Regional Tertiary Psychiatric Care and Rehabilitation Authorities for People with Severe Mental Illness in Canada

In Canada and other countries, such as the United Kingdom,1 we seem to be permanently in an era of budgetary restrictions. A balanced mental health system has been difficult to achieve during the last few decades because funding associated with downsizing and closure of psychiatric hospital beds has been moved to other health care and social services.2 The justice system has taken over some of the functions of the mental health system, with the police in many areas being the only 24/7 service, and the jail system housing people with schizophrenia, who frequently receive inadequate mental health care.3 Not to mention the system failure indicator that homeless people with severe mental illness (SMI) represent in Canadian cities, or the excess mortality of psychiatric patients.4 Moreover, even if medication is generally well provided for people with SMI, evidence-based psychosocial interventions are only implemented piecemeal in our resources-rich systems of care (see the 2 In Review papers by Mr Matthew Menear and Dr Catherine Briand5,6 in this issue of The Canadian Journal of Psychiatry [The CJP]).However, with proper leadership by clinicians and managers at the regional and provincial levels, regional psychiatric rehabilitation centres and authorities, properly funded, could offer better tertiary psychiatric services and evidence-based rehabilitation interventions to all patients requiring it in their region or province.We will briefly describe the system issues, such as reform of mental health services in Canada, under the 4 headings suggested by Health Canada7 (governance, funding, training, and evaluation), supported by the In Review papers in this issue on evidencebased rehabilitation interventions (see Dr Tania Lecomte, Dr Marc Corbiere, and Dr Claude Leclerc8) and effective implementation strategies in programs and systems (see Menear and Briand5 and Briand and Menear6). For training of the future generation of Canadian psychiatrists in the rehabilitation of SMI (see Freeland et al9 in the Canadian Psychiatric Association's book Approaches to Postgraduate Education in Psychiatry in Canada).FundingThe system costs for the array of required services in the treatment and rehabilitation of SMI, estimated at 1.5% of the population, are illustrated as a simulation in Table 1. The table excludes other direct system costs, such as medical services, medication, disabilities, and income supplement, or other sectors, such as the judiciary system; it represents what most provincial ministries of health and social services consider as their mental health program expenditures. The items, proposed ratios, and costs could be modulated and are further explained in Lesage.10 It is of interest that the simulated average per capita of $134 is only 20% higher than Quebec's mental health program when it launched its action plan in 2005: a balanced mental health care system for SMI need not be much more expensive, but must be better organized. In Table 1, it can be seen that hospital and supervised residential settings will represent at least 65% of this total simulated mental health budget. A similar funding distribution has been reported by the United Kingdom11 and in a best practice area of Italy, which has been a leader in mental health care reform.12GovernanceIn the United Kingdom, it has been suggested that in each local area, psychiatric services, along with social services and health services, develop specialist psychiatric rehabilitation services working with all the other relevant mental health and social programs. The latter include the Community Mental Health Teams (CMHTs), mental retardation teams, and specialist substance dependence teams. Interestingly, in Quebec, mental retardation and specialist addiction services are under the authority of regionalized mental retardation or addiction rehabilitation centres. These local or regional psychiatric rehabilitation services cover the patients in the array of services described in Table 1, from long-term hospitalization to supplement to rent. …

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