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

Abstract

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 DOI: 10.1111/eip.12812