Improving youth mental health supports in Canada
================================================

* David Cawthorpe

[See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.180277](http://www.cmaj.ca/lookup/volpage/190/E1183)

KEY POINTS
*   First presentation with a mental health disorder to the emergency department signals problems with access to more appropriate mental health services.

*   From a 1949 call for the mobilization of comprehensive resources in support of early childhood development to optimize potential and mitigate against developmental risk to a more recent report that called children’s mental health the orphan’s orphan and called for better services, youth mental health has been identified as a neglected area in Canada.

*   Some champions have worked to optimize identification of mental illness in schools and support effective management in primary care.

*   Scarce resources should be mobilized appropriately to recognize and address the mental health needs of all Canadian youth in the right place.

From the Welcome to Ontario Settlement website ([https://settlement.org/](https://settlement.org/)), there is a navigation link for mental health services next to the link for emergency services ([https://settlement.org/ontario/health/emergency-services/help-in-an-emergency/you-might-not-know-about-hospital-emergency-room-visit/](https://settlement.org/ontario/health/emergency-services/help-in-an-emergency/you-might-not-know-about-hospital-emergency-room-visit/)), both in perfect English. Navigating to the emergency services link, the following advice is encountered: “If you’ve never been to a hospital in Canada, knowing what to expect from a hospital visit can be difficult. There are some things to keep in mind before you go. Depending on your situation, and if you have a non-life-threatening medical emergency, you have other options instead of going to a hospital emergency room.” The view from the emergency department is somewhat different, however.

In linked research, Saunders and colleagues1 provide a perspective on visits to the emergency department for mental health problems among immigrant and refugee youth in Ontario, concluding that overrepresentation of refugee and immigrant youth for first presentation of a mental health crisis may be due to barriers in accessing more appropriate services. The authors consider that efforts to identify mental illness earlier, and to reduce the stigma of mental illness for immigrant and refugee youth, would be helpful – a reasonable conclusion based on the data and analysis presented.

Saunders and colleagues assumed that these visits to the emergency department for mental health concerns represent an individual in crisis, yet there is no measurement of crisis level in the study. Furthermore, the authors found only marginal differences in rate ratios of emergency department visits as a first presentation of mental illness for immigrants compared with non-immigrants, which may be statistically significant because of the study’s large sample size. Including per capita rate comparisons might refine the findings. What is clear from this study, however, is that first presentation with a mental health issue to the emergency department is common for all youth in Ontario, which signals general problems with access to appropriate mental health services in the province.

Addressing mental health problems in immigrants and refugees is important, as important as addressing those of every Canadian. Although it is necessary to identify issues outstanding within unique groups, and the particular needs of immigrant and refugee populations in particular,2 we may in the same stroke perform a disservice to these individuals by increasing stigma. For example, homelessness is often associated with increased rates of mental disorder,3 as is suicidality.4 The association of mental disorder with important and apparently intractable social issues, such as homelessness, violence, immigration or refugee status, may serve to further marginalize groups of individuals and increase stigma.

The reality is that there is a silent epidemic. Fifty-four percent of the total population of Canada and 32% of children and youth had a physician-assigned psychiatric diagnosis over a 16-year period, with the per capita rate for children and youth doubling over the interval.5 As such, it might be better to normalize mental health care by focusing on optimizing mental health in early life.

In 1949, Minister of National Health and Welfare Paul Martin Sr. called for the mobilization of comprehensive resources in support of early childhood development to optimize developmental potential and mitigate against developmental risk – services adequate to optimize the developmental potential of every Canadian.6 Again, in 1999, the US Surgeon General lamented that the model of child and adolescent mental health service delivery did not possess the intellectual capacity – meaning the numbers of providers with the required skills to address the unmet need then identified – and that services ought to be delivered where children and youth are; i.e., in schools.7 In 2008, the Kirby report, *Mental Health in Canada: Out of the Shadows Forever*, identified all health services to be in disarray, describing mental health services for children as the orphan’s orphan, in relation to adult mental health services (the orphan) and general health services.8 Some champions have taken up the cause of changing the approach to mental health disorders to optimizing identification in schools with navigation to appropriate services4 and supporting effective management in primary care.9–12 Implemented systematically, such an approach would go a long way to improve access to mental health services for Canadian youth and those families who are newly arrived in Canada.

In 2008, with the help of the Norlien Foundation,5 Calgary won the bid for the International Association of Child and Adolescent Psychiatry and Allied Professions congress, which was held in 2016 in Canada for the first time in more than 60 years.12 Given the lead-in period, the original organizing committee advocated with local provincial and national governments and organizations with a vision of the future mental health services for Canadian children and youth to showcase at the congress. But it seemed then, as it does now, that nobody has really joined the relay and run with the torch. Instead with the best of intentions, we remain relatively fractured by special interest in our approach to provision of mental health services for children and youth at multiple levels of society.

There is no question that marginal groups may be overrepresented at the gateways to service, and it is necessary to understand and address the contributing factors. Nevertheless, failing to grasp the overarching issues, such as the lack of integration and organization of health and mental health services, will perpetuate current barriers to access and treatment. Youth mental health resources remain the orphan’s orphan – segregated and scarce – and proven fledging innovations directed at shaping access to appropriate services require wider dissemination.10–12

It’s time to recognize the main issues underpinning access and mobilize to address the mental and physical health needs of all Canadian children and youth in the right place at the right time.

## Footnotes

*   **Competing interests:** David Cawthorpe is a shareholder of International Graduate Medical Education Inc. and a consultant to Canadian Research and Education for the Advancement of Child Health Trust.

*   This article was solicited and has not been peer reviewed.

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