The urgent need to address mental health and substance use structural stigma in BC

British Columbians living with mental health and substance use (MHSU) disorders are experiencing a “quality chasm”[1] and are dying at unprecedented rates, in part due to structural stigma. Structural stigma refers to the inequitable deprioritization, devaluation, and othering of MHSU—as compared with physical health—within health care delivery, governance, knowledge building, and training systems, creating and perpetuating health and social inequalities and poorer standards of care for people with MHSU disorders. Structural stigma is particularly damaging because it represents unfairness and inequity embedded in how we think and act toward people with MHSU disorders and in the fabric of our institutions.

Structural stigma limits access to quality care for MHSU disorders, leading to increased emergency department presentations, more severe and harder-to-treat illnesses, and increased mortality. Indigenous people are disproportionately affected, highlighting structural racism and the ongoing perpetuation of colonial violence. This is happening within the context of a worsening opioid crisis.

The 2023 BC provincial budget includes $1 billion for MHSU funding over the next 3 years. However, it is essential that funds are spent wisely to ensure they are tied to evidence-based frontline services. Since “every system is perfectly designed to get the results it gets,”[1] it’s time to treat structural stigma as a quality-of-care indicator and a health-equity issue and to prioritize system redesign.

How structural stigma manifests in the health care system:

• Unequal funding for MHSU compared with physical health even after considering the new investment.
• Artificial separation of services for substance use disorders and mental illnesses, especially since concurrent disorders are the rule rather than the exception.
• Limited MHSU training in primary care and other specialties relative to the burden of disease.
• Lack of acknowledgment that unaddressed MHSU disorders impact outcomes in virtually all specialties.[2]
• Absence of a comprehensive vision or action plan for MHSU care provincially, with large gaps in prevention and treatment in the current provincial strategy.[3]
• High distress levels and frustration felt by providers, patients, and families from working in and/or accessing MHSU care in a subpar system.
• Anticipated stigma and system distrust, leading to decreased willingness to seek help.
• Siloing the Ministry of Mental Health and Addictions (MMHA) from the Ministry of Health (MoH) and children’s mental health services residing in the Ministry of Children and Family Development (MCFD).

While there can be benefits to creating a distinct entity to draw attention to MHSU, creating more separation between other domains of health ultimately contributes to the chasm. We need reduced fragmentation and a cohesive system built on the understanding that mental health is intimately tied to all other aspects of health.

How to decrease harm and create a cohesive system that delivers high-quality care:

• Reduce fragmentation by evaluating the structure of institutions, including the MoH, MMHA, and MCFD. Evaluate allocation of funding to prioritize and support evidence-based frontline care.[1]
• Measure wait times and outcomes for MHSU disorders with benchmarks, wait-time targets, and treatment pathways so all patients can expect high-quality care regardless of identity or home community. Embedded measurements and targets will allow for transparency and hold the government and health authorities accountable for system performance.
• Review all health and human service policies, along with accreditation standards for hospitals and medical schools, through a health-equity lens to address the barriers to MHSU services for so many people.
• Include training on robust stigma reduction and structural competency components for all health professions.[4]
• Examine biases, seek further education, and advocate.

Courageous, bold personal and collective action at all levels is needed to address MHSU structural stigma. The statement “there is no health without mental health” could not be more true.
—Rachel Grimminck, MD, FRCPC
COHP Vice-Chair
—Stephanie Knaak, PhD
Adjunct Assistant Professor, Department of Psychiatry, Cumming School of Medicine, University of Calgary
Adjunct Clinical Associate, Faculty of Nursing, University of Calgary
Adjunct Professor, Department of Community Health Sciences, University of Manitoba
—Andrew Szeto, PhD
Associate Professor, Department of Psychology, University of Calgary
—Veronic Clair, MD-PhD, FRCPC
COHP Chair

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This article is the opinion of the authors and not necessarily the Council on Health Promotion or Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Knaak S, Patten S, Ungar T. Mental illness stigma as a quality-of-care problem. Lancet Psychiatry 2015;2:863-864.

2.    Public Health Agency of Canada. Addressing stigma: Towards a more inclusive health system, 2019. Accessed 4 May 2023. www.canada.ca/content/dam/phac-aspc/documents/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/addressing-stigma-what-we-heard/stigma-eng.pdf.

3.    Ministry of Mental Health and Addictions. A pathway to hope: A roadmap for making mental health and addictions care better for people in British Columbia. 2021. Accessed 4 May 2023. www2.gov.bc.ca/assets/gov/british-columbians-our-governments/initiatives-plans-strategies/mental-health-and-addictions-strategy/bcmentalhealthroadmap_2019web-5.pdf.

4.    Sukhera J, Knaak S, Ungar T, Rehman M. Dismantling structural stigma related to mental health and substance use: An educational framework. Acad Med 2022;97:175-181.