Game Changers in the Treatment of and Engagement With Persons Living With Mental Health and Substance Use Disorders: The Role of the Nurse

ABSTRACT

The game changers in mental health and substance use disorder treatment have been shaped by historical sea changes marked by transformative advancements that have significantly enhanced patient care. Breakthroughs in psychotherapy, psychosurgery and psychopharmacology have each contributed to reshaping clinical practices, especially the revolutionary discovery of psychotropics. More recently, the rapid development of artificial intelligence has begun to address long‐standing barriers in access to care for individuals experiencing mental health and substance use disorders. Transitioning from past eras characterised by institutionalisation and inhumane treatment, the field of mental health and substance use has embraced a more holistic, patient‐centred and community‐based approach. Landmark legislation and progressive policy frameworks have played a vital role in safeguarding the rights and dignity of individuals living with mental health and substance use disorders. Patient engagement, the cornerstone of effective treatment, continues to evolve alongside the expansion of therapeutic options, from patients having no autonomy over decisions to encouraging clients to make informed decisions about their care. Within this dynamic landscape, nurses serve as essential gatekeepers of the healthcare system, providing critical functions such as clinical assessment, medication administration, patient education, counselling and ongoing monitoring to mitigate adverse treatment outcomes and support recovery, while establishing a therapeutic relationship in all aspects of care. This historical discussion paper explores and summarises the key game changer events by highlighting the treatment and engagement of persons living with mental health and substance abuse disorders of the past in timeline periods. Predictions for the future are also projected to encourage reflections of the past and thought‐provoking acumens for the future.

Abbreviations

AA

alcoholics anonymous

AHS

Alberta Health Services

AI

artificial intelligence

AMC

Abilify MyCite

APN

advanced practice nurse

AUD

alcohol use disorder

BPD

borderline personality disorder

CanLII

Canadian Legal Information Institute

CBC

Canadian Broadcasting Corporation

CBT

cognitive‐behavioural therapy

CFMHN

Canadian Federation of Mental Health Nurses

CMHA

Canadian Mental Health Association

COVID‐19

coronavirus 2019

CPZ

chlorpromazine

CRNS

College of Registered Nurses of Saskatchewan

CSC

Correctional Services Canada

CT

cognitive therapy

CTO

community treatment orders

DBT

dialectical behavioural therapy

DEIAJ

diversity, equity, inclusion, access, justice

ECT

electroconvulsive therapy

ED

Emergency Department

EDI

equity, diversity, inclusion

EPS

extrapyramidal symptoms

FDA

Federal Food and Drug Administration‐US

FGA

first generation antipsychotics

GC

Government of Canada

GMHSA

Guide to the Mental Health Services Act of Saskatchewan

GoA

Government of Alberta

GOS

Government of Saskatchewan

HCV

hepatitis C virus

HIV

human immunodeficiency virus

HR

harm reduction

IEM

ingestible event marker

IM

intermuscular

ISC

Indigenous Services Canada

KATA

Ketamine‐Assisted Therapy Association of Canada

KWI

Ketamine Wellness Institute

LAI

long acting injectables

LGBTQ2S+

lesbian, gay, bisexual, transgender, queer or questioning, and two‐Spirit +

MAOIs

monoamine oxidase inhibitors

MH

mental health

MHA

Mental Health Act

MHCC

Mental Health Commission of Canada

MHD

mental health disorder

NAI

noradrenaline reuptake inhibitors

NGA

new generation antipsychotics or fourth generation antipsychotics

NIMH

National Institute of Mental Health

NMS

neuroleptic malignant syndrome

NP

nurse practitioner

NTHK

narcan take home kits

OAT

opioid agonist therapy

ODP

opioid dependency programs

OUD

opioid use disorder

PChAD

Protection of Children Abusing Drugs Act

PHO

Public Health Ontario

PMHN

psychiatric mental health nurse

PNEP

prison needle exchange program

PTSD

post traumatic stress disorder

RN

registered nurse

RPN

registered practical nurse (Eastern & Atlantic provinces in Canada)

RPN

registered psychiatric nurse (Western & Pacific provinces in Canada)

SDOH

social determinants of health

SGA

second‐generation antipsychotics

SL

sublingual

SS

serotonin syndrome

SUD

substance use disorders

TCAs

tricyclic antidepressants

TD

tardive dyskinesia

TGA

third‐generation antipsychotics

TIC

trauma‐informed care

TIT

trauma‐informed therapy

TPP

tracked prescription program

TRC

Truth and Reconciliation Commission of Canada

TRD

treatment‐resistant depression

US

United States of America

VR

virtual reality therapy

WHO

World Health Organization

A ‘game changer’ is defined as a newly introduced element or factor that changes an existing situation or activity in a significant way (Merriam‐Webster Dictionary ²⁰²⁵) or an event, idea or procedure that significantly shifts the current way of doing or thinking about something (Oxford Learners Dictionary ²⁰²⁶). In mental health (MH) and substance use disorders (SUD) care, game‐changing treatments have expanded options and reshaped societal and professional perceptions. Breakthroughs in psychotropic medications, psychotherapy, legislation, social movements and policy have helped ensure individuals with MH and SUD are treated with dignity and autonomy in their care decisions.

Purpose

Pivotal ‘game changers’ are explored in this paper that have advanced both fields of MH and SUD treatment, with particular attention to patient engagement in their care. The historical evolution of treatment approaches and care is traced using structured timelines. The purpose of the paper is to serve as a valuable resource for nursing and health‐related students, educators, clinicians and those seeking to update or deepen their understanding of past and contemporary MH and SUD treatments. Although written from a Canadian perspective, the timelines of game changers also reflect the broader North American developments and global initiatives.

1. Definitions of Key Terms

Prior to addressing the historical timelines, it is important to define the key concepts used in this paper from recognised professional organisational and government reports. The concepts defined are mental health (MH), substance use disorders (SUD), concurrent or co‐occurring and comorbidity disorders.

1.1. Mental Health (MH)

The World Health Organization (WHO ^2025b) emphasises that MH is an essential component of health. ‘Mental health is a state of mental well‐being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community’ (para. 1). Mental health has intrinsic and instrumental value, is integral to well‐being and is a basic human right (WHO ^2025b).

1.2. Mental Health Disorder (MHD)

In contrast, MHD is characterised by a disorder of thought, perception, feelings or behaviour that severely impairs a person's judgement, ability to recognise reality, ability to associate with others or ability to meet the ordinary demands of life, with respect to which treatment is advisable (DSM‐5‐TR: American Psychiatric Association [APA] ²⁰²²). Mental disorders may also be referred to as mental health conditions. The latter is a broader term covering mental disorders, psychosocial disabilities and (other) mental states associated with significant distress, impairment in functioning or risk of self‐harm (International Classification of Diseases, ICD‐11: WHO ^2025a).

1.3. Substance Use Disorder (SUD)

Substance use disorder (SUD) is defined as a treatable medical condition, often described as a chronic disease of the brain, characterised by a compulsive, uncontrollable and continuous use of drugs or alcohol despite harmful, negative consequences to an individual's health, relationships, work or daily functioning (Health Canada ²⁰²⁴). Health Canada and clinicians generally use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5‐TR, APA ²⁰²²) to diagnose SUD, which combines substance abuse and dependence into a single, spectrum‐based disorder.

1.4. Concurrent or Co‐Occurring Disorders

Concurrent disorders is a term used to refer to co‐occurring addiction and mental health problems. It covers a wide array of combinations of problems, such as anxiety disorder and an alcohol problem, schizophrenia and cannabis dependence, borderline personality disorder and heroin dependence and bipolar disorder and problem gambling (Centre for Addiction and Mental Health [CAMH] ^{2026a, 2026b}). Concurrent disorders are also sometimes called dual disorders or a co‐occurring substance use and mental health problems. However, in some parts of Canada, this term dual diagnosis is used when a person has an intellectual disability and a mental health problem (CAMH ^2026a).

1.5. Comorbidity

In Canada, comorbidity refers to the simultaneous presence or co‐occurrence of two or more distinct medical or mental health conditions in one person. An individual can have a mental health problem or illness and a physical disease or disorder. For example, someone can have depression and chronic heart disease (Mental Health Commission of Canada [MHCC] ^2026b). Outside of the MH and SUD clinical area, comorbidity is commonly used to describe chronic conditions like diabetes, hypertension and mental health issues; however, within the MH and SUD clinical areas, we more often use the term ‘concurrent disorders’ or ‘co‐occurring’ to describe multiple physical and mental disorders. More often, dual or multiple concurrent disorders are the norm rather than a single disorder for our patients.

2. Timeline of Events

Each period of time has significant historical game changers in treatment approaches, including medication (dosage and route) and psychotherapy. Legislative and social policies in each period have shaped the landscape of MH and SUD care. Nurses have consistently played a crucial role in patient engagement, with their responsibilities expanding in scope and complexity over time. The MH and SUD field comes with many acronyms commonly used by healthcare professionals. The acronyms are included throughout the paper to familiarise the reader with this field. A list of acronyms used in this paper is included at the end of the paper.

3. 1800–1950

3.1. Mental Illness Treatment/Therapy, 1800–1950

Historically, individuals with mental disorders (MD) experienced discrimination, stigma and limited access to care (Lauzière et al. 2021). Before the 19th century, families provided care at home unless patients were violent; then, they were confined to jails or poorhouses (Boschma and Groening 2023). With population growth, overcrowded institutions emerged, marked by human rights violations and harmful practices such as insulin therapy, hydrotherapy and lobotomy. Terms like ‘lunatic asylum’ reflected widespread stigma (Boschma and Groening 2023; Remington et al. ²⁰²¹).

3.1.1. Medication Therapy

Drugs were introduced in the mid‐1800s largely to sedate patients, functioning as chemical restraints (Fabian 2017). Opium, morphine and toxic mercury were early treatments for mania. Barbiturates, discovered in 1903, became common for calming patients or inducing sleep but caused complications and addiction (López‐Muñoz et al. ²⁰⁰⁵). These drugs reduced reliance on physical restraints but offered little therapeutic benefit.

3.1.2. Psychotherapy, Somatic, Shock and Sleep Therapies

Many types of therapy were created and experimented with during this era in an attempt to control psychosis and unmanageable behaviour. Freud's psychoanalysis in the early 1900s emphasised unconscious processes and childhood trauma, but its cost and accessibility limited use (Boschma and Groening 2023; Tarzian et al. ²⁰²³). Insulin shock beginning around the 1920s induced comas but was later discredited (Rogers 2025); Electroconvulsive therapy (ECT), introduced in the 1930s, provoked seizures without anaesthesia, causing trauma and stigma. Sleep therapy administered by psychiatrists during this period of time used heavy sedation to manage violent behaviour but raised ethical concerns.

3.1.3. Psychosurgery

In 1935, Egas Moniz introduced the leucotomy (lobotomy), severing brain connections to reduce symptoms (Caruso and Sheehan 2017). Although the surgical procedure itself won a Nobel Prize, lobotomies caused apathy, personality changes and death (Staudt et al. 2019). Lobotomies faced declining support in the decade that followed, and the later discovery of psychotropics rendered this practice obsolete.

3.2. Alcohol/Drug Treatment/Therapy 1800–1950

Physicians during this time had limited pharmacological options for mental disorders. They prescribed opiates for conditions ranging from malaria to gynaecological pain, creating widespread dependency, especially among Civil War veterans and Victorian women (Courtwright 1978; Kandall ²⁰¹⁰).

The disease model of addiction evolved. While earlier perspectives largely viewed alcohol addiction as a moral failing with abstinence the only ‘cure’ (Sarkar 2021). Medical perspectives on addiction became more common in the late 19th and early 20th centuries. This marked a shift towards understanding addiction as a health issue, as opposed to a character flaw. The disease model gained even more momentum in the mid‐20th century with the rise of Alcoholics Anonymous (AA) and increased scientific research into the brain's reward system (Friedman 2024). In 1935, Wilson and Smith founded Alcoholics Anonymous (AA), whose 12‐step program emphasised surrender to a higher power. Research, including a Cochrane review, found AA often more effective than psychotherapy in promoting abstinence (Kelly et al. 2020).

Disulfiram, (Antabuse) FDA‐approved in 1949, was the first pharmacological treatment for alcohol use disorder (Kranzler and Hartwell 2023).

3.3. Legislation, 1800–1950

3.3.1. Eugenics and Colonial Policies

The period of 1800–1950 was a dark time in Canadian history. Colonial policies, including the Indian Act of 1876 and the policy of residential schools from the early to mid‐1800s to late 1900s, imposed lasting trauma. In addition to patients being subjected to electroshocks, drug‐induced sleep and huge doses of lysergic acid diethylamide (LSD) against their will (Kassam 2018), there was forced sterilisation of women deemed to be mentally unfit and experiments conducted in the name of research not only on persons incarcerated or in the mental asylums but also on children in the residential schools. From the 1920s to 1970s, the sexual Sterilisation Acts authorised involuntary sterilisations, disproportionately targeting Indigenous women (Leason 2021). Nutrition experiments in the 1940s–50s deliberately malnourished Indigenous children, violating human rights (Mosby 2013).

3.3.2. Human Rights Legislation

At the time legislation included Canada's 1879 Act to Protect Rights of the Mentally Ill, alcohol prohibition laws around 1900–1925 and the 1908 Opium Act (Kent‐Wilkinson ²⁰²⁵). Throughout the first half of the 19th century, institutional confinement under Insanity Acts dominated. Psychiatric or mental hospitals were overcrowded, custodial and resembled prisons.

The 1948 UN Declaration of Human Rights began to shift public views. Provincial Mental Health Acts began to reflect more modern perspectives (Boschma and Groening 2023). The changing terminology in the overall name of the Insanity Act itself reflects the beginning of social trends of political correctness, reflected in all provinces and territories.

3.4. Social Movements and Trends 1800–1950

3.4.1. Patient Rights/Autonomy, 1800–1950

Patients did not have autonomy in decision‐making regarding their treatment prior to the enactment of specific legislation. Those with severe mental illness were kept in asylums against their wishes and had to comply with the treatment plan of their providers. Medication was forced on the patient without their consent. If patients refused the oral medication prescribed by the psychiatrist, they were restrained by the nursing and security staff and, through force, were given the medication by intramuscular (IM) injection.

3.5. Role of the Nurse, 1800–1950

Prior to 1950, nursing education offered limited training in the area of psychiatric mental health nursing. The oversimplified classification of patients having a mental illness at the time was that patients were either ‘mad’, ‘sad’ or ‘bad’. Custodial care was prevalent, with the workforce in MH units and prisons being predominantly male veterans of war (Nolan and Hopper 1997). These veteran male nurses were often selected due to the physical demands of managing patients with challenging behaviours. Their experience equipped them with diverse skills and transformed their perspective on MH care (Nolan and Hopper 1997). In this time period, gender equality in roles for women in police, firefighting or prisons was yet to be seen.

4. 1950–1975

A groundbreaking event, the discovery of antipsychotics occurred in 1949–1950, transforming the trajectory of psychiatric treatment. The early antipsychotics heralded the ‘psychopharmacological era’ and replaced biological therapies such as insulin coma and frontal lobotomy and for a time ECT.

4.1. Mental Illness/Treatment, 1950–1975

The first antipsychotic, chlorpromazine (CPZ) or Thorazine (Largactil), with its profound effects, marked the ‘psychopharmacological era’, enabling deinstitutionalisation as patients were discharged and managed with psychotropics (Boschma and Groening 2023; Lamb and Bachrach ²⁰⁰¹). Community care emphasized autonomy and compassion.

4.1.1. First‐Generation Antipsychotics (FGAs)

Chlorpromazine, marketed under the brand or trade name of Thorazine in the United States and Largactil in Canada, was the first modern antipsychotic (López‐Muñoz et al. ²⁰⁰⁵). Typical antipsychotics, phenothiazines and butyrophenones became standard for schizophrenia (Munayco Maldonado and Schwartz ²⁰²⁴; Dattani ²⁰²⁴). By blocking dopamine‐2 receptors, FGAs reduced hallucinations, delusions and disorganised thought (Meissner 2024; Remington et al. ²⁰²¹). Generic examples included chlorpromazine, fluphenazine, haloperidol, thiothixene and trifluoperazine (Meissner 2024; Dattani ²⁰²⁴). Although safer than psychosurgery (Staudt et al. 2019), FGAs caused extrapyramidal symptoms (EPS), tardive dyskinesia and hyperprolactinemia (Monteleone et al. 2022; Remington et al. ²⁰²¹). Side effects often reduced compliance (Staudt et al. 2019).

4.1.2. Antidepressants/Mood Stabilisers

Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) were discovered in the 1950s. Iproniazid (Iprazid), originally for tuberculosis, became the first MAOI and imipramine became the first TCA (López‐Muñoz and Alamo ²⁰⁰⁹). Later, TCAs such as lofepramine and the noradrenaline reuptake inhibitor maprotiline appeared in the 1970s (Moller and Volz 1996). Lithium, discovered by John Cade in 1949 and FDA‐approved in 1970, remains highly effective for bipolar disorder and suicide prevention (Abu‐Hijleh et al. ²⁰²¹; Del Matto et al. ²⁰²⁰; Ruffalo ²⁰¹⁷). The use of lithium declined due to toxicity risks and limited marketing, though evidence supports its efficacy (Carvalho et al. 2021).

4.2. Alcohol/Drug Treatment, 1950–1975

4.2.1. Psychedelic Therapies

In the 1950s, Saskatchewan became a hub of psychedelic research. Psychiatrist Humphry Osmond coined ‘psychedelic’ in 1957, and LSD and mescaline were studied as treatments for psychosis and addiction (Dyck 2019). Research trials on LSD also took place in Ontario and Quebec in the 1950s and 1960s. Safety concerns after the thalidomide scandal and rising recreational use ended most research by the late 1960s.

4.2.2. Methadone Treatment

In the 1960s, methadone treatment was approved in New York City as a therapeutic intervention for women struggling with heroin addiction (Kandall 2010). The treatment aimed to reduce the euphoric effects of opioids and curb cravings, leading to positive outcomes for many women (Kandall 2010). During the same period, cocaine addiction also became more prevalent, as the drug was commonly found in over‐the‐counter remedies and tonics (Kandall 2010).

4.3. Legislation 1950s–1975

The 1960s marked deinstitutionalisation, with psychiatric hospitals downsized in favour of community‐based care. Although new laws promoted local services, inadequate housing and limited supports undermined outcomes. Provincial Mental Health Acts were revised to reflect modernised care. Provinces consolidated existing mental health legislation into new acts, which aimed to facilitate the delivery of mental health services closer to where people lived.

4.4. Social Movements & Trends, 1950–1975

Overcrowded psychiatric institutions remained custodial in the 1950s–60s, resembling prisons (Ontario Human Rights Commission ^2024b). Deinstitutionalisation aimed to shift towards community‐based models but faced social challenges as enough community services were not available.

4.4.1. Terminology

Terminology also evolved: ‘lunatics’ was replaced by ‘insane’ in the 1961 MHA Respecting Insane Persons and later by ‘mentally ill’ (Government of Saskatchewan [GOS] ²⁰¹⁵). The word ‘asylums’ to describe the ‘institutions’ where the mentally ill were housed was replaced by the term ‘mental hospitals’ in Canada and ‘special hospitals’ in the United Kingdom.

4.4.1.1. Patient Refusal/Resistance

Physicians and nurses often enforced treatment without the patients' consent (Majerus 2016). This practice continued from the previous era in cases where patients refused medication, either due to adverse side effects or a lack of insight into their illness. The methods employed by nurses to ensure compliance were frequently undocumented (Majerus 2016). Patients' resistance to medical authority significantly impacted their compliance and willingness to participate in treatment.

4.5. Role of the Nurse, 1950–1975

Care of patients slowly moved from custodian to more therapeutic. The gender of nurses hired to practice in acute and long‐term mental health units in general hospitals, psychiatric hospitals and prisons began to change in this era. The care of the mentally ill had long been considered too dangerous a place for women to work, as physical strength was the attribute most needed. However, with the women's movement in the 1960s and the availability of antipsychotics to manage patient behaviour, women became a permanent feature of the workforce. In 1971, Correctional Services Canada (CSC) hired its first female nurse to work at Drumheller Penitentiary (now called Institution) in Alberta (Norens 1971). At about the same time, women were hired to work as correctional officers, not just in the smaller female units but also in the larger dormitories housing male offenders. In the early 1980s, correctional facilities started to be accepted as important clinical placements for nursing students.

Nurses have played a vital role in supporting patients in deinstitutionalisation, when transitioning from institutional care to community living, helping them maintain MH stability. A key nursing responsibility in this context is the close monitoring of patients receiving psychotropic medications to prevent adverse outcomes. Patients often report dissatisfaction with FGAs due to the severity of their side effects (Hartling et al. 2012; Semahegn et al. ²⁰²⁰). To ensure timely and appropriate medical intervention, nurses educated patients and their families about the potential adverse effects of psychotropics and clinical manifestations. Notable examples of such adverse effects include EPS (Monteleone et al. 2022), as previously mentioned, as well as serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS).

5. 1975–2000

Between 1975 and 2000, MH and SUD treatment saw major advancements. This period marked a shift from rigid, traditional models to patient‐centred, evidence‐based approaches. Key developments included progress in psychopharmacology, the adoption of cognitive behavioural therapy (CBT), motivational interviewing, and the introduction of harm reduction strategies (Ritter and Cameron 2006). The Canadian Charter of Rights and Freedoms, enacted in 1982, provided important new legislation that safeguarded patient rights (Government of Canada [GC] ¹⁹⁸²).

5.1. Mental Illness Treatment/Therapy, 1975–2000

Following the initial discovery of FGAs, a substantial timeframe elapsed before the development of second‐generation antipsychotics (SGAs), otherwise known as atypical antipsychotics (Hartling et al. 2012). Chloral hydrate remained in use but caused adverse effects (Fabian 2017). Thorazine, safer and more effective than prior drugs, was followed by newer agents such as risperidone (Risperdal), olanzapine (Zyprexa), aripiprazole (Abilify) and quetiapine (Seroquel) (Fabian 2017). The introduction of SGAs provided patients with more options for psychotropic treatment.

5.1.1. Second‐Generation Antipsychotics (SGAs)

The SGAs emerged, offering broader symptom relief (Hartling et al. 2012). Clozapine (Clozaril) proved most effective for treatment‐resistant schizophrenia but carried risks of weight gain, diabetes and heart complications (Dattani 2024). Examples include clozapine, risperidone and quetiapine (Meissner 2024). Long‐acting injectable (LAIs) formulations improved adherence (Riboldi et al. 2022). The following are examples of LAIs: aripiprazole (Abilify Maintena), flupentixol (Fluanxol depot), fluphenazine (Prolixin), olanzapine (Zyprexa Relprevv), paliperidone (Invega Sustenna, Invega Trinza), zuclopenthixol (Cloxpixol) and risperidone (Risperidol) (Pai et al. 2023).

5.1.2. Administration of Medication/Antipsychotics

Most antipsychotics are administered by oral or intramuscular (IM) injection. Intravenous (IV) injection rarely is the prescribed route due to the high potency of these drugs. Game changers in the administration of antipsychotics were the arrival of the LAIs, which first appeared in the 1960s, but became more widely used in Canada in the 1970s. Then, in the early 1990s, oral disintegrating tablets administered sublingually began to be clinically trialled (e.g., olanzapine).

5.1.3. Electroconvulsive Therapy (Continues)

The use of ECT re‐emerged during this period, despite a setback by media depictions of movies like the 1975 drama comedy One Flew Over the Cuckoo's Nest (Hilton 2007). Psychiatrists themselves advocated for ECT as some psychiatrists who lived with a depressive disorder themselves professed that ECT provided the best and sometimes the only relief for their own severe bouts of treatment‐resistant depression. Slowly ECT began to be used again in acute care psychiatric units.

5.2. Alcohol/Drug Treatment, 1975–2000

The co‐occurrence of MH and SUD was common, highlighting the complexity of care required for this population (National Institute of Mental Health [NIMH] ²⁰²⁵). Added to these co‐occurring disorders are often comorbid disorders (the existence of one or more physical disorders), which also increase the risk of death or complicate treatment. In addition, there was a growing awareness of the widespread impact of trauma, co‐existing with physical and mental health issues, substance use problems and involvement with the justice system (Ponic et al. 2021).

The rise of designer drugs, synthesised in laboratories, presented a significant and concerning development in the drug crisis during this period (Jekel and Allen 1987). Likewise, the alteration of common drugs at home to produce more potent substances posed a significant threat to the health and safety of people using illegal substances (e.g., Crystal Meth). Cocaine, particularly in its smokable form known as ‘crack’, was among the fastest growing illicit drugs globally in this period (Jekel and Allen 1987).

5.2.1. Psychotherapy

In this time period, psychotherapy became more pronounced as an added treatment modality for MH and SUD. Therapies included but were not limited to Gestalt therapy, reality therapy, family systems therapy, group counselling and motivational therapy; followed by cognitive‐behavioural therapy (CBT) and dialectical behavioural therapy (DBT).

5.2.1.1. Cognitive‐Behavioural Therapy (CBT)

As a psychotherapy, CBT integrates behavioural and cognitive approaches to replace destructive thought patterns. For most MH and SUD conditions, CBT is now considered a first‐ or second‐line treatment (Nakao et al. 2021).

5.2.1.2. Dialectical Behavioural Therapy (DBT)

A form of CBT that is well utilised is DBT. In the 1970–1980s, DBT was developed by American psychologist Marsha Linehan for borderline personality disorder (Yale Medicine ²⁰²⁵). As emotional dysregulation and behaviours such as self‐harm and aggressive behaviours can be targeted by DBT, it is now applied more broadly (Byrne and Ní Ghráda ²⁰¹⁹; Marceau et al. ²⁰²¹).

5.2.2. Harm Reduction (HR)

Canada adopted HR strategies in the 1980s, emphasising public health and human rights (Ritter and Cameron 2006). Some examples of HR practices are smoking patches, condoms and needle exchange. The human immunodeficiency virus (HIV) risks drove programmes like needle exchanges, first launched in Vancouver, Toronto and Montreal in the 1980s. Almost 30 years later, Correction Service Canada (CSC) introduced prison needle exchanges in 2018 to reduce HIV/HCV spread in the criminal justice system (CSC ²⁰²⁴).

5.3. Legislation in Canada, 1975–2000

5.3.1. Provincial Mental Health Acts

The Canada Health Act, enacted in 1984, aimed to standardise healthcare services, including mental health, across provinces. Key areas of legislation included the implementation of provincial mental health acts, which outline the process for psychiatric assessments and involuntary admissions. ‘There are 13 Mental Health Acts in Canada because the ten provinces and three territories are responsible for their own health laws and services’ (O'Reilly and Gray ²⁰¹⁴, 65).

5.3.2. Danger to Self or Others

In the 1970s, involuntary admission criteria in many North American jurisdictions began to shift from ‘need for treatment’ to ‘risk of harm’, as a basis for involuntary hospitalisation (O'Reilly and Gray ²⁰¹⁴). In the 1990s, the Mental Health Act and Health Care Consent Act separated treatment from decision‐making capacity (Ontario Human Rights Commission ^2024a).

5.3.3. Right to Refuse Treatment

Capable patients gained the legal right to refuse medication and no longer could be forcibly treated when committed (O'Reilly and Gray ²⁰¹⁴). This shift was influenced by a growing emphasis on individual autonomy and rights, as well as concerns about the potential for abuse of involuntary commitment laws (O'Reilly and Gray ²⁰¹⁴).

5.4. Social Movements/Trends, 1975–2000

5.4.1. Stigma (Continues)

Community‐based care expanded, but vulnerable groups (e.g., mentally ill persons, Indigenous peoples, racial minorities, homeless and incarcerated persons) faced layered stigma (O'Reilly and Gray ²⁰¹⁴). Although stigma and discriminatory behaviour about mental and addiction disorders still exist in some societies globally, MH advocacy organisations like the Canadian Mental Health Association (CMHA ²⁰²⁴), the Mental Health Commission of Canada (MHCC ²⁰¹²) and other non‐governmental organisations began to create much awareness in developed countries to dispel this attitude.

5.4.2. Terminology

Changes in terminology parallel broader shifts in societal attitudes, policies and practices related to MH and SUD treatment. Labels shifted from ‘patient’ to ‘client’, ‘consumer’ or ‘partner’, sparking debate. Many recipients preferred ‘patient’ to alternatives implying market relationships (Deber et al. 2005).

5.4.2.1. Patient Compliance/Concordance

In 1976, Sackett introduced the term ‘compliance’ in the medical context, reflecting a paternalistic approach prioritising obedience to prescribers' instructions, often at the expense of patient autonomy (Rae 2021; Vrijens et al. ²⁰¹²). Patients who did not strictly follow treatment recommendations were labelled ‘non‐compliant’ (Rae 2021). The adoption of terms like treatment ‘acceptance/refusal’ or ‘compliance/non‐compliance’ further reflects this evolving social perspective. Hence, the Royal Pharmaceutical Society of Great Britain's joint working group introduced the term ‘concordance’ in 1995, marking a shift towards a more collaborative model of care that respects patient choice and shared decision‐making (Vrijens et al. 2012).

5.5. Role of the Nurse, 1975–2000

Mental health care in Canada is provided under the provisions of federal, provincial and territorial MHAs and respective legislation. According to the Professional Nursing Acts in each province, nurses play a critical role in verifying the patient understands the medication, can give consent voluntarily and is competent to do so (College of Registered Nurses of Saskatchewan [CRNS] ²⁰²¹). The nurse's role is to ensure the informed consent process is completed correctly by: confirming the patient understands the medication's risks, benefits and alternatives; acting as a witness to the patient's consent; and ensuring the consent was given without coercion (CRNS ²⁰²¹). Nurses must monitor for and manage any adverse reactions, report such reactions to the physician and meticulously document all treatment outcomes (CRNS ²⁰²¹). Lifestyle changes are crucial for patients to avoid the metabolic impact of antipsychotic medications; therefore, patient education is paramount.

5.5.1. Registered/Licensure

In Canada, nurses are a broad group of practitioners who are licensed in their respective provinces and territories. Regulated nursing professionals in Canada include registered nurses (RNs), registered psychiatric nurses (RPNs) and licensed practical nurses or registered practice nurses (L/RPNs). Registered Psychiatric Nurses (RPNs) are only registered in the western provinces, some of the Maritimes, Nunavut and the Yukon. Advanced practice positions, such as nurse practitioner (NP) or clinical nurse specialist (CNS) roles, may be held by RNs and RPNs (Canadian Federation of Mental Health Nurses ²⁰²³, 10). Nurses of all designations may work in the speciality areas of psych/mental health or forensic nursing; however, all nurses in all areas of hospitals or communities will have patients with MH or SUD conditions or will have co‐existing conditions. Therefore, knowledge in this area is essential!

5.5.2. Speciality Areas and Roles in Mental Health Nursing

From the 1970s to the 1990s, specialised roles emerged in geriatrics, adolescent psych, adult psych and forensic nursing. Certification and subspecialities, such as correctional or sexual‐assault nursing, became formalised by the 1990s. The psychiatric nursing program in the Western provinces of Canada developed degree and master's level programmes.

5.5.3. Cultural Safety

Cultural safety originated with Maori nurses in New Zealand in the 1980s, led by Irihapeti Ramsden. It was developed in response to health inequities experienced by the Maori people, emphasising the patient's perspective to ensure healthcare environments and interactions are spiritually, socially, emotionally and physically safe (Papps and Ramsden 1996). The concept of cultural safety gained prominence in the early 1990s when the Nursing Council of New Zealand made it a mandatory requirement for nursing education. The goal of cultural safety is to create healthcare environments where Indigenous peoples feel that their identity is respected and that their needs are being met, moving beyond just cultural competence to actively address systemic issues and power imbalances (Papps and Ramsden 1996).

6. 2000–2025

Over the past few decades, understanding of psychiatric illness has shifted from the idea of chemical imbalance to genetic risks and changes in molecular and cellular development (Scangos et al. 2023). Today, patients with MH and SUD often live near families and are supported by community MH teams.

Side effects from the first, second and third generation of anti‐psychotics continue to interfere with ongoing acceptance of taking these medications. Although effective in reducing symptoms of the illness, the side effect of gaining excessive weight over time is prohibitive.

6.1. Mental Disorders Treatment/Therapy, 2000–2025

Key game changers since 2000 include the approval of third‐generation antipsychotics (TGAs) and also Ketamine/Esketamine for treatment‐resistant depression (TRD). Discovered in 2024, Cobenfy was being considered as a fourth‐generation antipsychotic (Bjugstad 2024).

6.1.1. Third‐Generation Antipsychotics (TGAs)

The TGAs act as dopamine partial agonists, stabilising dopamine activity (Meissner 2024). Aripiprazole (Abilify), the first TGA, and others like brexpiprazole, cariprazine and lumateperone treat schizophrenia spectrum disorders, bipolar disorder and as adjunctive therapy for depression (Munayco Maldonado and Schwartz ²⁰²⁴). Compared to FGAs and SGAs, TGAs cause fewer EPS and cardiometabolic issues and may improve cognitive and negative symptoms (Meissner 2024).

6.1.1.1. Abilify

Abilify was developed in Japan and approved in 2012 as an oral tablet. Abilify was followed by Abilify Maintena in 2013 and Abilify MyCite in 2017 (Drugs.com ²⁰²³).

6.1.1.2. Digital Tracking Device

Abilify MyCite (AMC) combines aripiprazole with an ingestible event marker to track medication adherence (Flore 2021). Signals from a pill‐embedded sensor pass to a torso patch, smartphone app and provider web portal (Shukla et al. 2021). While novel, AMC faces high costs ($1641.92 vs. $17.81), complexity, privacy concerns and limited acceptance, especially among patients with paranoia. To date, AMC is not available in Canada (Shukla et al. 2021).

6.1.1.3. Ketamine

Synthesised in 1962 and used as an anaesthetic since the 1970s, Ketamine was found to have antidepressant effects in the early 2000s (Ketamine Wellness Institute ²⁰²³; Mathew et al. ²⁰²³). At low doses, it provides rapid relief for TRD and suicidality but can cause transient dissociative effects (Mathew et al. 2023).

A Canadian study (n = 19) of Ketamine for TRD showed improvements in mood and functioning (Perepelkin et al. 2025). A study in the United Kingdom (n = 14) found reduced suicidal ideation in 12 patients (Lascelles et al. 2019). Despite benefits, misuse risks of Ketamine remain (Schak et al. 2016). The Ketamine‐Assisted Therapy Association of Canada (KATA), founded in 2019, promotes standards, research and education (KATA ²⁰²²).

6.1.1.4. Esketamine (SPRAVATO)

Approved by the Federal Food and Drug Administration (FDA) in the United States in 2019 and Health Canada in 2020, Esketamine (Spravato) treats TRD in adults (John Hopkins Medicare ²⁰²⁵; Press Release PR Newswire ²⁰¹⁹). As a more potent ketamine derivative, it causes fewer dissociative effects but requires clinical monitoring for initial doses (Song et al. 2024).

6.1.2. Fourth‐Generation Antipsychotic or New‐Generation Antipsychotic (NGA)

In 2024, the FDA approved xanomeline/trospium chloride (Cobenfy), developed by Karuna Therapeutics and Bristol Myers Squibb, for schizophrenia (Bilsland 2024; Mills ²⁰²⁴). Unlike dopamine/serotonin‐targeting drugs, xanomeline/trospium chloride acts as a muscarinic receptor agonist, reducing both positive and negative symptoms (Torjesen 2024). Its dual‐drug formulation, xanomeline (brain‐acting) and trospium chloride (side‐effect limiting), represents a new antipsychotic class (NGA) and/or is being considered as a fourth‐generation antipsychotic, though more research is needed (Mueser and Fulford 2024).

6.1.3. Electroconvulsive Therapy (ECT) (Continues)

In the 2000s, ECT remained effective for TRD, refined for precise sedation and voltage. Nurses play key roles in first and second stage recovery, reassurance and psychoeducation, reducing stigma and supporting informed decisions (de Mangoux et al. ²⁰²²).

6.2. Substance Use Disorders Treatment/Therapy, 2000–2025

The SUDs remain chronic conditions with high morbidity (Liu et al. 2020). The opioid crisis escalated after OxyContin's misuse and withdrawal in 2012, leading to fentanyl and heroin use (Canadian Broadcasting News ²⁰¹⁶; Craig ²⁰¹⁹). In 2024, Canada averaged 21 opioid deaths daily, mostly among men aged 30–39, with fentanyl in 79% of cases (Fischer 2023; GC ^2024a). Rural Indigenous communities remain disproportionately affected (Alpert et al. 2022). Rural Indigenous populations face significant barriers to treatment access (Alpert et al. 2022; Kourgiantakis et al. ²⁰²³; Ontario Drug Policy Research Network and Public Health Ontario ²⁰²³; Tarasuk et al. ²⁰²¹).

6.2.1. Naloxone (Narcan)

Freely distributed Take‐Home Naloxone kits have reversed thousands of overdoses (Government of Alberta [GoA] ²⁰²⁰). Available intranasally and via IM injection, it is a cornerstone of harm reduction (Ferguson et al. 2023). The administrative route of intranasal spray is new in the MH and SUD field. Other drugs administered intranasally are fentanyl, ketamine and dexmedetomidine.

6.2.2. Opioid Agonist Therapy (OAT)

Medications like methadone, buprenorphine and naltrexone reduce overdose risk and improve treatment retention (Taylor et al. 2021). Methadone, though effective, is stigmatised and tightly regulated (College of Physicians and Surgeons of Alberta ²⁰²⁵). Engagement challenges remain despite rising use of OAT for SUD diagnoses (Liu et al. 2020).

6.2.3. Increase in Benzodiazepine‐Laced Drugs

Recently, there has been a stark increase in synthetic benzodiazepine‐laced opioids (i.e., ‘benzodope’) in some Canadian jurisdictions. The emergence of benzodiazepines within the illicit drug supply has substantially contributed to drug‐related morbidity and mortality in Canada and has further complicated current public health initiatives and overdose prevention efforts (Drugs.com ²⁰²⁵; Russel et al. ²⁰²³).

6.2.4. Harm Reduction (HR Continues)

The HR strategies of naloxone, safe supply and supervised sites reduce deaths and disease spread (Alberta Health Services ²⁰²⁵). Cuts in 2024 towards ‘recovery‐oriented’ care raise concerns (Wyton 2024). Harm reduction (HR) is not simply access to sterile syringes, naloxone or condoms but a life‐saving movement of mutual aid by and for people who have been relegated to harm or death by society more broadly (Hassen et al. 2021, as cited by Johnson and Sue ²⁰²⁴). In January 2024, the Saskatchewan Health Authority decided to ‘realign’ the harm reduction approach to a ‘recovery‐oriented system of care’ (Wyton 2024). Cuts to harm reduction services occurred across Canada, with outcomes projected in terms of lives lost are yet to be reported. Healthcare professionals and researchers, who support HR approaches, lobby the government and those in positions of power to make decisions to look closer at the reasons for the high rates of blood‐borne infections and injectable drug users, rather than cutting HR services.

6.2.5. Psychotherapy

6.2.5.1. Trauma‐Informed Care (TIC)/Therapy

In 2001, Drs. Maxine Harris and Roger Fallot in the United States first introduced the concept of trauma‐informed approaches (Harris and Fallot 2001), which was a paradigm shift from traditional services that were not designed to recognise the impact of trauma. The five guiding trauma‐informed values and principles proposed by Harris and Fallot (2001) are safety (physical and emotional), trustworthiness, choice, collaboration and empowerment. Given the presence of individual, historical, racial, cultural and systemic trauma, true universal precaution requires that considerations of diversity, equity, inclusion, accessibility and justice (DEIAJ) are centred when applying the values and principles of TIC (University at Buffalo ²⁰²⁵).

Evolving since the early 2000s, TIC or trauma‐informed therapy emphasises understanding trauma's impact and shifting the question from ‘what's wrong with you?’ to ‘what happened to you?’ (Centre for Health Care Strategies ²⁰²⁵; Ponic et al. ²⁰²¹). Applying a trauma‐informed lens helps patients who may not disclose trauma histories. Therapy grounded in awareness fosters safer healing environments (Sweeney et al. 2018).

6.3. Legislation in Canada, 2000–2025

6.3.1. 2000s

The federal government in this decade worked towards standardised mental health and substance use care across the country. Addiction or substance use services were integrated with mental health; community treatment orders (CTOs) and drug treatment courts were introduced.

In 2006, the Protection of Children Abusing Drugs Act (PChAD), 2006, enables a guardian to apply to the Court for an order to protect a child who is abusing drugs. This Act was amended in 2023 (Government of Alberta [GoA] ²⁰²³).

6.3.2. 2010s

In 2012, Canada's first national mental health strategy was the document Changing Directions, Changing Lives Strategy, 2012 by the Mental Health Commission of Canada (MHCC ²⁰¹²). The Mental Health Strategy for Canada advanced youth MH and rights‐based care, and the Strategy outlined a strategic direction specific to Indigenous mental health (MHCC ²⁰¹²).

In 2017, the Good Samaritan Drug Overdose Act was passed providing some legal protection for individuals who seek emergency help during an overdose. The Act protects bystanders administering naloxone from being sued in cases where the person who overdosed does not survive (GC ^2024a).

In 2018, Canada legalised recreational cannabis with the passage of the Cannabis Act on 17 October 2018 (GC ²⁰¹⁸). This made Canada the second country in the world to legalise recreational cannabis nationwide; the first was Uruguay in 2013 (British Broadcasting Company ²⁰¹⁹).

6.3.3. 2020s

In 2023, British Columbia (BC) decriminalised possession of small amounts of some illegal substances for personal use by people over 18 years old (GC ^2024a). This was an exemption to the federal Controlled Drugs and Substances Act (GC ^2024a) for a 3‐year trial period and it is important to note that decriminalisation is not legalisation. The trafficking of drugs remains illegal, and there are no government‐approved systems for the manufacturing, buying and selling of these substances.

In 2025, the Compassionate Interventions Act 2025 (formerly Bill 53) received royal assent (GOA ²⁰²⁵). The Act creates a new framework for parents, family members, guardians, healthcare professionals and police or peace officers to request a treatment order or a care plan for those individuals with severe substance use disorders who pose a likely risk of harm to themselves or others. The Act is the first law in Canada to compel addiction treatment for adults beyond existing mental health laws (GOA ²⁰²⁵).

6.4. Societal Movements/Trends, 2000–2025

6.4.1. Stigma (Continues)

Stigma from clinicians themselves and the public has been found to be the greatest threat of all to discourage care‐seeking among persons living with MH and SUD (MHCC ²⁰¹²). Societal awareness of stigma faced by many vulnerable populations was a focus in the early 2000–2025 timeframe for populations such as mentally ill, Indigenous, incarcerated, homeless, immigrants, refugees and LGBTQ2S+ (lesbian, gay, bisexual, transgender, queer or questioning and two‐Spirit +). Mental health‐related stigma is often grounded in stereotypes that persons with mental health issues are dangerous (unpredictable, violent), responsible for their mental health issues, cannot be controlled nor recover and should be ashamed (Corrigan and Watson 2007). Landmark reports, recognition of the Rights of Indigenous Peoples (United Nations ²⁰²¹), and anti‐stigma campaigns have significantly improved awareness of the stigma of MH and SUD. These initiatives aim to reduce harmful attitudes, discrimination and shame, which act as major barriers to treatment, while encouraging open conversations and increasing mental health literacy (MHCC ^2026a).

6.4.1.1. Out of the Shadows at Last, 2006

The 2006 report, ‘Out of the Shadows at Last: Transforming Mental Health, Mental Illness’ was significant as it was the first report to address stigma! (GC ²⁰⁰⁶). The report also included a chapter on the specific circumstances of aboriginal peoples in Canada. This prompted provincial governments to address stigma in all their reports and led to the creation of the Mental Health Commission of Canada (MHCC) in 2007 to catalyse change.

6.4.1.2. Anti‐Stigma Campaigns in Canada

A number of anti‐stigma campaigns in Canada have sustained momentum and no doubt have been a game changer in destigmatising MH and SUD by educating students and the public: (1) Partnership Program by the Schizophrenia Society of Canada since 1999; (2) Elephant in the Room Campaign by the Mood Disorders Society of Canada (MDSC) since 2006; (3) Mental Health First Aid (started in Australia in 2002) by the Mental Health Commission of Canada (MHCC) since 2007 in Canada; (4) Opening Minds Initiative: 10‐Year Anti‐Stigma and Discrimination Reduction Campaign 2009–2019 by the MHCC; and (5) Bell Let's Talk by Bell Canada since 2010 (Gronholm et al. 2017; MHCC ^2026a). Evaluations of anti‐stigma programmes have concluded that the sustainability of programmes over long periods of time is the most effective, and that the person living with the MH and SUD are the experts and the best educators of their disorders (Evans‐Lacko et al. ²⁰¹⁰; Walsh and Foster ²⁰²¹).

Opening Minds was the largest systematic effort in Canadian history focused on reducing stigma related to mental illness. Established by the MHCC in 2009, its goal was to change Canadians' behaviours and attitudes towards people living with mental illness to ensure they are treated fairly and as full citizens with opportunities to contribute to society like anyone else (MHCC ^2026a). Opening Minds was a 10‐year initiative aimed to reduce stigma related to mental illness through evidence‐based, contact‐based education programmes. Opening Minds, a targeted approach, focused on groups such as youth, healthcare providers, workplaces and the media. Findings showed that structured, well‐evaluated interventions can effectively change attitudes and reduce stigma across Canada (MHCC ^{2022, 2026a}; Stuart et al. ²⁰¹⁴).

Many people continue to hide their mental health challenges because they fear being judged, discriminated against or excluded (CMHA ²⁰²⁵). As a result, 60% of individuals experiencing mental health problems avoid seeking help due to concerns about being labelled. A 2022 survey from the MHCC (2023) found that 72% of those with mental health or substance use disorders reported serious self‐stigma, which has negative impacts on their self‐perceptions, including self‐esteem.

6.4.1.3. Racism and Discrimination/Equity, Diversity and Inclusion (EDI)

In the 2020s, while stigma regarding various issues (such as mental health or social status) still exists, the primary spotlight has moved towards addressing racism, discrimination and EDI (Schouler‐Ocak et al. ²⁰²¹). The overarching goal of EDI is to create environments that are fair and welcoming to individuals regardless of their background, identity or intersectional factors (Canadian Council on Rehabilitation and Work ²⁰²⁵; Moreno and Chhatwal ²⁰²⁰). Asumah and Nagel (2024) explain in their book Reframing Diversity and Inclusive Leadership: Race, Gender and Institutional Change how genuine diversity and inclusive leadership practices can drive anti‐racist, equitable and transformative change within colleges and universities in the United States and around the world. It highlights the tension between the ideals of democracy and diversity in a time marked by gender‐related challenges, such as the MeToo movement. Asumah and Nagel (2024) argue that EDI represents a shift away from traditional affirmative action towards a model focused on diversity management—one that involves speaking truth to power, fostering active listening and engaging in the difficult but necessary conversations that support institutional change.

There is an increased requirement for professionals, particularly in health care, to undergo training in anti‐racism, trauma‐informed care and cultural competence to foster safer, more equitable environments (Canadian Association of Schools of Nursing [CASN] ²⁰²⁵; Hassen et al. ²⁰²¹; Semahegn et al. ²⁰²⁰). Training requirements in Canada regarding anti‐racism, trauma‐informed care (TIC) and cultural competence (specifically Indigenous cultural safety) are rapidly increasing, driven by the Truth and Reconciliation Commission (TRC ²⁰¹⁵) Calls to Action and provincial health reforms (CASN ²⁰²⁵). While not currently uniform across all sectors nationally, they are mandatory for many healthcare professionals and federal employees, specifically in the Prairie provinces.

6.4.2. Social Determinants of Health (SDOH)

6.4.2.1. Romanow Report, 2002

The Romanow Report, 2002 emphasised Indigenous inequities (GC ²⁰⁰²). The report highlights the disparities due to the SHOH faced by Indigenous peoples in Canada compared to the broader population, particularly regarding their access to the benefits of the Canadian healthcare system (Douglas 2022).

6.4.2.2. Closing the Gap

Indigenous peoples in Canada are succeeding at advancing their health and outcomes related to some SDOH. From 2015 to 2020, the income gap between Indigenous and non‐Indigenous Canadians was narrowed (Indigenous Services Canada [ISC] ²⁰²³). Additionally, academic achievement was noted with increases in both secondary and post‐secondary achievement; as SDOH increased income and education for Indigenous peoples led to improved health outcomes as well (ISC ²⁰²³). Programmes and interventions that target the SDOH are yielding promising opportunities for future growth in Indigenous health, including mental health (ISC ²⁰²³).

6.4.3. Advanced Technology/Access to Care

One of the essential SDOH in Canada has been access to care, as the geographic distances between major centres are so vast. With advances in technology, telehealth emerged as a method to provide therapy to rural and remote areas of Canada. The use of robots began to be experimented with and simulation expanded to standardised patients and high‐fidelity simulators (Simonelli‐Muñoz et al. ²⁰²³) to provide education by healthcare professional in the larger cites to students in remote and urban settings when resources of hands‐on clinical examples and expert professionals to teach is limited.

6.4.3.1. COVID 19 Pandemic (Coronavirus 2019) (2019‐nCoV Acute Respiratory Disease)

In March of 2020, Canada and the world experienced the largest pandemic in the last 100 years. The health care and education systems, as did all government and private systems, had to adapt quickly to try to provide their services to the general public and to students.

Concurrently, policy reforms such as the Introduction of Wellness Together Canada in 2021 (CMHA ²⁰²⁴), during the COVID‐19 pandemic underscored the nation's need to increase prioritisation of MH and SUD services. Lockdowns, isolation and stressors worsened MH and SUD, while telepsychiatry expanded access (CMHA ²⁰²⁴).

There was a substantial decrease in the availability and capacity of substance use treatment and harm reduction services in the early phase of the pandemic (March–June) due to closures and restrictions on the number of clients allowed at clinics and inpatient facilities (Canadian Centre on Substance Use and Addiction [CCSUA] ²⁰²⁰). This decrease, along with other factors, led to many clients returning to or engaging in higher risk substance use and growing wait times for services (CCSUA ²⁰²⁰).

The COVID‐19 pandemic in Canada, as in other countries, increased stress across the population on many fronts. Mental health impacts were increasingly clear, including symptoms of anxiety, depression and suicidal ideation. Alcohol and cannabis use also increased (MHCC ²⁰²¹).

The mental health and substance use impacts of the pandemic were greater for people living with, or at risk of MH and SUD. In a summary report conducted by Leger for the CCSUA and the MHCC at the end of 2020 found only two in five respondents reported strong (very good/excellent) mental health, 14% of respondents reported moderately severe/severe current symptoms of depression, 24% reported moderate/severe symptoms of anxiety, and 5%–6% had seriously contemplated suicide since March 2020 (MHCC ²⁰²¹). Leger also found that one in three respondents who used alcohol reported increased use, and one in five reported problematic use, while two of five who used cannabis reported increased use and problematic use (MHCC ²⁰²¹).

Reports during and following the pandemic revealed significant increases in MD and SUD. One report identified early on the shadow pandemic of violence against women during COVID that was occurring worldwide (United Nations Women ²⁰²⁰). In Canada, federal consultations with front‐line organisations found a concerning increase of 20%–30% in rates of sexual‐ and gender‐based violence, and specifically domestic violence, in some regions when lockdowns were imposed (Canadian Red Cross ²⁰²¹). A 2022 study by Weeks et al. (2025) reports a 6.9% prevalence of post‐traumatic stress disorder (PTSD) among Canadians in the post‐COVID‐19 era, underscoring a notable rise in mental health burden.

Many advances in technology and communication already in place by the early 2000s, increased and evolved even further during and after the pandemic. Video conferencing and messenger examples during 2000–2025 were SKYPE, MSN Messenger, Yahoo Messenger WebEX, Zoom and Teams. Video conferencing quickly began to hybridize in‐person meetings (e.g., interviews for hiring and research data collection) and, in some cases, replaced in‐person meetings due to the financial cost‐saving benefits. Companies and institutions began to more accept the “working‐from‐home” trend as both the employer and the employee could see that the time and financial benefits overshadowed the barriers.

6.4.3.2. Artificial Intelligence (AI)

Since 2020, AI has transformed MH care by improving diagnosis, monitoring and access (Yong et al. 2024). Telepsychiatry, mobile apps and virtual reality (VR) therapy support treatment (De Berardis and Martinotti ²⁰²³). Chatbots are AI tools that show promise in CBT delivery and suicide risk assessment, but raise privacy concerns (Dehbozorgi et al. 2025).

6.4.4. Terminology—Preferred Changes

6.4.4.1. Mental Illness/Mental Disorder

During this time period, it was noted that the term ‘mental illness’ was now to be referred to as ‘mental disorders’. The DSM‐5 in 2013 (APA ²⁰²²) and amendments to the Mental Health Service Acts (GOS ²⁰²¹) both noted this change.

6.4.4.2. Patients With a Condition’ to ‘Patients Living With a Condition’

The shift towards using the phrase ‘patients living with a condition’ (i.e., MH and SUD) rather than ‘patients with condition’ was a deliberate adoption of person‐first language, which aimed to reduce stigma and emphasise that a person is not defined by their diagnosis. This shift in vocabulary signified a more inclusive, respectful approach to care (St. Louis ²⁰²²).

6.4.4.3. Patient Adherence

The WHO defined ‘adherence’ in 2003 as less paternalistic than compliance. Intentional and non‐intentional adherence were introduced in 2005 (Vrijens et al. 2012), and in 2008, the term ‘medication adherence’ became a recognised medical term (Vrijens et al. 2012).

6.4.4.4. Patient Engagement

In the 2020s, the new term in vogue is ‘patient engagement’. Engagement, previously referred to as adherence, compliance or concordance, is a dynamic and multifaceted process that includes accepting treatment, establishing a therapeutic relationship between patients and clinicians, mutual acceptance and collaboration to achieve a common goal of clinical resolution (O'Brien et al. ²⁰⁰⁹; Rae ²⁰²¹; Reynolds et al. ²⁰¹⁹). ‘Over‐involvement’ or ‘under‐involvement’ or ‘over or under‐engagement’, however, continues to be the involvement with patients that all healthcare professionals need to be cautious to identify and avoid with regard to themselves and with their colleagues.

Some individuals willing to engage in the treatment regimen lack access to the required treatment (WHO ²⁰²²). Various factors that impact the treatment engagement of psychiatric patients have been associated with exacerbating mental illness, triggering relapse symptoms, increasing suicidal tendencies, resulting in rehospitalisation and reducing the quality of life for this population (Peräkylä et al. 2022; Zeleke et al. ²⁰²³). Patients' engagement in treatment decision‐making is key to a successful treatment plan (Jochems et al. 2012).

Game‐changing approaches, such as direct observation, pill counts and ingestible biosensors, have addressed the challenge of non‐engagement in diverse patient populations (Gackowski et al. 2024). Medication side effects are the most frequently cited cause of patient non‐engagement with medication regimens (Semahegn et al. 2020; Zeleke et al. ²⁰²³). Nurses are accountable to patients and their families for ensuring the safe administration of medications (CRNS ²⁰²¹).

6.5. Role of the Nurse, 2000–2025

6.5.1. Retention and Shortage

The nursing profession has historically experienced a ‘boom and bust’ cycle of shortages roughly every 6–7 years, often tied to economic downturns, retirement waves and burnout cycle (Xpress Health ²⁰²⁵). Following the COVID‐19 pandemic, Canada has faced a further acute crisis in nursing retention (Baumann and Crea‐Arsenio ²⁰²³). Key factors include burnout and mental health with high rates of PTSD, exhaustion and moral distress; retirement wave from an ageing workforce of nurses retiring; workforce drain from nurses leaving bedside care for administrative roles, agencies or leaving the profession entirely; and similarly, a severe shortage of psychiatrists has left many Canadians, particularly in rural or underserved areas, without access to mental healthcare (Baumann and Crea‐Arsenio ²⁰²³; Canadian Federation of Nursing Unions ²⁰²²; Xpress Health ²⁰²⁵).

6.5.2. The Role of NPs and APNs

Nurse practitioners (NPs) and advanced practice nurses (APNs) are playing a critical role in mitigating these shortages by working to their full scope of practice (Health Canada ²⁰²⁵). As primary care substitution, NPs are increasingly managing primary care caseloads, which alleviates pressure on family physicians and emergency departments. In specialised care, mental health and psychiatric NPs and clinical nurse specialists (a type of APN) are providing medication management, psychotherapy and diagnostics, bridging the gap left by the psychiatrist shortage. In addition, nurses are utilising their full scope of practice as provinces are revising legislation to allow NPs to order diagnostic imaging, prescribe medications and admit patients to hospital more freely (Health Canada ²⁰²⁵).

6.5.3. Regulation of Nurses in Canada

In June 2018, the Canadian Nurses Association (CNA ²⁰²¹) started a new chapter in its history with an overwhelming vote by its members to open membership beyond registered nurses (RNs) and nurse practitioners (NPs) to include licensed and registered practical nurses (L/RPNs) and registered psychiatric nurses (RPNs). The CNA (2021) strives to determine how Canada's 440 000 nurses of every type can most effectively be deployed. In 2025, CNA released their revised publication entitled Code of Ethics for Nurses (CNA ²⁰²⁵); previous publications were titled Code of Ethics for Registered Nurses. The rationale was that, although standards and competencies should be specific to registered nurses, the same code of ethics should apply to all categories of nurses.

6.5.4. Expanded Practice and Advanced Practice

Nurses now collaborate with community partners, including schools, forensic units, the courts and the police (Kent‐Wilkinson ^{1993, 2010}; Petreca et al. ²⁰²⁵). The responsibilities of the nurse have expanded to include advocacy, reflective allyship, first and second stage recovery, emergency assessments both in the community and in the emergency department and acute care (Circle of Care ²⁰²⁵).

6.5.5. Cultural Competence, Humility and Safety

Mahmoud et al. (2024) highlight the potential for nurses to hold unconscious biases shaped by societal attitudes (Angermeyer and Dietrich 2006) towards substance misuse or addiction, which may negatively affect patient care. Colonial practices, policies and laws of the past such as nutritional experiments (Mosby 2013) and forced sterilisation (Dyck 2013) created a legacy of mistrust in the healthcare system and highlight the ongoing need for culturally safe and equitable care. Nurses are, therefore, encouraged to practice self‐reflection, recognise and address implicit biases and foster an inclusive and supportive care environment.

Many institutions of nursing employment and regional health authorities in Canada offer mandatory training in trauma‐informed care and cultural competence. Cultural competence, humility and safety are key concepts in nursing education.

7. 2025–2050—Current and Future Predictions

7.1. Mental Disorders Treatment/Therapy, 2025–2050

Throughout the previous timelines from 1850 to 2025, we have highlighted the game changers in medication and therapy for most of the main areas of MH and SUD (schizophrenia, bipolar, depression); however, the classification of ‘personality disorders’ has not been addressed. Although classifications of MH and SUD have become very complex, the old criteria of ‘mad’, ‘sad’ or ‘bad’ still seem to be relative to describe the main disorders. As with other mental health disorders in DSM‐5, personality disorders exist on a spectrum from mild to severe.

7.1.1. Personality Disorders

The ‘personality disorder spectrum’ refers to the idea that personality disorders exist on a continuum, rather than as distinct, separate categories (DSM‐5‐TR: APA ²⁰²²). This means individuals may exhibit varying degrees of personality traits associated with different disorders, rather than fitting neatly into one specific diagnosis. Borderline personality disorder (BPD) is viewed as having a spectrum of severity, while narcissistic personality disorder (NPD) is associated with harmful behaviours. Malignant narcissism, a more severe form, combines NPD traits with antisocial and sometimes sadistic tendencies, making it particularly dangerous (DSM‐5‐TR: APA ²⁰²²).

The treatment of personality disorders (PDs) is a complex, evolving field that continues to be debated, moving away from past views of ‘untreatability’ towards evidence‐based psychotherapies, despite ongoing challenges with stigma, diagnosis and resource allocation. (Dingfelder 2004). While BPD has benefited from significant research and specialised treatments, controversies remain regarding the best therapeutic approaches for other personality disorders, the role of medication and the very structure of how these disorders are classified (categorical vs. dimensional) (CAMH ^2026b).

7.1.1.1. Debate on Treatment

While there has historically been scepticism about the ‘treatability’ of personality disorders, modern clinical psychology holds that they are treatable (Dingfelder 2004). Dialectical behaviour therapy (DBT) is specifically recognised as an effective, evidence‐based treatment for emotional dysregulation, self‐harm and impulsive behaviours, which often underlie both the personality disorder and the criminal behaviour (CAMH ^2026b).

Identification and/or recognition of those with specific traits of personality disorder is what is most needed. The authors who are mental health nurse educators acknowledge that perhaps we have not done a good job in educating nursing students and the public in how to identify behaviours and traits of those with a personality disorder.

7.1.1.2. Danger to Others

The criteria of ‘danger to self and others’ have long been the admission criteria for treatment of mental disorders. Perhaps once identified, this criteria of ‘danger to others’ need to be considered to avoid those with personality disorders (especially malignant narcissism) when forming personal relationships with others; when hiring into leadership positions in the workplace; and when voting for political candidates at the local, provincial, state or country level into positions of power.

7.2. Substance Use Disorders Treatment/Therapy, 2025–2050

In 2025, the world witnessed the beginning of a period of turbulent political and economic friction south of the Canadian border. The US administration introduced aggressive tariffs on many countries for imports coming into their country (Grantham‐Philips ²⁰²⁵); they also made several unfavourable proposed cuts to government and social programmes, research funding for cancer and drug research, education and Medicare and Medicaid (Faiman 2025). The US administration proposed and enacted significant cuts to the Department of Health and Human Services (HHS) budget, often aiming to eliminate or restructure agencies like the Substance Abuse and Mental Health Services Administration (Grantham‐Philips ²⁰²⁵). In addition, the US administration no longer recognises the WHO as the directing and coordinating authority on international health within the United Nations system and withdrew from the WHO in January 2026 (Rigby and Farge 2026).

One drug or programme elimination proposed was the funding for Narcan/Naloxone (Fifield 2026). Reports in May 2025 highlighted plans to cut at least $56 million in grants that provided Narcan (naloxone) kits and training to first responders. By late 2025/early 2026, it was reported that these cuts had severely impacted the ‘backbone’ of addiction and overdose prevention infrastructure (Fifield 2026). The long‐term ramifications of these policies remain to be determined.

7.3. Legislation in Canada, 2025–2050

7.3.1. Harm Reduction

Since the 1980s, harm reduction has been an approach, model, or policy for care. Research has long validated its effectiveness, however, harm reduction often faces financial cuts with changing political agendas. True change seems to occur when policies become law! The authors believe that harm reduction should be put under the provincial Mental Health Acts. In addition, there is a need to further develop adult protection laws in Canada with attached funding.

7.3.2. Medical Assistance in Dying MAiD and Mental Illness

Persons living with mental health disorders and their families and allies will continue to fight for increased rights—that is, MAiD for chronic mental disorders. Medical Assistance in Dying (MAiD) legislation, first enacted in Canada in 2016 is set to expand to include people whose sole underlying medical condition is a mental illness on 17 March 2027 (GC ^2024b). This delayed implementation date was put in place to give provinces, territories and healthcare providers more time to prepare their systems for the change.

7.4. Social Movements/Trends 2025–2050

7.4.1. Nursing Education

A projection by the authors is that textbooks will go the way of encyclopaedias, no longer produced or published in its current state, as information is outdated before the time of publication. We have already seen this transition to e‐books, with even those numbers declining.

The University Bookstores now serve more as university gift shops, replacing rows and rows of textbooks of yesteryear. Perhaps, the content for theory courses in MH and SUD in the future will be chapter‐type online doi access manuscripts like this one.

7.4.2. Artificial Intelligence (AI)

We are now living in a digital age (Kalin 2022). Because AI was already here by 2025, it is easy to predict that AI will expand into all areas of health and mental health care at a faster rate than even imagined. Policies will continue to be developed in the management of generated AI in an effort to have some control or guidelines in research, practice and education.

7.4.2.1. Virtual Health Hub

In the future, more centres like the Virtual Health Hub opening in early 2027 in Saskatoon for the province of Saskatchewan will be needed to operate as a centralised command centre to support the delivery of healthcare services for communities that are entirely remote. State‐of‐the‐art virtual care technologies, AI and robotic systems will allow doctors, nurses and other healthcare workers to assess patients from across the provinces in real time. In addition to on‐demand services, they will provide a comprehensive range of virtual care services, including mental health care, remote patient monitoring, remote imaging diagnostic services, physiotherapy and speech therapy (Virtual Health Hub ²⁰²⁵).

7.4.3. Patient Engagement

Patients will continue to have more control over their own health care. With access to information readily available, some are able to educate themselves on conditions and treatment options. However, marginalised vulnerable groups of people will need nurses to advocate for them perhaps more in the future than ever before.

7.5. Role of the Nurse, 2025–2050

7.5.1. Increased Need for Roles With Vulnerable Populations

More nursing positions are needed with vulnerable populations of people where they are at or where they live. For many decades, nurses have worked in the community and at the street level as well as with the police and in institutions with incarcerated MH and SUD persons (Kent‐Wilkinson ^{1993, 2010}; Nurses.com. ²⁰²⁵; Petreca et al. ²⁰²⁵). Another specific role for nurses is emerging with fire department services (Beach 2023; Dizizdayana ²⁰²⁵). In the past decade, the role of firefighters is changing from their primary role of fighting fires to dealing with drug overdose crisis and encampment relocations of the homeless populations (Aiken 2024). Firefighter nurses or community health nurses within a fire authority provide a specialised blend of clinical expertise, on‐scene emergency care and occupational health services (Dizizdayana 2025). Nurses are needed in police and fire services as the first responder (Petreca et al. 2025).

Nursing will continue to be the primary provider of care for those with MH and SUD. Advanced education will become even more important to keep up with all the changes in science and technology (Brousseau 2024; Tierney et al. ²⁰²⁵).

8. Nursing Implications

Canadian RN and RPNs working in mental health and addiction settings have long advocated for changes to the country's evolving mental healthcare system and policies. They continue to support and respond to Canada's mental health strategy (MHCC ²⁰¹²) entitled Changing Directions Changing Lives: The Mental Health Strategy for Canada and the Truth and Reconciliation Commission of Canada: Calls to Action (TRC ²⁰¹⁵). Nursing practice is also informed by the SDOH (WHO ^2025c), and the United Nations' 17 sustainable development goals by 2030 (Department of Economic and Social Affairs, n.d., as cited in CFMHN ²⁰²³, 10). Nurses, who constitute the largest segment of the healthcare workforce, play a pivotal role in identifying individuals at risk of alcohol and opioid misuse and providing timely intervention (Mahmoud et al. 2024). Nurses play a crucial role in the delivery of 24/7 holistic care, administration of medication and supporting patients and their families through education, advocacy and informed decision‐making. As such, nurses are critically responsible for educating patients and families about their conditions and treatments, supporting informed decision‐making and meaningful engagement in care.

9. Limitations and Future Research

In an attempt to explore the main game changers in the treatment and engagement of persons living with MH and SUD, we may have missed some important areas that were sea changes in this complex nursing practice. There is a notable lack of peer‐reviewed literature examining historical breakthroughs in these areas in Canada; therefore, we drew from other countries and the grey literature of professional organisations that focus on specific areas of the MH and SUD field. Future research should address this gap by comprehensively analysing past innovations and their long‐term effects on MH and SUD treatment.

10. Conclusion

We have explored many transformative developments in MH and SUD treatment focusing on key ‘game changers’ that have significantly shaped and improved patient outcomes. Specifically, we have traced the historical evolution of treatment approaches through structured timelines.

10.1. Mental Health and Substance Use Treatments

The treatment of and engagement with persons living with MH and SUD has evolved significantly, transitioning from the confinement of individuals in asylums during the 1800s to a more comprehensive, community‐based, person‐centred care model. This shift reflects a broader societal change in understanding MH and SUD as a medical condition requiring appropriate care and support. Key advancements in MH and SUD care have evolved under the umbrella of psychotherapy, psychosurgery and psychopharmacology. The field continues to evolve with advancements in science and clinical knowledge, offering hope for even a better future.

10.2. Legislation, Social Trends, Terminology

Legislative measures such as the MHAs and HR initiatives offer vital pathways for addressing the multifaceted challenges that affected individuals face. Harm reduction models, legislative reforms, and emerging technologies such as AI are expanding access to care and/or significantly improving patient outcomes, as they hold great promise for the future of MH and SUD treatment (Yong et al. 2024).

Terminology has evolved in the care of MD and SUD. The terminology changed from ‘crazy’ or ‘insane’ to ‘mentally ill’ and now to ‘mental health disorders’. The terms for which our patients ‘living with’ MD and SUD have accepted or refused our care have evolved from ‘compliance/non‐compliance’, ‘adherence/non‐adherence’, ‘concordance/non concordance’ and now to ‘engagement/non‐engagement’.

10.3. Role of Nurses

The approach to mental illness is vastly different from earlier times, yet stigma persists. Nurses are essential in addressing stigma and breaking down barriers to accessing MH and SUD services, many of which remain inaccessible to low‐income individuals due to financial constraints. Given that individuals with SUDs often come from lower socioeconomic backgrounds, nurses in all areas of nursing practice are instrumental in assessing needs and connecting patients to appropriate, affordable resources, in addition to advocating for society's most vulnerable.

Digitisation (Kalin 2022) and the new frontier of artificial intelligence (Yong et al. 2024) are transforming the way we provide MH and SUD care; the way we communicate within and across borders; and the way nurses and other health professionals are educated. New frontiers can be exciting and provide opportunities to gain new knowledge and skills. Together, we must navigate these new frontiers and game changers safely and successfully to support the provision of quality nursing care to people living with MH and SUD and develop innovative ways to reach underserved individuals, groups and communities.

11. Relevance to Clinical Practice

Nurses are responsible for staying informed of the many changes in the treatment and engagement of persons living with MH and SUDs. An understanding of the key game changers in the past prepares us for game changers that will arrive in the future—game changers that can make a profound difference for our patients. Game changers where we ourselves will be in a position to create and introduce into our clinical practice.

Funding

The authors have nothing to report.

Consent

All authors consent to this submission and agree to the order of authorship.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.