After decades in the shadows of Canadian healthcare, mental health is suddenly centre stage. And with good reason: According to the Mental Health Commission of Canada (MHCC), one in five Canadians suffers from some form of mental illness. The toll on individuals, families and society, the Commission emphasizes, is vast. So too are the economic costs - as high as $50 billion annually. To face these challenges, warns the Commission, which was established with federal funding in 2007, urgent national action is needed to raise awareness, expand treatment and “reduce disparities in risk factors and access to mental health services.”
But identifying – let alone mitigating - the key risk factors that propel mental illnesses is a tricky and controversial task. Beyond a handful of well-known factors, explains Scott Patten, a University of Calgary specialist in mental health epidemiology, there is little expert consensus on what creates and propels mental illnesses. In large part, says Patten, this is because mental health surveillance “lags behind other chronic disease surveillance, and far behind infectious disease surveillance.” The MHCC agrees: In a recently-released study of mental health surveillance data, the Commission warned that “there is no clear vision for mental health information as a whole” in Canada, and “no single organization at the national level dedicated to gathering and reporting on all mental health services and policies.”
Defining a core set of risk factors for mental illness is a key priority for the MHCC. In its 2012 Mental Health Strategy for Canada, which the Commission described as a landmark document intended to guide national action well into the future, the Commission shortlisted a dozen risk factors: poverty, genetics, childhood trauma, sexual abuse, social isolation, substance use problems, racism, bullying, stigma, domestic violence, overcrowded housing, and having a parent who lives with a mental illness. It’s a list that could easily be expanded. But before that can happen, the Commission warned, “there is a long way to go before we have the data that are needed.”
To broaden the consensus on mental health risk factors, massive reams of disparate data from scores of provincial and national sources will have to be compiled and distilled, says Elliot Goldner, a Simon Fraser University epidemiologist recruited by the MHCC to forge a comprehensive risk factor list. “That process is now well underway,” he says. If all goes well, Goldner and his team will be ready to publish a comprehensive list of the main risk factors for mental illness in early 2015.
Complementary efforts are underway at the Public Health Agency of Canada (PHAC), where extensive expert consultations were recently completed on a forthcoming “Positive Mental Health Indicator Framework”. As part of the leadup to this effort, last spring, PHAC published a Chronic Disease Indicator Framework in which three of 41 key risk factors identified for chronic diseases sit squarely within the mental health domain. These factors include exposure to chronic stress, barriers to access to primary health care, and associations between mental health problems and chronic diseases. “Mental health problems, especially depression and anxiety, frequently precede chronic disease development,” PHAC concluded. “People with long-term chronic diseases [also] have an increased risk of developing mental health problems and report high levels of distress.”
The efforts by the MHCC and PHAC to fashion evidence-based indicator frameworks both for mental illness and for mental health are long-awaited and much-needed, says Alain Lesage of the Université de Montréal Department of Psychiatry. “This will be a good start in helping to expedite action,” Lesage believes. Action is especially needed on suicide prevention, he argues.
“Suicide is a huge cause of death but still gets far less attention than many infectious and non–infectious diseases which are far less significant causes of mortality. There’s a lack of focus and energy. We need better information about the risk factors, and better surveillance of those risk factors.”
The Mental Health Commission and PHAC aren’t the only federally-funded bodies interested in mental health risk factors. In recent years the Canadian Institute for Health Information and Statistics Canada have jointly produced a series of surveys of mental health indicators including mood disorders, heavy drinking, perceived life stress, and life satisfaction. In 2013, they added “perceived need for mental health care” and “generalized anxiety disorder” to the list of risk factors worth monitoring. In September, a StatsCan study added chronic pain, age, marital status, and religiousness to the lengthening list of potentially important factors influencing mental health.
Provincial public health agencies also show growing interest in probing and identifying risk factors relevant to mental health.
In 2012, Public Health Ontario (PHO) and the Toronto-based Institute for Clinical Evaluative Sciences released a report estimating that the burden of mental illness and addictions in Ontario is more than 1.5 times that of all cancers, and more than seven times that of all infectious diseases.
“As our understanding of the burden of mental illness and addictions comes into focus,” the report argued “the case for a broad mental health promotion and mental illness and addictions prevention strategy becomes stronger.” A first step in this process, the report concluded, would be to develop “key indicators of mental health and its determinants”.
Heather Manson, PHO’s Chief of Health Promotion, Chronic Disease and Injury Prevention, says the burden of mental disease study revealed a strong role for childhood experience in the development of mental illness. “There’s very little data on child mental health,” says Manson, “but the treatment of infants and children obviously plays a huge role in the development of mental illness. We need to examine the factors that lead to more and less maternal attachment, and how factors that promote mother-child attachment protect against mental illness.”
Gustavo Turecki, Director of the McGill University Group for Suicide Studies in Montreal, agrees. “Childhood maltreatment is an extremely important risk factor for negative mental health outcomes,” he argues. “I think a lot more work is necessary for life adversity surveillance.” A new study headed by Tracie Afifi, a mental trauma specialist at the University of Manitoba, reports that 32% of the adult population has experienced physical abuse, sexual abuse and/or exposure to intimate partner violence in childhood. All of which “were associated with all types of interview-diagnosed mental disorders, self-reported mental conditions, suicidal ideation and suicide attempts in models adjusting for socio demographic variables.”
Corporate Canada is also stepping-up action on mental illness risk factors through initiatives like the Canadian Alliance on Mental Illness and Mental Health. Since 2010, Bell Canada alone has committed more than $62 million to mental health-related initiatives in Canada, focussing strongly on anti-stigma, community care and access, and workplace mental health. Heather Stuart, who holds the Bell Canada Mental Health and Anti-Stigma Research Chair at Queen’s University, says stigmatization of mental illness is an important risk factor.
“We have seen instances where youth who were described by their families as healthy and happy have become depressed and suicidal after being cyber bullied and ostracized,” Stuart observes while noting that public health surveillance of stigmatization is entirely possible through tools such as the ‘Mental Health Experiences Module’ recently adopted within Statistics Canada’s Canadian Community Health Survey - Mental Health.
“People who have experienced stigma tell us that it is worse than the illness itself,” Stuart emphasises. “We know that stress can trigger repeat episodes of an illness. We don't have systematic data on this, but could if studies were funded to address this problem.” <>