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Integrated Understanding of Health in Context

Mental Health and Concurrent Disorders in Ontario

After reflecting on my experience during the MHST 601 – Foundations of Health Systems in Canada course, I realised I have been able to enhance my understanding of mental health and concurrent disorders in a Canadian context from a broader scope, rather than the narrow focus of my own role. Prior to this course, I had an understanding of the contours and details of my own ‘puzzle piece,' without always understanding how it fits into the bigger picture of healthcare provincially and federally. The reflections and learning through this course have provided me with a greater scope with which to understand my own practice.

Initially, we were invited to think critically about information; both the type of information we gather and the process of curating it (“What Are Digital Competencies?” n.d.). After being introduced to new tools for information and knowledge exchange, we were encouraged to consider what format and purpose a professional online presence would serve, particularly to “improve or enhance professional networking and education” (Ventola, 2014, p. 491). I began developing this ePortfolio as a working document to demonstrate my ongoing professional development and growth in an easily accessible site; this process of developing a professional identity and values supported me in locating a balance between privacy and dissemination of information to “enable [my] network to expand while limiting the exposure of information to people outside of the network” (“Professional Portfolios,” n.d.; Ventola, 2014, p. 496).

This discussion of professional values and our interactions with other health care professionals allowed us to centre ourselves within our various provincial/federal health care milieus; through this process we were encouraged to reflect on our own healthcare practice. Considering the history of the Canada Health Act (CHA), and reflecting on possible modernisations, we were encouraged to critically contemplate the healthcare system and how its structure impacts health and health outcomes for vulnerable individuals. For example, in terms of mental health care, Bartram and Lurrie (2017) note:

mental health policy in Canada has developed in a highly political, highly complex environment…Not only is the Canadian federal system highly decentralized but health care may be the most politically contested policy arena, resulting in intensely political policy negotiations between federal, provincial, and territorial governments at different points in Canadian history (p. 7).

From a mental health lens, I agree with Flood and Thomas (2016) in their proposal that “the CHA be expanded to include a broad range of kinds of health care, including…mental health” (p. 409). This is in alignment with recommendations outlined by the Mental Health Commission of Canada; I believe we would benefit from increased funding allocated towards community mental health and substance use counselling, as well as including counselling and psychotherapy for funding under Ontario Health Insurance Plan (OHIP) (Mental Health Commission of Canada, 2017).

Events currently unfolding in Ontario have provided an interesting backdrop to our coursework conversations about modernising health care. The recently elected Conservative government in Ontario has announced great structural changes in how healthcare is administered in this province by eliminating more than half of the Local Health Integration Networks (LHINs), which were the administration agencies responsible for planning, integrating, and funding local health service within specific geographical regions (Crawley & Janus, 2019). These changes may have an impact on how resources are allocated in healthcare moving forward; however these events have provided context to broaden our analysis of multilevel approaches to health care concerns.

We also considered other factors beyond resource allocation and health care system structure which can predict or maintain health. Social determinants of health are a “broad range of personal, social, economic, and environmental factors that determine individual and population health,” and include “the societal factors that shape the health of individuals and populations” (Government of Canada, 2018, para. 2; Bryant, Raphael, Schrecker, & Labonte, 2011, p. 45). There are a few models of social determinants of health; the Government of Canada (2018) has identified 11 determinants of health, which include:

Income and social status; employment and working conditions; education and literacy; childhood experiences; physical environments; social supports and coping skills; healthy behaviours; access to health services; biology and genetic endowment; gender; culture (para. 2).

Mikkoken and Raphael's (2010) model of the social determinants of health include up 14 determinants, which are:

Aboriginal status; gender; disability; housing; early life; income and income distribution; education; race; employment and working conditions; social exclusion; food insecurity; social safety net; health services; unemployment and job security (p. 9).

These social determinants of health impact vulnerable individuals, or individuals living at the margins, in terms of both access to health care, and in health outcomes. For example, poverty or income disparity “is largely discussed as a risk factor for poor mental health, and there is little discussion of the significant role poverty plays in organizing the lives of people with psychiatric disabilities” (Frederick, Tarasoff, Voronka, Costa, & Kidd, 2018, p. 6). Poverty can impact where people live, and subsequently affect access to appropriate care through factors like transportation barriers. As Mikkonen and Raphael (2010) note, “in Canada, income determines the quality of other social determinants of health such as food security, housing, and other basic prerequisites of health” (p. 12). Research on the intersections between social determinants of health and mental illness indicates that factors such as “poverty, housing and food insecurity, histories of violence and trauma, racism, and exclusion from the medical system [are noted as] key determinants of patients' health crises as well as predominant factors shaping care relationships” (Fleming et al, 2017, p. 14).

Health inequalities are defined as “differences in the health status of individuals and groups,” and these refer to differences in social determinants of health among groups or populations (Government of Canada, 2018, para. 5). While these terms are used interchangeably, the difference between social determinants of health and health inequalities is in the “unequal social distribution” between social factors and social processes that shape this distribution (Graham, 2004, p. 118). The concept of health inequalities is illustrated in our discussions on vulnerable populations, namely Indigenous populations in Canada. As Logan McCallum (2017) notes:

Indigenous public and community health research acknowledges colonization as a "determinant" of health and even that "history" can cause ill health. A great deal of research points to the disparities between the health of Indigenous people and non-Indigenous people (p. 112).

Ontario “has the largest provincial Aboriginal population, a population that comprises 21 percent of Canada’s total Aboriginal people,” so as a mental health clinician who lives and practices here it is essential that I reflect on the intersections and impacts of colonialism, loss of identity, and historical trauma, and their impact on mental health (Ontario Federation of Indian Friendship Centres, 2013, p. 7). Historical trauma “has become a significant tool for identifying and theorizing the impact of histories of colonization on Indigenous health” and in understanding how these legacies impact health (Logan McCallum, 2017, p. 108).

We also considered definitions of health which expanded on the original 1948 World Health Organization (WHO) definition of health; this declared health to be “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” This is an aspirational movement towards a definition of health that focuses on the presence of wellness, and one that is also limited by the terms "state" and "complete." Health being a static "state" does not allow for dynamic understandings of health across lifespans, and the term “complete well-being” creates a false opposition between complete and incomplete health. Viewing health along a continuum allows for nuanced considerations of chronic illness and health.

An example of this continuum model is Keyes’ (2003) two continua model of mental health. This model indicates that mental illness and mental health are related but distinct dimensions, and “each dimension respectively ranges from a high to a low level of symptoms of mental illness and mental health" (Keyes, 2003, p. 302). Mental health is defined as either flourishing or languishing, and is differentiated from a definition of mental illness. Therefore in this framework, an individual could have poor mental health (languishing) in the absence of mental illness, or conversely could have optimal mental health (flourishing) in the presence of mental illness (Keyes, 2003). Optimal mental health in the presence of mental illness is the goal of Recovery Oriented practice (Mental Health Commission of Canada, 2015). As Slade (2010) notes:

Personal recovery involves working towards better mental health, regardless of the presence of mental illness. People with mental illness who are in recovery are those who are actively engaged in working away from Floundering (through hope-supporting relationships) and Languishing (by developing a positive identity), and towards Struggling (through Framing and self-managing the mental illness) and Flourishing (by developing valued social roles) (p. 3).

This continuum between flourishing and languishing health has a broader application outside of mental health, and could be a conceptualisation of health for chronic illness.

Ontario has developed a framework to ensure that individuals with chronic disease receive appropriate care that goes beyond treatment of acute illness. A focus on reactive care results in environments which do not support the appropriate treatment of chronic disease, including: healthcare professionals who rely on clients to access care, passive patients, symptom focused visits, and lack of overall health promotion or prevention as a health care system priority (Ministry of Health and Long Term Care, 2007). Ontario’s framework seeks to empower clients to be full participants in their care, through organised care delivery. An example of this is Health Links, which is a coordinated care plan for complex-needs patients; recently these plans have been identified as a priority to support individuals with mental health and addictions concerns to provide seamless care across systems (Ministry of Health and Long-Term Care, 2015).

As we look to the future of health care, and some emerging trends, one thing that I believe will become increasingly vital to the mental health and concurrent disorders sector is “patient engagement;” this construct is also referred to as “recovery-oriented care, patient-centered care, consumer involvement, and collaborative care” (Livingston, Nijdam-Jones, Lapsley, Calderwood, & Brink, 2013, p. 132). This concept describes:

processes that, among other things, provide patients with self-determination and control over health care decisions… Recovery oriented service systems support the autonomy and self determination of people with mental illness so that they can reclaim their rights as citizens and regain meaning in their lives (Livingston et al, 2013, p. 132).

As Ewalds Mulliez, Pomey, Bordeleau, Desbiens, and Pelletier (2018) note: “there is a consensus in the literature on the importance of engaging patients in different ways within the healthcare system to improve quality of care” (p. 2). There are unique needs for patient engagement in mental health organizations, which “include actor preparation, support mechanisms, and resource allocation” (Ewalds Mulliez et al, 2018, p. 3). However, it is worth noting the impacts of social determinants of health on patient engagement as “patients who are more socioeconomically marginalized or have faced sustained barriers to care appear less willing to engage in care…attention to socioeconomic determinants of health will be crucial to efforts by clinicians, researchers, and policy-makers to define and operationalize patient engagement in care” (Fleming et al., 2017, p. 17). Being mindful of the impacts of social determinants of health and health inequalities while developing patient engagement strategies will ensure that care improvement efforts are met in a way that is supportive to vulnerable health care consumers.

References

Bartram, M., & Lurie, S. (2017). Closing the mental health gap: The long and winding road? Canadian Journal of Community Mental Health, 36(2), 5–18. https://0-doi-org.aupac.lib.athabascau.ca/10.7870/cjcmh-2017-021

Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. (2011). Canada: A land of missed opportunity for addressing the social determinants of health. Health Policy, 101(1), 44-58.

Crawley, M. & Janus, A. (2019, February 26). Ford government creating Ontario Health super-agency. Toronto Star. Retrieved from https://www.cbc.ca/news/canada/toronto/doug-ford-ontario-health-super-agency-lhin-cancer-care-1.5032830

Ewalds Mulliez, A.-P., Pomey, M.-P., Bordeleau, J., Desbiens, F., & Pelletier, J.-F. (2018). A voice for the patients: Evaluation of the implementation of a strategic organizational committee for patient engagement in mental health. PLoS ONE, (10), 1-22. Retrieved from http://0-search.ebscohost.com.aupac.lib.athabascau.ca/login.aspx?direct=true&db=edsgov&AN=edsgcl.559617317&site=eds-live

Flood, C. M. & Thomas, B. P. (2016). Modernizing the Canada Health Act. Ottawa Faculty of Law Working Paper No. 2017-08. Retrieved from https://ssrn.com/abstract=2907029

Fleming, M. D., Shim, J. K., Yen, I. H., Thompson-Lastad, A., Rubin, S., Van Natta, M., & Burke, N. J. (2017). Patient engagement at the margins: Health care providers’ assessments of engagement and the structural determinants of health in the safety-net. Social Science & Medicine, 183, 11–18. https://0-doi-org.aupac.lib.athabascau.ca/10.1016/j.socscimed.2017.04.028

Frederick, T., Tarasoff, L. A., Voronka, J., Costa, L., & Kidd, S. (2018). The problem with “community” in the mental health field. Canadian Journal of Community Mental Health, 36, 3–32. https://0-doi-org.aupac.lib.athabascau.ca/10.7870/cjcmh-2017-030

Government of Canada (2018). Social determinants of health and health inequalities. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Graham, H., & Lancaster University. (2004). Social determinants and their unequal distribution: Clarifying policy understandings. The Milbank Quarterly, 82(1), 101-124. Retrieved from http://0-www.jstor.org.aupac.lib.athabascau.ca/stable/4149077

Jones, R., Reupert, A., Sutton, K., & Maybery, D. (2014). The interplay of rural issues, mental illness, substance use and housing problems. Journal of Mental Health, 23(6), 317–322. https://0-doi-org.aupac.lib.athabascau.ca/10.3109/09638237.2014.951476

Keyes, C. L. M. (2003). Complete mental health: An agenda for the 21st century. In C. L. M. Keyes & J. Haidt (Eds.), Flourishing: Positive Psychology and the Life Well-Lived (pp. 293-312). Washington, DC, US: American Psychological Association. https://0-doi-org.aupac.lib.athabascau.ca/10.1037/10594-013

Livingston, J. D., Nijdam-Jones, A., Lapsley, S., Calderwood, C., & Brink, J. (2013). Supporting recovery by improving patient engagement in a forensic mental health hospital: Results from a demonstration project. Journal of the American Psychiatric Nurses Association, 19(3), 132–145. https://0-doi-org.aupac.lib.athabascau.ca/10.1177/1078390313489730

Logan McCallum, M. J. (2017). Starvation, experimentation, segregation, and trauma: Words for reading Indigenous health history. Canadian Historical Review, 98(1), 96–113. https://0-doi-org.aupac.lib.athabascau.ca/10.3138/chr.98.1.McCallum

Mental Health Commission of Canada. (2015). Guidelines for Recovery-Oriented Practice. Ottawa, ON: Mental Health Commission of Canada. Retrieved from https://www.mentalhealthcommission.ca/sites/default/files/2016-07/MHCC_Recovery_Guidelines_2016_ENG.PDF

Mental Health Commission of Canada (2017). Options for improving access to counselling, psychotherapy and psychological services for mental health problems and illnesses. Calgary, AB, CA: Mental Health Commission of Canada, 2017. Retrieved from https://www.mentalhealthcommission.ca/sites/default/files/2017-07/Options_for_improving_access_to_counselling_psychotherapy_and_psychological_services_eng.pdf

Mikkonen, J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management. Retrieved from http://thecanadianfacts.org/

Ministry of Health and Long-Term Care (2007, May). Preventing and managing chronic disease: Ontario’s framework. Retrieved from http://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf

Ministry of Health and Long-Term Care (2015, February). Patients first: Action plan for health care. Retrieved from http://health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_patientsfirst.pdf

Ontario Federation of Indian Friendship Centres (2013, June). Aboriginal mental health strategy. Retrieved from http://ofifc.org/sites/default/files/content-files/2013-06-26%20Aboriginal%20Mental%20Health%20Strategy.pdf

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, NY, June 19-22, 1946; signed on July 22, 1946, by the representatives of 61 states (Official Records of the World Health Organization, No. 2, p 100); and entered into force on April 7, 1948.

Professional Portfolios. (n.d.). Retrieved January 27, 2019, from University of Lethbridge Faculty of Education: https://www.uleth.ca/education/resources/professional-portfolios

Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC health services research, 10 (26), 1-14. doi:10.1186/1472-6963-10-26

Ventola, C. (2014). Social media and health care professionals: benefits, risks, and best practices. P&T: A Peer Reviewed Journal for Formulary Management, 39(7), 491-520.

What Are Digital Competencies? | Bryn Mawr College. (n.d.). Retrieved January 17, 2019, from https://www.brynmawr.edu/digitalcompetencies/what-are-digital-competencies

Silos to Systems: Looking at Concurrent Disorders in Ontario

What are the multiple levels of impact from lack of comprehensive integrated care?

Concurrent disorders is a term used for mental illness and substance use concerns that occur concurrently; they are sometimes also known as co-occurring disorders, co-morbid disorders, or dual diagnosis (although in Canada, the term dual diagnosis is typically used to describe co-occurring developmental and mental health concerns). Research on prevalence of concurrent disorders indicates that “more than 50% of those seeking help for an addiction also have a mental illness, and 15-20% of those seeking help from mental health services are also living with an addiction” (Canadian Centre on Substance Abuse, 2009, p. 9). Concurrent disorders require particular attention to screening, assessment, and treatment as:

they are associated with more severe adverse outcomes than either condition alone. These negative outcomes include increased rates of rehospitalization and incarceration, disruption of family and social relationships, homelessness, depression, suicide, comorbid medical problems, relapse, and treatment dropout (McKee, 2017, p. 50).

Substance use/dependence and mental illness can interact in several ways. Substance use can mask, mimic, manifest, or maintain mental illness. Substance use can also interfere with treatment for mental illness, for example making medications less effective or leading to non-adherence of medication regimens. Relapse in one condition can trigger relapse in the other. Subsequently, individuals with concurrent disorders have some of the highest clinical needs.

Silos

Historically, both mental illness and substance use/dependence treatments or agencies have operated independently, and have been compartmentalised and fragmented in a silo model (Canadian Centre on Substance Abuse, 2009). This fragmentation remains a concern today, and greater integration and coordination has been noted as a priority in Canada’s mental health strategy, Changing Directions, Changing Lives: The Mental Health Strategy for Canada. This report notes “much work remains to be done to translate this policy integration into appropriate and effective collaboration at the direct service level” (Mental Health Commission of Canada, 2012, p. 68).

Socio-Ecological Model

In considering the overall impact of concurrent disorders and the need for implementation of integrated care models, we can use the Socio-Ecological Model to explore the various implications and unmet needs across domains. The complexities of concurrent disorders and “influences on…outcomes require a multi-level perspective that the social-ecological model offers” (Thompson, McGee, Munoz, & Walker, 2015, p. 132). The Socio-Ecological Model (SEM) was developed by sociologists and “studies how behaviors form based on characteristics of individuals, communities, nations and levels in between;” it notes that there are multiple factors which influence human behaviours, in multidimensional environments along different levels of organisation (Poux, 2017, para. 2). This model recognises the dynamic interplay among personal and environmental factors and “interrelations among environmental conditions and human behavior and well-being” (Stokols, 1996, p. 285). Additionally, this model provides a “framework for understanding how the social determinants of health influence and maintain health and health-related issues….and provide a better understanding of how social problems are produced and sustained within and across the various subsystems” (Max, Sedivy & Garrido, 2015, p. 1).

In considering the “the dynamic interplay among persons, groups, and their sociophysical milieus” there are multiple levels to consider (Stokols, 1996, p. 283). The original model included four levels, which have been expanded to five in some adaptations (Poux, 2017, para. 4). For this analysis, we use the Public Health Agency of Canada’s four level ecological model as indicated in the Positive Mental Health Surveillance Indicator Framework (Orpana, Vachon, Dykxhoorn, McRae, & Jayaraman, 2016). These levels include:

1. Individual
2. Family
3. Community
4. Society

This will not be a fulsome analysis of all the socio-ecological factors influenced and impacted by concurrent disorders, but will highlight some of the main considerations (See Figure 1).

Individual – Intrapersonal

This level of the SEM considers the individual characteristics, “traits and identities…which have the capacity to influence” behaviour (Poux, 2017, para. 5). At this level, we examine intrapersonal factors as well, for example, personal beliefs which impact access to care. This first factor to consider, is poverty/income disparity; as noted by Mikkonen and Raphael (2010):

income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning, and influences health-related behaviours…income determines the quality of other social determinants of health such as food security, housing, and other basic prerequisites of health (p. 12, emphasis mine).

Income interplays with other social determinants of health such as physical environments, namely housing/homelessness. Research has indicated that individuals with concurrent disorders experience greater rates of housing instability and that “comorbid substance abuse among patients with severe mental illness was associated with low-quality housing, residential instability, prior homelessness, or current homelessness” (Drake & Brunette, p. 289). Individuals who have concurrent disorders may be on income assistance, and can experience difficulty with lack of employment due to sequalae of their illnesses. This can lead to reduced opportunities to fix this income discrepancy, and result in sustained poverty.

Individuals with concurrent disorders can experience increased stress and physical heath concerns as a sequalae of what Thompson et al. (2015) identifies as:

isolation based upon atypical experiences and the associated social stigma; confusion about whether and when to rely on one’s own perceptions; difficulty determining whose perceptions to trust; and the physical sensations and physical health outcomes that can result from stress, depression, anxiety, and other disorders (p. 127).

Physical health and mental health can intersect in varying ways, and individuals with concurrent disorders can be at “higher risk of chronic disease” (Thompson et al., 2015, p. 128). This increased chronic disease risk can relate to high-risk behaviours associated with substance use e.g. intravenous drug use; additionally, individuals with mental illness experience higher rates of some physical health problems, such as diabetes and cardiovascular disease (Czosnek et al., 2018). The experience of chronic disease can also have negative impacts on mental health. Ultimately, these factors can have implications on help-seeking behaviour and reduce the ability of the individual to access care (Thompson et al., 2015).

As noted by the SEM, concurrent disorders and the social determinants of health interact and can be bidirectional. Concurrent disorders can impact social factors, and vice versa, in an interdependent manner. For example, lack of income can lead to housing instability, which increases stress and increased use of substances; housing instability can lead to transience, and decreased access to care, which can interfere with treatment of concurrent disorders. This can sustain or maintain health conditions.

Family - Interpersonal

This level of the SEM considers “relationships and social networks” (Poux, 2015, para.6). Concurrent disorders can have great impacts on informal support networks. Research has indicated that family relationship can be impacted in a negative way as “substance abuse complicates family relationships for patients with severe mental illness” and can be positively impacted by appropriate integrated treatment (Drake & Brunette, 2002, p. 289). Some families experience caregiver burnout as “family members and others who are close to them often assume supportive functions…these persons are more likely than other caregivers to have to make work accommodations and to report a decline in their own health as a result of their role” (Thompson et al., 2015, p. 126). A reduction of the protective factors of informal support networks can have implications on the factors in the Individual level.

As noted in the Individual level, individuals with concurrent disorders can experience internalised stigma which interferes with help-seeking behaviours. Corrigan (2004) notes:

many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun…to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care (p. 614).

Individuals with concurrent disorders can experience stigma in relationship to the greater community related to both mental illness and substance use, and perhaps intersections of other discriminations related to poverty, homelessness, etc. Families also can experience stigma, and individuals “informally caring for people with mental disorders also have to manage the stigma associated with many mental illnesses” (Thompson et al., 2015, p. 126).

This stigma and isolation can lead to reduction of social networks and social exclusion. This intrapersonal difficulty can interact with interpersonal level domains, as “socially excluded Canadians are more likely to be unemployed and earn lower wages. They have less access to health and social services, and means of furthering their education…Social exclusion creates the living conditions and personal experiences that endanger health” (Mikkonon & Raphael, 2010, p. 32).

Community

This level considers “networks between organizations and institutions that make up the greater community” (Poux, 2015, para. 7). The first consideration at this level as it relates to concurrent disorders is the provision of healthcare through mental health or substance use agencies, in addition to “three interlinked service delivery channels: self-care and informal health care; primary health care; and specialist health care” (Shidhaye, Lund, & Chisholm, 2015, p. 2). The provision of healthcare includes structural organisation, and how resources are allocated based on priorities set by communities.

Interagency and intra-agency collaboration are essential for the appropriate treatment of concurrent disorders, and enhancing access and organisation of health and social services. Given the complex nature of concurrent disorders, “a large proportion of individuals with concurrent disorders report high levels of unmet need and low levels of satisfaction with care. As many as 35–50% of those with concurrent disorders do not access formal care,” leading to greater pressures on systems outside health care, such as the shelter system or the criminal justice system (Wiktorowicz, Abdulle, Di Pierdomenico, & Boamah, 2019, p. 1). The previous silo model and “historical separation of substance-use from mental health services has limited health professionals’ scope of practice for concurrent disorders and produced gaps in care” and led to community organisation that did not include collaborative approaches (Wiktorowicz, Abdulle, Di Pierdomenico, & Boamah, 2019, p. 12).

Collaboration between mental health and substance use agencies (or within agencies) can be supported by enhancing teamwork, participating in joint treatment planning, and engaging in knowledge exchange; this is essential in the provision of care, particularly in complex presentations (Shepherd & Meehan, 2012). The healthcare system in Ontario related to the support of concurrent disorders is challenging for individuals or families to navigate without this collaboration; the lack of appropriate navigation or coordinated planning can result in poorer health outcomes at the intrapersonal/interpersonal levels .

This collaboration also includes the development and initiation of best practices, or evidence based processes. An example of this is the Tiered Model of Care, which is a conceptual approach to support planned collaboration between sectors, and coordinate services for individuals with concurrent disorders. In this model, stacked levels of tiers reflect increasing severity, and subsequent intensity and specialisation of services required for support (Addiction and Mental Health Collaborative Project Steering Committee, 2015). Conceptualisations of the Tiered Model can be seen in Figures 2 and 3. These interventions move away from “vertical programs to horizontal health service platforms” where “any door is the right door” (Shidhaye, Lund, & Chisholm, 2015, p. 9; Addiction and Mental Health Collaborative Project Steering Committee, 2015, p. 12). This structural model of access to care is an organised approach at the community level that can enhance health outcomes for individuals with concurrent disorders.

Other considerations for this level includes physical environment of communities, particularly in how communities are structured. This relates to healthcare access when considering factors such as transportation barriers in accessing care; an example of this would be having to travel far distances to access integrated concurrent disorder treatment.

Society

This final level considers overarching “policies and laws that are instigated at local, national and global levels” (Poux, 2015, para. 9). This level has the broadest sphere of influence, as any changes in this level impacts greater numbers of individuals. Advocacy is a driving force to ensure social change on this ecological level, to reduce the impacts of health inequities; this involves a “whole-of government approach… the health system cannot tackle the health, social, and economic determinants and consequences of [concurrent disorders] disorders alone” (Shidhaye, Lund, & Chisholm, 2015, p. 4).

An example of this advocacy through policy is Canada’s mental health strategy entitled Changing Directions, Changing Lives: The Mental Health Strategy for Canada. This report notes the importance of specialised and integrated care, and highlights recommendations to ensure “appropriate and effective collaboration at the direct service level” (Mental Health Commission of Canada 2012). This strategy advocates for funding from various levels of government to achieve its aims.

Political will is another important factor in this level, particularly in relation to funding. In Canada, health care is highly decentralised at the federal level, and as noted by Wiktorowicz, Abdulle, Di Pierdomenico, and Boamah (2019):

changes in provincial and regional governance affect the organization of and incentives that support service coordination…healthcare may be the most politically contested policy arena, resulting in intensely political policy negotiations between federal, provincial, and territorial governments as well as physician associations (p. 13).

We are currently experiencing this in Ontario, as the recently elected Conservative government has announced great structural changes in how healthcare is administered in this province (Crawley & Janus, 2019). Restructuring provides an opportunity to set new priorities for funding, as determined by communities and community organisation. This could have impacts on the provision of specialised or integrated care.

Policies at the various government levels influence elements such as housing strategy, access to health care, and income assistance policies, and impact factors and domains noted in earlier levels. These health inequities “are created and maintained through a complex interaction of factors occurring at multiple levels of the ecological context” (Trickett & Beehler, 2013, p. 1228). Interventions in this level “must target the contextual or social determinants of health at multiple ecological levels that create and maintain health inequities;" examples of interventions can be supporting multiple voices and viewpoints when developing policy (including individuals with lived experience), strengthening community resources, and allocating funding for population-based health initiatives (Trickett & Beehler, 2013, p. 1229)

Systems

Integrated treatment is a way of making sure that treatment is coordinated and comprehensive for the individual, and will mitigate these stresses illustrated by the SEM analysis. It “involves targeting both the substance use and the mental illness at the same time in a systematic way and is a recommended practice for [concurrent disorders]” (McKee, 2017, p. 50). This is typically provided in an intensive case management approach, and ensures that the individual receives support not only with the concurrent disorder(s), but also in other life domains, such as income, housing, social integration, and employment. This integrated care “can be differentiated from sequential and parallel treatment…sequential treatment has been criticized for ignoring the interconnected nature of concurrent disorders, and parallel approaches can lead to contradictory or incompatible treatment and inferior outcomes” (Wiktorowicz, Abdulle, Di Pierdomenico, & Boamah, 2019, p. 2). One model that has been developed to conceptualise this integrated treatment, as well as locus of treatment, is the four quadrant model. This model “describes how psychiatric and substance use problems co-occur in terms of severity, as well as how psychiatric and substance use treatment systems might most effectively treat these individuals” and is illustrated in Figure 4 (McDonell et al., 2012, p. 267). This model is a framework that informs the Tiered Model of approach discussed earlier. Integrated treatment modalities (with a systems approach) are the best-practice, evidence-based intervention.

References

Addiction and Mental Health Collaborative Project Steering Committee. (2015). Collaboration for addiction and mental health care: Best advice. Ottawa, Ont.: Canadian Centre on Substance Abuse. Retrieved from http://www.ccsa.ca/Resource%20Library/CCSA-Collaboration-Addiction-Mental-Health-Best-Advice-Report-2015-en.pdf

Canadian Centre on Substance Abuse. (2009). Substance abuse in Canada: concurrent disorders. Ottawa, ON: Canadian Centre on Substance Abuse

Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://0-doi-org.aupac.lib.athabascau.ca/10.1037/0003-066X.59.7.614

Crawley, M. & Janus, A. (2019, February 26). Ford government creating Ontario Health super-agency. Toronto Star. Retrieved from https://www.cbc.ca/news/canada/toronto/doug-ford-ontario-health-super-agency-lhin-cancer-care-1.5032830

Czosnek, L., Lederman, O., Cormie, P., Zopf, E., Stubbs, B., & Rosenbaum, S. (2018). Health benefits, safety and cost of physical activity interventions for mental health conditions: A meta-review to inform translation efforts. Mental Health and Physical Activity. https://0-doi-org.aupac.lib.athabascau.ca/10.1016/j.mhpa.2018.11.001

Drake, R. E., & Brunette, M. F. (1998). Complications of severe mental illness related to alcohol and other drug use disorders. In M. Galanter (Ed.), Recent developments in alcoholism: Vol. 14. Consequences of alcoholism (pp. 285–299). New York, NY: Plenum Press.

Max, J. L., Sedivy, V., & Garrido, M. (2015). Increasing our impact by using a social-ecological approach. Washington, DC: Administration on Children, Youth and Families, Family and Youth Services Bureau. Retrieved from https://www.healthyteennetwork.org/wp-content/uploads/2015/06/TipSheet_IncreasingOurImpactUsingSocial-EcologicalApproach.pdf

McDonell, M., Kerbrat, A., Comtois, K., Russo, J., Lowe, J. & Ries, R. (2012). Validation of the co-occurring disorder quadrant model. Journal of Psychoactive Drugs. 44. 266-73. 10.1080/02791072.2012.705065.

McKee, S. A. (2017). Concurrent substance use disorders and mental illness: Bridging the gap between research and treatment. Canadian Psychology/Psychologie Canadienne, 58(1), 50–57. https://0-doi-org.aupac.lib.athabascau.ca/10.1037/cap0000093

Mental Health Commission of Canada. (2012). Changing directions, changing lives: The mental health strategy for Canada. Calgary, AB: Author

Mikkonen, J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto: York University School of Health Policy and Management. Retrieved from http://thecanadianfacts.org/

National Treatment Strategy Working Group. (2008). A systems approach to substance use in Canada: Recommendations for a national treatment strategy. Ottawa: National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada. Retrieved from http://www.ccsa.ca/Resource%20Library/nts-systems-approach-substance-abuse-canada-2008-en.pdf

Orpana, H., Vachon, J., Dykxhoorn, J., McRae, L., Jayaraman, G. (2016). Monitoring positive mental health and its determinants in Canada: the development of the Positive Mental Health Surveillance Indicator Framework. Health Promotion and Chronic Disease Prevention in Canada, 36(1), 1-10.

Poux, S. (2017, August 5). Social ecological model offers new approach to Public Health [blog post]. Retrieved from https://borgenproject.org/social-ecological-model/

Shepherd, N., & Meehan, T. J. (2012). A multilevel framework for effective interagency collaboration in mental health. Australian Journal of Public Administration, 71(4), 403–411. https://0-doi-org.aupac.lib.athabascau.ca/10.1111/j.1467-8500.2012.00791.x

Shidhaye, R., Lund, C., & Chisholm, D. (2015). Closing the treatment gap for mental, neurological and substance use disorders by strengthening existing health care platforms: strategies for delivery and integration of evidence-based interventions. International Journal of Mental Health Systems, 9, 1–11. https://0-doi-org.aupac.lib.athabascau.ca/10.1186/s13033-015-0031-9

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Thompson, N .J., McGee, R. E., Munoz, L. C., & Walker, E. R. (2015). Reflections on mental health advocacy across differing ecological levels. Journal of the Georgia Public Health Association, 5 (1), 126-134. Retrieved from https://augusta.openrepository.com/augusta/bitstream/10675.2/618648/1/Thompson_5_1.pdf

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What is Health?- Moving Towards an Understanding

In 1948, the World Health Organization (WHO) offered a simple definition of health noting it as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” While this was a progressive and aspirational movement towards a definition of health that focused on the presence of wellness and the inclusion of a broader scope of domains, it is also limited by the terms state and complete. Health being a “state” does not allow for dynamic understandings of health or wellness across the course of ones life, and the term “complete well-being” initiates a false dichotomy between complete and incomplete wellness. In the last 70 years, there have been ongoing attempts to both narrow and broaden the focus of this definition, to incorporate a holistic model and understanding of health, with enough utility and specificity to inform research and policy. While this post will not be a fulsome description of all the attempts at pinning down what can be an elusive concept, some themes have emerged.

Health as a Capability

In 1986, the Ottawa Charter for Health Promotion underscored the “social, economic and environmental aspects of ‘health,’” noting that “in order to be healthy, “an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment”” (Public Health Agency of Canada, 2008, para. 3). In this perspective, “health became a resource for everyday life (a process) and not the object of living (a state)” (Leonardi, 2018, p. 738). Huber (2011) emphasised that health should encompass an individual’s “ability to adapt and to self-manage” in response to challenges across "three domains of health: physical, mental, and social" (p. 236). In this way, health becomes a capability. Leonardi (2018) expands on this in developing a definition of heath, which:

configures health as the capability to cope with and to manage one’s own malaise and well-being conditions...health may be conceptualized as the capability to react to all kinds of environmental events having the desired emotional, cognitive, and behavioral responses and avoiding those undesirable ones. (p. 742)

Health as a Philosophical Discussion

Ryff and Singer (1998) attempted to shift the focus further towards a positive, active definition of wellness, and discussed three principles of human health, noting that:

1) Positive health is not merely a medical issue but a philosophical discussion "that requires articulation of the meaning of the good life" (p. 2)

2) Human wellness is about the body and the mind, and their constructiveness, therefore "a comprehensive assessment of positive health must include both mental and physical components" (p. 2)

3) "Positive human health is best construed as a multidimensional dynamic process rather than a discrete end state," meaning that it is understood as an "ongoing engagement with living, involving expression of a broad range of human potentialities" (p. 2).

Health as a Continuum

Further explorations of health as a dynamic state include teasing out continuums between health and illness. In the context of mental health, Keyes (2003) introduces the two continua model which indicates that mental illness and mental health are related but distinct dimensions, where "each dimension respectively ranges from a high to a low level of symptoms of mental illness and mental health" (p. 302). Mental health is defined as either flourishing or languishing, separate from any diagnosis or definition of mental illness. In this framework, an individual could have poor mental health (languishing) in the absence of mental illness, or conversely could have optimal mental health (flourishing) in the presence of mental illness (Figure 1). This differentiation allows for the focus on engagement in "genuine mental health promotion, which includes the objectives of reducing the amount of languishing adults and increasing the number of flourishing individuals in the population" rather than on just the prevention and treatment of mental illness (Keyes, 2003, p. 309). This continuum could have a broader application outside of mental health, to health across a number of domains.

Health as a Comprehensive – Bringing it all Together

Manwell et al. (2015) introduce a Transdomain Model of Health (Figure 2) to “inform the development of a comprehensive definition for all aspects of health” (p. 8). In this model,

there are three domains of health (ie, physical, mental, and social), each of which would be defined in terms of a basic (human rights) standard of functioning and adaptation. There are four dynamic areas of integration or synergy between domains. (p. 9).

These basic “standards of functioning and adaptation” include allostasis for physical health, a sense of coherence for mental health, and interdependence for social health; this model also notes “how these domains interact to affect overall quality of life” (Manwell et al., 2015, p. 8).

My Reflections

I believe that a helpful definition of health is of necessity a broad one, to incorporate all the meaningful elements that contribute to wellness. We can experience dynamic shifts between illness and wellness continuums across multiple domains, including the three domains originally noted by WHO. However, Ryff and Singer’s (1998) definition of positive human health most resonates with me; in my counselling practice, I will often invite individuals to describe their ‘life worth living,’ as an active vision towards wellness. I also appreciate the understanding of health as a “multidimensional dynamic process rather than a discrete end state” as wellness can be an ongoing journey towards a meaningful quality of life (Ryff & Singer, 1998, p. 2).

References

Huber, M. (2011). Health: How should we define it? British Medical Journal, 343,(7817), 235-237. https://doi.org/10.1136/bmj.d4163 Retrieved from: http://www.jstor.org/stable/23051314

Keyes, C. L. M. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 207-222.

Keyes, C. L. M. (2003). Complete mental health: An agenda for the 21st century. In C. L. M. Keyes & J. Haidt (Eds.), Flourishing: Positive Psychology and the Life Well-Lived (pp. 293-312). Washington, DC, US: American Psychological Association. https://0-doi-org.aupac.lib.athabascau.ca/10.1037/10594-013

Leonardi, F. (2018). The definition of health: Towards new perspectives. International Journal of Health Services, 48(4), 735–748. https://doi.org/10.1177/0020731418782653

Manwell, L. A., Barbic, S. P., Roberts, K., Durisko, Z., Lee, C., Ware, E., & McKenzie, K. (2015). What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. BMJ open, 5(6), e007079. doi:10.1136/bmjopen-2014-007079

MacKean (2011). Mental health continuum [image]. Adapted from: The Health Communication Unit at the Dalla Lana School of Public Health at the University of Toronto and Canadian Mental Health Association, Ontario; based on the conceptual work of Corey Keyes. Retrieved from https://www.mta.ca/Community/Student_services/Health_and_wellness/Mental_health_and_wellness/What_is_mental_health/What_is_mental_health/

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, NY, June 19-22, 1946; signed on July 22, 1946, by the representatives of 61 states (Official Records of the World Health Organization, No. 2, p 100); and entered into force on April 7, 1948.

Public Health Agency of Canada. (2008, September 12). What is health? Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-approach/what-is-health.html

Ryff, C. D., & Singer, B. (1998). The contours of positive human health. Psychological Inquiry, (1), 1. Retrieved from http://0-search.ebscohost.com.aupac.lib.athabascau.ca/login.aspx?direct=true&db=edsbl&AN=RN042909816&site=eds-live