may not necessarily involve wealth accumulation.[234]

Witnesses described the different dynamics and outcomes between those with shorter-term mental illnesses and those with more serious mental illness. Those with serious mental illness tend not to recover quickly and return to work. The Committee heard that workers absent from work for six months only have a 50% chance of returning to employment while those away from work due to illness for one year or longer have only a 10% chance of returning to employment, which explained why 90% of those with severe or serious mental illness are unemployed.[235]

However, witnesses stressed that many people with mental illness wish to be employed but experience multiple challenges. The Mental Health Commission of Canada referred to those who have left employment or those who have never entered the workforce as a result of mental health problems as “the aspiring workforce,” people who face barriers such as lack of work experience caused by mental health difficulties early in life, disruptive education, training, and employment, and a lack of accommodation in the workforce.[236]

A further consequence of unemployment for those with mental illness is the loss of health benefits that can be provided with paid employment. Often mental health therapies include pharmaceuticals, which may be unaffordable for those who lose employment and their associated health benefits, delaying their recovery and return to the workforce. This is also an issue for younger workers who are often in precarious employment with fewer benefits.[237]

e.   Data gaps

The Committee was made aware that much of the information related to mental health among Canadians was not comprehensive, as the Statistics Canada Canadian Community Health Survey on Mental Health did not include data on children under the age of 15, nor data related to the territories, First Nations reserves, the Canadian Armed Forces or the homeless.[238]

C.  Approaches and Options

1.   General

a.   Access to employment

Witnesses told the Committee that governments should strengthen policy that rewards and supports people who return to work after suffering from mental health problems. The Committee also heard that current income support systems are inadequate and penalize or fail to incentivize earned income, as those with mental illness either cannot find work or work episodically due to their illness.[239] The federal government could also work with employers to ensure that workplace policies, practices, and cultures are made more welcoming for those with mental health problems and ensure that employers accommodate their needs, as they do with other workers with disabilities.

The Mental Health Commission of Canada called on the federal government to work with employers in determining effective measures, identifying best practices for changing workplace cultures, and developing policies and practices for keeping those with mental illness in the workplace, and facilitating their early return to work in the event of sick leave. They also called on the federal government to facilitate the sharing of best practices to support those seeking employment but who have never been in the workforce due to mental illness.[240] The Centre for Addiction and Mental Health told the Committee that the federal government should support initiatives that assist people with mental illness to gain and keep employment.[241]

Because of the interrelationships between mental health and poverty, the Committee heard that programs aimed at addressing mental health should extend beyond the health care sector and should be linked to training and employment programs so that people with mental illness are able to gain and maintain employment.[242]

b.   Service delivery

The Committee was told that there is a need for better access to treatment for post-traumatic stress disorder and better access to culturally informed psychotherapies for immigrants and refugees who may suffer from trauma due to experiences in their countries of origin.[243]

Witnesses advised that governments should invest in funding mental health programs similar to the approach used in the Housing First model, under which wraparound supports for clients are provided, integrating services from different sectors and organizations into a coordinated focus on the specific needs of the client.[244] Witnesses suggested that it is important to bring mental health services and supports to community sites such as community centres, gyms, and schools, in order to make them more accessible for individuals and families and to reduce stigma.[245]

c.   Youth

Witnesses told the Committee that increasing the willingness of youth and their families to access mental health services could include increased online information about mental health conditions and how to access services and supports. Other options include increasing the access to mental health services by telehealth, and including the topic of mental health in the curriculum of schools.[246]

The Committee heard that because 70% of mental health problems emerged in children, youth and young adults, investments in mental health services should be targeted to these cohorts. In addition to further funding for mental health services and supports, witnesses said that assistance could be provided to help children and youth remain in and complete school, as well as to support youth with mental health disorders to obtain training and employment.[247]

d.   Indigenous mental health

While the Committee heard that a return to traditional lifestyles is not realistic for Inuit communities, community representatives called for strengthened mental health services that are culturally appropriate and that are developed in close collaboration with the communities.[248] It was also proposed that governments could establish more community-based services and more group services so that more Inuit families could be served simultaneously.[249]

To address recent mental health and suicide crises in First Nations and Inuit communities, additional measures have been undertaken, including sending a mental crisis intervention team to support communities in crisis, providing mental wellness teams to build ongoing services and support, and establishing a crisis line providing 24 hour crisis counselling in English, French, Inuktitut and Cree. Health Canada officials stated that the Department has recognized that the siloed approach to the delivery of government services for First Nations communities from multiple departments and programs has led to a lack of integration of services and facilitated gaps in care. They have found that when communities control the programs and services, the quality and response to First Nations’ needs improved, such that almost 90% of federally funded mental health services and programs are currently controlled by First Nations communities.[250]

The Committee heard that the federal government and Inuit communities need to identify innovative ways of delivering mental health services, including suicide prevention programs, to Inuit communities. One witness told the Committee that telehealth has been used in Nunavik in other areas of health service delivery and that this could be one type of support for remote communities. Health Canada officials stated that while no framework such as the First Nations Mental Wellness Continuum Framework currently exists for Inuit mental health, the government is considering a similar approach to meet the needs of Inuit communities.[251] The Committee was also advised that the National Mental Health Strategy should have a First Nations, Inuit, and Metis specific component.[252]

The Committee was reminded that mental wellness will not be resolved solely by crisis interventions or having short-term deployment of health care professionals sent to communities, but that service supports were needed on a consistent basis. Witnesses also advised that the determinants of health need to be considered by governments and that other supports related to mental health wellness, such as adequate housing, community infrastructure, and education, are also critical to improving mental health.[253]

e.   Federal investments

Witnesses proposed that the federal government support a pharmacare program, which would provide some financial relief for those requiring pharmaceutical treatments for mental health, facilitating their recovery and return to work.[254] However, other witnesses noted that those with severe mental illness, who were often among the homeless, would not benefit from a pharmacare program and told the Committee that the federal government should focus on other priorities. They also noted that there are non-medical treatments and therapies for mental illness and addiction that are underfunded and should be financially supported.[255] The Committee heard that the federal government should provide further leadership in supporting safe injection sites in urban and rural environments and communities.[256]

f.    More research

Witnesses encouraged the federal government, in collaboration with other levels of governments and stakeholders, to support funding for advancing research that provides deeper knowledge of the links between the social determinants of health, mental health and overall health. As well, there should be increased support for research related to best practices and effective policies and programs for service delivery to those with mental health problems.[257]

Witnesses told the Committee the federal government could have an impact on improving mental health by providing resources for research to examine effective approaches and treatments and to support policy development in this area.[258]

g.   Role of federal government as employer and procurer

The Committee heard that the federal government, as a major employer in Canada, has provided a good example to other employers by adopting the national standard for psychological health and safety for the federal public service. Ed Mantler of the Mental Health Commission of Canada suggested that further federal leadership could be shown to other employers by developing policies that support those with mental health disorders to return to federal workplaces and by removing barriers such as financial disincentives for returning to work.[259] The Committee also heard that any federal government measures to include social procurement as part of federal procurement practices could incorporate the employment of those affected by mental illness into federal procurement policies.[260] It was also suggested that procurement policies directed to those employing workers with mental illness could be extended to include contracts involving recent federal government budget infrastructure investments.[261]

2.   Innovative concepts

During the course of the study, the Committee learned of various ideas and projects related to mental wellness, some of which could be applied to other projects related to poverty reduction, such as:

• Local Poverty Reduction Fund: One witness described the Local Poverty Reduction Fund, created by the Ontario Poverty Reduction Strategy Office. The Fund provides grants for community organizations working on poverty to evaluate initiatives, report on their viability, and make recommendations on whether or not they should be scaled up.[262]
• Examine innovative workplace accommodation practices: The Mental Health Commission of Canada has prepared a case study of 40 organizations that are implementing psychological health and safety in the workplace that will highlight innovations implemented in the workplace. The workplaces have been modified to make them more accessible to those with mental illness who are either currently in the workplace or who are entering the workforce.[263]
• Using seniors housing to enhance mental and social health: One witness proposed the integration of low-income housing for seniors within university and college campuses. This could serve to provide students with a better understanding of the needs of seniors in communities, while reducing the social isolation that exists among some seniors.[264]
• Multi-sectoral teams on case management of individuals: The province of Ontario has adopted a risk-driven community safety program, based on a model of the city of Glasgow, Scotland. The model facilitates regular intensive communications across the service providers of multiple sectors that deal with the same vulnerable individuals, sharing information that was not shared in the past. The multi-sectoral team members meet regularly to discuss individual cases, resulting in improved coordination of case management and fewer service delivery gaps.[265]
• Age-friendly communities initiative: The province of Quebec is using the age-friendly communities initiative extensively in communities across the province.[266] The program aims to use policies, services, and structures to help seniors remain active, engaged, and healthy in their communities. Initiatives can range from making community infrastructure more age-friendly, to reducing social isolation among seniors and providing supports to ensure they have access to the information they need.
• First Nations Mental Wellness Continuum Framework: Health Canada’s First Nations Mental Wellness Continuum Framework was developed with First Nations and provides an approach to developing and promoting mental health wellness programs and services, both on and off reserve, that incorporates the key elements of Elders, families, culture, and languages, as well as providing practical guidance on how to redesign existing programs, shift resources to more effective measures, and integrate services across sectors and jurisdictions.