Addressing Mental Health Service Access among Black Canadians
As conceptualized by the World Health Organization, mental health is the state of well-being where an individual can deal with stressors, be productive, and an active member within their community [1]. It extends beyond the absence of mental health conditions such as anxiety or depression to include a positive sense of well-being and the capacity to enjoy life [2]. On the other end, one’s mental health is likely to be compromised when the demands placed on an individual surpass their ability to cope with their challenges [3]. The inability to effectively manage poor mental health for long periods of time can conversely contribute to the acquisition of more serious mental health conditions, such as depression; one of the leading causes of disability worldwide [3,4]. Mental health awareness has been prioritized by national governments globally to aid in the development and integration of effective mental health policies and services to reduce the incidence of mental health problems for all [1]. Yet, the gap between those in need of psychological counseling to manage their poor mental health and those with access to care remains an extensive area of mental health research and discourse [5]. This article will discuss the prevalence of poor mental health and the barriers associated with poor service access among Black Canadians, as well as emphasize the significance of reconsidering structural and individual-level factors to effectively attend to the varied ethnic and cultural mental health needs of this population group.
Original illustration by Karly Franz.
Global mental health has primarily focused on grass-roots approaches such as task-shifting to address the most blatant and unmet needs in mental healthcare for example, psychological and psychiatric worker shortages, in poor-resource contexts [6, 7]. Thus, low-to-middle income countries have served as priority settings for mental health service development due to the ineffectiveness to develop useful mental health resources and support for populations living in these regions [7]. At the same time, there has been a growing concern about improving the equity, access, and quality of mental health services in high-income countries [8]. An emphasis has been placed on urban areas among marginalized groups including the urban poor, refugees, racialized communities, and members of the LGBTQ+ community [9]. Despite wealthier countries’ financial leverage to develop and fund mental healthcare, a global mental health approach must necessitate the capacity to improve mental healthcare in all contexts [6, 7].
Canada is a high-income country that can be used as an example to highlight inequitable mental healthcare access among marginalized groups within rich-resource contexts. The prevalence of mental health conditions in Canada is concerning as 1 in 5 people are likely to experience a mental illness or substance use disorder in any given year [10]. Out of approximately 38 million Canadians, only about 30% have access to mental health services to address their psychological needs [11, 12]. This is against the widely held notion of Canada being distinctively known for the delivery of accessible and quality healthcare [13]. Though the nation generally receives positive views for providing publicly funded healthcare to its citizens, mental healthcare is generally privatized, requiring many to pay out of pocket to utilize such services [14]. Among those impacted by the inability to access mental health supports, racialized groups are the majority [15]. In diverse urbanized locations, such as Toronto, Ontario, where many residents identify as an ethnic minority, it is crucial to identify the factors which impact service access as well as understand the variation in mental health experiences among these communities [15].
Black Canadians are of particular interest among racialized groups with limited mental health service access. This group only represents 3.5% of the population and is characterized as individuals who identify with the cultures, ethnicities, histories, and experiences of African and Diaspora communities [16]. What separates this population group from other ethnic minorities is the disproportionate prevalence of avoidable social and health inequalities due to historical and contemporary instances of anti-Black racism [17]. Research has shown that the subjection to slavery, colonialism, marginalization, and oppression contribute to structural inequalities such as poor access to healthcare services and low socioeconomic status [17]. Much of these instances possess long-standing impacts on the mental health experience of Black communities today. For example, mood and anxiety disorders, namely depression, among Black Canadians is nearly 6 times the prevalence of the majority population [17, 18]. The persistence of these inequalities is most apparent at critical periods when mental health services are required. Analysis of the impact of Covid-19 on healthcare access validates existing literature that vulnerabilities of racialized groups are intensified in pandemics [19]. Other studies have cited limited mental health literacy and awareness, stigma, myths and misconceptions about mental illness, and a lack of representation in mental health practice as barriers to utilizing mental health resources among Black communities [17].
“In diverse urbanized locations, such as Toronto, Ontario, where many residents identify as an ethnic minority, it is crucial to identify the factors which impact service access as well as understand the variation in mental health experiences among these communities”
Notwithstanding what is known, the increasing risk of developing mental health conditions and poor service access among Black Canadians suggest the problem may be due to substantial data gaps [16]. Several national and provincial organizations have implemented initiatives within their larger health directives to address evidence gaps in mental health surveillance, data collection, and reporting [20]. For instance, the Public Health Agency of Canada has prioritized stronger systems for mental health surveillance while Statistics Canada has made mental health a central feature in its nation-wide health surveys [20]. Although these initiatives continue to make valuable efforts to expand our understanding of mental health, research on Black mental health in Canada remains monolithic and fails to highlight comprehensive data on poor mental health prevalence and service access at the intersection of varying personal and social identities including sexual orientation, age, gender, or immigration status [16, 20]. A notable discrepancy is how mental health outcomes are measured and analyzed at the national level, where existing data does not accurately reflect how Black communities perceive and discuss mental health [16].
As suggested in studies on race and health, the starting point in the long journey to addressing poor access to mental healthcare can take the form of analyzing structural and individual-level determinants of mental health service use [21]. Such analysis should emphasize the connection between national and provincial-level health policy and inequalities in healthcare access and outcomes. The way health decisions are designed can directly affect health outcomes among various population groups if their unique health needs are not taken into consideration [21]. In the past 30 years, mental health policy reform in Ontario has shifted mental health care from the institutionalization of people with mental illness in psychiatric hospitals to a system of care that can be readily accessed by the community when they want to use them [22]. Mental health reform should continue to move in this direction for more equitable mental healthcare outcomes but should take a closer look into the process of how mental health policy and services are organized and implemented at the structural level in catering to diverse groups. It may be important for upcoming mental health policies to highlight the heterogeneity of Black populations – ethnic and cultural differences as well as their experiences within mental health spaces.
“[R]esearch on Black mental health in Canada remains monolithic and fails to highlight comprehensive data on poor mental health prevalence and service access at the intersection of varying personal and social identities including sexual orientation, age, gender, or immigration status”
Some current strategies are aiming to improve the utilization of mental healthcare for Black populations in Ontario. For instance, the Centre for Addiction and Mental Health (CAMH) launched a strategy in February 2022 that includes 22 action items to dismantle anti-Black racism inside and outside CAMH [23]. The overarching goals of this intervention includes a plan to provide more equitable access to mental health services among Black populations. Specifically, to provide safe, accessible, and equitable mental healthcare for Black patients and their families by training staff members to provide interventions that are made to cater to Black populations, create an equitable work environment for Black staff employed CAMH such as opportunities to advance within the company, and lastly, to create a mental health system by building supportive infrastructure within and outside CAMH to reduce unjust treatment for Black patients and their families [23]. How this strategy will unfold to address and attend to the varied ethnic and cultural differences of Black populations’ mental health needs will be of interest.
“It may be important for upcoming mental health policies to highlight the heterogeneity of Black populations – ethnic and cultural differences as well as their experiences within mental health spaces”
The multicultural landscape in Canada makes the analysis of mental healthcare crucial to understand the varying mental health needs of its diverse population. Doing so will ensure that culturally relevant mental health services are available and provided to those that require them. Improving data quality in this area has the potential to uncover factors impacting access and help-seeking practices which can, in turn, increase utilization of mainstream mental healthcare. Furthermore, a closer look into structural and social factors that influence mental health service use among Black groups in Canada can help inform solutions and strategies for other minority populations in different contexts where inequities in mental health outcomes are also prevalent.
Ethel Barnes (she/her) is a PhD student at the Dalla Lana School of Public Health, University of Toronto, Canada. Her research interests include Global Health, Health Policy, and Inequities in Health Service Use and Access among Black Populations.
References
[1] World Health Organization. Mental health: strengthening our response. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response (2018).
[2] Canadian Mental Health Association. Positive mental health and well-being. Canadian Mental Health Association. https://ontario.cmha.ca/documents/positive-mental-health-and-well-being/ (2022).
[3] Centers for Disease Control and Prevention. About mental health. Centers for Disease Control and Prevention. https://www.cdc.gov/mentalhealth/learn/index.htm (2021).
[4] World Health Organization. Mental health. World Health Organization https://www.who.int/health-topics/mental-health#tab=tab_1 (2022).
[5] Rebello, T., Marques, A., Gureje, O. & Pike, K. Innovative strategies for closing the mental health treatment gap globally. Current Opinion in Psychiatry 27, 308–314 (2014).
[6] Sashidharan, S. P., White, R., Mezzina, R., Jansen, S. & Gishoma, D. Global mental health in high-income countries. The British Journal of Psychiatry 209, 3–5 (2016).
[7] Susser, E. & Patel, V. Psychiatric epidemiology and global mental health: joining forces. Int J Epidemiol 43, 287–293 (2014).
[8] Alegria, M., Nakash, O. & NeMoyer, A. Increasing equity in access to mental health care: a critical first step in improving service quality. World Psychiatry 17, 43–44 (2018).
[9] Kirmayer, L. & Pedersen, D. Toward a new architecture for global mental health. Transcult Psychiatry 51, 759–776 (2014).
[10] Centre for Addiction and Mental Health. Mental illness and addiction: facts and statistics. Centre for Addiction and Mental Health https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics (2022).
[11] Government of Canada. Canada’s population estimates, first quarter 2022. Government of Canadahttps://www150.statcan.gc.ca/n1/daily-quotidien/220622/dq220622d-eng.htm (2022).
[12] Government of Canada. Mood and anxiety disorders in Canada. Government of Canada https://www.canada.ca/en/public-health/services/publications/diseases-conditions/mood-anxiety-disorders-canada.html (2015).
[13] Hankivsky, O. & Christoffersen, A. Intersectionality and the determinants of health: a Canadian perspective. Crit Public Health 18, 271–283 (2008).
[14] Martin, D. et al. Canada’s universal health-care system: achieving its potential. The Lancet 391, 1718–1735 (2018).
[15] Chiu, M., Amartey, A., Wang, X. & Kurdyak, P. Ethnic differences in mental health status and service utilization: A Population-Based Study in Ontario, Canada. The Canadian Journal of Psychiatry 63, 481–491 (2018).
[16] Government of Canada. Social determinants and inequities in health for Black Canadians: A Snapshot. Government of Canada 1–14 https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health/social-determinants-inequities-black-canadians-snapshot.html (2020).
[17] Mental Health Commission of Canada. Shining a light on mental health in black communities. Mental Health Commission of Canada 1–4 https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/2021-02/covid_19_tip_sheet%20_health_in_black_communities_eng.pdf (2021).
[18] Cenat, J. M. et al. Prevalence and correlates of depression among Black individuals in Canada: The major role of everyday racial discrimination. Depression and Anxiety (2021).
[19] Chung, E., Adhopia, V. & Glanz, M. Black Canadians get sick more from COVID-19. Scientists aim to find out why. CBC News https://www.cbc.ca/news/health/black-covid-antibody-study-1.5737452 (2020).
[20] Mental Health Commission of Canada. Overview on mental health data in Canada: background, needs, and gaps. Mental Health Commission of Canada (2014).
[21] Low, A. & Low, A. Importance of relative measures in policy on health inequalities. BMJ 332, 967–969 (2006).
[22] Canadian Mental Health Association. History of mental health reform. Canadian Mental Health Associationhttps://ontario.cmha.ca/provincial-policy/health-systems-transformation/history-of-mental-health-reform/ (2022).
[23] Centre for Addiction and Mental Health. Dismantling anti-Black racism: A strategy of fair & just CAMH. Centre for Addiction and Mental Health https://www.camh.ca/-/media/files/camh-dismantling-anti-black-racism-pdf.pdf (2021).