Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach.

Medical assistance in dying for mental illness as a sole underlying medical condition (MAiD MI-SUMC) is a controversial and complex policy in terms of psychosocial and ethical medical practice implications. We discuss the status of MAiD MI-SUMC in Canada and argue for the use of the UK Medical Research Council's framework on complex interventions in programme evaluations of MAiD MI-SUMC. It is imperative to carefully and rigorously evaluate the implementation of MAiD MI-SUMC to ensure an understanding of the multiple facets of implementation in contexts permeated by unique social, economic, cultural and historical influences, with a correspondingly diverse array of outcomes. This requires a complexity-informed programme evaluation focused on context-dependent mechanisms and stakeholder experiences, including patients, service providers and other people affected by the policy. It is also important to consider the economic impact on health and social welfare systems. Such evaluations can provide the data needed to guide evidence-informed decision-making that can contribute to safer implementation and refinement of MAiD MI-SUMC.

Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives.

BACKGROUND: Persons with mental illness as their sole underlying medical condition are eligible to access medical assistance in dying (MAiD) in a small number of countries, including Belgium, the Netherlands, Luxemburg and Switzerland. In Canada, it is anticipated that people experiencing mental illness as their sole underlying medical condition (MI-SUMC) will be eligible to request MAiD as of March 17th 2024. To date, few studies have addressed patient and family perspectives on MAiD MI-SUMC care processes. This study aimed to address this gap and qualitatively explore the perspectives of persons with lived experience of mental illness and family members on care considerations during MI-SUMC implementation. METHODS: Thirty adults with lived experience of mental illness and 25 adult family members residing in Ontario participated in this study. To facilitate participant engagement, the semi-structured interview used a persona-scenario exercise to discuss perspectives on MAiD MI-SUMC acceptability and care considerations. Framework analysis was used to inductively analyze data using NVivo 12 Pro. Steps, processes, or other care considerations suggested by the participants were charted in a framework matrix after familiarization with the narratives. Key themes were further identified. A lived-experience advisory group participated in every aspect of this study. RESULTS: Six themes were developed from the patient and family narratives: (1) Raising MAiD MI-SUMC awareness; (2) Sensitive Introduction of MAiD MI-SUMC in goals of care discussions; (3) Asking for MAiD MI-SUMC: a person-focused response; (4) A comprehensive circle of MAiD MI-SUMC care; (5) A holistic, person-centered assessment process; and (6) Need for support in the aftermath of the decision. These themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making. CONCLUSIONS: Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards. These stakeholders' perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.

Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition.

Medical assistance in dying (MAiD) was introduced into Canadian federal legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is currently excluded from eligibility; such exclusion is scheduled to expire on March 17, 2024. Irremediability, capacity, quality of life, autonomy, family involvement, and healthcare system constraints have been debated intensively. Recent studies have not explored the views of family members of persons with mental illness on MAiD MI-SUMC. This study aimed to fill this knowledge gap. Twenty-five Ontario residents who had a loved one with mental illness participated. A persona-scenario exercise was designed to explore participants' views on MAiD MI-SUMC in hypothetical situations. Reflexive thematic analysis was used to analyze the data. A lived experience-advisory panel was engaged throughout the study. Seven themes were developed: Witnessing suffering; A road with barriers and limitations; Societal barriers; The unknowns of mental illness; Individual choices: the life or death that a person wants; MAiD MI-SUMC as an acceptable choice when suffering cannot be relieved with available treatments and supports; and The emotional outcome. Participants constructed their views based on their experience of supporting a loved one with mental illness. MAiD MI-SUMC was perceived as a multifaceted issue, whose acceptability and potential introduction required a concurrent exploration and discussion of the challenges arising due to limitations of the healthcare system, the opportunities and limits to family involvement, and the value of patient autonomy.

Searching for relief from suffering: A patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition.

Medical assistance in dying (MAiD) was introduced into Canadian legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is excluded from eligibility; this is expected to change in 2024. Incurability, intolerable suffering, capacity to make healthcare decisions, and suicidality have been publicly debated in connection with mental illness. Few studies have explored the views of persons with mental illness on the introduction and acceptability of MAiD MI-SUMC; this study aimed to fill this gap. Thirty adults, residing in Ontario, Canada, who self-identified as living with mental illness participated. A semi-structured interview including a persona-scenario exercise was designed to discuss participants' views on MAiD MI-SUMC and when it could be acceptable or not. Reflexive thematic analysis was used to inductively analyze data. Codes and themes were developed after extensive familiarization with the dataset. A lived-experience advisory group was engaged throughout the study. We identified six themes: The certainty of suffering; Is there a suffering threshold to be met? The uncertainty of mental illness; My own limits, values, and decisions; MAiD MI-SUMCas acceptable when therapeutic means, and othersupports, have been tried to alleviate long-term suffering; and Between relief and rejection. These themes underline how the participants' lived experience comprised negative impacts caused by long-term mental illness, stigma, and in some cases, socioeconomic factors. The need for therapeutic and non-therapeutic supports was highlighted, along with unresolved tensions about the links between mental illness, capacity, and suicidality. Although not all participants viewed MAiD MI-SUMC as acceptable for mental illness, they autonomously embraced limits, values, and decisions of their own along their search for relief. Identifying individual and contextual elements in each person's experience of illness and suffering is necessary to understand diverse perspectives on MAiD MI-SUMC.

Understanding the service needs of youth with opioid use: A descriptive study of demographics and co-occurring substance use and mental health concerns.

INTRODUCTION: Opioid misuse among youth is a significant concern given its potential negative consequences; yet youth who use opioids continue to face challenges in seeking treatment. The goal of this study was to understand the demographics, mental health, and substance use and co-occurring concerns of service-seeking youth with opioid use to inform future services and research. METHODS: This study characterized 1769 youth between 14 and 24 years old seeking services at an urban treatment facility in Toronto, Ontario (ON) between 2008 and 2019. Youth who could adequately read English, had no immediate psychiatric service needs, provided research consent, and responded to a question about opioid use history were eligible. Participants provided information on demographics, substance use, mental health, and treatment motivation. RESULTS: Youth who use opioids were more likely to report challenges with social determinants of health, use more substances, initiate substance use earlier, and use some substances at a higher frequency than youth who do not use opioids. Youth with opioid use reported more co-occurring mental health and substance use concerns than youth with no opioid use. They also endorsed more trauma and a likely PTSD diagnosis. Not being in employment, education, or training and using a higher number of substances positively predicted youth opioid use. In terms of treatment motivation, youth who use opioids endorsed more internal forms of motivation than youth who do not use opioids. CONCLUSIONS: Youth who use opioids have complex social and co-occurring mental health and substance use needs that may be addressed with integrated community-based services. Future research should focus on developing evidence-based opioid treatment programs in this context and other innovative platforms.

Social Determinants of Health among Youth Seeking Substance Use and Mental Health Treatment.

OBJECTIVE: The extent to which social determinants of health problems occur among youth with mental health and addiction concerns and the impact of social determinants on their treatment is unknown. This study examined the prevalence of social determinants of health problems among treatment-seeking youth, their perceptions of interference with treatment, and the association between social determinants of health and mental health/addiction difficulties. METHOD: Youth ages 15-24 seeking out-patient treatment for substance use concerns, with or without concurrent mental health concerns, reported on substance use, mental health and social determinants of health. Descriptive statistics and logistic regression analyses were used to determine the extent of social determinant of health problems and their relationship with mental health, substance use, and crime or violence problems. RESULTS: In all, 80% of youth endorsed social determinants of health concerns in at least one domain; nearly 70% identified financial concerns, and many identified substantial problems in each domain and anticipated treatment impacts. Youth most frequently identified financial problems as likely to impact treatment. Cumulative number of social determinants of health problems and individual domains of social determinants of health problems were related to overall mental health and addiction concerns. CONCLUSIONS: Given their prevalence and association with mental health and addiction concerns, social determinants of health problems should be routinely assessed among treatment-seeking youth and integrative services that address these concerns in addition to symptomatology should be considered.

OBJECTIF: La mesure dans laquelle les déterminants sociaux des problèmes de santé sont présents chez les jeunes ayant des problèmes de santé mentale et de dépendance ainsi que l'impact des déterminants sociaux sur leur traitement sont inconnus. Cette étude a examiné la prévalence des déterminants sociaux des problèmes de santé chez les jeunes recherchant un traitement, leurs perceptions de l'interférence avec le traitement, et l'association entre les déterminants sociaux de la santé et les difficultés de santé mentale/dépendance. MÉTHODE: Des jeunes de 15 à 24 ans cherchant un traitement ambulatoire pour des problèmes d'utilisation de substances, avec ou sans problèmes de santé mentale co-occurrents, ont rapporté leur utilisation de substances, leur santé mentale et les déterminants sociaux de la santé. Des statistiques descriptives et des analyses de régression logistique ont servi à déterminer la portée des déterminants sociaux des problèmes de santé et leur relation avec les problèmes de santé mentale, d'utilisation de substances, et de criminalité ou de violence. RÉSULTATS: En tout, 80 % des jeunes ont reconnu l'action des déterminants sociaux des problèmes de santé dans au moins un domaine; près de 70 % ont identifié les ennuis financiers, et beaucoup ont identifié des problèmes substantiels dans chaque domaine et anticipé les impacts sur le traitement. Les jeunes estimaient très fréquemment que les problèmes financiers étaient susceptibles d'avoir un impact sur le traitement. Le nombre cumulatif de déterminants sociaux des problèmes de santé et les domaines individuels des déterminants sociaux des problèmes de santé étaient liés aux problèmes généraux de santé mentale et de dépendance. CONCLUSIONS: Étant donné leur prévalence et leur association aux problèmes de santé mentale et de dépendance, les déterminants sociaux des problèmes de santé devraient être régulièrement évalués chez les jeunes recherchant un traitement et des services intégratifs qui s'attaquent à ces problèmes en plus de la symptomatologie devaient être envisagés.

Essential components of integrated care for youth with mental health and addiction needs: protocol for a scoping review.

INTRODUCTION: Efforts to move towards integrated care have been met with increased interest and enthusiasm in recent years given the potential to improve care and population health while containing costs. However, there is a need to better understand community-based integrated care approaches for youth with mental health and/or addiction concerns to guide future implementation efforts and develop a set of standards for key components. The objectives of this scoping review are to: (1) identify the populations, settings, service providers, interventions, infrastructure and care coordination methods that have been included in integrated care for youth with mental health and/or addiction needs and (2) identify constructs that have been measured and evaluated (eg, outcomes, engagement) in the context of youth integrated care. METHODS AND ANALYSIS: Seven electronic databases and several grey literature sources will be searched for material from 2001 to 2016. Inclusion criteria will be broad with respect to type of work, as we will include all types of research studies as well as non-research studies that provide information relevant to characteristics and constructs measured in the context of integrated care for youth mental health. Titles and abstracts will be independently screened for eligibility by two raters using inclusion criteria. Full-text articles will then be accessed and independently screened for inclusion. A formal data extraction method will be employed, enabling synthesis of results in quantitative and qualitative formats. ETHICS AND DISSEMINATION: Results will be widely disseminated to various stakeholders to inform implementation and research efforts. Findings will also launch a Delphi method study leading to the development of an assessment tool for youth mental health services integration. This review does not require ethics approval.

Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: protocol for a pragmatic randomised controlled trial.

INTRODUCTION: Among youth, the prevalence of mental health and addiction (MHA) disorders is roughly 20%, yet youth are challenged to access evidence-based services in a timely fashion. To address MHA system gaps, this study tests the benefits of an Integrated Collaborative Care Team (ICCT) model for youth with MHA challenges. A rapid, stepped-care approach geared to need in a youth-friendly environment is expected to result in better youth MHA outcomes. Moreover, the ICCT approach is expected to decrease service wait-times, be more youth-friendly and family-friendly, and be more cost-effective, providing substantial public health benefits. METHODS AND ANALYSIS: In partnership with four community agencies, four adolescent psychiatry hospital departments, youth and family members with lived experience of MHA service use, and other stakeholders, we have developed an innovative model of collaborative, community-based service provision involving rapid access to needs-based MHA services. A total of 500 youth presenting for hospital-based, outpatient psychiatric service will be randomised to ICCT services or hospital-based treatment as usual, following a pragmatic randomised controlled trial design. The primary outcome variable will be the youth's functioning, assessed at intake, 6 months and 12 months. Secondary outcomes will include clinical change, youth/family satisfaction and perception of care, empowerment, engagement and the incremental cost-effectiveness ratio (ICER). Intent-to-treat analyses will be used on repeated-measures data, along with cost-effectiveness and cost-utility analyses, to determine intervention effectiveness. ETHICS AND DISSEMINATION: Research Ethics Board approval has been received from the Centre for Addiction and Mental Health, as well as institutional ethical approval from participating community sites. This study will be conducted according to Good Clinical Practice guidelines. Participants will provide informed consent prior to study participation and data confidentiality will be ensured. A data safety monitoring panel will monitor the study. Results will be disseminated through community and peer-reviewed academic channels. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov NCT02836080.