According to a 2018 study published in The Canadian Medical Association Journal, life expectancy in Canada is higher than in the United States.[1] However, the rates of “deaths of despair” (i.e. poisoning, suicide, and alcoholic liver disease) have increased in recent years which may be contributing to declining life expectancy in Canada.[2]
Should we be concerned? How much does mental health play a role in drug addiction and suicide rates in Canada? And how does this affect life expectancy in North America?
Mental Health and Life Expectancy Decline in Canada
Research conducted in British Columbia (BC) shows that people who use mental health services have a 20–25% shorter life expectancy due to cardiometabolic disorders.[3] This includes obesity, diabetes, dyslipidemia (abnormal blood fat levels), and cardiovascular disease.[4]
For example, individuals with depression have a 60% increased risk of developing type-2 diabetes.[5] Obesity is twice as likely among people with lifetime mood disorders or schizophrenia than for the rest of the population.[6] And, those with schizophrenia or bipolar disorder die at least 10 years earlier, on average, from causes other than suicide.[7],[8]
It’s not just in BC that mental health disorders have been linked to lower life expectancy. When scientists compiled and analyzed data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), they were able to measure the “mortality gap” of people with mental health disorders at provincial and regional levels.[9]
The team found that 1-in-8 women and 1-in-10 men in Quebec were diagnosed with a mental health disorder between 2009 and 2010, which equals over 900,000 people.[10] Women were almost twice as likely as men to suffer from depression or anxiety disorders.[11]
Interestingly, mood and anxiety disorders weren’t found to lower women’s life expectancy, whereas they did in men by an average of four years.[12] Mental health disorders were found to lower life expectancy in both sexes though, with an average of five years lost in women and eight years lost in men.[13] This lost time is likely a significant contributor to life expectancy decline in Canada.
Hospital Visits and Comorbidities
According to a study conducted in Ottawa, people who use prescription or recreational drugs are twice as likely to visit the emergency department or be admitted to hospital (non-emergency) if they have a comorbidity (i.e. a concurrent health problem), including a mental health diagnosis, or if they have made a suicide attempt in the past year.[14] In the same study, people who used drugs were also found to be twice as likely to be admitted to hospital if they took non-injection drugs, such as opioids.[15]
The most common causes of premature death among people who’ve been diagnosed with a mental health disorder, accounting for 80–85% of all preventable deaths, are chronic physical health disorders, such as the following:[16],[17]
- Cardiovascular disease
- Cancer
- Respiratory diseases
The remaining 15–20% of preventable deaths can be accounted for by suicide.[18],[19] The rate of hospitalizations in Canada due to opioid poisoning has increased by 53% in the past 10 years.[20] Approximately 30% of hospital admissions for opioid poisoning in Canada in 2016 were the result of self-inflicted harm, including suicide attempts.[21]
Research also shows that people who die by suicide using opioids have higher rates of musculoskeletal, gastrointestinal, or liver disorders, pain (e.g. back), migraine, and cancer.[22],[23] It’s easy to see the emerging connection between mental health disorders, comorbidities, and suicide by opioids in Canada.
Around half of all primary care patients with chronic pain have depressive disorders.[24] And, individuals with common depressive or anxiety disorders are six times more likely to receive opioids than individuals without these disorders.[25]
That being said, there is an overall lack of tools and knowledge to effectively treat patients with multiple comorbidities, such as mental health disorders, addiction, and chronic pain.[26] Long-term opioid treatment must involve carefully weighing risks and benefits before and during treatment, which can require a lot of trial and error and is complicated by the need to increase dosages over time as a patient becomes more tolerant to opioids.[27] Thus, mental health disorders may contribute to life expectancy decline in Canada both through comorbidities and through opioid use related to them.
Alcohol, Drugs, Addiction, and Life Expectancy in Canada
Alcohol and drug use are the most important risk factors for premature death among young adults in Canada, accounting for less than 20% of deaths in 1990 but 25% of total deaths in 2016.[28] People who use drugs are more likely to experience premature mortality due to the following causes:[29]
- Medical conditions
- Drug overdoses
- Accidents
- Violence
A Vancouver-based study found that women under 30 years of age who inject drugs were 54 times more likely to die prematurely than Canadian women of the same age who don’t inject drugs.[30] The risk for young males who inject drugs was 13 times higher than their non-drug-injecting counterparts.[31]
Part of this increased risk may be accounted for by drug binging behaviour. Binge episodes of drug use may occur during times of significant distress among individuals trying to cope with a persistent burden related to their drug use.[32] Unsurprisingly, the odds of someone making a suicide attempt is almost twice as high if they have had at least one binge episode.[33]
A six-month study of 1,240 people in Montreal who injected drugs found that binging behaviour was more common among younger, less educated individuals with a shorter history of injection drug use.[34] They had also started injecting drugs at a younger age and reported higher levels of psychological disorders.[35] They were also more likely to use other drugs besides cannabis and alcohol.[36]
Based on the evidence that we’ve reviewed thus far, there appears to be a strong connection between attempted suicide, injection drug use, and alcohol consumption.[37] Likewise, depression and other mood disorders closely follow substance use disorders as one of the major risk factors for suicide in Canada.[38] Both of these problem areas appear to be contributors to falling life expectancy in Canada.
The Shift in Opioid Preferences
We’ve already seen some of the scientific evidence suggesting that opioid use is lowering life expectancy in Canada, particularly due to higher levels of opioid use among individuals with mental health disorders. Now, let’s take a closer look and try to understand what exactly is going on with opioids.
A decade ago, there was a shift in opioid preferences in North America: rates of heroin use declined and more people started taking prescription opioids as an alternative.[39] The prescription opioid situation is still a big problem—now one of the most severe substance-use-related public-health crises ever.[40]
Deaths from opioid overdoses have risen to record levels in the past few years.[41] In a 2018 study conducted in Montreal, 1-in-17 people who injected drugs, such as opioids, reported making a suicide attempt within the past six months.[42]
The current prescription opioid crisis in North America is characterized by an unprecedented number of opioid-related fatalities, substance use program admissions, emergency department visits, and non-medical opioid users.[43]
In 2016, there were 2,800, arguably preventable, opioid-related deaths in Canada.[44] In Alberta, 20% of suicides involve drug toxicity, of which 22% are opioid-related.[45] 58% of drug-related deaths in Ontario can be attributed in whole or in part to opioids.[46] And, 10% of suicide attempts in Montreal involve opioids.[47]
In Toronto, opioids are the most common class of lethal medication in self-poisoning, followed by benzodiazepines and antidepressants.[48] The most commonly used opioids for suicide include the following:[49]
- Morphine (Statex, MSContin, Oramorph, Sevredol, and others)
- Hydromorphone (Dilaudid, Hydromorph Contin, Palladone, and others)
- Oxycodone (OxyContin and others)
- Codeine
Of the above, oxycodone is a particular threat, being involved in approximately one third of all opioid-related deaths in Ontario.[50] Thus, changes in usage patterns, and increasing overall use of opioids are both contributing to declining life expectancy in Canada.
Has the NSA Act of 2010 Reduced Suicides and Slowed Life Expectancy Decline in Canada?
Every year, approximately 4,000 people die by suicide in Canada and almost 90% of these individuals have been diagnosed with a mental health disorder.[51] What is the government doing to reduce suicides in this vulnerable population?
The Narcotics Safety and Awareness Act (NSA Act) was implemented from November 2011 onwards in Ontario.[52] According to the Ontario Ministry of Health, the NSA Act seeks to improve the health and safety of Ontarians in the following ways:[53]
- Promoting appropriate prescribing and dispensing practices for narcotics and other controlled substances
- Identifying and reducing the misuse and diversion of these drugs
- Reducing the risk of addiction and death from the misuse of these drugs
To understand the effects of the NSA act, researchers studied suicide deaths by opioid self-poisoning in Toronto, both before and after the NSA Act came into effect.[54] There were 773 suicides in Toronto between 1998 and 2015, a third of which involved opioids.[55] The average number of yearly suicides involving opioids actually increased from 16 to 18 after the NSA Act was implemented.[56] Not what the government was hoping for!
As a leading cause of premature mortality among Canadians struggling with mental health disorders, suicide continues be a major factor in life expectancy decline in Canada. It’s clear that more needs to be done to support struggling Canadians who are at high risk for suicide.
Suicide and the Homeless
Evidence suggests that socioeconomic status is related to life expectancy, and that inequality is likely related to lower life expectancy in Canada. People who use drugs in Ottawa are three times more likely to visit the emergency department if they receive disability pay or income assistance.[57] They’re also twice as likely to be admitted to hospital if they have unstable housing (i.e. accommodation arrangements that are prone to sudden changes).[58]
Fewer people in Canada live below the poverty line compared to the United States.[59] However, income inequality has increased in recent years.[60] Research shows that Canadians are four-to-five times more likely to die from drug or alcohol-related causes if they’re in the lowest income quintiles (i.e. the lowest of 5 equal population groups, separated by household income).[61]
Homeless individuals—those living on the streets or in temporary accommodation—are even more severely affected. Over 85% of homeless youth report high levels of psychological stress. Compared to the general youth population, they experience much higher rates of the following problems:[62]
- Mental health disorders
- Psychosis
- Substance misuse
- Self-harm
- Suicidal ideation and behaviours
- Premature mortality
Suicide and drug overdose are leading causes of premature death among the homeless. A shocking 42% of youth accessing homelessness services in Ontario, BC, and Alberta report one or more suicide attempts.[63] It was estimated that over 3,000 people were homeless in Montreal in 2015, and one in five of these people were less than 30 years of age.[64] A large part of the problem is that Canadian homeless people have very limited access to mental health care.[65]
Strategies to Help Individuals With Mental Health Disorders or Addiction to Increase Life Expectancy in Canada
What can we do about the life expectancy decline in Canada resulting from mental health disorders or addiction, related to higher rates of suicide and comorbidities such as chronic pain or cancer.[66] Research suggests there are many ways that we can help improve health outcomes for Canadians.
Increasing access to opioid replacement therapy
This has been shown to reduce hospital admissions among people who use drugs.[67]
Improving mental health treatment programs
Treatment programs that make patients feel valued and help them experience personal growth are more successful.[68]
Reducing opioid prescription rates
Prescription opioids are highly associated with non-medical opioid use, opioid use disorders, and opioid deaths.[69]
Educating Canadian pharmacists
More training and education surrounding controlled medication (e.g. opioid) prescription is needed in Canada.[70]
Encouraging collaboration in healthcare
Point-of-care health professionals can be educated, and then train each other, on suicide risk assessment and intervention.[71]
Strengthening alcohol control policies
This limits heavy alcohol use among higher income groups in Canada, which may reduce suicide risk.[72]
Reducing income inequality
People with a higher socioeconomic status have lower mortality rates in Canada.[73]
Increasing homeless youth accessibility
Initiatives in Montreal have achieved some success in reducing age-based disparities in access to mental health services. These results could likely be replicated throughout Canada.[74]
We Can Help You
If you would like to learn more about the addiction and mental health treatment programs provided by EHN Canada, enrol yourself in one of our programs, or refer someone else, please call us at one of the numbers below. Our phone lines are open 24/7—so you can call us anytime.
- 1-800-387-6198 for Bellwood Health Services in Toronto, ON
- 1-587-350-6818 for EHN Sandstone, in Calgary, AB
- 1-800-683-0111 for Edgewood Treatment Centre in Nanaimo, BC
- 1-888-488-2611 for Clinique Nouveau Depart in Montreal, QC
References
[1] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[2] Ibid.
[3] C. Graham, C. Rollings, S. de Leeuw, L. Anderson, B. Griffiths, and N. Long, “A qualitative study exploring facilitators for improved health behaviors and health behavior programs: mental health service users’ perspectives,” ScientificWorldJournal, vol. 2014, p. 870497, 2014, doi: 10.1155/2014/870497.
[4] Ibid.
[5] Ibid.
[6] Ibid.
[7] Ibid.
[8] A. Lesage et al., “A Surveillance System to Monitor Excess Mortality of People With Mental Illness in Canada,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 60, no. 12, pp. 571–579, Dec. 2015, doi: 10.1177/070674371506001208.
[9] Ibid.
[10] Ibid.
[11] Ibid.
[12] Ibid.
[13] Ibid.
[14] C. E. Kendall et al., “A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada,” Harm. Reduct. J., vol. 14, no. 1, p. 16, 12 2017, doi: 10.1186/s12954-017-0143-4.
[15] Ibid.
[16] A. Lesage et al., “A Surveillance System to Monitor Excess Mortality of People With Mental Illness in Canada,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 60, no. 12, pp. 571–579, Dec. 2015, doi: 10.1177/070674371506001208.
[17] L. Cailhol et al., “Prevalence, Mortality, and Health Care Use among Patients with Cluster B Personality Disorders Clinically Diagnosed in Quebec: A Provincial Cohort Study, 2001-2012,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 62, no. 5, pp. 336–342, 2017, doi: 10.1177/0706743717700818.
[18] A. Lesage et al., “A Surveillance System to Monitor Excess Mortality of People With Mental Illness in Canada,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 60, no. 12, pp. 571–579, Dec. 2015, doi: 10.1177/070674371506001208.
[19] L. Cailhol et al., “Prevalence, Mortality, and Health Care Use among Patients with Cluster B Personality Disorders Clinically Diagnosed in Quebec: A Provincial Cohort Study, 2001-2012,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 62, no. 5, pp. 336–342, 2017, doi: 10.1177/0706743717700818.
[20] E. Y. L. Chan, B. M. McDonald, E. Brooks-Lim, G. R. Jones, K. B. Klein, and L. W. Svenson, “At-a-glance – The role of opioid toxicity in suicide deaths in Alberta, 2000 to 2016,” Health Promot. Chronic Dis. Prev. Can. Res. Policy Pract., vol. 38, no. 9, pp. 343–347, Sep. 2018, doi: 10.24095/hpcdp.38.9.07.
[21] Ibid.
[22] M. Sinyor, M. Williams, S. Gulati, and A. Schaffer, “An Observational Study of Suicide Deaths by Self-Poisoning with Opioids in Toronto (1998-2015),” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 64, no. 8, pp. 577–583, Aug. 2019, doi: 10.1177/0706743719838777.
[23] P. Madadi and N. Persaud, “Suicide by means of opioid overdose in patients with chronic pain,” Curr. Pain Headache Rep., vol. 18, no. 11, p. 460, Nov. 2014, doi: 10.1007/s11916-014-0460-1.
[24] Ibid.
[25] Ibid.
[26] Ibid.
[27] Ibid.
[28] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[29] C. Fournier et al., “Association between binge drug use and suicide attempt among people who inject drugs,” Subst. Abuse, vol. 39, no. 3, pp. 315–321, 2018, doi: 10.1080/08897077.2017.1389800.
[30] C. L. Miller, T. Kerr, S. A. Strathdee, K. Li, and E. Wood, “Factors associated with premature mortality among young injection drug users in Vancouver,” Harm. Reduct. J., vol. 4, p. 1, Jan. 2007, doi: 10.1186/1477-7517-4-1.
[31] Ibid.
[32] C. Fournier et al., “Association between binge drug use and suicide attempt among people who inject drugs,” Subst. Abuse, vol. 39, no. 3, pp. 315–321, 2018, doi: 10.1080/08897077.2017.1389800.
[33] Ibid.
[34] Ibid.
[35] Ibid.
[36] Ibid.
[37] A. A. Artenie et al., “Licit and illicit substance use among people who inject drugs and the association with subsequent suicidal attempt,” Addict. Abingdon Engl., vol. 110, no. 10, pp. 1636–1643, Oct. 2015, doi: 10.1111/add.13030.
[38] Ibid
[39] B. Fischer and J. Rehm, “Revisiting the ‘paradigm shift’ in opioid use: Developments and implications 10 years later,” Drug Alcohol Rev., vol. 37 Suppl 1, pp. S199–S202, 2018, doi: 10.1111/dar.12539.
[40] Ibid
[41] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[42] C. Fournier et al., “Association between binge drug use and suicide attempt among people who inject drugs,” Subst. Abuse, vol. 39, no. 3, pp. 315–321, 2018, doi: 10.1080/08897077.2017.1389800.
[43] P. Madadi and N. Persaud, “Suicide by means of opioid overdose in patients with chronic pain,” Curr. Pain Headache Rep., vol. 18, no. 11, p. 460, Nov. 2014, doi: 10.1007/s11916-014-0460-1.
[44] E. Y. L. Chan, B. M. McDonald, E. Brooks-Lim, G. R. Jones, K. B. Klein, and L. W. Svenson, “At-a-glance – The role of opioid toxicity in suicide deaths in Alberta, 2000 to 2016,” Health Promot. Chronic Dis. Prev. Can. Res. Policy Pract., vol. 38, no. 9, pp. 343–347, Sep. 2018, doi: 10.24095/hpcdp.38.9.07.
[45] Ibid.
[46] P. Madadi and N. Persaud, “Suicide by means of opioid overdose in patients with chronic pain,” Curr. Pain Headache Rep., vol. 18, no. 11, p. 460, Nov. 2014, doi: 10.1007/s11916-014-0460-1.
[47] A. Mikhail et al., “Over-the-Counter Drugs and Other Substances Used in Attempted Suicide Presented to Emergency Departments in Montreal, Canada,” Crisis, vol. 40, no. 3, pp. 166–175, May 2019, doi: 10.1027/0227-5910/a000545.
[48] A. Schaffer et al., “Self-poisoning suicide deaths in people with bipolar disorder: characterizing a subgroup and identifying treatment patterns,” Int. J. Bipolar Disord., vol. 5, no. 1, p. 16, Dec. 2017, doi: 10.1186/s40345-017-0081-9.
[49] E. Y. L. Chan, B. M. McDonald, E. Brooks-Lim, G. R. Jones, K. B. Klein, and L. W. Svenson, “At-a-glance – The role of opioid toxicity in suicide deaths in Alberta, 2000 to 2016,” Health Promot. Chronic Dis. Prev. Can. Res. Policy Pract., vol. 38, no. 9, pp. 343–347, Sep. 2018, doi: 10.24095/hpcdp.38.9.07.
[50] P. Madadi and N. Persaud, “Suicide by means of opioid overdose in patients with chronic pain,” Curr. Pain Headache Rep., vol. 18, no. 11, p. 460, Nov. 2014, doi: 10.1007/s11916-014-0460-1.
[51] K. Ryan, C. Tindall, and G. Strudwick, “Enhancing Key Competencies of Health Professionals in the Assessment and Care of Adults at Risk of Suicide Through Education and Technology,” Clin. Nurse Spec. CNS, vol. 31, no. 5, pp. 268–275, Oct. 2017, doi: 10.1097/NUR.0000000000000322.
[52] Government of Ontario Ministry of Health and Long-Term Care, “The Narcotics Safety and Awareness Act, 2010,” Ontario’s Narcotics Strategy, n.d. [Online]. Available: https://www.health.gov.on.ca/en/public/programs/drugs/ons/ons_legislation.aspx. [Accessed: 16-Feb-2020].
[53] Ibid.
[54] M. Sinyor, M. Williams, S. Gulati, and A. Schaffer, “An Observational Study of Suicide Deaths by Self-Poisoning with Opioids in Toronto (1998-2015),” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 64, no. 8, pp. 577–583, Aug. 2019, doi: 10.1177/0706743719838777.
[55] Ibid.
[56] Ibid.
[57] C. E. Kendall et al., “A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada,” Harm. Reduct. J., vol. 14, no. 1, p. 16, 12 2017, doi: 10.1186/s12954-017-0143-4.
[58] Ibid.
[59] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[60] Ibid.
[61] Ibid.
[62] A. Abdel-Baki et al., “Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative,” Early Interv. Psychiatry, vol. 13 Suppl 1, pp. 20–28, 2019, doi: 10.1111/eip.12814.
[63] S. A. Kidd, S. Gaetz, and B. O’Grady, “The 2015 National Canadian Homeless Youth Survey: Mental Health and Addiction Findings,” Can. J. Psychiatry Rev. Can. Psychiatr., vol. 62, no. 7, pp. 493–500, 2017, doi: 10.1177/0706743717702076.
[64] Ibid.
[65] A. Abdel-Baki et al., “Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative,” Early Interv. Psychiatry, vol. 13 Suppl 1, pp. 20–28, 2019, doi: 10.1111/eip.12814.
[66] P. Madadi and N. Persaud, “Suicide by means of opioid overdose in patients with chronic pain,” Curr. Pain Headache Rep., vol. 18, no. 11, p. 460, Nov. 2014, doi: 10.1007/s11916-014-0460-1.
[67] C. E. Kendall et al., “A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada,” Harm. Reduct. J., vol. 14, no. 1, p. 16, 12 2017, doi: 10.1186/s12954-017-0143-4.
[68] C. Graham, C. Rollings, S. de Leeuw, L. Anderson, B. Griffiths, and N. Long, “A qualitative study exploring facilitators for improved health behaviors and health behavior programs: mental health service users’ perspectives,” ScientificWorldJournal, vol. 2014, p. 870497, 2014, doi: 10.1155/2014/870497.
[69] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[70] C. Leong, S. Alessi-Severini, J. Sareen, M. W. Enns, and J. Bolton, “Community Pharmacists’ Perspectives on Dispensing Medications With the Potential for Misuse, Diversion, and Intentional Overdose: Results of a Province-Wide Survey of Community Pharmacists in Canada,” Subst. Use Misuse, vol. 51, no. 13, pp. 1724–1730, 09 2016, doi: 10.1080/10826084.2016.1197261.
[71] K. Ryan, C. Tindall, and G. Strudwick, “Enhancing Key Competencies of Health Professionals in the Assessment and Care of Adults at Risk of Suicide Through Education and Technology,” Clin. Nurse Spec. CNS, vol. 31, no. 5, pp. 268–275, Oct. 2017, doi: 10.1097/NUR.0000000000000322.
[72] C. Probst and J. Rehm, “Alcohol use, opioid overdose and socioeconomic status in Canada: A threat to life expectancy?,” CMAJ Can. Med. Assoc. J. J. Assoc. Medicale Can., vol. 190, no. 44, pp. E1294–E1295, 05 2018, doi: 10.1503/cmaj.180806.
[73] Ibid.
[74] A. Abdel-Baki et al., “Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative,” Early Interv. Psychiatry, vol. 13 Suppl 1, pp. 20–28, 2019, doi: 10.1111/eip.12814.
