Mental Health & Substance Use Nursing in BC

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As a Registered Nurse (RN) practicing in British Columbia, I belong to the College of Registered Nurses of British Columbia (CRNBC) and the Association of Registered Nurses of British Columbia (ARNBC). I am also a member of the Canadian Nurses Association (CNA) and hold specialty certification in Psychiatric Mental Health Nursing. In my current role as a mental health and substance use Community Integration Care Co-ordinator, I work closely with nurses as well as several other professions, including family physicians, psychiatrists, occupational therapists, physiotherapists, pharmacists, addictions workers, aboriginal patient navigators, lab and x-ray technicians, social workers, and psychologists. Services provided by our mental health and substance use programs are funded under the federal legislation of the Canada Health Act.

Under the Canada Health Act, funding is provided for provinces and territories to provide coverage for health services that are deemed to be “medically necessary” for the purposes of maintaining health, preventing disease, and diagnosing or treating an injury or disability (Health Canada, 2015). The Canada Health Act acknowledges mental health as a fundamental aspect of one’s health by stating that the primary focus of the Canada Health Act is to “protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers (Government of Canada, 2017)”. However, most mental health services do not meet the eligibility requirement of “medically necessary,” unless they are received in or through a hospital. The lack of accessibility to mental health services across Canada has led to requests, through Canadian health care reform (Canadian Civil Liberties Association, 2018) that public funding cover all mental health services and programs, with the goal of improving mental health outcomes leading to improved overall health. This modernization to the Canada Health Act is crucial as it would create increased access and reduced the stigma that surrounds mental health and substance use services, allowing for increased overall health for the clients we serve.

Clients who struggle with mental health and substance use issues represent a very vulnerable population as this population is subjected to stigma and discrimination on a daily basis, experience extremely high rates of physical and sexual victimization, frequently encounter restrictions in the exercise of their political and civil rights, and in their ability to participate in public affairs, are restricted in their ability to access essential health and social care, including emergency relief services, often face disproportionate barriers in attending school and finding employment, frequently live in poverty and struggle with poor physical health and are much more likely to experience a physical disabilities and die prematurely when compared to the general population (WHO, 2018). Lack of access to appropriate mental health and substance use services, for this vulnerable population, is an issue that significantly impacts all Canadians.

Mental health and substance use disorders contribute to a significant proportion of the global burden of disease (Whiteford, Ferrari, Degenhardt, Feigin & Vos, 2015). The causes of mental health and substance use disorders are complex. Biological, psychological, and environmental factors all contribute to the development and/or the exacerbation of mental health and substance use disorders, and most disorders are a result of a combination of several “biopsychosocial” factors as opposed to just a single factor (Bashshur, Shannon, Bashshur, & Yellowlees, 2016). In Canada, mental health illnesses constitute more than 15% of the disease burden, however Canada currently spends only about 7% of public health care dollar on mental illness (Mental Health Commission of Canada, 2012). There is a need for the Canadian health system to respond appropriately by increasing funding, at the very least, to be proportionate to the burden and by implementing proven, cost-effective interventions. However, change will not be possible without a comprehensive multilevel approach which focuses on all the determinants of health.

The social determinants of health in Canada, serve as the foundation of health and include aboriginal status, disability, early life, education, employment and working conditions, food insecurity, health services, gender and gender identity, housing, income and income distribution, race, sexual orientation, social exclusion, social safety net and unemployment and job security (CMHA, 2018). The Canadian Mental Health Association (2018), notes that three social determinants are particularly significant for individual struggling with mental illness and include freedom from discrimination and violence, social inclusion and assess to economic resources.

Everyone living in Canada should have access to the same high level of health care. Equitable distribution of resources that support health across social groups benefits everyone. Health systems have an important role to play in improving health equity, there are several actions that health system can take, through careful planning and delivery of health services, to reduce health inequities (PHSA, 2018). The availability of mental health and substance use resources vary greatly across Canada and much more work needs to be done to achieve true health equity across all areas of Canada (Public Health Agency of Canada, 2018).

British Columbia’s population is widely dispersed over a vast and diverse geography which presents significant challenges when it comes to the delivery of mental health and substance use services, especially in rural and remote locations. Rural and remote communities tend to be under-resourced and often specialized resources and services are required to meet the unique needs of individual communities and to ensure health equity and positive health outcomes (Select Standing Committee on Health, 2017). In the rural and remote areas that I practice nursing some of the unique challenges that our team deals with on a daily basis include how to ensure that our clients can physically access health care services as many of our sites are located in communities that do not have access to any form of public transportation and are several hours, by vehicle, away from our regional centres. Two of the main barriers that our clients have encountered is accessing specialized psychiatric and substance use services. For example, seeing a Psychiatrist and/or accessing opioid agonist treatment (OAT).

With the recent introduction of telehealth technology, which provides secure, encrypted videoconferencing, into our rural/remote communities, clients can now be seen by a Psychiatrist without having to leave their own community. Although, additional research is needed to further evaluate the effectiveness of telepsychiatry in the management of mental illness, it is strongly hypothesised that telepsychiatry-based treatment obtains the same results as face-to-face sessions and that telepsychiatry is a useful alternative when face-to-face therapy is not possible (García-Lizana & Muñoz-Mayorga, 2010).

We are currently in the process of setting up telehealth supported OAT clinics at several of our mental health and substance use sites. Physicians need additional training to be approved to prescribe methadone and therefore OAT services have historically not been offered in most rural and remote communities. Distance has frequently been a major barrier to accessing OAT services (Eibl et al., 2015). Studies have demonstrated similar rates of retention when OAT services are offered in person or through telehealth and services offered through telehealth offer increased flexibility benefiting both clients and physicians (Eibl et al., 2015). Telehealth offers many additional benefits to our clients and families, as well as our health care team including decreased travelling leading to increased accessibility, reduced waiting time to see specialists, easier and more timely access to expert advice and clinical expertise, improved skills and knowledge through on-site education and training resulting in increased capacity at a community level, and reduced isolation of remote communities (Interior Health, 2018).

References:

Bashshur, R. L., Shannon, G. W., Bashshur, N., & Yellowlees, P. M. (2016). The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemedicine Journal and E-Health, 22(2), 87–113. Retrieved from, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744872/

Canadian Civil Liberties Association. (2018). The Current State of Mental Health in Canada. Retrieved from, https://ccla.org/current-state-mental-health-canada/

Canadian Mental Health Association: Ontario (CMHA). (2018). Social Determinants of Health. Retrieved from, https://ontario.cmha.ca/provincial-policy/social-determinants/

Eibl, J.K., Gomes, T., Martins, D., Camacho, X., Juurlink, D.N., Mamdani, M.M., Dhalla, A.I., Marsh, D.C. (2015). Evaluating the effectiveness of first-time methadone maintenance therapy across northern, rural, and urban regions of Ontario, Canada. Journal of Addictions Medicine. 9, pp. 440-446. Retrieved from, https://www.scopus.com/record/display.uri?eid=2-s2.0-84957632610&origin=inward&txGid=6af2be8654dfcd896ca9962b47c17300

García-Lizana, F., & Muñoz-Mayorga, I. (2010). What About Telepsychiatry? A Systematic Review. Primary Care Companion to The Journal of Clinical Psychiatry, 12(2). Retrieved from, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911004/

Government of Canada. (2017). Canada Health Act. Retrieved from, https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html

Health Canada. (2015). Canada Health Act: Annual Report 2014-2015. Retrieved from, https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/hcs-sss/alt_formats/pdf/pubs/cha-ics/2015-cha-lcs-ar-ra-eng.pdf

Interior Health. (2018). Telehealth Services: Connecting patients to health care through technology. Retrieved from, https://www.interiorhealth.ca/YourCare/telehealth/Pages/default.aspx

Mental Health Commission of Canada. (2012). Changing Directions Changing Lives: The Mental Health Strategy for Canada. Retrieved from, https://www.mentalhealthcommission.ca/sites/default/files/MHStrategy_Strategy_ENG.pdf

Provincial Health Services Authority (PHSA). (2018). Caring for people with mental health & substance use challenges. Retrieved from, http://www.bcmhsus.ca/

Public Health Agency of Canada. (2016). Social Determinants of Health. Retrieved from, http://cbpp-pcpe.phac-aspc.gc.ca/public-health-topics/social-determinants-of-health/

Public Health Agency of Canada. (2018). Key Health Inequalities in Canada: A National Portrait. Retrieved from, https://www.canada.ca/content/dam/phac-

aspc/documents/services/publications/science-research/key-health-inequalities-canada-national-portrait-executive-summary/hir-executive-summary-eng.pdf

Select Standing Committee on Health. (2017). Looking Forward: Improving Rural Health Care, Primary Care, and Addiction Recovery Programs. Retrieved from, https://www.leg.bc.ca/content/CommitteeDocuments/40th-parliament/6th-session/health/Health_20170301_Report_LookingForward.pdf

Whiteford, H.A., Ferrari, A.J., Degenhardt, L., Feigin, V., & Vos, T. (2015) The Global Burden of Mental, Neurological and Substance Use Disorders: An Analysis from the Global Burden of Disease Study 2010. Retrieved from, http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116820

World Health Organization (WHO). (2018). Mental Health, Poverty and Development. Retrieved from, http://www.who.int/mental_health/policy/development/en/