Easing the Disruption of COVID-19: Supporting the Mental Health of the People of Canada

The COVID-19 pandemic has had a significant impact on the mental health of the people of Canada. Most have found it challenging to cope with social distancing, isolation, anxiety about infection, financial security and the future, and balancing demands of work and home life. For some, especially those who have had to face pre-existing challenges such as structural racism, poverty, and discrimination and those with prior mental health problems, the pandemic has been a major impact. The Policy Briefing Report focuses on the current situation, how the COVID-19 pandemic has exacerbated significant long-standing weaknesses in the mental health system and makes specific recommendations to meet these challenges to improve the well-being of the people of Canada. The COVID-19 pandemic has had a detrimental effect on mental health of people in Canada but the impact has been variable, impacting those facing pre-existing structural inequities hardest. Those living in poverty, and in some socially stratified groups facing greater economic and social disadvantage, such as some racialized and some Indigenous groups and those with preexisting mental health problems, have suffered the most. Some occupational groups have been more exposed to the virus and to psychological stress with the pandemic. The mental health care system was already overextended and under resourced. The pandemic has exacerbated the problems. The care system responded by a massive move to virtual care. The future challenge is for Canada to strengthen our knowledge base in mental health, to learn from the pandemic, and to provide all in Canada the support they need to fully participate in and contribute to Canada’s recovery from the pandemic.

https://thebodyelectric-lecorpselectrique.ca/. We have chosen to include this art as a way of highlighting the importance of patient and provider voice in advocating for and codesigning the best quality of healthcare.

Jenny Chen, Pillow Talk
Land Acknowledgement The headquarters of the Royal Society of Canada is located in Ottawa, the traditional and unceded territory of the Algonquin nation.
The opinions expressed in this report are those of the authors and do not necessarily represent those of the Royal Society of Canada.
The COVID-19 pandemic has had a significant impact on the mental health of the people of Canada. Most have found it challenging to cope with social distancing, isolation, anxiety about infection, financial security and the future and balancing demands of work and home life. For some, especially those who have had to face pre-existing challenges such as structural racism, poverty and discrimination and those with prior mental health problems, the pandemic has been a major impact.
The Policy Briefing Report focuses on the current situation, how the COVID-19 pandemic has exacerbated significant long standing weaknesses in the mental health system, and makes specific recommendations to meet these challenges to improve the well-being of the people of Canada.
The COVID-19 pandemic has had a detrimental effect on mental health of people in Canada but the impact has been variable, impacting those facing pre-existing structural inequities hardest. Those living in poverty, and in some socially stratified groups facing greater economic and social disadvantage, such as some racialized, and some Indigenous groups and those with preexisting mental health problems, have suffered the most. Some occupational groups have been more exposed to the virus and to psychological stress with the pandemic. The mental health care system was already overextended and under resourced. The pandemic has exacerbated the problems. The care system responded by a massive move to virtual care. The future challenge is for Canada to strengthen our knowledge base in mental health, to learn from the pandemic and provide all in Canada the support they need to fully participate in and contribute to Canada's recovery from the pandemic.

Recommendations
Recommendation 1: That the Federal Government, in conjunction with Provincial and Territorial Governments, increase the funding for mental health services to at least 12% of the health services budget to respond to the longstanding unmet need that has been exacerbated by the COVID-19 pandemic.
Recommendation 2: That the Federal Government, in conjunction with Provincial and Territorial Governments, establish national standards of access and quality of mental health services by the introduction of a Mental Health Parity Act.
Recommendation 3: That the Canadian Institute of Health Information (CIHI) should receive adequate resources to work collaboratively with the provinces and territories, and other stakeholders, to develop an up-to-date national public and private health expenditure series in mental health. CIHI should also accelerate the development of health system performance indicators for mental health (including wait times).
Recommendation 4: That the Federal, Provincial and Territorial Governments fund and develop a program similar to the UK's Improving Access to Psychological Therapies. The program should cover adults, children and youth. Considering the vast geography, consideration should be given to a virtual service.

Executive Summary
Recommendation 16: That the Federal, Provincial and Territorial Governments adequately fund efforts to minimize viral transmission within schools to reduce the chances that children will become ill and/or spread the virus to their teachers, school support staff, and family members.
Recommendation 17: That, should schools need to close again due to second or more wave(s) of the virus, parents be better supported in the education of their children at home. This includes supporting the increased mental health service needs of parents during mandatory homeschooling.
Recommendation 18: That if schools close again, Provincial and Territorial governments have mental health and substance use supports ready to stabilize family wellbeing using the vehicles used to deliver school curriculum to families.
Recommendation 19: That Provinces should attempt to keep high risk families of vulnerable neonates together and carefully weigh the cost/benefit ratio of restricting family presence during neonatal intensive care admission in the event of another wave of COVID-19.
Recommendation 20: That the Provincial and Federal Governments adequately fund efforts to determine the impact of family presence restriction on family and infant mental wellbeing and health outcomes.
Recommendation 21: That if hospital family restrictions are implemented again, Provincial governments have mental health supports ready to stabilize family wellbeing using virtual care delivery similar to school curriculum to families.

Introduction
The COVID-19 pandemic has created unprecedented upheaval for people in Canada, and around the world. Millions have been confined to their homes, many having to work from home, others have lost their jobs and many are worried about future employment. Parents of children have the demanding and unfamiliar responsibility of home-schooling their children, often while also working from home, as schools closed. Residents of long-term care facilities have been at high risk for infection and death, and have been denied vital family visits. During self-isolation, some people in the community have been trapped at home in coercive or abusive situations. A number have lost loved ones to COVID-19 and been unable to engage in normal grieving rituals. Many frontline workers including personal care workers, nurses and doctors in Emergency Departments; delivery drivers and retail clerks and first responders have been exposed to extreme and often unremitting stress, leading to mental distress, anxiety and traumatic stress symptoms. Many people in the community experienced symptoms and anxiously awaited test results, fearing for their own health and those they have come in contact with. Some have been diagnosed, some hospitalized, some admitted to ICUs with COVID-19 and some have died.
All people in Canada have experienced thousands of health warnings, the uncertainty of changing requirements/public health measures, increased fears, and the disruptions of our social and work lives. As in previous pandemics (Taylor, 2019), there has been a widespread increase in distress (Taylor et al., 2020a,b,c,d). The Conference Board and the Mental Health Commission (2020), in a survey conducted between April 27 and May 15, 2020, found that 84% reported that their mental health had declined during the pandemic. The biggest concerns were family wellbeing, one's future, isolation and loneliness, and anxiety and fear. There also appears to be an increase in mental health disorders including anxiety disorders, mood disorders, substance-use disorders, and traumatic stress for an important but as yet unknown percentage of people in Canada. Different surveys (Taylor et al., 2020a,b;CAMH, 2020) have described how about 20-25% of people in Canada are experiencing moderate or severe COVID-19-related mental health problems. Emerging evidence indicates that people with pre-existing anxiety disorders may be more adversely impacted by COVID-19 than those with mood disorders or no mental health diagnoses .
A Nanos poll for the Canadian Centre on Substance Use and Addiction, (Nanos, 2020) showed that about 20% have increased their use of alcohol as a result of the pandemic. Evidence from previous pandemics, and current evidence from other countries who are farther advanced in the chronology of the pandemic, also suggests significant increases in mental health problems and that mental health impacts can persist far beyond the acute phase of the pandemic. Much of the international evidence on COVID-19 and its mental health effects can be instructive for Canada.
The pandemic has affected the mental well-being of people in Canada differentially, however. COVID-19 is not just an illness; it also intensifies social ills that have long created health inequities. The data on mental health effects from COVID-19 are quickly emerging, and related evidence suggests that those living in poverty and adverse social circumstances will be the most impacted. Moreover, those who have been subjected to previous adverse events, especially in childhood, are Easing the Disruption of COVID-19: Supporting the Mental Health of the People of Canada more at risk (Asmundson & Afifi, 2020). Even prior to the current pandemic, people in the lowest income groups were 3 to 4 times more likely than those in the highest income group to report poor mental health (Public Health Agency of Canada, 2018). Human Rights Watch (Carling & Mankani, 2020) emphasizes that many First Nations communities don't have clean water and suffer from overcrowding so that handwashing and social distancing are difficult. Similarly, individuals in the LGBTQ community and racialized individuals are often at higher risk of COVID-19. For example, in Toronto, persons who are White make up 48% of the population and only about 17% of those with COVID-19 (Toronto, 2020). Chronic illness, homelessness, imprisonment and poverty exacerbate the risk of severe illness from COVID-19.The DepressD Living Systematic Review of Mental Health in COVID-19 (2020) has found initial evidence of differential effects related to pre-existing inequities of COVID-19 on mental health around the world. Prior to the pandemic, Canada was facing a serious opioid epidemic which has only been made worse by the COVID-19 pandemic. Canada has seen an increase in fatal drug overdoses since the onset of the pandemic . The restrictions on travel and border closures have impacted illegal drug supply chains, which has resulted in the use of more dangerous substances and more efficient, yet riskier, routes of administration (Tsai & Wilson, 2020). During the pandemic, there has also been an increased risk of drug withdrawal and related complications for homeless people who use substances and an increased risk of negative health consequences in this vulnerable group (UNODC, 2020).

What I Hear I Keep
The mental health effects of COVID-19 have occurred in the context of mental health services suffering chronic underfunding. The Mental Health Commission of Canada has estimated the prevalence of significant mental health problems at about one in five and the cost to the Canadian economy of mental health problems at about $50 billion a year prior to the pandemic (Smetanin et al., 2011). The Mental Health Commission (2017) noted that Canada spends about 7.2% of our total (public and private) health spending on mental health (cf. 13% for the UK) and well below what most other developed nations spend on mental health. Children and youth may be particularly affected as most children with mental health problems do not receive the care they need (Waddell et al. 2005). Waiting lists for child mental health pre-pandemic were growing and some children waited 2.5 years for service (Children's Mental Health Ontario, 2020). Waitlists for all were lengthy even before the pandemic. The disruption of services and the stress of the pandemic has exacerbated the problem.
The Federal government recognized the desperate need for additional funding for mental health before the pandemic. In the 2017 budget, there was pledged a modest beginning to overcome the disparity; that is $5 billion over 10 years to improve mental health care (Government of Canada, 2017 Mental health services must be accountable by adapting the best practices and reporting on their compliance to quality standards. Effectiveness can only be established by routine collection and analysis of outcomes. Stepped care, a hierarchy of interventions, from the least to the most intensive matched to the individual's needs is less burdensome to those we serve and more cost effective for the system. Most will utilize the least intensive mental health interventions usually delivered in primary care. These interventions must be effectively integrated with mental health care. Accreditation Canada (2020), in their statement of health standards, emphasized patient and family experience of, and satisfaction with, care and involving patients and other stakeholders in the design of care. A crucial dimension of quality care is to ensure culturally safe care, which respects the cultural beliefs, values, and preferences of users. In the UK, this role is played by the National Institute for Health Care and Excellence (NICE).
The Canadian Institutes of Health Research (CIHR) is the principal funder of health research in Canada. In 2018-19, the last year that data are available, the CIHR funded grants and awards worth $1.089 billion. Of this amount, $28.1 million was allocated to addictions research and $72.1 million to mental health research for a total of $100.3 million or approximately 9% of the funding (Canada, 2020). This is in sharp contrast to the population burden of mental health which would suggest at least a doubling of this spending.
The Canadian Institute of Health Information (CIHI) is the federally-funded health agency that collects and analyses data on the health system and the health of people in Canada. This type of systems information is vital to the planning and evaluation of mental health and substance use care.
As the pandemic continues to effect all people in Canada, the federal government needs to respond not only to the infection itself and the economic consequences, but to enact policies and fund programs and services that respond to current data on mental health and ensure the people of Canada survive and thrive following the pandemic.

Access
Access to publicly-funded mental health care Access to publicly-funded, evidence-based and appropriate mental health services was limited before COVID-19. Children's mental health may be particularly crucial as lack of services interferes with social and cognitive development and can lead to cumulative barriers and exponential challenges.
The stress of the pandemic is leading to an increase in demand for services that are already stretched where many do not receive the care they need. Prior to the COVID-19 global pandemic, people in Canada have expressed concern about the lack of access to a range of publicly funded mental health and addiction care services. Specifically: • 94% of people in Canada think that provincial and territorial governments' health plans should cover mental health care (Cohen & Hosseiny, 2019).
• 89% of people in Canada support increasing funding for mental health care professionals including psychologists and counsellors. Fifty three percent report that they know someone who has had a mental health problem or illness and has experienced delays in accessing services (Mental Health Commission of Canada, 2019) • 55% of people in Canada were dissatisfied with wait times for publicly-funded mental health practitioners, and 20% said they had to seek and pay for private mental health services due to long wait times or lack of publicly-funded mental health services (Ipsos, 2019).
The COVID-19 pandemic has highlighted the vulnerability of our mental health system. Some provisions have been made for self-management, e.g., through the Wellness Together Canada Portal https://ca.portal.gs/ which may be helpful for those with very modest mental health burden.
Nonetheless, there has been a reduction in provincial services as they grapple with social distancing. In fact, many have closed all but emergency services. Some groups have borne the brunt of increased stress and difficulty accessing mental health services. For example, people with serious mental health problems have had their clinics eliminate face-to-face services. Those without services (e.g., many rural and Indigenous communities) have not had mental health services despite the added stress of the pandemic. In addition, first responders and health workers in long term care and in many emergency services and ICU's have been subjected to incredible stress, with depression, health anxiety, and PTSD among some, yet there is little increase in mental health services to meet these needs.
Public expenditures on mental health are disproportionately low relative to the burden of mental illness. Prior to the pandemic, Vigo et al. (2019) found that mental health and pain were the leading source of health burden accounting for 24% of the burden. They also found that mental health and pain spending in Canada represented an imbalance in the ratio between disease burden and spending of 3:1. A way of examining more pronounced burden is disability. Statistics Canada (2012) determined that 28% of people with disability in Canada have a mental health disability. A comprehensive study that captures the full spectrum of public and private mental health expenditures in Canada has not yet been completed and is a critical informational need. The data that is available indicates that in 2013/14, public mental health spending as a proportion of total public health spending in Canada was 4.6% (Institute of Health Economics, 2019). All provinces fell short of the minimum figure of 9.0% that was recommended by the Mental Health Commission of Canada (Mental Health Commission (2012). This has likely increased because of recent efforts.
Increasing mental health expenditures to at least 12% of health expenditures is warranted. This level of funding would still be a large under spending in relationship to burden but would help meet the unmet needs. Statistics Canada (2019) estimated that 43% of people in Canada with mental health needs had unmet needs. The largest unmet need was for counselling or therapy.
All people in Canada should have timely access to evidence-based care with clear accountability of governments meeting their responsibilities. In the last two decades, the science of evidence-based care has been translated into guidance advice, pathways, and standards of care. In particular, the United Kingdom's National Institute for Health and Care Excellence (NICE, https://www.nice.org.uk/) has led the way in this effort. The Improving Access to Psychological Therapies program of the United Kingdom's National Health Services is an ambitious program that will reach 1.9 million people in 2023/2024 towards its goal of providing evidence-based talk therapy to all who need it (https://www.england.nhs.uk/mental-health/adults/iapt/). As mentioned previously, the lack of access to talk therapy is the largest unmet need in Canada (Statistics Canada, 2019).
Federal, Provincial and Territorial governments in Canada are uniformly in favour of quality and appropriate standards for mental health and addictions care. Excellent work has been done by individual groups, professional bodies and associations developing clinical practice guidelines (Remington et al. 2017;Katzman et al, 2014;Lam et al. 2016). In addition, many provinces have health quality councils. There has, however, been no pan-Canadian government sponsored, legally-mandated structure for equity, quality, and standards.

Access to employment-based mental health care
There has been a significant increase in the number of unemployed people in Canada and, as a consequence, they have lost or have limited access to their employer-sponsored supplementary health benefits-which includes an array of mental health and substance use programs, services and supports.
COVID-19 brings with it a triple threat. First, there has been a loss or reduction of employersponsored supplementary health benefits. These benefits are delivered by non-physician health care providers like psychologists, social workers, psychotherapists, and counsellors whose services are not typically funded through the public health system. Second, much of what is publicly funded is situated within hospital and physician settings which have had partial shutdown, increasing already very long wait lists. Third, there is a growing demand for mental health and substance use care services that is exacerbating the existing gap between the mental health and addictions care that people in Canada need and the capacity of the public and private sectors to provide such care. Combined, this has had a significant impact on Canadians' ability to access a range of mental health services and supports on a timely basis. Moving forward, it will be important to consider a coordinated policy response that extends across the public and private sectors.
Furthermore, the pandemic also underscores the importance of reviewing the breadth of evidencebased coverage employers are providing their employees for mental health care. A recent survey by the Canadian Life and Health Insurance Association (2020) noted that 18% of plan sponsors recently increased the maximum amount of coverage for counselling services related to mental health, e.g., psychologists and other mental health providers. Unionized workforces (29%) and public sector employers (29%) were also more likely to do so. An additional 25% of plan sponsors intend to increase the maximum coverage. It also found that the current median and annual maximum coverage for counselling services related to mental health is $1,011. The majority (68%) have a maximum that is less than $1,000 or 5 hours of a psychologist's time at a standard rate of $200/hr. These caps fall short of delivering an evidence-based dose of care (Lambert, 2013).
Without taking any additional measures, people in Canada will fall through the cracks in terms of not being able to access the mental health care they need due to limited access via the public system, or with the loss of employer-sponsored health benefits they must now pay out-of-pocket for such services. Either way, timely access to needed mental health care has been compromised.
Employers need to review their internal human resource policies to ensure that employees who are temporarily laid-off can have access to their supplementary health benefits. Employers, in dialogue with employees and insurers, need to ensure that they facilitate access to a comprehensive set of evidence-based mental health programs and services through their supplementary health benefit plans. Given the relationship between employee access to mental health care benefits and access to the publicly-funded health care system, it will be important to consider a coordinated policy response across the public and private sectors.
Employees who sustain injury in the course of their work are typically covered through Provincial Workers' Compensation Boards. They are now eligible for coverage if they can show they were infected with COVID-19 on the job. However, employees who sustain subsequent mental health injuries by becoming infected or by caring for those who are infected may have a more difficult challenge proving their mental health injuries are employment related. The federal government in conjunction with the Canadian Association of Workers' Compensation Boards could develop model presumptive-cause regulations for front line health workers and first responders who develop conditions like health anxiety, depression, or PTSD during the pandemic, so that they are presumed to have developed these disorders from occupational causes and thus are eligible for Workers' Compensation support and services.
Self-management approaches can be very low cost and are useful to many, but they may not be effective for those without the skills to navigate and sustain self-management or those with more significant mental health problems.
Recommendation 1: That the Federal Government, in conjunction with Provincial and Territorial Governments, increase the funding for mental health services to at least 12% of the health services budget to respond to the longstanding unmet need that has been exacerbated by the COVID-19 pandemic.
Recommendation 2: That the Federal Government, in conjunction with Provincial and Territorial Governments, establish national standards of access and quality of mental health services by the introduction of a Mental Health Parity Act.
Recommendation 3: That the Canadian Institute of Health Information (CIHI) should receive adequate resources to work collaboratively with the provinces and territories, and other stakeholders, to develop an up-to-date national public and private health expenditure series in mental health. CIHI should also accelerate the development of health system performance indicators for mental health (including wait times).
Recommendation 4: That the Federal, Provincial and Territorial Governments fund and develop a program similar to the UK's Improving Access to Psychological Therapies. The program should cover adults, children and youth. Considering the vast geography, consideration should be given to a virtual service.

Indigenous Mental Health
Pre-COVID, Indigenous people bore a disproportionate burden of mental health difficulties when compared to non-Indigenous people in Canada. Population data for the general population of Indigenous and non-Indigenous individuals using the same methodologies are not available. However, there are good data on specific issues. The national rate of suicide among First Nations communities is double that of the general public and the rate among First Nations youth is approximately three times higher than non-Indigenous people in Canada. The rate of suicide in Inuit communities is estimated to be nine times higher than non-Indigenous people in Canada (Kumar & Tiepkema, 2019). Indigenous adolescents begin using substances and consuming alcohol at a younger age than non-Indigenous adolescents (Falk et al., 2006;Miller et al., 2008). Among a sample of Indigenous youth in the upper-Midwest of the United States and Ontario, there was a 54% chance of meeting criteria for a substance use disorder by late adolescence (Hautala, Sittner, & Walls, 2018). Indigenous youth experiencing homelessness are more likely to develop a mental health problem or addiction than non-Indigenous youth experiencing homelessness (Kidd, Gaetz & O'Grady, 2017). Finally, there are cumulative impacts on mental health within families and communities; individuals with parents who attended residential schools, for example, demonstrate greater depressive symptoms compared to those whose parents did not attend (Bombay, Matheson & Anisman, 2011).
These disparities are largely understood to have emerged as consequences of systematic colonial attempts at assimilation of the Indigenous population into the broader Canadian body politic. Canadian governmental policies directed at eradicating cultural practices through disruption of communities and families through such well-documented mechanisms as the residential school and child welfare systems have led to what has been termed intergenerational trauma-the transmission of trauma across generations of Indigenous peoples. At the same time, many rural and remote communities have limited access to culturally-and contextually-appropriate care, and experienced chronically underfunded systems and services across all sectors.
Despite this multi-generational colonial effort, Indigenous peoples have demonstrated great resilience and many communities have found ways to be adaptive and innovative as a means of developing greater capacity in mental health and addiction services. Culture-based approaches have been demonstrated to be particularly important in improving wellness for Indigenous people.
As COVID-19 spread across Canada, the relative geographic isolation, coupled with quick and decisive action by many Indigenous leaders led to effective quarantine of community from outside visitors, thus limiting transmission of the COVID-19 virus. This resilient and effective response highlights the need for, and the efficacy of, Indigenous leadership and approaches to health.
The COVID-19 pandemic has highlighted, and in many cases, exacerbated known gaps in services, equitable access to resources, and human resource capacity to manage mental health related crises. Vitally important community programs and service organizations were forced to suspend services as a means of preventing viral spread to isolated communities with limited resources to care for the ill in the event that COVID-19 arrived in the communities. Many communities have reported increases in child welfare-related issues (e.g., abuse, neglect), domestic violence due to suspending of residential treatment facilities/shelters for women, and acute withdrawal episodes as a result of disruptions in illicit substance supply-chains (due to community checkpoint screening) combined with limited access to medically-assisted withdrawal services. With the well-documented rates of chronic disease comorbidity, many communities were at great risk from the virus. Moreover, social crowding from limited housing capacity, and in some cases, poor

Tia Cavanagh
An Exploration in Identity: In Honour of my Nokimos access to clean running water made social distancing and handwashing recommendations lack relevance and applicability for many communities. This with the cultural importance of Elders and community wellness, places Indigenous communities in a desperate situation.
Access to culturally-and contextually-appropriate care is essential for Indigenous communities in Canada. Certain non-Indigenous approaches to mental health care (e.g., psychological, psychiatric, medical) have shown effectiveness in addressing the disproportionate burden of mental health. Culture-based and on-the-land/land-based approaches have also demonstrated improvements in wellness, in addition to improvements in culturally-based wellness outcomes like improvements in purpose, hope, belonging, and meaning.
Recommendation 7: That the Federal Government work closely with Indigenous governance structures to find exemplar Indigenous communities, Indigenous-specific programs, and Indigenous-governed organizations that are leading the way in mental health and in Indigenous communities. These culturally-and contextually-appropriate services need to be funded for expansion to other communities.
Recommendation 8: That in consultation with First Nations, Metis, and Inuit communities, the federal, provincial, and territorial governments implement solutions to remedy the across the board public services inequities and structural discrimination that contributes to over-represented rates of mental illness.
Recommendation 9: That the Federal Government facilitate and resource connected and holistic approaches to mental health care, inclusive of child welfare, housing/social services, education, justice, and other overlapping domains that often exist in silos and are sometimes at odds in terms of approach.

Virtual Mental Health Care -Immediate Potential and Future Promise
The COVID-19 pandemic has precipitated the cessation of most non-urgent, in-person mental health and substance use care, compounding the pre-existing problem of access to mental health and addictions care for people in Canada (McIntyre & Lee, 2020;Findlay, Arim, & Kohen, 2020;Koushik, 2020). These public health measures tasked entire healthcare systems to change the way they deliver mental health services, including a large-scale shift away from in-person care to digital or virtual delivery of care for many mental health services. As a result, we saw rapid and large increases in use of technology for the delivery of mental health care (Torous et al., 2020;Fisk et al., 2020;Ohannessian et al., 2020). Digital health and virtual care have been on the horizon for decades now in Canada, but always struggling to come into full ascendency. Digital health is the integration of electronic material and compilation of health data, decision support tools, and analytics using technologies to deliver preventive, diagnostic and treatment services (Canadian Medical Association, 2019). Virtual care is any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies to achieve patient care (Shaw et al., 2018). Despite a large evidence base demonstrating equivalency with in-person mental health care across many diagnoses and evidence-based interventions (Langarizadeh et al., 2017;Hilty et al., 2013;Hubley et al., 2016), prior to COVID-19 virtual modalities had low rates of adoption (Canadian Medical Association, 2019). In a recent study in Ontario, for example, less than 1% of adult patients in need received care via telepsychiatry, and only 7% of psychiatrists provided it (Serhal et al., 2017). This low rate of implementation occurred despite the potential of virtual care to address bridging large geographic distances and maldistribution of heath human resources (Wozney et al., 2017). These challenges contribute to health inequities across the country, with those in rural areas bearing the added barrier of finding funds to travel long distances to access services. Prior to COVID-19, virtual care was a relatively untapped resource. Some of the reasons suggested for this lack of adoption and penetration of virtual care are: poor implementation; health governance and funding that does not contribute to care across regional or provincial boundaries; lack of funding and remuneration for virtual care; and inadequate training for health care providers (Serhal et al., 2017;Cowan et al., 2019).
In response to COVID-19, the rapid implementation of virtual care has been facilitated by relaxed regulations and a quick funding shift in many provinces. Many have rightly lauded the flexibility of this modality of care to allow patients to continued access to many essential health services. For example, recent guidelines recommend a shift to greater use of virtual care in combination with greater flexibility in prescribing practices for opioid agonist therapy during the pandemic (e.g., allowing more flexibility in take home privileges combined with patient monitoring via telemedicine). This would allow the system to respond to the increased demand for access to methadone to manage exacerbations in the opioid epidemic (Bruneau et al., 2020).
According to a recent survey, 38% of people in Canada would prefer to continue receiving virtual health care, and the majority would like to see virtual care continue as an option (Abacus/Canadian Medical Association, 2020). And yet there are evident challenges with virtual care that urgently need to be addressed in order to sustain this initial rapid scaling. The first relates to unintended health equity impacts of virtual care, with many vulnerable groups unable to access care (Crawford & Serhal, 2020) amplifying mental health disparities that predated COVID-19. The second has to do with the implementation and integration of virtual care at both local and health systems levels, made more challenging because of pre-existing fragmentation and poor integration of health services.
We need to shift our thinking and approaches from the urgent response to the pandemic to sustainability and integration. There are opportunities here to finally harness the underused potential of virtual care, granting more freedom and choice to persons accessing mental health care. While virtual care options were critical to maintaining access to services, as we move out of the acute crisis phase, we need to attend to the quality of care provided, and whether it meets the needs of patients, families, and communities. Quality of care is as important in virtual care as it is in face-to-face care.
Of particular importance is ensuring digital health equity. While virtual care can increase access, it may pose barriers related to other social and structural inequities, making virtual care inaccessible or ineffective for groups who are experiencing poverty or homelessness, or who have poor digital literacy skills (Crawford & Serhal, 2020;Levesque et al., 2013).
Recommendation 10: That the Federal Government, in conjunction with Provincial and Territorial Governments, track digital health equity and improve funding and infrastructure to create virtually connected communities.

Establishing a Continuum of Virtual Care -Person-Centred Integration Across the Health System
Often when we speak of virtual care, we only consider care at the provider-patient level of care. Technology within healthcare is part of an ecosystem of care that includes the organizational setting, but also all stakeholders, community, health systems, and governments (Wiljer et al., 2020). As with other health services in Canada, provincial and regional funding and governance makes integration across health systems challenging. Virtual care directly challenges this status quo because of the capacity to easily provide care across jurisdictional lines. However, providers are faced with a complex system of jurisdictions, licensures, and regulators to navigate. Poor integration leads to poor care transitions and poor follow-up. We need to plan systems of virtual care that ensure an acceptable, efficacious, and efficient blend of in-person and virtual care. Navigating care, transitioning between care providers and settings, and receiving appropriate follow-up all require systems planning.
Virtual care can facilitate the delivery of collaborative or integrated care across distance, integrating mental health providers into primary care teams. We can start thinking about digital health and virtual care as the collection of support tools (Fortney et al., 2013;Adaji et al., 2017;Hilty et al., 2018) and technology that can provide care along the continuum of health including prevention, diagnosis, and treatment. Stepped care provides patients and primary care providers access to increasing levels of care based upon need. Preliminary research shows the feasibility and value of these models, which can also introduce efficiencies. Further research into and funding of these models of care, including studies on return on investment, is critical to the penetration of virtual care, and to systems integration.
Recommendation 11: That the Federal, Provincial and Territorial Governments ensure that systems, including technology, records, professional licensure and funding are harmonized and interoperable to support integration across points of care and across the health system in Canada.
Most provinces have provided temporary reimbursement or billing codes to physicians for the practice of telemedicine during COVID-19, including for telepsychiatry and have transferred most care by non-physicians to digital care. Funding will be critical to sustainability, and patients will likely demand ongoing access. But funding is also needed at program and organizational levels to support the administration of virtual care. Economic analysis of different models of care will be important to determine the relative value of virtual care. A recent study, a cost comparison between telepsychiatry, in-person care, and a travel subsidy program for patients found telepsychiatry to be the most economical (Serhal et al., 2020). Virtual care must be covered in a systematic way within health professions education at all stages of training and continuing professional development.
Virtual care can also be used as to establish alternative models of care such as paraprofessionals delivering care (McGrath et al., 2011) and communities of learning and practice that can facilitate the learning and evidence-based practice of providers (Sockalingam et al., 2020).
Recommendation 12: That the Provincial and Territorial governments develop stable funding models for virtual mental health care with remuneration aligned to in-person care, including funding for collaborative, indirect care and intervention models that employ peers and paraprofessionals.
Recommendation 13: That training in the implementation of virtual care become standard for all mental health professionals in their education and via continuing education.

Prevention
Despite a longstanding call to governments and health systems from the World Health Organization (WHO 2004), and the Institute of Medicine (Munoz et al. 1996), to provide a more proactive and preventative approach to mental health, our policies and practices in Canada remain largely reactive. Primary preventative interventions can be effective and cost effective (WHO, 2004;McDaid et al., 2019;Furber et al. 2015;Carbone, 2020;Arango et al. 2018;van Zoonen et al. 2014). And yet, Canada invests very little in the primary prevention in mental health, despite indications that our current approach is not sustainable (Roberts & Grimes 2020).
Mental health prevention strategies as a response to COVID-19 are needed to flatten the cost and alter the curve (Carbone, 2020;Moreno et al. 2020). Prevention aims to reduce the incidence, prevalence, and recurrence of mental disorders and addictions and their associated disabilities.
Interventions are based on modifying known risks, and strengthening capacity to cope, and can be understood as: 1) universal prevention, applied to entire populations; 2) specific prevention, aimed at groups with specific risk factors; or 3) indicated prevention for individuals who are experiencing current or recurrent symptoms or diagnoses (Munoz et al., 1996). The Mental Health Commission of Canada, and other health advocacy groups, support the idea that the continuum of care should also include health promotion and illness prevention through virtual means (Mental Health Commission, 2014).
Secondary prevention may also be achieved through virtual care. Keeping people with mental illness connected and connected to care virtually, through programs such as remote monitoring, virtual communities of care, etc., can also reduce relapse. Suicide prevention is another obvious target for virtual intervention. The promise of these interventions is great because they can impact many people in a cost-effective manner; however, they are relatively new and require greater research and evaluation.
Recommendation 14: That the Federal Government undertake a National Task Force on the prevention of mental illness and the promotion of mental health and wellness with special reference to pandemics and similar national emergencies.

Detrimental Behaviour
Whereas compliance with the restrictions posed by COVID-19 has varied during the course of the pandemic, there is an important subgroup of about 20%, that have psychological characteristics that influence them to disregarded public health demands and may present serious barriers to future public health initiatives as the pandemic continues. In April 2020, about 20% of adults worldwide were failing to comply with public health viral containment measures like physical distancing (Lavoie, 2020). Non-adherence is higher among males (Litton, 2020;DeGrace et al., 2020) and among younger people (Lavoie, 2020;Moore et al., 2020).
Major epidemics and pandemics are managed by (a) risk communication (i.e., providing information to the public about the outbreak and how people can protect their health and safety), (b) vaccines and antiviral therapies (if or when available), (c) hygiene practices (e.g., washing hands, wearing facial masks), and (d) physical distancing (e.g., staying 2 metres apart). Willingness to be vaccinated is a major issue affecting the success of vaccination programs. Most people do not adhere to vaccination recommendations (Taylor, 2019). Data from Taylor and Asmundson's CIHR funded multi-wave population-representative survey of approximately 7000 Canadian and US residents indicates that 20% would not get a COVID-19 vaccine once it is available. There may be hesitation to be vaccinated due to concerns over safety of the vaccine, due to fear of needles, or due to beliefs that vaccination programs infringe on civil liberties.
Psychological factors play a vital role in the success of each of these methods (Taylor, 2019). Willingness to participate in activities such as hygiene practices and physical distancing are critical in the mitigation of viral spread. Unfortunately, many people do not adhere to handwashing recommendations (Pfattheicher et al., 2018). During the 2009 H1N1 pandemic, people who viewed themselves as having a low risk of infection were less likely to wash their hands (Gilles et al., 2009). Likewise, many people fail to adhere to social distancing recommendations. During the 2009 H1N1 pandemic, many in the UK and US (79% and 44%, respectively) made no effort to avoid being near someone who had influenza like symptoms (SteelFisher et al. 2009). In the context of COVID-19 there have also been challenges with respect to hygiene practices and physical distancing, with a substantial number of Canadians and Americans failing or refusing to follow recommendations (Taylor et al., unpublished data).
Psychological factors, including amongst other things, low perceived vulnerability to threat and unrealistic over-optimism bias, may play a major role in these disease-spreading behaviours. In such cases, getting people to adhere to recommendations that ultimately diminish infection rates and mortality-getting vaccinated, following recommended hygiene practices, physical distancing-may require public health officials to take a strategic approach to messaging that calls on the public's altruistic sense; that is, messages that emphasize that a person should be doing these things not for themselves but to protect potentially vulnerable family members, friends, and neighbours (WHO, 2006;Taylor, 2019).

Profondeurs
Personality characteristics also appear to be associated with greater non-adherence. For example, impulsivity (Baptist-Mohseni et al., 2020) and sensation seeking (DeGrace et al., 2020) have both been associated with higher levels of non-adherence to public health COVID-19-prevention strategies. Moreover, higher sensation seeking in males has been shown to help explain gender differences in non-adherence (DeGrace et al., 2020). Again, public health messaging and prevention programming may need to be targeted toward these higher-risk groups.

Parenting and Home Schooling
Public health policy response to the pandemic closed schools and workplaces, leaving families "sheltering in place", often in close quarters, with parents facing far greater home responsibilities than ever before, including homeschooling their children. In April of 2020, UNESCO (2020) data showed that more than 90% of children around the world were out of school. Parents faced mandatory homeschooling often with little support from the educational system, while many also struggled to work from home with heightened uncertainty and stress about their children's education, houseful finances, and family health. Parents were in an impossible situation (Lyons, 2020;Mandel, 2020) because of conflict between the demands of work and home, role strain that contributes to mental health problems and addictive behaviours (e.g., Abbey et al., 1993). The mental health consequences of the pandemic are predicted to be especially severe for families, even more so for women and children (Brooks et al., 2020;Wenham et al., 2020).
The consequences of this confluence of forces on family well-being intersect with pre-existing social inequities. For example, the effects of having children at home during the pandemic and of homeschooling appear to be amplified for women , potentially due to traditional gender roles where women still bear most of the burden of household chores and childcare. Adding the work of homeschooling, COVID-19 has compounded pre-existing gender inequalities in household labour (UNSDG, 2020). Recent articles, including Minello (2020), suggest that increased household workload in recent pandemic times has largely fallen to women, validating predictions from UNESCO (2020) and other organizations. A recent largescale survey in the US (Miller, 2020) showed that women do most of the homeschooling, with similar data emerging in Canada (Elgendi et al., 2020). Further, higher levels of COVID-related psychological distress were recently associated with greater drinking, particularly among women, providing evidence for important gender differences .
COVID-19 is also exacerbating pre-existing educational inequalities (Andrew et al., 2020). Parents with higher levels of education and income had more resources offered by schools during COVID-19-related shutdowns, even within the public education system (Andrew et al., 2020). Another study in the US showed that Black, Native American, and Latino students had less access to internet connectivity, electronic devices, and quality virtual learning programs during the pandemic (Winter, 2020). School closures place additional strains on disadvantaged families who may rely on schools for more than just education (e.g., meal programs) (Dooley et al., 2020).
Children are a vulnerable group. With school closures, children cannot access the first place that they would normally seek help for psychological distress: the school (Sellers et al., 2019). As such, parents' effectiveness in maintaining their own mental health may be even more important to children's mental health during pandemic times. And, with mandatory homeschooling increasing family conflict (Elgendi et al., 2020), observing parental conflict due to homeschooling (e.g., about division of the homeschooling workload) is likely to negatively affect children's mental health, given established adverse effects of parental conflict on children's psychological distress (Barletta & O'Mara, 2006). Additionally, parent-child conflict may increase with mandatory homeschooling as children resist parents taking on the role of teacher. As one 9-year-old told CBC's Cross-Country Checkup, "It's horrible to have your parent as a teacher because there's no difference between school and home" (CBC Radio One, 2020).
Parenting through a pandemic has mental health consequences. Recent data from the UK found that adults with children in the home during the COVID-19 lockdown were far more likely to suffer anxiety and depression than were those without children (Shevlin et al., 2020). In another study of 754 adults in the US, having children at home during the lockdown was associated with increased alcohol use . This effect is the reverse of that evidenced in nonpandemic times in which having children is a protective factor against heavy drinking (Bowden et al., 2019).
Homeschooling mandated in response to a pandemic is a unique context (Dalton et al., 2020;Holmes et al., 2020;Lee, 2020), about which there is little associated evidence. Most of what we know about the effects of homeschooling on parents and children comes from research outside of the pandemic on voluntary homeschooling. During the recent shutdowns, a study was conducted with 760 Canadian couples in June of 2020 (Elgendi et al., 2020); participants were asked to retrospectively report on the month of April 2020, close to the time when schools were first closed. After controlling for parental age, those homeschooling children (n = 203 couples) reported less optimism, more role strain, and more cannabis use to cope than those without children at home. In addition, more hours spent homeschooling was associated with greater anxiety, depression, COVID-related traumatic stress, and more frequent cannabis use. There were also some gender differences observed with greater effects of increased hours that mothers [vs. fathers] spent homeschooling on the frequency of drinking by both parents. These pilot data with 203 couples homeschooling children illustrate the effects that mandatory homeschooling during a pandemic has on parents' psychological well-being (Elgendi et al., 2020). These findings are cause for concern given that increased psychological distress and increased substance use among homeschooling parents is likely to impede their ability to cope and support their families in these challenging times.
Unfortunately, there is little research yet conducted to address the impacts of mandatory homeschooling on children's mental health. However, we do know that the COVID-19 pandemic more generally is having an adverse impact on children's mental health. Data from China shows increased rates of both depression and anxiety in children during the first COVID-19 outbreak (Dalton et al., 2020), perhaps due at least in part to exposure to increased stress in their parents.
Going into the 2020-21 academic year with the pandemic ongoing, jurisdictions have been struggling with how to handle schooling of the nation's children, given predictions of future waves of COVID-19 (Scher, 2020), as has happened elsewhere around the world (Bensadoun, 2020;Gutierrez & Kirk, 2020;Euronews, 2020). According to a recent Kaiser Family Foundation report (Michaud & Kates, 2020), most countries that have reopened schools have not experienced consequent COVID-19 outbreaks, but most of those countries had low community transmission rates. Some countries, including Canada, did experience school-based outbreaks upon school reopening requiring schools to close a second time (Michaud & Kates, 2020). This implies that jurisdictions reopening schools must carefully prepare for the very real possibility that they may need to close again in the event of an outbreak. Indeed, going into the 2020-21 academic year, mandatory homeschooling is included in most planned responses to predicted second waves.
And yet, with this option in hand, we are left with a core question: Is it better to keep schools closed to prevent viral spread at the expense of the mental health costs to families and to our economies? Or should we open schools doing our best to ensure public health strategies are followed within the schools? When schools are opened, efforts to reduce viral transmission must be implemented. These methods include ensuring physical distancing within the classroom through smaller class sizes, mandatory mask-wearing by children, teachers, and support staff, alternating days of learning at school vs. at home, or alternating half-days of learning at school, among other options. Such efforts could reduce viral spread as well as stress on families many of whom are anxious about appropriate public health measures being taken as children return to schools (Kroshus et al., 2020).
As we consider the potential options for schooling children, we hope this report shines a spotlight on the very real mental health consequences on families of requiring parents to homeschool. These consequences include evidence of increased levels of role conflict between demands of home and work, increased substance use, and heightened depression and anxiety, amongst other adverse impacts. Many of these impacts may be lasting, for example with increased substance use often continuing beyond pandemic times. We need to weigh these mental health consequences against the potential benefits to physical health of school closures. Closing schools has a very real cost to families, and one that we need to consider in public discussion and policy making. Returning children to school will be important to our nation's economic recovery, including from the "she-cession" with women disproportionately impacted economically by COVID-19 (Queisser et al., 2020).
The main arguments against returning children to schools are concerns for children's health and concerns that infected children may carry the virus home to family members or infect teachers and school support staff. The recent review by the Kaiser Family Foundation (Michaud & Kates, 2020) concluded that, while children are much less likely than adults to become severely ill, they can transmit the virus to others. This suggests that if children are to be returned to schools, extraordinary efforts will be required to ensure that schools closely follow public health recommendations (e.g., adequate physical distancing, mask wearing, and frequent handwashing). These efforts will be incredibly difficult to implement, particularly for younger children who may not understand the public health context and also for adolescents who have been particularly unlikely to adhere to public health recommendations (Moore et al., 2020). Some jurisdictions have considered enhancing physical distancing between children within schools through either part-days or oscillating days (Rocca & Dhanraj, 2020; CBC, 2020; The Canadian Press, 2020). Such policies would still require families to partially homeschool with unknown consequences to family well-being.
Offering a choice of schooling option to parents does not solve the debate. In a recent US survey in June 2020 (Kroshus et al., 2020), 31% of parents reported they would keep their child home even if in-person schooling were provided. Those more likely to want to keep children at home had lower incomes, greater rates of unemployment, more flexible jobs, increased fears of COVID-19, fewer perceived challenges to homeschooling, and lower confidence in schools (Kroshus et al.,2020). However, many parents do not have the luxury of flexibility within their jobs or the resources to enable children to engage in virtual learning (Dooley et al., 2020) and so voluntary homeschooling is simply not an option for many families. Jurisdictions must resource increased educational and mental health supports to parents in the event another period of mandatory homeschooling should be required.
A further complication is that the return to school protocols often are not friendly to children with neurodevelopmental challenges and will often preclude their return to school. This will leave them at greater risk of falling further behind and their parents at greater risk of the dramatically increased stress of homeschooling their children.
Recommendation 15: That Provinces and Territories should attempt to keep children in school and carefully weigh the cost/benefit ratio of closing schools in the event of another wave of COVID-19.
Recommendation 16: That the Federal, Provincial and Territorial Governments adequately fund efforts to minimize viral transmission within schools to reduce the chances that children will become ill and/or spread the virus to their teachers, school support staff, and family members.
Recommendation 17: That, should schools need to close again due to second or more wave(s) of the virus, parents be better supported in the education of their children at home. This includes supporting the increased mental health service needs of parents during mandatory homeschooling.
Recommendation 18: That if schools close again, Provincial and Territorial governments have mental health and substance use supports ready to stabilize family wellbeing using the vehicles used to deliver school curriculum to families.

Parenting and the Unintended Consequences of Universal COVID-19 Restrictions on Vulnerable Populations
The impact of the unintended consequences of the COVID-19 pandemic response on vulnerable populations and their families related to social and physical distancing policies remain unknown. One example includes the vulnerability of neonatal populations and their families and potential adverse effects of uniform pandemic response measures. The impact on persons in extended care homes has been treated in Restoring Trust: COVID-19 and The Future of Long-Term Care and is not repeated here.
Nearly 400,000 babies are born in Canada each year (Government of Canada, 2020). Of these, approximately 8% will be born preterm (less than 37 weeks gestational age), with the majority requiring neonatal intensive care and 10% of babies overall are admitted to NICU, equating to thirty to forty thousand Canadian babies requiring hospital care annually (Government of Canada, 2020). Babies born extremely preterm are the most vulnerable, but even those delivered one to two weeks early are at risk for immediate and long-term negative outcomes, including developmental delays, social, emotional and behavioural problems (Moster, et al., 2008;Woythaler et al., 2019). As a result, prematurity is the leading cause of infant disability and death, costing the Canadian health system in excess of $8 billion annually, with the length of stay over 100 days for the sickest and smallest infants .
Beyond infant outcomes, there is strong evidence that the parents of these infants report higher levels of immediate stress, anxiety, depression, posttraumatic stress and greater adverse parenting outcomes than parents of healthy newborns (Schecter, et al., 2020;Roque, et al., 2017). In order to improve the outcomes of vulnerable infants and their families and ease Although a concern in newborn infants, COVID-19 appears to be a very mild disease that is usually asymptomatic in this population. To date, evidence supports the lack of vertical transmission of the coronavirus during pregnancy (Qiu et al., 2020;Choi et al., 2020). In contrast to adults, infants and children under 10 however only account for 1% of COVID-19 cases . In Wuhan, only three confirmed cases of COVID-19 have been identified in neonates, with all infected neonates having mild or no symptoms (Choi et al., 2020). These milder cases suggest that there may be a mechanism that regulates how the immune system interacts with the virus in the respiratory system in children potentially pointing to the host adaptive response involvement in cases of more severe illness.
Despite this apparent reduced risk, restricted parental contact and extensive infection prevention and control measures have been instituted in neonatal units across Canada and worldwide to prevent COVID-19. It is not known if such approaches are effective nor if they lead to unwarranted side effects. Specifically, the development and maturation of neonatal gut microbiome are largely determined by maternal-neonatal microbial exchange and it plays an integral role in the immune and metabolic health of the infants (Prince et al., 2014;Mueller et al., 2014). Having limited contact with the mother and being exposed to other bacterial sources is likely to increase the chances of the baby being colonized with pathogenic organisms. There is some evidence that in addition to numerous other life saving benefits, the provision of breastmilk may protect newborns from contracting COVID-19, yet institution of universal public health social distancing policies restricting parental presence has been linked with reduced breastfeeding (Dong et al., 2020).
The mental health of at-risk parents of sick newborns has been exacerbated by universal social distancing restrictions that have not taken into consideration the potential risk and consequences in this vulnerable population (Mahoney, 2020). No parent wants to be separated from their baby. This is especially true for parents of premature or sick infants requiring hospitalization in a NICU, already with heightened risk for adverse mental health outcomes. Yet, given the restrictions of the COVID-19 global pandemic response, this is the reality for many mothers and almost every father of our smallest and extremely vulnerable patients. Changes to care standards at most Canadian NICU's do not permit both parents to remain with their infant for the duration of stay if they are admitted. Partners are not permitted to return to the hospital following attendance at the birth. Mothers who must leave to care for other children or relatives at home, are unable to return to the NICU. As a result, up to half of infants receiving care may not have a parent present due to COVID-19 restrictions. If one parent is allowed to remain in the NICU with their infant, they lack access to their usual social support systems, their partners have little engagement, and usual inperson support, education delivery, and discharge teaching has been disrupted.
Environmental restrictions and modifications have been put in place to prevent COVID-19 in babies, families and staff based on universal public health social distancing policies. They may exacerbate mental health outcomes in already at-risk parents and adversely impact later infant development and emotional well-being and may promote dysbiosis and abnormal immune system development of babies in the NICU. To prevent or limit the spread of COVID-19, the majority of NICU's have limited or eliminated parental presence and contact with their infant leaving most infants with limited or no parental contact during their hospitalization. The tension between protection of infants and caregivers from serious infection and the desire to maximize the developmental outcome of newborns and reduce parent mental health concerns forces consideration of several options for restricted interaction, rather than relying on a universal approach. While neonatal COVID-19 disease appears relatively uncommon, the risk-benefit calculation for restricting NICU access remains unclear.
Recommendation 19: That Provinces should attempt to keep high risk families of vulnerable neonates together and carefully weigh the cost/benefit ratio of restricting family presence during neonatal intensive care admission in the event of another wave of COVID-19.
Recommendation 20: That the Provincial and Federal Governments adequately fund efforts to determine the impact of family presence restriction on family and infant mental wellbeing and health outcomes.
Recommendation 21: That if hospital family restrictions are implemented again, Provincial governments have mental health supports ready to stabilize family wellbeing using virtual care delivery similar to school curriculum to families.

Summary
The COVID-19 pandemic has had a detrimental effect on mental health of people in Canada but the impact has been variable, impacting those facing pre-existing structural inequities hardest. Those living in poverty, and in some socially stratified groups facing greater economic and social disadvantage, such as some racialized, and some Indigenous groups and those with preexisting mental health problems, have suffered the most. Some occupational groups have been more exposed to the virus and to psychological stress with the pandemic. The mental health care system was already overextended and under resourced. The pandemic has exacerbated the problems. The care system responded by a massive move to virtual care. The future challenge is for Canada to strengthen our knowledge base in mental health, to learn from the pandemic and provide all in Canada the support they need to fully participate in and contribute to Canada's recovery from the pandemic.