Invited commentary: ACCESS Open Minds/Esprits ouverts—A seismic shift in Canadian mental healthcare

This series of reports from seven of the 14 sites of the ACCESS Open Minds (ACCESS OM) initiative provides compelling perspectives on the adaptation of a single vision and research/evaluation design to the local and diverse realities of the Canadian landscape. ACCESS OM is jointly funded by the Canadian Institutes of Health Research and the Graham Boeckh Foundation, a private family-run foundation that “aims to be a catalyst in bringing about transformational changes that significantly improve the lives of people with or at risk of mental illness” (Graham Boeckh Foundation, n.d.). At just under $25 million in budget, ACCESS OM is the largest clinical research action initiative in Canada and indeed one of the largest funded clinical research projects ever supported by the Canadian Institutes for Health Research. The last major mental health clinical research initiative of similar scope in Canada was the Mental Health Commission's At Home/Chez Soi programme, funded by the federal government in the amount of $110 million—a randomized clinical trial of a housing-first initiative vs treatment as usual for homeless mentally ill individuals in five Canadian cities—Moncton, Montreal, Toronto, Winnipeg and Vancouver (Goering et al., 2014). That study addressed an urgent social and mental health problem using an experimental design, a commitment to community building as well as to data collection, flexibility and innovation as well as rigour in adapting a single national design to local realities, and an early identification of the importance of sustainability and scaling up in moving Canada beyond the land of pilot projects to a transformed new reality. At Home/Chez Soi had an impact on government policy and funding, and its unprecedented scale as a research initiative on homelessness has led to replication and impact in other countries. ACCESS OM appears poised to have a similar or greater impact in the arena of youth mental health at a time when awareness is driving demand for help and traditional approaches are overwhelmed, ineffective or simply unavailable. There is broad acknowledgement of both unmet need and significant cost, from social role impairment to suicide, in this population that is vulnerable to the emergence of the majority of adult psychiatric disorders. The reality of Canada is, despite a national ethos of universal and accessible healthcare, a complex array of local youth mental health services that are difficult to access, challenging to navigate, often unavailable to those over the age of 18, and governed and funded through local and provincial rather than national sources. Enter ACCESS OM: It is a pan-Canadian study, with a single design that reflects core principles embedded in its acronym: adolescent/young adult connections to community-driven, early, strengths-based, stigma-free services). Spread across 14 sites in six provinces and territories, its diverse contexts reported in this issue include: an isolated Indigenous hamlet of 396 people in the far north; homeless youth in a major urban and predominantly francophone setting of 1.7 million people; a rural francophone community with 4000 youth; first-year undergraduates at a large university population of 38 000 students; a mid-size city of 100 000 people and surrounding rural area; a large Indigenous reserve of 4500 people, 50% of whom are under age 25; and a city of over one million people, one-third of them under age 25, that includes a large urban Indigenous population as well as a significant homeless population. The variety inherent in these contexts is both a challenge and an opportunity—how to accommodate the diversity within the context of a study design and how to show the initiative can be successful in communities that reflect the reality of Canada. And with almost 50% of the sites in Indigenous communities, there is a tremendous opportunity for bidirectional sharing of knowledge, identifying similarities and celebrating differences while trying to meet the underserved mental health needs of Indigenous youth. This series of seven papers from ACCESS OM sites reflects some important themes. First, people were not sitting on their thumbs waiting for ACCESS OM to happen. In most settings, there was awareness that youth mental health needs were not being well met and efforts were underway to achieve change and improvement. However, ACCESS OM brought to them a vision, some organizing principles, and funding—as well as a strong commitment to evidence and measurement. This is reflected in the similar structure of each of these seven reports that allows an understanding of the intersect between common requirements and local realities. The community mapping required at baseline likely catalysed change as well, since any kind of measurement tends to trigger change on its own. Like At Home/Chez Soi, it brings together a disparate array of providers and stakeholders who otherwise might not be at the same table. But the setting of clinical targets—measured in hours and days—for early identification and rapid access to help are still sadly novel in Canadian mental healthcare. The engagement of youth and families, to which lip service is often paid, was established at the outset as a foundational reality—not simply in the role of providing reactive advice and support but rather being involved actively in the design, governance and evaluation. The commitment to a single data set and to incorporating it into care, in a way that cuts across traditional provincial boundaries for capturing health information, is another important aspect of ACCESS OM that should have repercussions well beyond this initiative. The late statistician W. Edwards Deming is perhaps apocryphally acknowledged as the author of the aphorism “In God we trust; all others bring data”. Of note, he also championed quality improvement through the “plan-do-study-act” cycle, and ACCESS OM is very much in this spirit. ACCESS OM's commitment to data collection will have important implications for its sustainability beyond the expiry of its research funding as well as its own evolution; it should allow for learning who the young people are for whom ACCESS OM does and does not work. One of the remarkable aspects of the ACCESS OM project is the simultaneous evolution of similar integrated youth services initiatives across Canada, including Foundry in British Columbia (https://foundrybc.ca/), with over a dozen established and developing centres, and Youth Wellness Hubs Ontario (https://youthhubs.ca/en/), with 10 planned or running centres. Like ACCESS OM, these initiatives emphasize storefront, “one-stop shopping” programs whose physical space design reflects youth input and a commitment to rapid access to services for mental health, physical health, education and employment support. The ultimate inspiration for ACCESS OM's services emanates from both the nominated principal investigator's two decades of research on early intervention in psychosis and from Australia, where the Headspace initiative (https://headspace.org.au/) has been running since 2006 and now operates over 100 centres across the nation. What is clear, however, from the reports in this series of ACCESS OM sites, is that adherence to the study design and principles is not the equivalent of opening a fast-food franchise, where the goal of standardization trumps the palate of the taster. Each site has implemented ACCESS OM on a foundation of previous efforts and in acknowledgment of local realities—but now poised to meet the same objectives using the same measures across the network. ACCESS OM now must insure that its data collection is optimized to generate the evidence that will justify its sustainability; apart from political pressures, governments increasingly need to demonstrate return on investment, especially in the highly competitive context of healthcare which consumes almost 50% of provincial budgets. But the political reality is that the costs and benefits of improving youth mental healthcare extend well beyond health budgets to social services, unemployment and disability support, criminal justice—not to mention hope for recovery, functioning and quality of life for young people and their families. The author currently sits on the Board of Directors of the Graham Boeckh Foundation, co-funder of this initiative, as well as on the National Advisory Council of ACCESS OM, but joined both well after the funding decision was made and the study initiated. He receives no personal funding in either volunteer role and has no other potential conflicts of interest to declare.

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