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Mental Health, Mental Illness and Addiction:

Overview of Policies and Programs in Canada

Report 1


PART 2

The Prevalence and Consequences of Mental Illness and Addiction


CHAPTER 4:
Concepts And Definitions

INTRODUCTION

Text Box: A respectful, common language to discuss mental illness and mental health is lacking between disciplines and sectors.
[Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health, Brief to the Committee, 18 July 2003, p. 8.]
The terms and concepts related to mental health, mental illness and addiction are not easy to define.  Different countries have adopted differing terminology and, within countries, professionals and lay groups, organizations and associations often utilize different conventions in defining and describing key concepts relevant to mental health, mental illness and addiction.  Consequently, one concept may be referred to by a variety of terms, while some terms will hold different meanings for different groups. Even within Canada, some terms have multiple meanings that are applied inconsistently, often creating confusion.

This chapter defines the various concepts used throughout the report related to mental health, mental illness and addiction.  It is divided into nine sections related to: mental health and mental illness (Section 4.1); major mental disorders (4.2); substance use and addiction (4.3); co-morbidity, concurrent disorders and dual diagnosis (4.4); suicidal behaviour (4.5); services and supports (4.6); chronic disease management (4.7); promotion, prevention and surveillance (4.8) and, individuals with mental illness/addiction and recovery (4.9).

4.1        MENTAL HEALTH AND MENTAL ILLNESS

Mental illness undermines mental health, but mental health is more than simply the absence of illness. It is a fundamental resource of all human beings and an essential component of all health.

[Tom Lips, Health Canada (11:7)]

Mental health is defined as the capacity to feel, think and act in ways that enhance one’s ability to enjoy life and deal with challenges.[184]  Expressed differently, mental health refers to various capacities including the ability to: understand oneself and one’s life; relate to other people and respond to one’s environment; experience pleasure and enjoyment; handle stress and withstand discomfort; evaluate challenges and problems; pursue goals and interests; and, explore choices and make decisions.

Good mental health is associated with positive self-esteem, happiness, interest in life, work satisfaction, mastery and sense of coherence.  It is well recognized that good mental health enables individuals to realize their full potential and contribute meaningfully to society.[185]

By contrast, mental health problems refer to diminished capacities – whether cognitive, emotional, attentional, interpersonal, motivational or behavioural – that interfere with a person’s enjoyment of life or adversely affect interactions with society and environment.  Feelings of low self-esteem, frequent frustration or irritability, burn out, feelings of stress, excessive worrying, are all examples of common mental health problems.[186]  Over the course of a lifetime, every individual will be likely, at some time, to experience mental health problems such as these.  Usually, they are normal, short-term reactions that occur in response to difficult situations (e.g., school pressures, work-related stress, marital conflict, grief, changes in living arrangements) which people cope with in a variety of ways, employing internal resilience, family and community support, etc.

Text Box: A widely used definition of mental illness or mental disorder is taken from the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition. (…) It is a definition that allows for the possibility of either biological or psychological causes of illness. It excludes normal reactions to stressful situations.
[Tom Lips, Health Canada (11:9)]
Mental health problems that resolve quickly, do not recur and do not result in significant disability do not meet the criteria required for the diagnosis of a mental illness.  Mental disorders or illnesses generally refer to clinically significant patterns of behavioural or emotional function that are associated with some level of distress, suffering (even to the point of pain and death), or impairment in one or more functional areas (e.g., school, work, social and family interactions).[187]

There are many different forms of mental disorders.  They vary widely in terms of the course and pattern of illness, the type and severity of symptoms produced and the degree of disability experienced.  An individual may have only one or may have repeated episodes of illness separated by long periods of wellness.  While some mental disorders are episodic or cyclical in nature, others are more persistent with lengthy or frequently recurring episodes.  Individuals with persistent illnesses usually require long term treatment and support.

4.2       MAJOR MENTAL DISORDERS

In Canada, the classification of mental illnesses follows either the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association, or the International Classification of Diseases (ICD), Mental Health Section, published by the World Health Organization.[188]  Each of the two classification systems lists more than 300 mental disorders that can be diagnosed; these are often grouped together on the basis of similarities in their symptoms or patterns of illness.

The complete list of mental disorder diagnoses is available in the DSM and ICD manuals.  Some of the major groupings of mental disorders include: mood disorders (depression and bipolar disorders), anxiety disorders (generalized anxiety disorder, phobias, panic disorder, obsessive-compulsive disorder and post-traumatic stress disorder), psychotic disorders (schizophrenia and schizoaffective disorder), eating disorders (anorexia nervosa and bulimia), personality disorders, pervasive developmental disorders (autism and Asperger’s disorder), attention deficit and disruptive behaviour disorders, and cognitive disorders (dementia and delirium from a variety of causes).[189]  Substance use disorder is also included within the classification of mental disorders.  In this report, substance use disorders are discussed in a separate section in order to highlight their importance and relationship to addiction.

Text Box: When we talk about mental disorders, it is important to mention that the most prevalent of these are anxiety and depressive disorders. (…) The third major area is substance abuse (…). What that means is that these disorders are highly prevalent. In contrast, you will also be hearing about major psychiatric disorders, such as schizophrenia, bipolar affective disorder, and in adolescent children, and possibly in adults, autistic disorders. These are clearly major mental disorders.
[Dr. Alain Lesage, Canadian Academy of Psychiatric Epidemiology (11:12)]
Mood disorders include both major depressive and bipolar disorders.  Major depressive disorder (also referred to as unipolar depression) is characterized by one or more depressive episodes lasting at least two weeks.  The core symptom is a sustained depressed mood (different than normal feelings of sadness) and/or a marked decrease in pleasure from or interest in usual activities.  This is accompanied by four or more other symptoms characteristic of depression such as disturbance, fatigue or loss of energy, appetite and weight loss or gain, decreased ability to concentrate, think, and make decisions, and recurrent thoughts of death.  Females have higher rates of major depression than males by a ratio of 2:1.  Bipolar disorder, classically known as manic depressive illness, is a mental illness associated with dramatic mood swings ranging from mania to depression.  Mania, a condition recognized since antiquity, is characterized by at least a week of an altered mood state of euphoria, labiality or irritability.  Like depression, it is associated with a number of other related symptoms, often as the mirror image of depression, including a marked increase in energy, decreased need for sleep, elevated self-esteem, and a propensity for risky activities.  Bipolar disorder usually begins in early adulthood; the average age of onset is around 18-24 years, although it can sometimes start in childhood or as late as the 40s or 50s.  Men and women are equally affected.[190]

Anxiety disorders may take many forms.  They include: generalized anxiety disorder, specific phobias, panic disorder (with or without agoraphobia), obsessive-compulsive disorder and post-traumatic stress disorder.  Generalized anxiety disorder is defined by a protracted period (i.e., over 6 months) of anxiety and worry that is accompanied by other symptoms such as muscle tension, fatigue, poor concentration, insomnia, and irritability.  Phobias reflect marked fear of certain things (such as animals, insects, heights, elevators, etc.) or situations (social phobia); exposure to the object of the phobia, either imaginary, on video or in real life, invariably elicits intense anxiety which may include a panic attack.  Panic disorder is diagnosed when an individual has experienced a number of unexpected panic attacks – periods with sudden onset of intense fear or discomfort, often associated with palpitations, rapid breathing, and a sense of impending doom – coupled with worries about further attacks.  Obsessive-compulsive disorder involves either or both obsessions or compulsions which the individual recognizes as excessive or unreasonable.  Obsessions consist of persistent, intrusive, inappropriate thoughts, ideas, impulses or images that cause marked anxiety or distress.  Compulsions refer to repetitive behaviours (such as hand washing) or mental acts (such as counting) that sometimes occur in a ritualistic way or in response to an obsession.  Post-traumatic stress disorder involves re-experiencing a traumatic event through dreams and recollections, avoiding stimuli reminiscent of the event, emotional numbing, and a heightened level of arousal; it occurs following a traumatic event in which the person experienced or witnessed threatened or actual physical harm (such as rape, child abuse, war/battle, or natural disaster).  Overall, anxiety disorders affect men and women equally; they tend to begin  early in life (during childhood or adolescence) and often persist for many years.[191]

Schizophrenia is a mental illness that typically emerges in late adolescence and early adulthood.  Classically, it has often been a chronic, severe and disabling long term disorder.  In the last decade, systematic efforts at earlier detection and comprehensive biopsychosocial intervention offer hope for a different trajectory for this often long term illness.  Decades of genetic, brain imaging, and other lines of research support a biological model of schizophrenia, although its cause remains unknown.  It seriously affects a person’s thinking, causing hallucinations (such as hearing voices when there is no one there), delusions (fixed false beliefs such as the fear that strangers are following the ill person or wanting to hurt him/her), a loss of contact with reality and disrupted work and social interactions.  The disease often begins slowly; once it has taken hold, it usually manifests itself in cycles of remission and relapse.  Men and women are affected by schizophrenia with equal frequency.[192]

Eating disorders involve serious disturbance in eating behaviours.  While some cases of eating disorders will resolve themselves spontaneously or with treatment during adolescence, others may become chronic conditions.  Some long term follow-up studies reveal death rates of up to 18% in affected individuals.  The most common eating disorders include anorexia nervosa, bulimia nervosa and binge eating disorder.  Anorexia nervosa is characterized by low body weight (under 85% of expected weight), intense fear of weight gain even when markedly underweight, an inaccurate perception of body weight or shape, denial of thinness, and an intense emphasis on weight as a yardstick of self-evaluation.  Bulimia nervosa, by contrast, most commonly occur in individuals of normal body weight. It is characterized by recurrent episodes of gorging, followed by compensatory activities to eliminate the ingested calories (such as self-induced vomiting, abuse of laxatives or diuretics, intensive exercise, etc).  It shares, with anorexia nervosa, however, many of the core psychological preoccupations with weight and shape.  Binge eating disorder is a newly recognized condition featuring episodic uncontrolled consumption of food, without the compensatory activities of bulimia nervosa.  Eating disorders usually arise in adolescence and affect females disproportionately.[193]

Personality disorders include a number of disorders that vary considerably in their characteristics and patterns or behaviour.[194]  However, they all share the following characteristics: an enduring pattern of inner experience and behaviour that deviates from the expectations of society and behavioural patterns that are pervasive, inflexible and stable over time, creating distress or impairment.[195]  Some forms of personality disorder result in suffering that primarily affects the individual (e.g., avoidant personality disorder, characterized by feelings of extreme discomfort and intense self-criticism in social circumstances, leading to marked loneliness and isolation despite intense longings for social contact).  Other forms of personality disorder may not only cause distress to the individual, but also produce profound harm to others and incur substantial cost to society (e.g., antisocial personality disorder, a pervasive pattern of disregard for and violation of the rights of others that often includes repeated criminal activity, impulsive violent behaviour, deceitfulness and lack of remorse.)  The onset of personality disorders usually occurs in adolescence or early adulthood, but they can also first manifest themselves in mid-adulthood.  In contrast to the mental illnesses described previously, personality disorders are more intimately linked to the affected person’s individual temperament and character.[196]

Autism is a mental disorder which emerges in childhood and which, for some affected individuals, may be an incapacitating and life-long disability.  Generally, autistic individuals display the following: impaired ability to engage in social interaction; impaired communication skills; and specific behavioural patterns (e.g., preoccupation, resistance to change, adherence to non-functional routines and stereotyped and repetitive behaviours).  Developmental delay or abnormality in interaction, language and play is evident before 3 years of age in affected individuals.  Autism may be accompanied by other disabling conditions, such as seizures or significant cognitive (intellectual) delays.[197]  The symptoms and deficits associated with autism, however, may vary.  For example, some individuals with autism function at a relatively high level, with speech and intelligence intact, while others are developmentally delayed, do not speak, or have serious language difficulties.[198]  Autism tends to be three-to-four times more common in males than females.

Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are terms used to describe patterns of behaviour that appear most often in school-aged children.  They adversely affect the learning process by reducing the child’s ability to pay attention.  Children with these disorders are inattentive, overly compulsive and, in the case of ADHD, hyperactive.  They have difficulty sitting still, attending to one thing for a long period of time, and may seem overactive.  ADD and ADHD are diagnosed 10 times more often in boys than in girls.[199]  The attention deficits associated with these disorders may persist throughout childhood and adolescence into adulthood, whereas the symptoms of hyperactivity and impulsivity tend to diminish with age.  Although many children with ADD and ADHD ultimately adjust, a higher proportion than in the population of unaffected individuals are more likely to drop out of school and fare more poorly in their careers later.  As they grow older, some teenagers who have had severe ADHD since middle childhood experience periods of anxiety or depression.  They may also be vulnerable to problems with substance abuse and antisocial behaviour.[200]

Alzheimer’s disease is an organic brain disorder that leads to the loss of mental and physical functions.  Together with a number of other illnesses including, for example, Parkinson’s disease and Huntington’s disease, it is classified as a degenerative disease of the central nervous system.  Alzheimer’s disease is the leading cause of dementia.  Several changes occur in the brain of the affected individuals, notably a progressive loss of neurons from the cerebral cortex and other areas.  Consequently, a person with Alzheimer’s disease has less brain tissue than a person who does not have the illness; the shrinkage continues over time, affecting how the brain functions.[201]  Memory loss is the most prominent early symptom of Alzheimer’s disease, often followed by a slow deterioration of cognitive functions and personality features and physical capacity.  Some individuals experience hallucinations, delusions, seizures and aggressive behaviour.  Alzheimer’s disease affects both men and women equally.[202]

Although not classified as mental disorders, Fetal Alcohol Syndrome and Fetal Alcohol Effects (FAS/FAE) are major birth defects leading to disturbance in brain function.  Damage to fetal brain development is caused by the effects of the mother’s drinking alcohol during pregnancy.  Infants with FAS/FAE display irritability, jitteriness, tremors, weak suck reflexes, problems with sleeping and eating, failure to thrive, delayed development, poor motor control and poor habituation.  In childhood, problems such as hyperactivity, attention problems, perceptual difficulties, cognitive deficits, language problems and poor motor coordination are common.  In adolescence and adulthood, the primary difficulties are memory impairment, problems with judgment and abstract reasoning and poor adaptive functioning.  Some common secondary disabilities, characteristic of adolescents and adults with FAS/FAE, include easy victimization, unfocused and distractable behaviour, difficulty handling money, problems in learning from experience, trouble understanding consequences and perceiving social cues, low frustration tolerance, inappropriate sexual behaviours, substance abuse and trouble with the law.[203]

4.3       SUBSTANCE USE AND ADDICTION

It is important to distinguish between substance use, abuse and dependence. Psychoactive substance use is very common. Abuse is less common and dependence affects only a minority of people who use psychoactive substances. The level of severity of consequences is higher for those with abuse and even higher for those with dependence.

[Dr. David Marsh, Centre for Addiction and Mental Health (16:44)]

According to Health Canada, substance use includes the use of any of a range of psychoactive substances – i.e., substances that have an effect on a person’s mental state – including alcohol, non-prescription and prescription drugs, illicit drugs, solvents and inhalants.  Patterns of use may range from abstinence, to occasional or regular use, to frequent heavy use, to full-blown substance abuse.[204]

Substance use disorders, which are considered to be mental disorders under both the DSM and the ICD, refers to a habitual pattern of alcohol or drug use that results in significant problems in work, relationships, physical health, financial well-being, and other aspects of a person’s life.  Substance use disorders encompass two sub-categories: substance abuse and substance dependence.[205]  Substance abuse refers to a maladaptive pattern of use despite the affected person’s knowledge of the negative consequences associated with such use.  Substance dependence is characterized by a loss of control, preoccupation with and continued use of substance(s) despite its negative consequences.[206]

Dependence can be physical, psychological, or both.  Physical dependence consists of tolerance (needing more of the substance for the same effect).  Psychological dependence is present when a person perceives an intense need to use the substance in order to function effectively or in particular situations.  The degrees of dependence range from mild to severe, the latter being characterized as addiction.[207]

Addiction implies uncontrollable use of one or more substances, associated with discomfort or distress when that use is discontinued or severely reduced.  Addiction may also describe certain other behavioural problems, such as compulsive or pathological gambling, which can be considered a process rather than a substance addiction.  Research to date suggests that pathological gambling may progress in stages similar to those in alcoholism.[208]

In this report, we often use the term “addiction” to refer to the broad field of substance abuse.  The addiction treatment system encompasses treatment, services and supports for those suffering from substance abuse and substance use disorders.

4.4       CO-MORBIDITY, CONCURRENT DISORDERS AND DUAL DIAGNOSIS

Co-morbidity simply denotes that two or more illnesses affect the same individual, whether two different mental disorders, two physical illnesses or a mental disorder and a physical illness.  In this report, the concept of co-morbidity refers to the occurrence of a mental illness together with a physical illness.  For example, epidemiological data show that 25% of arthritic patients have co-morbid depression or anxiety; there is a high level of co-morbidity between cancer, diabetes, respiratory problems, hypertension or migraine and some mental disorders.  The interactions of physical and mental illnesses are, however, very complex.[209]

Text Box: In general terms, the “concurrent disorders” population refers to those people who are experiencing a combination of mental/ emotional/psychiatric problems with the abuse of alcohol and/or another psychoactive drugs. More technically speaking, and in diagnostic terms, it refers to any combination of mental health and substance use disorders, as defined for example on either Axis I and/or Axis II of DSM-IV.
[Brian Rush, Ph.D., CAMH, Brief to the Committee ,May 2004, p. 2.]
The term concurrent disorders most commonly refers to individuals who suffer from a mental illness and a substance use disorder at the same point in time.  The relationships between mental illness and substance use are not straightforward.  One the one hand, mental health problems/illnesses may act as risk factors for increased substance use (e.g., increased anxiety may lead to increased reliance on alcohol) and, on the other, substance abuse may act as a risk factor for increasing mental health problems/illnesses (e.g., problematic alcohol use may be a risk factor for depression).  In other situations, a shared causal explanation may apply in which both disorders are promoted by a third factor such as genetic predisposition or family environment.  Research indicates, however, that, in some circumstances, mental illness and substance use disorder occur independent of each other.[210]

In this report, dual diagnosis refers to individuals who have a mental health problem or illness together with developmental disability (formerly referred to as “mental retardation”).  Because there are difficulties in diagnosing mental illness in a person with developmental disability, dual diagnosis is often unrecognized (undiagnosed) and untreated.  Affected individuals have complex and challenging needs and are certainly among the most vulnerable members of the Canadian population.  They are more likely to experience abuse (more particularly sexual abuse), neglect and exploitation than other Canadians.  They often “fall through the cracks.”[211]

4.5       SUICIDAL BEHAVIOUR

Text Box: The presence of mental health problems is probably the single most important predictor of suicide. Accordingly, approximately 90% of suicide cases meet the criteria for a psychiatric disorder, particularly major depression, substance use disorders and schizophrenia. However, it is only a minority of people with these diagnoses that will eventually commit suicide indicating that a psychiatric disorder may be a necessary, but insufficient risk factor for suicide.
[Dr. Gustavo Turecki, Brief to the Committee, 21 April 2004, p. 1.]
The term suicidal behaviour encompasses completed suicide (death by suicide), attempted suicide (including intentional self-inflicted harm) and suicidal ideation (thinking about suicide).  Suicidal behaviour is often the consequence of a number of factors that have interacted, including acute stressors and negative life events (e.g., bereavement, loss of employment, separation, illness), symptoms associated with an acute episode of mental illness or substance use disorder (e.g., psychosis, depression, intoxication), personality characteristics, social and/or economic circumstances.

While not itself a mental disorder, suicidal behaviour is highly correlated to mental illness and addiction.  Studies indicate that more than 90% of suicide victims have a diagnosable mental illness or substance use disorder.[212]  Suicide is the most common cause of death of individuals with schizophrenia.  Suicide also accounts for 15% to 25% of all deaths among individuals with severe mood disorders.[213]  Addiction often predisposes to suicidal behaviour by intensifying a depressive mood swing and by reducing self-control.[214]

 

 

4.6       SERVICES AND SUPPORTS

Traditionally, mental health care in the formal health care system has encompassed primary, secondary and tertiary care.  Primary mental health care, i.e., first-line services, traditionally included simple diagnostic procedures, basic treatment, and referral to more specialized services as needed.  A great deal of attention has been directed to enhance the capacity of primary mental health care given that it is now recognized that a large proportion of the population should receive services for mental health problems in this sector of the health care system.  Secondary care is more specialized care that provides more extensive and complicated procedures and treatment; it may be provided within hospitals, clinics or office-based practices, on an inpatient or outpatient basis.  Tertiary care is generally defined as specialized interventions delivered by highly trained professionals to individuals with problems that are particularly complex and difficult to treat in primary or secondary settings.  In the mental health system, tertiary care also refers to the long term care that has historically been provided in large psychiatric hospitals to individuals with persistent mental disorders.  Research and teaching activities are also undertaken within tertiary care institutions.

In this report, it is recognized that many and diverse services and supports are required by those who experience mental illnesses and substance use disorders and, as such, they are provided by numerous professional and non-professional service providers and organizations.  These services and supports extend beyond those provided in the traditional mental health care system.  A Canadian review of best practices suggests the need for the following core mental health and addiction services and supports[215]:

·        Case management refers to the constant ongoing support provided to individuals with mental illnesses/substance use disorders to help them obtain the services they need.  The case manager assesses needs, identifies skill deficits and refers the individual to providers of the appropriate services.  Case management is intended to help patients/clients to develop skills for daily living, enhance their community tenure and prevent hospitalization.  Assertive Community Treatment (ACT) is acknowledged to be the most appropriate model of case management to provide services to those with severe and persistent mental illnesses and concurrent disorders.  In the ACT model, case management is provided by a multidisciplinary team in the community where the individual lives rather than in an office-based practice or an institution.  The team involves psychiatrists, family physicians, social workers, nurses, occupational therapists, vocational specialists, etc., and is available to the patient/client 24 hour a day, 7 days a week.

·        A wide range of inpatient and outpatient services are needed, including: counselling; psychotherapy; individual and group therapy; partial hospitalization (day treatment programs); acute home treatment (as an alternative to acute hospitalization); specialty services in both the community and psychiatric units/facilities; forensic psychiatry; and shared care.  Shared mental health care[216] is of particular interest.  This refers to a broad spectrum of collaborative activities between primary health care providers and psychiatrists or other mental health care providers; some have a strong clinical focus, integrating mental health services into primary health care settings, while others offer creative educational programs to primary health care providers through collaboration among academic departments.

·        Community supports, including housing, vocational services, supported education and supported employment are important components of the spectrum of services required by individuals with mental disorders.  It has been demonstrated that the availability of such community supports can substantially improve outcomes.  It is recognized that individuals with mental illness have the capacity to work and that employment programs should be encouraged for even the most disabled of individuals.  Similarly, supported education programs enable individuals to return to school on a full-time basis.  Evidence also suggests that community residential programs can successfully substitute for long-term inpatient care.  Thus, a range of different housing alternatives (e.g. supervised group homes or other residential settings) should be provided.

·        Mental health crisis/emergency response provides a broad range of services to address the widely varying manifestations of acute mental health/substance use.  There are five essential components to the crisis response/emergency service: telephone crisis lines, mobile crisis outreach, walk-in crisis stabilization services, crisis residential (non-hospital) services, and hospital-based psychiatric emergency services.

·        Most importantly, there should be a strong focus on initiatives by individuals with mental illness and addiction and their families: The involvement of individuals who themselves have had mental illness/addiction problems in the planning, delivery, management, evaluation and reform of mental health services and supports has led to the development of a wide range of consumer/family initiatives that provide information, education, training, self-help, mutual aid and peer support.  More importantly, significant strides have been made in this domain with the recent development of consumer based businesses as a means to promote self fulfillment and a reduce dependence on social services.

In this report, the mental health system refers to the broad range of services and supports available to individuals with mental illness.  Similarly, the addiction system describes the entire range of services aimed at preventing or reducing/treating substance abuse, substance use disorders and problematic gambling.

4.7       CHRONIC DISEASE MANAGEMENT AND SELF-MANAGEMENT

Text Box: Chronic disease management as an approach to mental health and addictions care emphasizes assisting individuals to maintain independence and to maintain optimal health through prevention, early detection, and management of chronic mental disorders and substance use disorders.
[Ministry of Health Services, British Columbia, Brief to the Committee, 9 September 2003, p. 7.]
Chronic disease management is a relatively new approach that has been shown to be very effective in the long term treatment of diseases.  The approach is based on the "Chronic Care Model" used by a United States national program called Improving Chronic Illness Care (ICIC) based in Seattle, Washington, at the MacColl Institute for Healthcare Innovation at the Group Health Cooperative of Puget Sound.[217]

Chronic disease management rests on evidence-based clinical guidelines and protocols and involves many health care professionals and administrators througout all sectors of the health care system that share a common vision and collaborating on several initiatives in parallel.  This approach contrasts with the model of treating a care episode as a single event – a visit to a health care provider.  In Canada and the United States, chronic disease management has been applied with great success to many chronic diseases, such as diabetes, arthritis and even asthma; it is now being contemplated for application to mental illness and addiction.  Chronic disease management emphasizes community based care and aims to foster independence and fulfillment.[218]

An important element of chronic disease management is the active participation of affected individuals themselves in the management of their illnesses on a day-to-day basis.  This participation of patients/clients is usually referred to as self-management.  The concept of self-management does not mean that individuals deal with their illnesses or disorders on their own.  It is a process that enables the individual to develop the knowledge, attitudes and skills necessary to manage his/her illness or disorder and to make improved use of existing health services and supports in order to access help when it is needed.[219]

4.8       PROMOTION, PREVENTION AND SURVEILLANCE

Text Box: Mental health literacy refers to knowledge and beliefs about mental disorders, which assist in the recognition, management or prevention of mental health and substance use problems, and mental and substance use disorders. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking.
[Ministry of Health Services, British Columbia, Brief to the Committee, 9 September 2003, p. 9.]
The goal of mental health promotion is to provide information to the public to raise and enhance awareness and understanding of mental health issues, reduce stigma and promote positive mental health.  Mental health promotion also includes education and training of human resources in the formal mental health/addiction system.

The concept of mental health literacy is often used in the context of mental health promotion.  Mental health literacy refers to the knowledge, beliefs and abilities that support the recognition, management or prevention of mental illnesses or substance use disorders.  A high public level of mental health literacy makes early recognition of and appropriate intervention in mental illnesses and substance use disorders more likely.  It is also effective in reducing stigma.[220]

Prevention is categorized as primary prevention when directed at averting a potential mental health/substance use problem; secondary prevention is directed at early detection and includes the appropriate intervention to prevent or delay onset or mitigate a mental health problem; tertiary prevention is directed at minimizing disability or avoiding relapse in a successfully treated, stable patient/client.

Surveillance usually refers to the ongoing systematic collection, analysis and interpretation of health-related data used to determine the occurrence of diseases, assess relevant needs and evaluate effectiveness of policies and programs.  Currently, Canada has no national surveillance system for tracking mental illnesses and substance use disorders.[221]

4.9       INDIVIDUALS WITH MENTAL ILLNESS/ADDICTION AND RECOVERY

As described at the outset of this chapter, no commonly accepted language and terminology exist to describe all concepts and issues in the field of mental illness and addiction.  There is little agreement in regard to the most respectful and appropriate terms to identify those individuals who themselves have experienced a mental illness or substance use disorder.  Some individuals have very strong feelings about the language used in view of the societal stigmatization and pejorative labelling that is far too commonly encountered by individuals with mental illness and addiction.

Text Box: Recovery is a journey, rather than a destination. It is an active, ongoing, highly individualized process through which a person is encouraged to assume responsibility for his or her life, often in collaboration with friends, families, peers and professionals.

Each person’s recovery is unique. No two people will have the same path or use the same measures to mark the success of their recovery. The real test for recovery is when people feel that they have recovered and are living a quality of life that is not dominated by their past situation or their current symptoms and stresses.

[Final Report of the Provincial Forum of Mental Health Implementation Task Force Chairs, Ontario, December 2002, p. 28.]
Traditionally, individuals with mental illness and addiction being cared for by physicians are called patients.  Other health professionals often refer to such individuals as clients or service users.  The individuals may describe themselves by a number of terms, commonly consumers and survivors.  Consumers usually refer to individuals with direct experience of significant mental health problems or mental illnesses who have used the resources available from the mental health system.  Some individuals have chosen to refer themselves as survivors, a term that they feel acknowledges their strength in coping with mental illness and/or addiction.  In this report, the Committee uses the terms individuals with mental illness and addiction or patient/client.

Individuals with mental illness and addiction often talk about recovery.  Recovery is not the same thing as being cured.  For many individuals, it is a way of living a satisfying, hopeful, and productive life even with limitations caused by the illness; for others, recovery means the reduction or complete remission of symptoms related to mental illness.

In the field of mental health, recovery is a personal process of overcoming the negative impact of mental illness despite its continued presence.  In the field of addiction, recovery describes an abstinence-based approach to substance use disorders, such as those practiced by Alcoholics Anonymous and Narcotics Anonymous.  The recovery concept presupposes that, with the appropriate treatment and supports in place, individuals with mental illness and addiction can take charge of their lives, create new goals and aspirations, and engage in society as productive citizens.[222]


CHAPTER 5:
Prevalence And Costs

Mental disorders are not the exclusive preserve of any social group; they are truly universal. Mental and behavioural disorders are found in people of all regions, all countries and all societies.

[WHO (2001), p. 23.]

INTRODUCTION

Text Box: If mental illness were an infectious disease, it would constitute an epidemic in Canada. The number of people affected is overwhelming (…).
[Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health, Brief to the Committee, 18 July 2003, p. 4.]
Mental illness and addiction are common, affecting about 1 in 5 Canadians during their lifetines.  They affect individuals of all ages, women and men, in all cultures and income groups.  They are prevalent in all regions, both rural and urban.  They have a huge economic impact, not only on the individual and his/her family, but also on the health care system, the broader social system, the workplace and society as a whole.

To plan adequately and organize the delivery of needed services and supports and to develop sound public policy on mental health, it is essential to properly assess the prevalence and economic burden of mental illness and addiction.  In this chapter, existing information on the prevalence and the economic cost of mental illness, addiction, pathological gambling and suicide in Canada is reviewed.  Where data are available, some international comparisons are also presented.

Section 5.1 provides information on the prevalence of mental illnesses, substance use disorders and pathological gambling.  Section 5.2 reviews the prevalence of suicidal behaviour.  Section 5.3 examines the prevalence of mental illness and addiction in specific population groups, including Aboriginals, homeless people and inmates.  Section 5.4 provides data on the economic burden of mental illness and addiction in Canada.  Finally, the Committee makes some commentary and concluding remarks in Section 5.5.


5.1        PREVALENCE OF MENTAL ILLNESSES, SUBSTANCE USE DISORDERS AND PATHOLOGICAL GAMBLING

Canada does not collect, in a systematic manner, national data on the mental health status of Canadians, nor the extent of any particular mental illness.

[Phil Upshall, President, Canadian Alliance on Mental Illness and Mental Health, Brief to the Committee, 18 July 2003, p. 6.]

Data on prevalence provide estimates of the proportion of individuals in a population who suffer from an illness or a disorder.  Prevalence rates differ depending on whether they refer to individuals who have a disease at a certain point in time (point prevalence), during a period of time (period prevalence – usually a year), or throughout their lifetime (lifetime prevalence).

Text Box: The Statistics Canada mental health survey that was published in the fall was an excellent start. That was the first population based survey of mental illnesses ever done in this country. Can you imagine if 2003 were the year of the first survey of heart disease or cancer in this country? That would be appalling. We need a better surveillance system.
[Dr. Blake Woodside, Chairman of the Board, Canadian Psychiatric Association (5:19)]
Currently, there is no national database capable of providing precise information on the prevalence of all mental disorders for all age groups in Canada.  Often, the best estimates are derived from epidemiological studies reported in the literature.  However, the 2002 Canadian Community Health Survey (CCHS), Cycle 1.2 on Mental Health and Well-Being, carried out by Statistics Canada, provided for the first time prevalence rates for some mental illnesses, substance use disorders and pathological gambling.  These are described below.

 

 

 

 

5.1.1     Canadians Aged 15 Years and Over

Text Box: Mental illnesses and addictions know no boundaries. They can strike at any age and in any population.
[Canadian Psychological Association, Brief to the Committee, 2003, p. 5.]
According to the CCHS (see Table 5.1), 1 out of every 10 Canadians aged 15 and over – about 2.6 million individuals – reported symptoms consistent with mental illnesses and/or substance use disorders during the past year.  The overall prevalence was about the same for women as for men: some 1.4 million of women (or 11% of total) experienced symptoms consistent with mental illnesses and/or substance use disorders, compared with 1.2 million (or 10%) of men.

There were, however, gender differences by type of disorder.  Mood disorders and anxiety disorders were more common among women (6%) than men (4%), while substance use disorders were more common in men (4%) than women (2%).


TABLE 5.1

ONE-YEAR PREVALENCE OF MENTAL DISORDERS AMONG CANADIANS AGED 15 YEARS AND OLDER, 2002

 

Total

Males

Females

 

Number (000’s)

Rate (%)

Number(000’s)

Rate (%)

Number(000’s)

Rate (%)

Unipolar Depression

1,120

4.5

420

3.4

700

5.5

Bipolar Depression

190

0.8

90

0.7

100

0.8

Any Mood

1,210

4.9

460

3.8

750

5.9

             

Panic Disorder

400

1.6

130

1.1

270

2.1

Agoraphobia

180

0.7

40

0.4

140

1.1

Social Phobia

750

3.0

310

2.6

430

3.4

Any Anxiety

1,180

4.7

440

3.6

740

5.8

             

Alcohol Dependence

640

2.6

470

3.8

170

1.3

Illicit Drug Dependence

170

0.7

120

1.0

50

0.4

Any Substance Use

740

3.0

540

4.4

200

1.6

Total – Any Disorder

2,600

10.4

1,190

9.7

1,410

11.1

Statistics Canada, “Canadian Community Health Survey: Mental Health and Well-Being”, The Daily, 3 September 2003.

The CCHS found that adolescents and young adults aged between 15 and 24 were more likely to report suffering from mental illnesses and/or substance use disorders than other age groups.  In this age group, 18% reported having experienced mental illness and/or substance abuse, compared to 12% of those aged 25-44, 8% of those aged 45-64, and 3% of seniors 65 and over.

Text Box: (…) we need to see co-occurring addiction and mental health problems as the norm, not the exception. To detect the presence of one problem should lead us to the assumption that the other is present unless it is determined otherwise.
[Wayne Skinner, CAMH, Brief to the Committee, May 2004, p. 2]
The CCHS survey was limited in the range of mental disorders observed in the Canadian population.  This contrasts with the National Survey of Mental Health and Well-Being undertaken in Australia in 1997.  The Australian survey covered a wider range of anxiety and affective mood disorders.  It also distinguished between the harmful use of, and dependence on, alcohol and drugs.  The Australian government also plans a survey of low prevalence psychotic disorders, such as schizophrenia.[223]

It is unfortunate that the CCHS survey did not correlate or cross-tabulate data in order to evaluate the prevalence rates of concurrent disorders (mental illness co-occurring with substance use disorder) among Canadians aged 15 and over.  The insufficiency of the information on the prevalence of concurrent disorders creates obstacles to better understanding them and to the effective planning and development of appropriate services and supports for those affected.  The design of the National Survey of Mental Health and Well-Being of Adults in Australia permitted an assessment of both concurrent disorders and co-morbidity (defined as the presence of both mental disorders and physical conditions).

Text Box: Where there is gambling, there will be people with a problem.
[Katherine Marshall and Harold Wynne, “Fighting the Odds”, p. 5.]
In contrast to the Australian survey, the CCHS survey did provide information on problem or pathological gambling.[224]  Some 1.2 million Canadians (or 5% of the adult population) in 2002 were estimated to have the potential to become problem gamblers or were so already (see Chart 5.1).  700,000 Canadians were at low risk (2.8%), some 370,000 individuals were at moderate risk (1.5%) and 120,000 were already problem gamblers (0.5%).  Men (8%) who gambled were significantly more likely than women (5%) to be at-risk or problem gamblers.  At-risk and problem gamblers were also, on average, younger than non-problem gamblers (40 versus 45) and less well educated (8% versus 5%).

 

Interestingly, the survey suggested a link between pathological gambling, mental illness and substance abuse.  More precisely, 42% of problem gamblers reported a high or extreme level of stress in their lives; 24% of them reported having had a major clinical depression; and 15% reported being dependent on alcohol.  The survey also found that 18% of problem gamblers had contemplated suicide in the past year.

Lifetime prevalence rates for mental illnesses and substance use disorders in Canada are based on various epidemiological studies.  Data compiled by Paula Stewart and her colleagues (October 2002), showed that nearly one in five Canadian adults (21% of the population or 4.5 million individuals) will personally experience a mental illness in their lifetime.[225]  Chart 5.2 illustrates the lifetime prevalence of mental illness among Canadian adults as derived from epidemiological studies.

As illustrated above, anxiety disorders and mood disorders are the most common mental illnesses among Canadian adults; they affect 12% and 9% of adults respectively.  Schizophrenia affects about 1% of the Canadian population.  Dementia associated with Alzheimer’s disease and organic brain disorders which are the result of physical disease or injury to the brain (e.g., AIDS dementia complex and vascular dementia), also affect some 1% of Canadian adults.  Between 6% and 9% of adults in Canada suffer from personality disorders.

Similar rates of prevalence are found worldwide.  With respect to point prevalence, the World Health Organization (WHO) reported in 2001 that mental illness and addiction at any point in time affect about 10% of the adult population – or some 450 million individuals worldwide.[226]  In terms of lifetime prevalence, the WHO reported that, throughout their lifetime, more than 25% of individuals develop one or more mental illnesses.[227]  The WHO also estimated that, throughout the world, one in four families has at least one member currently suffering from a mental illness or addiction.[228]

With respect to one-year prevalence rates, the WHO World Mental Health Survey Consortium found that mental disorders are highly prevalent in both developed and less developed countries, although there is substantial cross-national variation; the prevalence is low in Asian countries in particular.  Anxiety disorders are the most common mental illnesses, with mood disorders next.  Broken down by the degree of severity, a substantial proportion of disorders were classified as mild; smaller proportions of the samples were considered serious or moderate disorders, although they were often associated with significant impairment in carrying out usual activities.[229]

5.1.2     Children and Adolescents (0 to 19 Years of Age)

Based on various epidemiological studies, Charlotte Waddell and Cody Shepherd (October 2002) estimated overall and disorder-specific prevalence rates of some mental disorders in children and adolescents in British Columbia.  Table 5.2 extrapolates from these rates to estimate the number of children and adolescents in Canada who may be affected by mental disorders.

The overall prevalence of mental illness in Canadian children and adolescents, at any given point in time, is about 15%.  This translates into approximately 1.2 million of children and adolescents who experience mental illness and/or addiction of sufficient severity to cause significant distress and impaired functioning.  The most common are anxiety (6.5%), conduct (3.3%), attention deficit (3.3%), depressive (2.1%) and substance use (0.8%) disorders.


TABLE 5.2

PREVALENCE OF MENTAL DISORDERS IN CHILDREN AND ADOLESCENTS(a)

MENTAL

DISORDER

PREVALENCE

RATE (%)

APPROXIMATE NUMBER

Anxiety Disorder

Conduct Disorder

ADHD

Depressive Disorder

Substance Abuse

Pervasive Developmental Disorder

Obsessive-Compulsive Disorder

Schizophrenia

Tourette’s Disorder

Eating Disorder

Bipolar Disorder

6.5

3.3

3.3

2.1

0.8

0.3

0.2

0.1

0.1

0.1

less than 0.1

513,780

260,842

260,842

165,990

63,234

23,713

15,809

7,904

7,904

7,904

less than 7,904

ANY DISORDER

15

1,185,645

(a)    Based on a population estimate by Statistics Canada of 7,904,300 children and adolescents (aged 0 to 19 years) in July 2002.

Source: Adapted from Charlotte Waddell and Cody Shepherd, Prevalence of Mental Disorders in Children and Youth, Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, University of British Columbia, October 2002.

An important fact that is not captured in the table is the presence of two or more mental disorders occurring together.  For example, an Ontario Child Health Survey reported that amongst children and adolescents who experienced a mental disorder, over two-thirds (68%) of them had two or more mental disorders.  Similarly, a recent study of adolescents with substance use disorders found that over three quarters (76%) had concurrent anxiety, mood or behaviour disorders.[230]

Dr. Joseph H. Beitchman, Psychiatrist-in-Chief, Hospital for Sick Children (Toronto), stressed in his brief that most adult mental disorders begin or originate in childhood or adolescence; they are serious, lifelong illnesses.[231]  This underscores the need for early detection and intervention.  It also highlights that the best opportunities for prevention and reduction in the emergence of new cases are in childhood and adolescence.  As pointed out by Charlotte Waddell et. al. (2002): “Good-quality epidemiological information is essential for developing sound public policies to improve children’s mental health.”[232]  It is interesting to note that the National Mental Health Strategy adopted by the Commonwealth, State and Territory governments of Australia called for a child and adolescent survey to be undertaken as well as their National Survey of Mental Health and Well-Being of Adults.  Such a study has never been done in Canada.

5.1.3     Seniors (65 Years and Over)

The CCHS survey, as reported above, found that, during the past year, some 3% of Canadians aged 65 and over (or some 107,283 seniors) reported symptoms associated with the five mental disorders and the two substance dependencies surveyed.  The one-year prevalence rate was 1.8% for unipolar disorder, 0.2% for panic disorder, 0.9% for social phobia and 0.4% for agoraphobia.  Mental illnesses and substance use disorders were more prevalent among women (3.2%) than men (2.5%).  The survey also found that about 2% of Canadian seniors reported having had suicidal thoughts in the past twelve months.

Other information was presented to the Committee on the prevalence of mental disorders among Canadian seniors:

·        The incidence of depression in seniors in long term care settings is three to four times higher than in the general population.  The prevalence of mental disorders among nursing home residents is extraordinarily high, between 80% and 90%.  The prevalence of psychosis ranges from 12% to 21% depending on how psychotic symptoms are measured.[233]

·        Alzheimer’s disease and related dementias currently affect more than 360,000 Canadians, including 1 in 13 over the age of 65 and 1 in 3 over 85 years of age.  Women are more affected by the disease than men. [234]

·        Estimates suggest that 25% to 50% of seniors who abuse or misuse alcohol also suffer from mental disorders.[235]

·        The incidence of suicide among men 80 years old and over is the highest of all age groups (31 per 100,000 population).[236]

5.1.4     Canadian Forces[237]

The more than 83,000 CF members (Regular Force and Reserve) are doubly concerned by [mental disorders] as they are exposed not only to the problems of a “normal” life, but also to those of a high-risk career.

[National Defence, Statistics Canada CF Mental Health Survey: A “Milestone”, 2003.]

The CCHS included a separate mental health survey of the Canadian Forces (CF).  It found a one year prevalence rate of 7.6% and a lifetime rate of 16.2% for unipolar depression within the CF regular force; the comparable prevalence rates for reservists were respectively 4.1% and 9.7%.  In the regular forces, the prevalence rate of social phobia is 3.6% (one year) and 8.7% (lifetime), and 2.3% and 7.1% for the reservists.  The one year and lifetime prevalence of Post Traumatic Stress Disorder is 2.8% and 7.2% for members of the regular forces and 1.2% and 4.7% for reservists.  The one year and lifetime prevalence of general anxiety disorder is 1.8% and 4.6% for members of the regular forces and 1.0% and 2.9% for reservists.  The comparable prevalence of panic disorder is 2.2% and 5.0% in the regular forces, and 1.4% and 3.3% in reservists.  The one year prevalence rate for alcoholism is 4.2% and the lifetime prevalence rate is 8.5% for the regular forces; the rates are respectively 6.2% and 8.8% for reservists.

5.1.5     FAE/FAS and Dual Diagnosis

Text Box: At least one baby a day in Canada is born with fetal alcohol syndrome, FAS, a disability that will have repercussions for the child, his or her family and the community for the individual's entire life. FAS is the leading cause of preventable birth defects and developmental delays in Canada. It is more common than Down's Syndrome.
[Pam Massad, Health Canada (13:5)]
The prevalence of Fetal Alcohol Syndrome and Fetal Alcohol Effects (FAS/FAE) in Canada has not been properly evaluated.  Based on worldwide prevalence rates, Health Canada estimated that there were some 341,901 individuals with FAS/FAE in Canada in 2001.  The prevalence rates of FAS/FEA in some communities, particularly among Aboriginal Canadians, are higher than the national average.[238]

As described in Chapter 4, dual diagnosis refers to individuals who have a mental health problem or illness together with developmental disability (formerly referred to as “mental retardation”).  Because of the difficulty of diagnosing mental illness in individuals with developmental disability, dual diagnosis is often unrecognized and untreated.  Data indicate that between 1% and 3% of Canadians have moderate or severe developmental disability.  Conservatively estimated, 30% of these individuals also have mental illness; some researchers estimate the prevalence as high as 50% to 60%.[239]

5.2       PREVALENCE OF SUICIDAL BEHAVIOUR

One in twenty-five Canadians will attempt suicide during their lifetime. [Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, University of British Columbia, At-a-Glance Suicide Facts]

Text Box: Suicide is a “stoppable” problem. It is an action, not an illness. (…) Moreover, attempted suicides, where the individual’s actions have been non-fatal – are like the submerged unseen base of an iceberg.
[Diane Yackel, Centre for Suicide Prevention, Brief to the Committee.]
As discussed in Chapter 4, the concept of suicidal behaviour is broad, encompassing completed suicide (death by suicide), attempted suicide (including intentional self-inflicted harm) and suicidal ideation (thinking about suicide).  This section presents recent data on the extent of suicidal behaviour in Canada and provides some international comparisons.

 

 

 

5.2.1     Completed Suicides

Chart 5.3 shows that suicide rates in Canada rose sharply from 1950 to the early 1980s, with a peak in 1983, after which the rates remained more or less stable, with a slight decrease between 1995 and 1998 (latest year for which data are available).

 


Text Box: Looking at the epidemiology of suicide we realize that suicide is an important problem from the public health perspective. It ranks among the 10 top causes of death for individuals of all ages.
[Dr. Gustavo Turecki, Director, McGill Group for Suicide Studies, McGill University (:)]
In 1998, 3,699 Canadians took their own lives, an average of 10 suicides per day.  Their distribution by age group is shown in Table 5.3.  Overall, these completed suicides represented 2% of all deaths in Canada in 1998.

 

 

 

TABLE 5.3

NUMBER OF SUICIDES AND SUICIDE RATES BY AGE GROUP AND SEX, CANADA, 1998

Age Group

Number of Suicides

Suicide Rates (per 100,000)

Total

Males

Females

Total

Males

Females

5-14

15-24

25-34

35-44

45-54

55-64

65-74

75+

46

562

701

895

672

366

260

197

30

457

568

713

513

296

201

147

16

105

133

182

159

70

59

50

1.2

13.5

13.7

19.0

19.2

15.5

14.9

16.5

1.5

21.6

22.1

30.3

29.0

25.9

26.7

31.6

0.8

5.1

5.2

7.7

9.2

5.8

6.0

6.9

Total

3,699

2925

774

12.2

19.5

5.1

* Per 100,000 population.

Source: World Health Organization, Suicide Prevention – Country Reports and Charts, Geneva, 2003.

In every age group, males had a higher suicide rate than did females (see Chart 5.4); approximately four men committed suicide for every woman who did so.

Text Box: I am sure you will agree that taking one's own life at 14 or 15, while thousands or even millions of people fight against death every day, remains a paradox. Suicide among young Canadians is a serious problem that should be made a priority.
[Dr. Johanne Renaud,Centre hospitalier Sainte-Justine (13 :13-14)]
According to Langlois and Morrison (2002), suicide was the leading cause of death for men in the age groups between 25 to 29 and 40 to 44, and for women between the ages of 30 to 34.  For the three age groups from 10 to 14, 15 to 19 and 20 to 24, it was the second leading cause of death for both sexes, surpassed only by motor vehicle accidents.[240]

 

 

Langlois and Morrison (2002) also demonstrated large provincial differences in suicide rates.  In 1998, Québec had the highest age-standardized suicide rate (21.3 suicide deaths per 100,000 population)[241], significantly above the national average of 14.0 suicide deaths per 100,000.  New Brunswick and Alberta also exceeded the national average (16.6 and 16.2 suicide deaths per 100,000 respectively).  Newfoundland, Prince Edward Island, Ontario and British Columbia reported rates significantly below the national average (see Chart 5.5).

According to WHO data, Canada’s suicide rate for the entire population ranks 9th among 12 industrialized countries (see Chart 5.6).  Age-standardized suicide rates range from a low of 7.5 per 100,000 population in the United Kingdom to a high of 22.5 in Finland.  The suicide rate in Canada (12.2 per 100,000 population) is higher than that in the United States (10.7 per 100,000).  It is important to note that international comparisons must be interpreted with caution as the methods for certifying the cause of death vary from one country to another.

 
Estimates from the WHO indicate that suicide is the leading cause of violent deaths worldwide, greater than homicide or war-related deaths (see Chart 5.7).

 

5.2.2    Attempted Suicides

While we know that the number of attempted suicides exceeds that of completed suicides, it is difficult to determine their number exactly.  The World Health Organization estimates that there are as many as 20 attempts for every suicide death.  In Canada, hospitalization rates are used as a measure of attempted suicides.

In 1998-1999, a total of 23,225 hospitalizations of Canadians aged 10 or older were related to attempted suicide and intentional self-inflicted injuries.  Female hospitalization rates for attempted suicide were consistently higher than for males, except for the group 75 years and over (see Table 5.4).  The hospitalization rate for attempted suicide among females peaked at age 15 to 19.  Male hospitalization rates for attempted suicide were highest at ages 20 to 29 and 30 to 44.  Hospitalization for attempted suicide was less common at older ages.


TABLE 5.4

HOSPITALIZATIONS FOR ATTEMPTED SUICIDE BY AGE GROUP AND SEX, CANADA, 1998-1999

(Rate Per 100,000 Age-Specific Population)

AGE GROUP

TOTAL

MALES

FEMALES

10 to 14

15 to 19

20 to 29

30 to 44

45 to 59

60 to 74

75 and over

40.8

152.2

117.9

118.3

68.3

25.0

21.0

15.5

87.3

98.0

97.6

55.1

24.7

27.6

67.5

220.8

138.4

139.3

81.3

25.2

17.2

Source: Stéphanie Langlois and Peter Morrison, “Suicide Deaths and Suicide Attempts”, Health Reports, Statistics Canada, Catalogue 82-003, Vol. 13, No. 2, January 2002.

5.2.3    Suicidal Ideation

According to the CCHS, about 3.7% of Canadians aged 15 years and over had suicidal thoughts during the previous year (see Table 5.5).  Women were slightly more likely than men to contemplate suicide (3.8% versus 3.6%).  Suicidal ideation occurred three times more often among Canadians aged between 15 and 24 than those aged 65 or older (6.0% versus 1.7%).

TABLE 5.5

PERCENTAGE OF CANADIANS WHO HAD SUICIDAL THOUGHTS IN THE PAST 12 MONTHS, 2002

AGE GROUP

SUICIDAL THOUGHTS (%)

Total, 15 Years and Over

            Men

            Women

3.7

3.6

3.8

15-24 Years

Men

Women

6.0

4.7

7.3

25-64 Years

Men

Women

3.6

3.7

3.4

65 Years and Over

            Men

            Women

1.7

1.3

n.a.

n.a.: Not available due to extreme sampling variability.

Source: Economics Division, Parliamentary Information and Research Services, Library of Parliament, March 2004. Based on data from the Canadian Community Health Survey, Cycle 1.2, Mental Health and Well-Being, 2002.

 

5.3       SPECIFIC POPULATION GROUPS: ABORIGINAL PEOPLES, HOMELESS PEOPLE AND INMATES

Although mental disorders affect individuals of all genders, ages and cultures, and in all occupations, educational and income levels, it appears that the prevalence in some population groups is higher than in others.  This section provides information on the prevalence of mental illness among Aboriginal peoples, homeless people and inmates.

 

5.3.1     Aboriginal Peoples

There is a significant amount of missing information in respect of the range of mental health problems [among Aboriginal Canadians]. There have been no studies to date that have really used up-to-date psychiatric epidemiological methods to estimate the range of psychiatric disorders in Aboriginal communities. Instead, we have health surveys that ask some general questions about people's understanding of their problems, their experience and their sense of what the dominant problems are. [Dr. Laurence J. Kirmayer, Department of Psychiatry, McGill University, Proceedings (9:41)]

Although data on the prevalence of psychiatric disorders among Aboriginal peoples are quite limited, there is a consensus in the general literature that Aboriginal communities suffer significantly higher rates of mental illness, addiction and suicidal behaviour than the general population.  What follows is a summary of key case studies and relevant findings.

·        The Aboriginal Healing Foundation reported in 2003 on the mental health profiles of residential school survivors in British Columbia.  Mental illness was indicated in all but two of the 127 case files examined.  The most common mental disorders were post-traumatic stress disorder (64.2%), substance use disorder (26.3%) and major depression (21.1%).  Half of those with post-traumatic stress disorder also had concurring mental disorders including substance use disorder (34.8%), major depression (30.4%); and, dysthymic disorder, a chronic form of depression (26.1%).[242]

·        A 2002 report by Statistics Canada, which examined the health of the off-reserve Aboriginal population, found that Aboriginal peoples who live off-reserve were 1.5 times more likely than the non-Aboriginal population to have experienced a major depressive episode in the previous year.  About 13% of the off-reserve Aboriginal population had experienced a major depressive episode in the year before the survey, compared with 7% for the non-Aboriginal population, suggesting that Aboriginal peoples living in urban areas may experience feelings of alienation, isolation, marginalization and cultural dislocation.[243]

·        The Flower of the Two Soils Project (1993) examined the relation among academic performance, psychosocial variables and mental health in Aboriginal children aged 11 to 18 years at several sites in the United States and Canada.  The Canadian locations included parts of Manitoba and British Columbia.  Among Aboriginal respondents, the most frequent diagnoses were disruptive behaviour disorders (22%), substance use disorders (18.4%), anxiety disorders (17.4%), affective disorders, including depression (9.3%), and post-traumatic stress disorder (5.0%).  Almost half of the children with behaviour and affective disorders also reported concurrent substance use disorders.

·        The 1996 Report of the Royal Commission on Aboriginal Peoples found that the suicide rate of Aboriginal Canadians was roughly three times that of the general population.  Amongst Aboriginal adolescents, suicide occurred roughly five to six times more frequently than for their non-Aboriginal counterparts.  The Commission reported that suicide was the leading cause of death among males aged 10 years to 49 years.[244]

·        A study by Chandler and Lalonde (1998), in which they surveyed 196 Aboriginal communities in British Columbia over a five-year period, found wide variation across communities in the prevalence of suicidal behaviour.  Communities with some measure of self-government had the lowest rates of suicide.  They also found that land claims and education were the second and third most important factors in predicting low suicide rates in Aboriginal communities.[245]

Experts in the field suggest that, while many of the causes of mental illness, addiction and suicidal behaviour in Aboriginal and non-Aboriginal communities may be similar, there are added cultural factors in Aboriginal communities that affect individual decision-making and suicidal ideation.  These cultural factors include past government policies, creation of the reserve system, the change from an active to a sedentary lifestyle, the impact of residential schools, racism, marginalization and the projection of an inferior self-image.[246]

5.3.2    Homeless Peoples

Measuring the prevalence of homelessness and the personal characteristics and state of the health of homeless persons presents significant challenges.  The “Pathways to Homelessness Project” in the City of Toronto attempted, over an 18-month period, to estimate the prevalence of mental illness and addiction among people who are homeless.  Key findings about lifetime prevalence rates included:

·        Approximately 66% of homeless persons had a lifetime diagnosis of mental illness. This was 2-3 times the rate in the general population.

·        About 66% of homeless persons had a lifetime diagnosis of substance abuse (of alcohol, marijuana and cocaine in particular), 4-5 times the rate in the general population.

·        Some 86% of homeless persons had either a lifetime diagnosis of mental illness or substance abuse, 2-3 times the rate in the general population.  In other words, only 14% of homeless persons exhibited no symptoms of either mental illness or substance abuse.

·        Some 75% of homeless persons in every diagnostic category of mental illness also had substance abuse disorders.

·        The lifetime prevalence rate of severe mental illness (psychotic disorders, including schizophrenia) was 5.7%, and that of mood disorder was 38%.

·        Text Box: (…) contrary to popular misconceptions, only a small proportion of the homeless population suffers from schizophrenia, (…) affective [mood] disorders are much more common.
[Bill Cameron, Director General, National Secretariat of Homelessness, Brief to the Committee, 29 April 2004, p. 2.]
Some 22% of homeless persons claimed that either mental illness (4%) or substance abuse (18%) was the reason for their becoming homeless.

·        In the year immediately prior to becoming homeless, 6% of homeless persons had been in a psychiatric institution, 20% had received services for substance abuse, 25% had received psychiatric outpatient services, and 30% had spent time in police stations or jails.[247]

A causal relationship between homelessness and mental illness/addiction remains difficult to establish because mental disorders can lead to homelessness, but they can also be caused by homelessness given the traumatic impact of being destitute and living on the streets.

 

5.3.3    Inmates

Research studies are confirming that those with serious mental health problems are being “trans-institutionalized”: Canadian prisons have replaced former psychiatric hospitals or wards.

[Canadian Mental Health Association, Brief to the Committee, June 2003, p. 21.]

The prison population is another group in which mental illnesses and substance use disorders are more prevalent than in the general population.  A study by Boe and Vuong (2002) showed that, between 1997 and 2001, the percentage of new offenders with a diagnosis of mental illness on admission into federal custody rose from 6% to 8.5%, an increase of 40%.  During the same period, the number of new offenders being prescribed medication to treat mental illness on admission increased by 80%, from approximately 10% to 18%.[248]

Text Box: Literature on offenders with mental disorders has shown that they are…
•	more vulnerable to arrest because of their behaviour
•	more likely entangled in a cyclical pattern of recurrent and brief encounters with both the mental health and criminal justice system
•	found in both provincial and federal correctional systems as well as under the care of provincial health systems in specialized forensic facilities
[Correctional Service Canada, Brief to the Committee, April 2004, p. 3.]
Data from Moloughney (2004) suggested that a high proportion of inmates have substance abuse problems on admission, with drug abuse being more commonly identified than alcohol abuse (see Table 5.6).  His study showed that on average, some 3% of inmates were identified with a mental disorder at intake, with higher proportions in female (from 2.5% to 8.6%) than in male (from 1.4% to 3.3%) inmates.  An average of 7% of male and female inmates were identified on psychological assessment as in need of immediate attention.  Some 31% of female inmates and 15% of male inmates reported emotional or mental health problems at intake, and overall, 14% of inmates were under recent psychiatric or psychological treatment prior to incarceration.  Substantial proportions of inmates (21% female and 14% male) had attempted suicide in the preceding 5 years.

There are no data from recent national studies that provide prevalence rates for specific mental disorders among federal inmates.  The latest data are from 1988 for federal male inmates and 1989 for federal female inmates (see Table 5.7).  Female inmates had substantially higher prevalence of all mental disorders than male inmates, with the exception of antisocial personality disorders.


TABLE 5.6

PROPORTION OF INMATES IDENTIFIED AT INTAKE WITH MENTAL HEALTH PROBLEMS, 2002

 

MALE

FEMALE

Min.

Med.

Max.

Min.

Med.

Max.

Alcohol Abuse

34.3

45.8

42.1

29.3

49.4

69..6

Drug Abuse

36.4

51.2

51.4

40.1

67.5

78.3

Appears mentally disordered

1.4

2.9

3.3

2.5

4.4

8.6

Emotional/mental health requiring immediate attention

4.4

7.3

7.6

6.8

15.4

17.1

Reporting emotional/mental health problems

11.4

15.7

13.6

17.08

40.4

37.1

Recent mental health intervention/hospitalization

10.6

14.5

15.3

12.2

24.7

19.6

Shows signs of depression

9.0

9.7

9.4

8.8

16.2

2.2

Previous suicide attempt(s)

9.5

14.5

16.4

10.9

23.4

41.3

May be suicidal

3.4

5.2

5.5

2.7

5.8

6.5

Nota: Min., Med. And Max. refer to minimum, medium and maximum security.

Source: Brent Moloughney, “A Health Care Needs Assessment of Federal Inmates in Canada”, Canadian Journal of Public Health, Vol. 95, Supplement 1, March-April 2004, p. S37.

TABLE 5.7

LIFETIME PREVALENCE (%) OF MENTAL DISORDERS
AMONG FEDERAL INMATES, CANADA

DISORDER

MALE (1988)

FEMALE (1989)

Major Depression

General Anxiety Disorder

Psychosocial Dysfunction

Antisocial Personality Disorder

Alcohol Use/Dependence

Drug Use/Dependance

13.6

31.9

19.6

57.2

47.4

41.6

32.9

19.7

34.2

36.8

63.2

50.0

 

5.4       ECONOMIC BURDEN OF MENTAL ILLNESS, ADDICTION AND SUICIDE

5.4.1     The Cost of Mental Illness

According to Stephens and Joubert (2001), the economic burden of mental illnesses (substance use disorders were not included in their study) in Canada was estimated to be $14.4 billion in 1998; direct health care costs amounted to $6.3 billion, and indirect costs related to lost productivity and premature death totalled $8.1 billion.[250]  The relative magnitude of the major cost components is given in Table 5.8.  Hospital care represented by far the largest direct cost, at $3.9 billion (26.9%) of the total burden of mental illness.

Cost Component

In Millions of Dollars

Percentage

of total

Direct Costs (Health Care) (1):

  • Medications
  • Physicians
  • Hospitals
  • Other Health Care Institutions

6,257

  642

  854

3,874

  887

43.5

  4.5

  5.9

26.9

  6.2

Indirect Costs (Lost Productivity):

  • Short Term Disability(2)
  • Long Term Disability
  • Premature Death

8,132

6,024

1,708

   400

56.5

40.6

11.9

  2.7 

Total

14,389

100.0

(1)     This category also includes $278 million in professional costs for social workers and psychologists incurred  as a result of depression or distress.

(2)     Attributable to depression and distress only.

Source: Thomas Stephens and Natacha Joubert, “The Economic Burden of Mental Health Problems”, Chronic Diseases in Canada, Vol. 22, No. 1, 2001.

The principal indirect cost component was the value of short term disability, estimated at $6.0 billion, or some 40.6% of the total economic burden.  The authors stressed that their data under-estimated the true situation due to the limitation of their dataset (only depression and distress were included were covered in their survey).

In 1998, mental illnesses accounted for 4.9% of the overall cost (direct and indirect) of disease in Canada.  As such, they ranked seventh among all diseases, behind cardiovascular diseases (11.6%), musculo-skeletal diseases (10.3%), cancer (8.9%), injuries (8.0%), respiratory diseases (5.4%) and diseases of the nervous system (5.2%).[251]  Mental illnesses were second only to cardiovascular disease in terms of direct health care costs alone.[252]  In terms of indirect costs, mental illnesses ranked fourth as the main cause of long term disability, behind musculo-skeletal diseases, diseases of the nervous system and cardiovascular diseases. [253]

A joint study by the World Health Organization, the World Bank and Harvard University – The Global Burden of Disease Study – estimated that mental illness, including suicide, accounts for 10.5% of the total burden of disease worldwide.  Their projections show that this proportion could increase to almost 15% in 2020.[254]  This study developed a single measure to allow comparison of the burden of disease across many different disease conditions.  This measure, called the Disability Adjusted Life Year (DALY), reflects the number of years of healthy life lost due to premature death or disability.  The study revealed that in established market economies, unipolar major depression ranks only second to ischemic heart disease in terms of DALYs.  In comparison, cardiovascular disease and alcohol abuse rank 3rd and 4th respectively in terms of leading sources of DALYs.  Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder, and post-traumatic stress disorder also contribute significantly to the total burden of illness as measured in terms of DALYs.[255]

It its 2001 report, the WHO stressed that the economic burden of mental illness is wide-ranging, long lasting and huge – but remains largely underestimated.  In particular, in addition to meeting the expenses of treatment, the burden for families in which one member suffers from a mental illness ranges from economic difficulties to emotional reactions to the illness, from the stress of coping with disturbed behaviour, to the disruption of household routine and the restriction of social activities.[256]

5.4.2    The Cost of Substance Abuse

The total cost (direct and indirect) of alcohol abuse was estimated at $7.5 billion in Canada in 1992, while the cost of illicit drug abuse amounted to some $1.2 billion (see Table 5.9).  The largest economic costs of alcohol abuse were $4.1 billion for lost productivity due to illness and premature death, $1.4 billion for law enforcement and $1.3 billion in direct health care costs.  Similarly, the greatest cost associated with illicit drug abuse was lost productivity due to illness and premature death ($823 million), followed by law enforcement ($400 million) and direct health care costs ($88 million).


TABLE 5.9

THE COST OF ALCOHOL AND ILLICIT DRUG ABUSE IN CANADA, 1992

 

Alcohol

Illicit Drugs

Total

Millions of Dollars

Direct Costs:

Health Care

Workplace (e.g.: EAP)

Social Programs

Prevention and Research

Law Enforcement

Other Costs

3,385.6

1,300.6

     14.2

     52.3

   141.4

1,359.1

   518.0

547.9

  88.0

    5.5

    1.5

   41.9

 400.3

   10.7

3,933.5

1,388.6

     19.7

     53.8

   183.3

1,759.4

   528.7

Indirect Costs (Productivity Losses Due To)::

Morbidity

Mortality

4,136.5

1,397.7

2,738.8

823.1

275.7

547.4

4,959.6

1,673.4

3,286,2

TOTAL

7,522.1

1,371.0

8,893.1

Source: Eric Shingle, Linda Robson, Xiaodi Xie, Jurgen Rehm et. al., The Costs of Substance Abuse in Canada, Canadian Centre on Substance Abuse, 1996 (http://www.ccsa.ca/).

5.4.3    The Cost of Suicide

To date, no national figures on the economic cost of suicide deaths are available, although a 1996 study in New Brunswick estimated the average cost per suicide death (direct and indirect) to be $850,000.[257]

5.5       COMMITTEE COMMENTARY

Canada currently lacks a national information base to enable us to identify accurately the prevalence of either mental illness or addiction, to measure the mental health status of Canadians and to assist in the evaluation of policies, programs and services in the fields of mental health, mental illness and addiction.  This is a major impediment to determining the need for and the level of provision of appropriate and adequate treatments and services.  The recent release of Statistics Canada’s Canadian Community Health Survey (CCHS) has helped to alleviate this situation by providing, for the first time, a set of data on some mental illnesses, substance use disorders and gambling.  However, the Committee feels that this survey should be repeated soon and that its base should be expanded to cover a wider range of disorders.  We also believe that a national study, like the one being planned in Australia, should be undertaken to assess the prevalence rates of mental disorders among children and adolescents.

The economic burden of mental illness, addiction and suicidal behaviour is enormous.  It is clear that governments must take the necessary steps to contain or reduce such a heavy burden.  The Committee concurs with the Canadian Psychological Association that mental health is as essential to a healthy society as physical health.  We believe that now is the time to develop mental illness and addiction policies and programs that reflect their burden, social and financial, to Canadian society.

Text Box: Mental health is at the core of a healthy society. The prevention and treatment of mental illness and addiction require the same attention and resources as any other disease based on prevalence, burden and outcomes research.
[Canadian Psychological Association, Brief, 2003, p. 12]
The indirect costs attributable to mental illness and addiction – the cost of absenteeism and lost productivity – are substantial and exert great pressures in the workplace.  In contrast to other illnesses, the indirect costs of mental disorders appear to be higher than the associated direct health care costs.  In the next chapter, we examine the prevalence and consequences of mental illness and addiction in the workplace.

 


CHAPTER 6:
Mental Illness, Addiction And Work

The effects of mental health are not just mental. (…) What is good for individual mental health is good for firm performance.

[Professor E. Kevin Kelloway, Saint Mary’s University, Halifax][258]

INTRODUCTION

The relationship between mental illness/addiction and work can be characterized as bi-directional.  On the one hand, mental illness and addiction are a major cause of absenteism from work, under-performance, employee turnover and reduced productivity.  On the other hand, the workplace can be a major cause of stress affecting mental health and work performance.  Some forms of workplace stress may even trigger the onset of mental illnesses and/or substance use disorders.

Text Box: The employers have a vested interest to support a strong mental health system as a result of absenteeism, or loss of productivity, and financial losses.
[Rod Phillips, President and CEO, Warren Shepell Consultants, (18:9)]
Whatever the direction of causality between mental illness and work, there is strong consensus among those who testified before the Committee that the workplace is a critical environment for the promotion of mental health, the early detection of mental illness and addiction, and the accommodation/integration of employees suffering from mental disorders.  Such attributes of a healthy workplace will benefit not only the individual and the employer but society as a whole by enhancing Canada’s productivity and reducing the overall economic burden of mental illness.

This chapter is divided into nine sections.  Section 6.1 briefly describes the benefits of employment and the consequences of unemployment for individuals with mental illness and addiction.  Section 6.2 summarizes the existing information on the prevalence of mental illness and addiction in the workplace.  Section 6.3 provides some data on the cost related to mental illness and addiction in the workplace.  Section 6.4 examines the issue of disability attributable to mental illness and addiction.  Section 6.5 highlights the role of employers with respect to Employee Assistance Programs and accommodation for workers with mental illness.  Section 6.6 summarizes the testimony heard by the Committee with respect to the role of governments in helping to reduce the economic cost of mental illness and addiction in the workplace.  Section 6.7 provides some information on businesses established and run by individuals with mental illness and addiction.  Section 6.8 discusses the need for a research agenda on mental illness, addiction and work.  Section 6.9 presents the Committee’s commentary.

6.1        THE BENEFITS OF EMPLOYMENT

Recently, Professor Heather Stuart, Community Health and Epidemiology, Queen’s University, eloquently pointed out that:

(…) no single activity conveys a sense of self more so than work.  Work influences how and where one lives, it promotes social contact and social support, and it confers title and social identity.[259]

For those affected by mental illness and addiction, employment is an important contributor to recovery.  It may aid recovery and reduce the frequency and severity of episodes of acute illness by providing structure, the opportunity for social connections and a fuller life.  Through regular remuneration, employment can end or reduce dependence on social assistance and reduce individual need for mental health services and supports.

In contrast, loss or lack of employment due to mental illness may jeopardize a person’s recovery.  Income and standard of living are reduced, resulting in economic dependence and low self-esteem.  Inadequate employment also leads to the loss of personal relationships with fellow workers, social marginalization and changed relationships with family and friends.

Many individuals with mental illness succeed in their employment without any assistance being provided to them; recent advances in treatment and drug therapy have increased their capacity to join the mainstream and live independently.  Those who participate in the labour force contribute to Canada’s productivity and competitiveness.  Others, however, need assistance to get and keep a job.  In this context, the issue of mental illness, addiction and work can be explored from three different perspectives.  The first addresses the issue of making employment accessible to individuals who never had a job.  The second emphasizes mental illness and addiction that may affect currently employed individuals.  The third focuses on individuals who have lost their job due to mental illness or addiction and wish to reintegrate the labour market.

As discussed in Chapter 4, the onset of a mental disorder tends to occur in late adolescence or early adulthood, at a time when the affected person’s education and training are not yet complete.  The process of obtaining qualifications is interrupted, often never to be resumed.  The young individuals affected are significantly disadvantaged, as their lack of skills and qualifications is a major lifelong barrier to their future employment.

For those who do find work, periods outside the labour force caused by their mental illness often impede re-entry into the labour force. Three key barriers apply.  First, individuals may be subject to discrimination by their employer and/or work colleagues.  Second, they may require flexible work arrangements that employers are unwilling, or do not know how to provide.  And third, those who have been outside of the labour force for extended periods are unlikely to possess the type of credentials, skills and employment experiences that make them attractive to employers.

The Committee was told that unemployment rates among individuals with mental illness are unacceptably high.  International evidence suggests that the unemployment rate of individuals affected by severe and persistent mental illness is around 90%.  This contrasts with the approximately 50% unemployment rate of individuals with physical or sensory disabilities.  In other words, only 10% of individuals with severe mental disorders who wish to work are judged capable of working and are in fact working.[260]

In Canada, information from the Canadian Psychiatric Association reveals that persons diagnosed with a mental illness are likely to experience long term unemployment, underemployment and dependency on social assistance.  The Association believes that, of all individuals with disabilities, those with a mental illness face the highest degree of stigmatization in the workplace and the greatest barriers to employment opportunities.[261]  A major problem with unemployment is that the longer a person is away from a job, the less likely it is that he or she will ever resume a  productive work life.  Statistics show that after six months on disability leave an individual has a 50% probability of returning to work; this is reduced to 20% after one year, and to 10% after two years.[262]

Two main factors make mental illness specifically a workplace issue.  First, mental illness usually strikes younger workers.  Second, many mental illnesses are both chronic and cyclical in nature, requiring treatment on and off for many years.  There is a vital role for employers and government to play in addressing mental illness and addiction in the workplace, including through accommodation policies, return to work programs and disability management.

In saying this, the Committee is not suggesting that this is an easy or an inexpensive task for either employers or governments.  Nevertheless, we feel strongly that increased attention to workplace mental health and addiction issues is essential.

 

6.2       PREVALENCE OF MENTAL ILLNESS AND ADDICTION IN THE WORKPLACE

There is currently no single source of information available in Canada that provides comprehensive and accurate information on the prevalence of mental illness and addiction in the workplace.  However, a review of the relevant literature provides some indication of the scope of the problem:

·        Addiction (alcohol and drug abuse) is a serious concern in the Canadian manufacturing sector.  The rate of addiction among employees in this sector is estimated to be almost twice the national average; this may be a substantial under-estimate given that addiction in the workplace is often not reported.  Levels of anxiety and anger have been rising significantly among employees in the manufacturing sector over the last three years.  A survey has shown anxiety disorders in the manufacturing sector to be more prevalent in male-dominant populations in which addictions issues are also present.[263]

·        Compared to national averages, the rates of depression and anxiety are high in the information technology sector.  Depression rates vary widely from one year to another, reflecting the volatility of the technology sector.[264]

·        Some segments of the workforce appear to be more vulnerable to mental illness and addiction, in particular men and women in their prime working years who have had 10 to 14 years of service with the same employer, and new entrants to the labour market.[265]

·        A recent survey indicates that more and more hospital workers are accessing employee assistance programs.  Hospital workers are experiencing progressively higher levels of stress than workers in other sectors.  This may be explained in part by hospital restructuring, downsizing and human resource shortages.  Addressing stress in the hospital sector may be even more important than in other sectors since stress-related errors in patient care can have a very negative impact on patients.[266]

·        Similarly, a survey by the Canadian Medical Association in 2003 reported that stress and dissatisfaction among physicians was rising.  More particularly, the survey found that 45.7% of physicians were in an advanced state of burnout.  In addition, women physicians appeared to be at a higher risk of suicide than others in the general population.[267]

·        Relative to other sectors, workers in the retail and hospitality sectors face a number of particular stress factors in their work environments, for example, the occurrence and threat of armed robbery.  Individuals working in the retail sector also report a higher incidence of domestic violence.  Employees of both the retail and hospitality sectors report greater stress and depression symptoms than employees in most other sectors.  Workers in the hospitality sector experience a higher frequency of substance use, including alcohol and tobacco, and a higher incidence of distress and anxiety than other workers.[268]

·        The Canadian Bar Association reported alarming and increasing rates of depression and addiction among lawyers.  The rate of alcoholism is three times that of the general population.  It has been suggested that excessive working hours, relentless competition, and unyielding pressures by law firms for increased billable hours are important contributors to these problems.[269]

·        In the Canadian workforce overall, some 3.5% of women and 3.0% of men report psychological distress (defined as depression and anxiety).  Psychological distress tends to be high among workers in jobs with high demands but little latitude for decision-making.  About 40% of workers in such jobs indicated high levels of psychological distress (see Table 6.1 below).[270]

TABLE 6.1

PERCENTAGE OF CANADIAN WORKERS REPORTING HIGH PSYCHOLOGICAL DISTRESS BY JOB DECISION LATITUDE AND JOB DEMANDS

JOB

DEMANDS

JOB DECISION LATITUDE

High

Moderate

Low

Very Low

High

Moderate

Low

Very Low

27

24

19

16

33

26

20

18

33

30

21

22

40

35

30

20

Source: Kathryn Wilkins and Marie P. Beaudet, “Work Stress and Health”, Health Reports, Statistics Canada, Catalogue 82-003, Winter 1998, Vol. 10, No. 3, p. 52.

·        In Québec, a 2001 study by Bourbonnais and colleagues found that individuals who experienced work-related stress were twice as likely to have a mental illness than those who did not (23% versus 11% for men and 30% versus 15% for women). [271]

·        Workplace stress and work-related conflict and harassment are among the top eight reasons why Canadian employees request help from an Employee’s Assistance Program (EAP).  Stress associated with work-related issues accounts for about 40% of all work-related EAP cases.  The number of employees seeking help for work-related conflict has increased from 23 percent of all work related cases in 1999 to close to nearly 30 percent in 2001.  The number of employees seeking help for harassment almost tripled from 1999 to 2001.[272]

·        In the United States, 40% of all EAP referrals in several leading companies relate to symptoms of depression.[273]

 

6.3       THE COST AND CONSEQUENCES OF MENTAL ILLNESS AND ADDICTION IN THE WORKPLACE

In the labour market, productivity can be linked to the concept of disability.  More precisely, the less disabled a worker, the more productive she/he is and vice versa.  Productivity is affected both by ‘presenteeism’ – days during which an individual is present at work but functions at less than full capacity – and by absenteeism – days during which an employee did not report to work.

Mental illness and addiction are among the most important causes of absenteeism and presenteeism worldwide: the 1998 report of the World Health Organization stated that “more working days are lost as a result of mental disorders than physical conditions.”[274]  In Canada, 20% of the normal work time of employees suffering from an undetected mental illness or addiction is not productive because it is “taken off”.  This is four times the rate of their co-workers.[275]

Text Box: We would suggest that employers are already bearing a significant burden of the costs associated with mental health in Canada. In that sense, they are subsidizing what we have in the public health care system and, in some cases, compensating for deficiencies in that system.
[Rod Phillips, President and CEO, Warren Shepell Consultants (18:9)]
When compared with all other diseases (such as cancer and heart disease), mental illness and addiction rank first and second in terms of causing disability in Canada, the United States and Western Europe (see Chart 6.1).[276]  Of the ten leading causes of disability worldwide, five are mental disorders: unipolar depression, alcohol use disorder, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder.[277]

As reported in Chapter 5, the value of lost productivity in Canada that is attributable to mental illness alone has been estimated at some $8.1 billion in 1998.[278]  More recently, it has been estimated that if substance abuse is taken into account as well, Canada’s economy loses some $33 billion annually to lost productivity caused by mental illness and addiction.[279]  This corresponds to 19% of the combined corporate profits of all Canadian companies or to 4% of the national debt.[280]  In other words, the business sector pays two-thirds of all costs associated with mental illness and addiction in the form of lost productivity, absenteeism, disability, wage replacement costs, employee group health care premiums and prescription drugs.[281]

CHART 6.1

CAUSES OF DISABILITY
CANADA, THE UNITED STATES AND WESTERN EUROPE, 2000


Note: Causes of disability for all ages combined. Measures of disability are based on the number of years of “healthy” life lost with less than full health (ie. YLD, years lost due to disability).

Source: President’s New Freedom Commission on Mental Health, Interim Report, United States, 29 October 2002.

Overall, there are many consequences deriving from mental illness, addiction and work-related stress in the workplace (see Table 6.2).  The Committee heard repeatedly that no one benefits from ignoring the existence of mental illness, addiction and occupational stress in the workplace and from the marginalization of potentially productive citizens– not the affected individuals, nor employer, nor society at large .  Given both the economic and social costs associated with these disorders, it is essential that the public and private sectors urgently address the issue.

Again, as the Committee noted at the end of Section 6.1, addressing this issue is not a simple task.  Nonetheless, there are both economic reasons and compassionate ones that require that it be done.

TABLE 6.2

CONSEQUENCES OF MENTAL ILLNESS, ADDICTION AND WORK-RELATED STESS IN THE WORKPLACE

Absenteeism

·        increase in overall sickness absence, particularly frequent short periods of absence

·        poor health (depression, stress, burnout)

·        physical conditions (high blood pressure, heart disease, ulcers, sleeping disorders, skin rashes, headache, neck- and backache, low resistance to infections)

Presenteeism

·        reduction in productivity and output

·        increase in error rates

·        increased number of accidents

·        poor decision-making

·        deterioration in planning and control of work

Staff Attitude

And Behaviour

·        loss of motivation and commitment

·        burnout

·        staff working increasingly long hours but with diminishing returns

·        poor timekeeping

·        labour turnover (particularly expensive for companies at top levels of management)

Relationships

at Work

·        tension and conflicts between colleagues

·        poor relationships with clients

·        increase in disciplinary problems

Source: Gaston Harnois and Phyllis Gabriel, Mental Health and Work: Impact, Issues and Good Practices, joint publication of the World Health Organization and the International Labour Organization, Geneva, 2000, pp. 8-9.

6.4       MENTAL ILLNESS, ADDICTION AND DISABILITY

Coverage for disability resulting from psychiatric disorder should be available just as it is for disability resulting from either medical or surgical illness.

[Canadian Psychiatric Association][282]

The unpredictable and episodic nature of disability resulting from mental illness is an important factor that distinguishes it from many other disabilities.  Individuals with mental illness tend to cycle between periods of illness and wellness.  When they are symptom-free, they are usually able to work and carry out the normal tasks of life.  During episodes of psychiatric illness, however, they may be incapable of functioning at a level that would permit them to work in regular employment.

Text Box: Mental illness and addiction in Canada generates tremendous suffering and disability – a situation we do not believe would be tolerated for physical illnesses of similar prevalence and severity.
[Centre for Addiction and Mental Health, Brief to the Committee, 27 June 2003, p. 6.]
The Committee was informed that disability claims attributable to mental illness have overtaken claims associated with cardiovascular disease as the fastest growing category of disability costs in Canada. [283]  Currently, mental illness and addiction account for 60-65% of all disability insurance claims among selected Canadian and American employers.[284]  It is expected that disability insurance claims for mental health problems and illnesses may climb to more than 50% of the total number of claims administered through employee group health plans over the next five years.[285]

The following sections provide information on the disability insurance claims associated with mental illness and addiction available through employer sponsored disability benefit plans, workers’ compensation boards (WCBs), the Canada Pension Plan Disability program (CPP(D)) and Employment Insurance (EI).

6.4.1     Employer-Sponsored Disability Insurance Plans[286]

There are two types of disability income insurance plans offered by employers: short term (STD) and long term disability (LTD).  STD plans replace a percentage of pre-disability employment earnings (70% for example) for periods less than one year of duration (e.g., six months).  They are generally harmonized with sick leave, other employee benefits and EI benefits, providing continuity of income for the plan member who has suffered a disabling illness or injury.

LTD plans focus on longer periods of disability.  They typically commence payments after the disabled individual has been off work for a significant period, such as six months, and replace a specified percentage of the person’s pre-disability employment income, for example 70%.  LTD benefits typically run for up to two years for recipients who are unable to perform their own jobs, and can continue to a limit of age 65 or the onset of retirement benefits for recipients who cannot perform their own or any reasonably comparable job.  LTD benefits provided by the employer’s plan may be reduced by the amount obtained by the recipient under CPP(D).

An important aspect of STD and LTD plans is the commitment to assiste recipients to return to the workplace, preferably to their own jobs, or to another job if that proves not to be feasible.  Consistent with this commitment, disability income insurance plans are designed to ensure that there is a financial incentive for recipients to return to work; thus disability income replacement benefits do not exceed and are usually less than pre-disability employment income.[287]

There is no comprehensive Canadian survey that provides information on the total cost borne by employers for STD and LTD benefits associated with mental illness and addiction.  The information given to the Committee on this issue is summarized below:

·        Since 1994, depressive disorders alone have doubled as a percentage of STD and LTD claims and have grown 55% across all categories of disability-related absences from work. [288]

·        Similarly, a 2002-2003 survey by Watson Wyatt Worldwide estimated that mental illness and addiction were the leading cause of STD claims, and 73% of the respondents confirmed that these disorders were also the leading cause of LTD claims.[289]

·        An analysis by the Global Business and Economic Roundtable on Addiction and Mental Health estimates that between 640,000 and 1,075,000 full-time employees in Canada are currently on disability leave with mental illness as their primary or secondary diagnosis.  This translates into 35 million days of work lost for the Canadian economy.  In other words, mental illness and addiction account for 46% of all long term and short term disability claims.[290]

Three specific issues were raised with respect to employer-sponsored disability insurance plans.  First, Watson Wyatt Worldwide, a global consulting firm focussing on human resources and group benefits and health care plans, stressed that all corporations should conduct a review of their STD and LTD claims in order to properly assess the incidence of mental illness and addiction in their workplaces.  The results of the review would help to identify the type of action that is required.[291]

Second, it would be important to understand the influence that the type and extent of disability coverage have on the duration of claims in order to determine the conditions necessary to optimize individual situations.  Disability insurance should not be a disincentive to work.  In this context, the Canadian Psychiatric Association explained:

Disability insurance for any illness requires a precise definition of that illness. Whereas it is important that disabled psychiatric patients receive an adequate income to protect themselves from serious financial reverses over the time that they are not able to work, it is just as important to recognize that disability payments may constitute a major secondary gain actually impeding a patient's progress and delaying rehabilitation. There are two factors to be considered: a) the prevalent misconception that work is ipso facto stressful and likely to aggravate a diagnosed psychiatric disorder; and b) the recognition that some patients who have undergone a serious psychiatric disorder may want to avoid exposure to what they presume to be stressful factors at work because of lack of confidence even after they have improved clinically. It should be recognized that return to work as soon as possible is likely to improve the patient's self-esteem, re-establish him/her in a familiar social network and otherwise aid rehabilitation. There is some evidence that work deprivation may be one of the causes of psychiatric disorder.[292]

Third, and perhaps more importantly, employers, managers and insurers must become more knowledgeable about mental illness and addiction in order to better manage disability claims.  During a recent speech, Bill Wilkerson, co-founder and CEO, Global Business and Economic Roundtable on Addiction and Mental Health, commented:

In a landmark Supreme Court of Canada case in Saskatchewan, a woman was disabled by a mental disorder, was off work and on long-term disability and was in hospital. While there, her disability insurance benefits continued. Once released, they were cut off – this, incredibly, because her institutionalization established the criteria of her continued eligibility. The Supreme Court ruled the practice discriminatory, because those with physical disabilities remained eligible for their benefits outside hospital while recuperating at home.

Meanwhile, were the insurer’s practices simply obsolete or malevolent? Either way, the company suffered its own perceptual disorder of what the reality of mental illness is or isn’t. The insurer, presumably, was confounded by the nature of mental disorders, by the treatment process and the critical even superior role of out-patient care and community family support in the patient’s sustainable recovery.

I tell this story not to belittle or criticize the insurance industry at large. I am part of that community and, to be sure, there are examples where the life and health insurance industry has shown leadership in the promotion of mental health. Rather, I speak to a broader point. This industry must develop a perspective based on knowledge of mental health issues. Like business generally, the insurance sector needs a mental health education agenda.

An example of where this is especially true is in the comorbidity of mental illness and physical chronic diseases as this pertains to: origin and the duration of human disability; the complexity, lengths and risks of treatment and recovery; and, the pace and timing of the sufferer’s return to work.

The insurance industry needs – at the levels of claims management – to know more about the medical science of mental health. (…). The industry needs to develop a knowledge base about the expanding universe of neuroscience and its illumination of the origins of behaviour.[293]

6.4.2    Workers’ Compensation Boards

In all provinces and territories, Workers’ Compensation Boards (WCBs) receive an increasing number of mental health related claims (referred to as “occupational stress”) and, in a growing number of cases, the Boards have provided compensation for claims related to mental illness.  A review of occupational stress claims reported to WCBs was undertaken by the Association of Workers’ Compensation Boards of Canada to find out how many types of claims were filed on an annual basis, whether they were of an episodic or chronic nature, and how much compensation was paid in each case.  This review proved to be very difficult.  In many cases, the Boards do not collect this type of data, or if they do, the data are not comparable because the definitions employed by each WCB may be different (see Table 6.3).  The review could not, therefore, provide a national perspective on the number of claims resulting from occupational stress and the associated costs of compensation.[294]


TABLE 6.3

WORKERS’ COMPENSATION BOARDS IN CANADA: INTERJURISDICTIONAL COMPARISON OF OCCUPATIONAL STRESS COMPENSABILITY

Alberta

Compensation for occupational stress provided if:

·         there is a confirmed diagnosis under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders;

·         the work-related events or stressors are the predominant cause of the injury;

·         the work-related events are excessive or unusual in comparison to the normal pressures experienced by the average worker in a similar occupation; and

·         there is objective confirmation of the events.

British Columbia

Compensable forms of stress include:

·         stress caused by a sudden and unexpected traumatic event; and

·         stress that results from a compensable injury such as severe anxiety following the amputation of a leg.

Stress that is caused by the pressures encountered in daily personal and work life is not compensable.

Manitoba

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

New Brunswick

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Newfoundland and Labrador

Legislative definition of injury covers stress only where it results from an acute reaction to a sudden and unexpected traumatic event and to exclude stress due to labour relations issues.

NWT &

Nunavit

Claims for occupational stress are considered on a case-by-case basis.

Nova Scotia

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Ontario

Mental stress is compensable in respect of situations where there is an acute response to a sudden and unexpected traumatic event arising out of and in the course of employment.

Mental stress due to the employer’s employment decisions does not entitle a worker to benefits.

Prince Edward Island

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Quebec

Stress is compensable if the worker can show a relationship between the illness and the work or a risk in the work.

Saskatchewan

Compensation for occupational stress is specifically allowed for as a matter of policy where clear and convincing evidence is provided that the work stress was excessive and unusual; routine industrial relations actions taken by the employer are considered normal and not unusual.

Yukon

Post-traumatic stress considered compensable under legislation; current practice is to assess all other stress-related claims on a case-by-case basis.

Source: Paul Kishchuk, Expansion of the Meaning of Disability, paper commissioned by the Yukon Workers’ Compensation Board, March 2003, p. 12.

A major issue raised with respect to compensation by WCBs concerns the fact that it is more difficult to prove the genesis of a mental disorder than it is of a physical illness.  As a result, there is some controversy about whether and how mental disorders should be covered under worker’s compensation schemes.  Under an occupational disease model, compensation for a disability is based on whether the disability arises from continuous exposure to hazardous conditions related to an individual’s employment.  Yet, most advanced etiological models of mental disorders include the variety of factors discussed in Chapter 4, such as genetic vulnerability, developmental circumstances and neurobiological factors, in addition to life events such as a stressful work environment.  The relative weight of each of these dimensions is not yet understood, nor is it clear how they fit together.  As a result, some WCBs are more reluctant than others to provide mental health related disability benefits.  They are left wrestling with the question of the extent to which disability benefits related to mental disorders should be paid by worker’s compensation rather than by health care insurance.[295]

6.4.3    Federal Income Security Programs

The Canada Pension Plan Disability program or CPP(D) is the largest single disability income program in Canada.  It is generally the first payor of disability benefits preceding other entities such as provincial workers’ compensation boards and private insurance companies.

CPP(D) benefits are paid to contributors under age 65 who have a physical or mental disability which is “severe and prolonged” (lasting at least one year and preventing work on a regular basis) and meets specific requirements relating to the level of earnings and years of contribution (contributions must have been paid in four out of the last six years).

In the past two decades, there has been a sharp increase in the number of CPP(D) beneficiaries due to mental illness.  Between 1980 and 2000, the proportion of individuals receiving CPP(D) benefits attributable to mental disorders increased from 11% to 23%.  Mental illness ranked second, behind disease of the musculoskeletal system, and affected a higher proportion of females than males.  In 2000, mental disorders also represented the most prominent cause of CPP(D) disability among younger beneficiaries.[296]

For many years, individuals with mental illness and addiction and their representatives have raised concerns that CPP(D) does not address the question of mental illness and disability appropriately.  More specifically:

·        Many individuals with mental illness have limited work histories.  Because mental illness often strikes in early adulthood at a time when education, job skills and careers are being developed, many of these individuals are not eligible for CPP(D) due to insufficient years of employment.  Out of necessity, many turn to provincial social assistance programs for support.

·        To qualify for CPP(D) disability benefits, the beneficiary must accept the designation of “permanently unemployable” by declaring him/herself as entirely incapable of pursuing any employment on a regular basis.  Because of the cyclical and unpredictable nature of mental disorders, individuals with mental illness can work, but often only on a part-time basis; they are not necessarily capable of achieving full financial independence.  Individuals with mental illness and addiction have recommended that CPP(D) pay partial or reduced benefits rather than full benefits to enable them to work part-time while still retaining a portion of their benefits.

·        Since disability is currently equated with permanent unemployability, individuals on CPP(D) are reluctant to look for or take employment for fear of losing their benefits.  Those affected are penalized for trying to improve their circumstances even if they are not capable of participating in regular full-time work again.

·        Some 66% of all initial applications to CPP(D) are denied and almost two-thirds of those rejected do not apply for reconsideration  It has been suggested that the proportion of applications rejected from those with mental illness is much higher.  Some experts claim that the system is designed in such a way as to discourage individuals from pursuing rightful claims.  This is particularly true for individuals with mental disorders who, because of their illness, may lack the ability to “push the system”.[297]

In its 2003 report, the House of Commons Standing Committee on Human Resources Development and the Status of Persons with Disabilities recognized that CPP(D) does not address the question of mental illness and disability appropriately.  The Committee made a number of recommendations to ensure that CPP(D) takes into account of the cyclical and unpredictable nature of mental illnesses.  In addition, it recommended that the federal government develop, in consultation with stakeholders and health care professionals, specific evaluation tools for these particular disabilities to be used in assessing eligibility for CPP(D).[298]

In its response to the House of Commons Committee’s report, the federal government indicated that CPP(D) guidelines already recognize recurrent and episodic disabilities, including mental disorders, and that many individuals with mental disorders currently receive CPP(D) benefits.  Furthermore, it stated:

The Government therefore does not believe regulations and guidelines need to be changed to accommodate the needs of individuals with episodic or recurring conditions. Because the determination of disability for CPP is based on the functional limitations that prevent a person from working, and not simply on a medical diagnosis or prognosis, the adjudication process is able to take into consideration the short- and long-term impacts of recurrent or episodic medical conditions on the client’s ability to function in the workplace.[299]

Individuals with mental illness may also be eligible to receive EI benefits as a source of temporary income replacement.  They have raised some concerns, however, with respect to EI:

·        In terms of EI eligibility, employees who are dismissed because of “misconduct” or quit “without just cause” are not eligible for EI benefits.  Due to stigma, individuals with mental illness in the workplace often conceal their illness.  When they experience difficulty on the job, they may be fired or may quit as a result of their illness, but would not be in a position to claim EI benefits because they have not previously disclosed their illness.

·        When a person applies for EI sickness benefits, he/she is required to obtain a medical certificate indicating how long the illness is expected to last.  The unpredictable nature of mental illness makes it difficult to provide this kind of medical information.

·        Individuals with mental illness and addiction share the view that EI should exempt individuals with recurring illnesses or disabilities from fulfilling the additional number of insurable hours required of those who are considered new to the labour force.  In their view, without this exemption, individuals with mental illness are unjustly disadvantaged.  Few are able to meet the eligibility criteria in terms of the total number of insurable hours required of new workers.

In his brief to the Committee, Dr. Sunil V. Patel, President of the Canadian Medical Association, recommended that the federal government review CPP(D) and other federal income support policies to ensure that mental illness is on a par with other chronic diseases and disabilities in terms of the benefits available to affected persons.[300]

6.5       THE ROLE OF EMPLOYERS

There is a compelling case for employers to address mental illness and addiction in the workplace.  In the global economy, information and innovation have become the keys to competitive success.  And using these keys requires skilled, motivated, reliable workers.  Human capital – motivation, knowledge, perspective, judgement, the ability to communicate, share ideas and have relationships – drives the global economy.  In short, it is mental performance that drives competitive success in the worldwide economy.[301]  According to Bill Wilkerson, co-founder and CEO of the Global Business and Economic Roundtable on Addiction and Mental Health:

(…) it falls to business to protect its strategic investment in its people – its vital asset – and, therefore, by definition of the economy of mental performance in which we compete, in their emotional and mental health.[302]

Text Box: Given recent estimates that about 75 per cent of the new jobs in the economy have to do with cognitive ability, not physical ability, and that the heavy lifting in the economy is now being done with people's minds, not with their backs, this aspect of mental disability is more significant than it might have been a number of years ago.
[Rod Phillips, President and CEO, Warren Sheppell ConsultantsCorporation (18:8)]
The Committee heard over and over again that, given the burden of mental illness and addiction on society and on individual workers, and given the rising cost of occupational disabilities, employers must help to enhance the level of awareness about mental illness and addiction in their organizations; they also must devote more attention to improving access to treatment and rehabilitation services for workers through their EAPs.  Employers must also place greater emphasis on work flexibility and accommodation for employees who suffer from mental illnesses.

Although the Committee was repeatedly told that employers had to do all the things listed in the previous paragraph, none of the testimony recognized explicitly how difficult this would be to do it in practice or how much it would cost.  The Committee hopes therefore that during the nationwide public hearings which will follow the release of the Committee’s Issues and Options paper in November 2004, we will receive advice on how employers can actually implement the changes suggested in the previous paragraphs and how much this would cost.  Consistent with the Committee’s earlier reports that contained recommendations for reform of the acute health care system, we are determined that the recommendations contained in our final report on mental health, mental illness and addiction, which will be released in November 2005, will be pragmatic and implementable, rather than merely pious statements of good intentions.

 

6.5.1     Employee Assistance Programs

Text Box: Employee assistance programs, EAPs, play a role in the current system of how mental health is delivered in Canada. Essentially, they provide professional assessment, short-term counselling, and referral services as a benefit to employees. In most cases, Canadian EAPs also cover employees and their dependents, similar to drug or other employee benefit plans.
[Rod Phillips, President and CEO, Warren Shepell Consultants (18:8)]
EAPs are employer-sponsored programs designed to alleviate and assist in eliminating a variety of workplace problems.  The source of these problems can be either personal (legal, financial, marital or family-related, mental health problems and illnesses, including addiction) or work-related (conflict on the job, harassment, violence, stress, etc.).

Typically EAPs provide counselling, diagnostic, referral and treatment services.  The staff of EAP programs usually hold a degree in a mental health or social service discipline (social work, psychology, psychiatry, counselling and/or marital and family therapy).  Some services may also be contracted out to persons with other degrees, diplomas and qualifications.

EAP services are available both in private and public organizations and are usually administered completely independently of other programs within the organization.  Confidentiality is the cornerstone of an effective EAP.  The anonymity of clients, the confidentiality of interviews, the maintenance, transfer and destruction of files are subject to the applicable federal and provincial laws which define the conduct of counsellors.  Generally, information may be released by an EAP counsellor only in situations where the client has provided informed and signed consent specifying what information is to be released and to whom.

The Committee was told that between 60 and 80 per cent of Canadians who are employed in a medium- or large-sized company (over 500 employees) currently have access to some form of EAP.  According to Rod Phillips, President and CEO, Warren Shepell Consultants Corporation, EAPs are very effective; they have become the primary portal through which working Canadians often get their first access to mental health care and addiction treatment:

In many cases, in our experience, you would have about 85 per cent of the people who we see in a given year getting sufficient treatment through the EAP program that they would require no further treatment. About 15 per cent of the people would then be referred into community programs or into the public health care system.[303]

EAPs also have a strong prevention component.  Much of the work being done with employers focuses on wellness and other programs that support a healthy mental health work environment,

Watson Wyatt Worldwide have recommended that employers who do not offer EAPs should consider implementing such programs in order to address mental illness and addiction, and a variety of other issues.  They pointed out that some insurers provide disability rate discounts to smaller employers who implement an EAP, usually through a preferred provider.[304]

For those organizations that already have an EAP in place, Watson Wyatt Worldwide recommended that their programs be reviewed and revised as needed to better address better the needs of employees affected by a mental illness and/or an addiction.  Specific elements to be examined should include the need for meaningful reports, performance standards and user feedback.  Internal reviews that compare EAP utilization and absenteeism data should be undertaken by operating units in order to identify internal ‘best practices’ which can then be introduced across the organization.  Finally, Watson Wyatt Worldwide recommended that employees be told about the  availability of the organization’s EAP on an ongoing basis.[305]

Ash Bender and his colleagues (2002) warned that EAP programs are effective only when the working environments into which they are injected actively promote healthy workplaces.  In other words, it is very important for employers to be well informed about mental illness and addiction, to address stigma and discrimination properly within their organization and to establish healthy workplaces.[306]

Another concern raised by Bender et al. related to the number of therapeutic sessions being offered to EAP clients; based on anecdotal evidence, these have decreased dramatically from 7 per individual to less than 3 over the last ten years.  The authors concluded that the likelihood of effectively addressing any serious substance abuse or mental illness problem in this limited therapeutic timeframe would be low.[307]  This concern requires particular attention.

 

6.5.2    Accommodation

The solution will certainly require involvement on the part of the workplace. We cannot consider the workplace as if it were a school or a hospital. It is an entity in itself, a family with its own rules and its own way of behaving and we cannot do without its involvement.

[Jean-Yves Savoie, President, Advisory Board, Institute of Population and Public Health, CIHR (18:6)]

Accommodation refers to “any modification of the workplace, or in the workplace procedures, that makes it possible for a person with special needs to do a job.”[308]  Just as individuals with physical disabilities may require physical aids or structural changes to the workplace, individuals with mental disorders most often require social and organizational accommodations to be made.  These generally involve changes to the way things have traditionally been done in a particular workplace.  Permitting someone with a mental illness to work flexible hours, for example, provides him or her access to employment in the same way that a ramp does for an individual in a wheelchair.  Such accommodation does not constitute preferential treatment.  Accommodation means equitable treatment for individuals with disabilities.[309]

According to the Canadian Psychiatric Association, accommodation should be built on positive arrangements that promote equality in employment, including:

·        Creating an environment in which arrangements are made in relation to the individual needs of each employee;

·        Respecting the employee’s desire for confidentiality as well as  identifying specific the form and the degree of confidentiality required;

·        Being willing to engage in joint problem solving;

·        Making all arrangements voluntary for the employee, and being prepared to review plans periodically to meet changing needs;

·        Being flexible in enforcing traditional policies;

·        Being concrete and specific when identifying accommodations that are made.  Putting them in writing is a good idea.[310]

One study suggests that the cost of accommodating an employee with a mental illness is fairly low, usually well under $500.  Moreover, for those who get effective treatment, the employer will save between $5000 to $10,000 per employee per year in the cost of prescription drugs, sick leave, and average wage replacement alone.  Employees who are diagnosed with depression and take appropriate medication will save their employer an average 11 days a year in prevented absenteeism.[311]

Another study found that over a 10 year period, 240 persons with serious mental illnesses were able to maintain gainful employment, largely because of formal work reintegration programs.  These individuals earned $5 million, paid $1.3 million in income taxes, and saved the government an estimated $700,000 in welfare costs.  The result was a net $2 million increase in collective wealth.[312]

For its part, the Global Business and Economic Roundtable on Addiction and Mental Health believes that employers must provide an appropriate environment for the promotion of good mental health, awareness of mental illness and addiction, early detection of mental illness and addiction, and integration of and accommodation for employees suffering from a mental disorder.  In this regard, the Roundtable published the 12-step business plan to mental illness and addiction, summarized in Table 6.3.


TABLE 6.3

12 STEP BUSINESS PLAN TO DEFEAT MENTAL ILLNESS
AND ADDICTION AT WORK

Step One:        CEO briefing on mental illness and addiction

Step Two:        Early detection of mental illness and addiction

Step Three:      Reforming EAP and group health plans

Step Four:        Establishing a healthy mental workplace

Step Five:         Reducing the overflow of e-mail and voice-mail messages

Step Six:          Developing flexible return to work policies

Step Seven:                  Educating managers and supervisors on connections between mental illness and physical illness

Step Eight:      Reducing emotional work hazards

Step Nine:       Promoting work/life balance policies

Step Ten:         Encouraging people to seek the necessary professional assistance

Step Eleven:    Monitoring the health status of the organization through specific targets

Step Twelve:    Eliminating the 10 main sources of workplace stress.

Source: Adapted from Bill Wilkerson, Mental Health – The Ultimate Productivity Weapon, Summary of Remarks to the Industrial Accident Prevention Association Conference and Trade Show, Toronto, 22 April 2002, pp. 10-14.

More recently, the Roundtable drafted its “Roadmap to Mental Disability Management” which unifies physical and mental health within a single environmental, health and safety system.  The Roadmap also provides standards for governing return-to-work policy.  More precisely:

·        Employers do not need to know the nature of the diagnosis of the disabling illness that is involved in any given case. This information is private and confidential.

·        Employers do need to understand, support and participate in return-to-work plans which will inevitably involve customized adjustments in the content of the employee’s job or hours of work in order to make the transition go smoothly.

·        Employers need to know that while the employee is coming back, he/she is not 100 per cent and gradual return-to-work is necessary to help the individual catch up with things, get up to speed and build tolerance and endurance.[313]

The Roadmap stressed that unions also share the responsibility to accommodate an employee’s return-to-work.  In particular, unions have a duty to represent their members at the higher end of the salary scale in matters concerning a disabled employee.  This is particularly true when an employee is mentally disabled and the issue is termination.[314]

Again, the Committee wants to emphasize the critical importance of turning the goals and objectives described throughout Section 6.5 into achievable recommendations.  The Committee will only be able to do this if it receives concrete suggestions from both workers and employers, along with estimates of what is would cost to implement these proposals.

 

6.6       THE ROLE OF GOVERNMENTS

The Committee was told that governments must share responsibility with employers for shouldering the economic burden of mental illness and addiction in the workplace.  According to Rod Phillips, such cost sharing could take the form of tax incentives:

Progressive employers are subsidizing Canada’s inadequate public mental health care system. Their investment in mental health programs for their employees and family members should be encouraged through tax-based incentives and rebates, cost sharing, and joint service delivery. (…) The absence of accessible publicly-funded mental health services in Canada is a significant failing of our health care system. Given that a great percentage of the rising costs of mental illness are being borne by employers, there is a huge incentive for the costs associated with reducing these to be shared between employers and government. This avenue for cost sharing is, in our opinion, under explored and underused. I urge the Committee to consider innovative options.[315]

For its part, the Canadian Mental Health Association (Ontario Division) strongly blamed governments from their lack of action with respect to mental illness and addiction:

For several years we have been talking about the projections by the World Health Organization that by 2020 mental illness will be the leading cause of days lost to disability.  What we have not heard is the commitment that governments usually make when faced with a growing health problem, particularly one that impacts not only on the individual, but on society as a whole, including the economy.  The WHO [projections] need to be treated as a challenge and wake up call, not an inevitable result.

(…)

Governments have an obligation to lead.  The federal, provincial and territorial governments should commit to working together – and to support businesses – to achieve specific goals in terms of reducing the potential days lost to disability from mental illness.  This requires a commitment on the part of all stakeholders to address the conditions that make people more vulnerable to mental illness and make the recovery or remission harder.[316]

During the hearings that the Committee will hold on its Issues and Options paper, the Committee will be seeking advice on how governments should go about implementing the suggestion that “governments have an obligation to lead”.  We need to hear the views of Canadians on what this actually means in practice.

 

6.7       BUSINESSES RUN BY INDIVIDUALS WITH MENTAL ILLNESS AND ADDICTION

During its hearings, the Committee learned about the Ontario Council of Alternative Business (OCAB).  This is a provincial organization that assists in the development of economic opportunities for individuals with mental illness and addiction.  It is an umbrella organization of 11 businesses operated by individuals with mental illness and addiction and which employ some 600 workers in various initiatives across the province.[317]

Evaluation of businesses run by individuals with mental illness and addiction demonstrates that individuals with mental disorders, even severe and persistent illnesses, can succeed and be competitive in the business they undertake.[318]  The Committee strongly encourages the development of these initiatives.

 

6.8       A RESEARCH AGENDA ON MENTAL ILLNESS, ADDICTION AND WORK

Text Box: From the currently existing body of literature, we know that mental health problems present a serious threat to the nation’s productivity. At the same time, we are only beginning to fully comprehend the prevalence and magnitude of the impact of mental health problems in the workplace. There is still much work to be done.
[Dewa, Lesage, Goering and Caveen, Nature and Amplitude of Mental Illness in the Workplace, April 2004.]
The issues related to mental illness, addiction and work are complex and multifaceted.  Society is confronted with a rapidly growing problem which has huge financial implications and involves a multitude of stakeholders.  However, there is currently no coordinated comprehensive strategy for pursuing research, disseminating information, implementing results, and evaluating them.  Such a strategy should include not only research on disease, treatment and therapy; it should also examine the relationship of the workplace to mental health, how therapies and treatments can be carried into the workplace and the home, as well as looking at how employers, employees and families can take action.

The need for more research in the field of mental illness, addiction and work was highlighted in a recent workshop organized jointly by the Institute of Neurosciences, Mental Health and Addiction and the Institute of Population and Public Health of the Canadian Institutes of Health Research (CIHR).  It enabled researchers to take stock of the nature and severity of mental illness and addiction in the workplace, to review the state of research in Canada in this field, and to develop a research agenda.

Participants at the workshop identified many areas that require more research, such as: understanding the patterns of mental disorders among the different occupational groups and industry sectors; understanding the relationship between employer– sponsored benefits and the prevalence and pattern of disability related to mental illness; examining the relationship between stress at work and the onset of disability; understanding how mental health is affected by prominent trends in workplace organizational practices; identifying effective methods to improve diagnoses and treatment interventions for mental illnesses amongst working individuals; analyzing policy and guidelines that relate to occupational disability; and determining the scope and nature of stigma in work settings.

The Committee welcomes this initiative by CIHR.  We hope that the workshop will lead to the development of a research agenda which will help advance the understanding of mental disorders and the disabilities they cause, and identify innovative business practices that can help employees with a mental disorder.

The Committee also heard about a research plan called the “Research and Return on Investment Initiative”, a joint initiative undertaken by the Global Business and Economic Roundtable on Addiction and Mental Health, the Centre for Addiction and Mental Health and the Institute for Work and Health, that is funded by CIBC, TD Bank, Scotiabank, RBC, BMO and Great-West Life.  The purpose of this research is to survey Canadian and American companies and gather and share information about successes in managing mental disability and facilitating the return-to-work of individuals with mental illness and addiction.[319]  The Committee strongly encourages the Roundtable and business leaders to share best practices in the management of mental disability in the workplace and in the development of effective return-to-work strategies.

 

6.9       COMMITTEE COMMENTARY

The Committee agrees with numerous witnesses that securing and sustaining meaningful employment is beneficial to individuals with mental illness; it is also an essential part of the recovery process.  In addition, we believe strongly that enabling these individuals to participate in the workforce can be beneficial to the companies employing them; recent advances in treatment now make it possible for people with mental illnesses to make valuable contributions in the workplace.

There is still a debate as to how much an employer wants to or should know concerning an employee’s mental illness.  The Committee is of the view that legislation should not allow disability to be a sufficient ground to refuse employment unless it is clearly impossible for the person to do the job.  The assurance that there will be quick and easy access to appropriate mental health services and supports has been found to influence very positively the willingness of employers to offer employment to persons with mental illness.  In the Committee’s opinion, the disability associated with mental illness and addiction can no longer serve as an excuse to deny employment to those who want a job and are able to do it.

There is no doubt that employers bear a large burden in terms of lost productivity as a result of mental illness and addiction in the workplace.  The presence of mental health and addiction problems in the workplace triggers the following question: “to what extent are these disorders imported into the workplace by individual employees and to what extent are they engendered by the workplace itself?”  Obviously, the answer given to this question has profound implications for strategies aimed at preventing and managing mental illness and addiction in the workplace; it could also impact substantially on how disability claims attributable to mental disorders should be managed.

The Committee believes that more research must be undertaken in the field of mental illness, addiction and work.  For example, we believe that it is important to understand the influence that the type and extent of disability coverage have on the duration of claims and to define the best model.  It is important to understand the influence of healthy and non-healthy workplaces on the incidence of mental illness claims.  It is also important to assess the impact of EAP programs.

The Committee strongly supports the view that it is imperative to provide education and awareness programs to inform everyone in the workplace, from the top down, about the causes, symptoms and treatment of mental illness and addiction.  This would help overcome the stigma associated with mental disorders.  While the implementation of such programs cannot eliminate stigma or guarantee that all employees will seek early treatment, they would certainly reduce the stress faced by those suffering from mental illness and addiction.

We also agree with experts that return-to-work policies must be reviewed and revised where necessary.  Mental disorders do not fit the typical model of disability; many employers still view disability in terms of a physical impairment.  Accordingly, the needs of employees returning to work following a mental health-related absence may be quite different from those of an employee returning after back surgery.  Existing return-to-work arrangements should be reviewed and revised to address such different situations.

Furthermore, the Committee believes that an organization’s internal culture can make a huge difference to how mental illness and addiction is approached in the workplace.  Employers should examine carefully all workplace issues (i.e., harassment, adversarial relationships between management and employees, etc.) that are creating unnecessary stress and hostility.  Such situations have a detrimental impact on all employees, but especially on employees affected by mental illness and addiction. Employers should take steps to remedy problems that emerge as a result of such examinations.

Finally, the concern raised with respect to the need to review CPP(D) and EI in order to take into account the cyclical and unpredictable nature of mental disorders must be examined.  The federal government should also consider how to share more equitably with employers the costs associated with mental illness and addiction.


(184)   Health Canada, Mental Health Promotion Unit, Mental Health Promotion: Promoting Mental Health Means Promoting the Best of Ourselves – Frequently Asked Questions.

      http://www.hc-sc.gc.ca/hppb/mentalhealth/mhp/e_faq.html).

[185]   Canadian Alliance on Mental Illness and Mental Health, A Call for Action – Building Consensus for a National Action Plan on Mental Illness and Mental Health, Discussion Paper, 2000, p. 7.  (http://www.mooddisorderscanada.ca/camimh/index.htm)

[186]   Thomas Stephens et al., “Mental Health of the Canadian Population: A Comprehensive Analysis,” Chronic Diseases in Canada, Vol. 20, No. 3, 1999.

[187]   Canadian Psychiatric Association, Youth and Mental Illness, not dated.

[188]   The DSM classification system addresses psychiatric disorders only, and no other illness or disease categories. The DSM that is in common usage at the present time in Canada is a revision of the fourth edition (DSM-IV-TR) and it is anticipated that the fifth edition (DSM-V) will soon be released. ICD-10, the tenth edition of the ICD system, which addresses all disease areas and health conditions, is currently being adopted across Canada, replacing ICD-9, which until recently has been the standard diagnostic system in Canadian hospitals and health care organizations. Both the DSM and ICD classification systems are updated regularly by experts in an effort to refine diagnostic accuracy and incorporate new research evidence.

[189]   Canadian Mental Health Association, Mental Illnesses, pamphlet, not dated.

[190]   According to information from the Internet site of the Mood Disorders Society of Canada (http://www.mooddisorderscanada.ca/).

[191]   According to information from the Internet site of the Anxiety Disorders Association of Canada (http://www.anxietycanada.ca/).

[192]   British Columbia Schizophrenia Society, Basic Facts About Schizophrenia, April 2002.

[193]   United States Surgeon General, Mental Health: A Report of the Surgeon General, 1999, p. 167.

[194]   Personality disorders include: borderline, antisocial, histrionic, narcissistic, avoidant, dependent, schizoid, obsessive-compulsive, and schizotypal personality disorders.

[195]   Paula Stewart, A Report on Mental Illnesses in Canada, Health Canada, October 2002, p. 70.

[196]   Paula Stewart (2002), pp. 72-73.

[197]   Autism Treatment Services of Canada, What is Autism?.

[198]   National Institute of Mental Health, Briefing Notes on the Mental Health of Children and Adolescents, United States, not dated. (www.nimh.nih.gov).

[199]   Canadian Mental Health Association, Children and Attention Deficit Disorders, Pamphlet Series, not dated.

[200]   US Surgeon General Report (1999), p. 144.

[201]   Canadian Alzheimer’s Disease Centre, http://www.alzheimercentre.ca/english/default.htm.

[202]   Sonya Norris, Alzheimer’s Disease, PRB 02-39E, Library of Parliament, 2 October 2002.

[203]   Fred J. Boland et al., Fetal Alcohol Syndrome: Implications for Correctional Service, Correctional Service Canada, July 1998.

[204]   Colleen Hood, Colin Mangham, Don McGuire and Gillian Leigh, Exploring the Links Between Substance Use and Mental Health, Section I (“A Discussion Paper”) and Section II, (“A Round Table”) Health Canada, 1996, p. 44. (http://www.hc-sc.gc.ca/hecs-sesc/cds/publications/index.htm)

[205]   Health Canada, Best Practices – Concurrent Mental Health and Substance Use Disorders, 2002, p. 8.

[206]   Ibid., pp. 89-90.

[207]   BC Partners for Mental Health and Addictions Information, “What is Addiction?”, The Primer – Fact Sheets on Mental Health and Addiction Issues, (http://mentalhealthaddictions.bc.ca/).

[208] Health Canada (1996), p. 30.

[209] Paula Stewart (2002), p. 22.

[210] Health Canada, Best Practices – Concurrent Mental Health and Substance Use Disorders, 2002.

[211]   Canadian Mental Health Association – Ontario Division, Dual Diagnosis: People with Developmental Disability and Mental Illness – Falling Through the Cracks, Fact Sheet, 1998.

[212]   BC Partners for Mental Health and Addictions Information, “Suicide: Follow the Warning Signs”, The Primer – Fact Sheets on Mental Health and Addictions Issues.

[213]   According to data from the Canadian Mental Health Association – Ontario Division (http://www.ontario.cmha.ca/).

[214]   The Merck Manual on Diagnosis and Therapy, “Suicidal Behaviour”, Section 15, Chapter 190.

[215]   Health Canada, Review of Best Practices in Mental Health Reform, prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health, 1997.

[216]   The College of Family Physicians of Canada and the Canadian Psychiatric Association, Shared Mental Health Care in Canada – A Compendium of Current Projects, Spring 2002.

[217]  For more information, please go the ICIC Website (http://www.improvingchroniccare.org./).

[218]   Mental Health and Addictions, Ministry of Health Services, Government of British Columbia, Brief to the Committee, 9 September 2003, p. 7.

[219]   BC Partners for Mental Health and Addictions Information, “Mental Health and Addictions Information Plan for Mental Health Literacy”, The Primer - Fact Sheets on Mental Health and Addictions Issues, British Columbia.

[220]   Ibid.

[221]   Paula Stewart, The Development of a Canadian Mental Illnesses and Mental Health Surveillance System: A Discussion Paper, prepared for the Canadian Alliance on Mental Illness and Mental Health, 1999 (unpublished).

[222]   Provincial Forum of Mental Health Implementation Task Force Chairs, The Time is Now: Themes and Recommendations for Mental Health Reform in Ontario, December 2002, p. 21.

[223] The Australian’s National Survey of Mental Health and Well-Being covered the following anxiety disorders – panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder – and the following affective disorders – depression, dysthymia, mania, hypomania, bipolar disorder.  In addition, it surveyed alcohol use disorders and drug use disorders in terms of both harmful use and dependence. For more information, visit the website of the Australian Bureau of Statistics.

      (http://www.abs.gov.au/Ausstats/abs@.nsf/0/3F8A5DFCBECAD9C0CA2568A900139380?Open).

[224]   Data on gambling are analyzed in details by Katherine Marshall and Harold Wynne in “Fighting the Odds”, Perspectives on Labour and Income, Statistics Canada, Catalogue No. 75-001-XIE, Vol. 4, No. 12, December 2003, pp. 5-13 (http://www.statcan.ca/).

[225]   Paula Stewart et al., A Report on Mental Illnesses in Canada, published by Health Canada, October 2002.

[226] World Health Organization, Mental Health : New Understanding, New Hope, 2001, p. 23.

[227] Ibid.

[228] WHO (2001), p. 24.

[229] The WHO World Mental Health Survey Consortium, “Prevalence, Severity, and Unmet Need for Treatment of Mental Disorders in the World Health Organization World Mental Health Surveys”, Journal of the American Medical Association, Vol. 291, No. 21, 2 June 2004, pp. 2581-2590.

[230]   Data quoted in Charlotte Waddell et. al., Child and Youth Mental Health: Population Health and Clinical Services Considerations, Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, University of British Columbia, April 2002, p. 15.

[231]   Dr. Joseph H. Beitchman, Psychiatrist-in-Chief, Hospital of Sick Children (Toronto), Brief to the Committee, 30 April 2003, p. 7.

[232]   Charlotte Waddell et. al., “Child Psychiatric Epidemiology and Canadian Public Policy-Making: The State of the Science and the Art of the Possible”, Canadian Journal of Psychiatry, Vol. 47, No. 9, November 2002, pp. 825-832.

[233]   Dr. David Conn, Co-Chair, Canadian Coalition for Seniors Mental Health, Brief to the Committee, 4 June 2003, p. 4 and p. 6.

[234]   Alzheimer Society of Canada, Brief to the Committee, 4 June 2003, p. 3.

[235]   Margaret Gibson, Department of Psychology, University of Western Ontario, Brief to the Committee, 4 June 2003, p. 2.

[236]   Dr. David Conn (4 June 2003), p. 5.

[237]   National Defence, Statistics Canada CF Mental Health Survey: A “Milestone”, 2003.

[238]   Health Canada, Fetal Alcohol Spectrum Disorder, Brief to the Committee, 30 April 2003.

[239]   Canadian Mental Health Association – Ontario Division, Dual Diagnosis: People with Developmental Disability and Mental Illness – Falling Through the Cracks, Fact Sheet, 1998.

[240]   Stéphanie Langlois and Peter Morrison, “Suicide Deaths and Suicide Attempts”, Health Reports, Statistics Canada, Catalogue 82-003, Vol. 13, No. 2, January 2002.

[241]   With the exception of the territories.

[242]   Aboriginal Healing Foundation, Mental Health Profiles for a Sample of British Columbia’s Aboriginal Survivors of the Canadian Residential School System, Research Series, Ottawa, 2003.

[243]   Statistics Canada, “Health of the Off-Reserve Aboriginal Population”, The Daily, 27 August 2002.

[244]   Royal Commission on Aboriginal Peoples, Choosing Life: A Special Report on Suicide Among Aboriginal Peoples, 1995.

[245]   J.J. Chandler and C. Lalonde, “Cultural Continuity as an Hedge Against Suicide in Canada’s Fisrt Nations”, Transcultural Psychiatry, Vol. 35, No. 2, 1998, pp. 191-219.

[246]    Laurence J. Kirmayer, Gregory M. Brass and Caroline L. Tait, “The Mental Health of Aboriginal Peoples: Transformations of Identity and Community”, Canadian Journal of Psychiatry, Vol. 45, September 2000, pp. 607-616.

[247]   Mental Health Policy Research Group, Mental Illness and Pathways into Homelessness: Proceedings and Recommendations, Toronto, 1998.  Similar findings are reported by Stephen W. Hwang, “Homelessness and Health”, in Canadian Medical Association Journal, Vol. 164, No. 2, pp. 229-233, 23 January 2001.

[248]   Roger Boe and Ben Vuong, “Mental Health Trends Among Federal Inmates”, FORUM on Corrections Research, Vol. 14, no. 2, May 2002.

[249]   Correctional Service Canada, Brief to the Committee, April 2004, p. 13.

[250]   Thomas Stephens and Natacha Joubert, “The Economic Burden of Mental Health Problems”, Chronic Diseases in Canada, Vol. 22, No. 1, 2001.

[251]   Health Canada, Economic Burden of Illness in Canada, 1998, Government of Canada, 2002.

[252]   Ibid.

[253]   Ibid.

[254]   The information on The Global Burden of Disease is well summarized by the National Institute of Mental Health, The Impact of Mental Illness on Society, January 2001. This fact sheet is available at www.nimh.nih.gov.

[255]   Ibid.

[256]   WHO (2001), pp. 24-25.

[257]   Dale Clayton and Alberto Barceló, “The Cost of Suicide Mortality in New Brunswick, 1996”, Chronic Diseases in Canada, Vol. 20, No. 2, 1999, pp. 89-93.

[258]   E. Kevin Kelloway, Ph.D., Professor of Management and Psychology, Saint Mary’s University (Halifax, Nova Scotia), Brief to the Committee, 2004.

[259]   Heather Stuart, Stigma and Work, discussion paper commissioned by the workshop supported by the Institute of Population Health and the Institute of Neurosciences, Mental Health and Addiction of the Canadian Institutes of Health Research, April 2004, p. 80.

[260]   Gaston Harnois and Phyllis Gabriel (2000), Mental Health and Work: Impact, Issues and Good Practices, joint publication of the World Health Organization and the International Labour Organization, Geneva, 2000, p. 19.

[261]   Canadian Psychiatric Association, Mental Illness and Work, pamphlet available on the Internet (accessed on 15 June 2004).

[262]   Ontario Medical Association, Mental Illness and Workplace Absenteeism: Exploring Risk Factors and Effective Return to Work Strategies, April 2002.

[263]   Based on a sample size of 136 companies and 54,050 employees.  Data from Warren Shepell Consultants Corporation, Sector Review: Organizational Health & Wellness Trends in Manufacturing, March 2003 (available at www.warrenshepell.com).

[264]   Based on a sample size of 153 organizations with 86,000 employees across Canada.  Data from Warren Shepell Consultants Corporation, Sector Review: Organizational Health & Wellness: Trends in Technology, February 2003 (available at www.warrenshepell.com).

[265]   Global Business and Economic Roundtable on Addiction and Mental Health, Roundtable Roadmap to Mental Disability Management in 2004-2005, 25 June 2004, p. 4.

[266]   Warren Shepell Consultants Corporation, Sector Review: Organizational Health & Wellness Trends in the Healthcare/Hospital Sector, Winter 2004 (available at www.warrenshepell.com).

[267]   Dr. Sunil V. Patel, President, Canadian Medical Association, Brief to the Committee, 31 March 2004, p. 3.

[268]   Warren Shepell Consultants Corporation, Sector Review: Organizational Health & Wellness Trends in Retail/Hospitality, Winter 2004 (available at www.warrenshepell.com).

[269]   Bill Wilkerson, Since September 11th – The Business State of Mind: Mental Health in the Knowledge Economy, Speech before the “Beyond Awareness Conference (A Campaign to Reduce the Stigma of Mental Illness), 6 February 2002, p. 7.

[270]   Kathryn Wilkins and Marie P. Beaudet, “Work Stress and Health”, Health Reports, Statistics Canada, Catalogue 82-003, Winter 1998, Vol. 10, No. 3, pp. 52-53.

[271]   Renée Bourbonnais, Brigitte Larocque, Chantal Brisson and Michel Vézina, «Contraintes psychosociales du travail», in Portrait Social du Québec, Institut de la Statistique du Québec, 2001, pp. 267-277.

[272]   Warren Shepell Consultants Corporation, Workplace Trends Linked to Mental Health Crisis in Canada, Press Release, 15 November 2002.

[273]   Bill Wilkerson, A Business Charter for Mental Health an Addiction in the Knowledge Economy, Speech to the Ontario Public Service Commission and Management Board, 25 September 2002, Toronto, p. 9.

[274]   World Health Organization, Life in the 21st Century: A Vision for All, Geneva, 1998.

[275]   Bill Wilkerson, Text of Speech, Warren Shepell Consultants Business Forum, 16 October 2002, p. 14.

[276]   President’s New Freedom Commission on Mental Health, Interim Report, United States, 29 October 2002.

[277]   Ibid.

[278]   According to calculation by Thomas Stephens and Natacha Joubert, “The Economic Burden of Mental Health Problems”, Chronic Diseases in Canada, Vol. 22, No. 1, 2001.

[279]   Martin Shain et. al., Mental Health and Substance Use at Work: Perspective from Research and Implications for Leaders, Backgrounder, prepared for the Global Business and Economic Roundtable on Addiction and Mental Health, 14 November 2002 (unpublished).

[280]   Estimated by the Economics Division, Parliamentary Information and Research Services, Library of Parliament.

[281]   Bill Wilkerson (6 February 2002), p. 8.

[282]   Canadian Psychiatric Association, Insurability of the Psychiatrically Ill or Those With a Past History of Psychiatric Disorder, Position Paper, 1988.

[283]   Mental Health Works, Mental Health in the Workplace: Facts and Figures, Canadian Mental Health Association – Ontario Division, 2003.

[284]   Global Business and Economic Roundtable on Addiction and Mental Health (25 June 2004), p. 14.

[285]   Bill Wilkerson, Mental Health – The Ultimate Productivity Weapon, Summary of Remarks to the Industrial Accident Prevention Association Conference and Trade Show, Toronto, 22 April 2002, p. 5.

[286]   Unless otherwise indicated, the information contained in this section is based on the following document: Canadian Life and Health Insurance Association Inc., The Role of Disability Income Insurance Plans in Canada’s Disability Income System, Submission to the House of Commons Sub-Committee on the Status of Persons with Disabilities, May 2003.

[287]   Disability income insurance plans are frequently part of a group benefits program that includes extended health care coverage (which may include prescription drugs, special nursing services, and special services that fall outside government plans such as registered psychologists, chiropractors, massage therapists, etc.).

[288]   Bill Wilkerson (6 February 2002), p. 7.

[289]   Watson Wyatt Worldwide, Addressing Mental Health in the Workplace, June 2003.

[290]   Global Business and Economic Roundtable on Addiction and Mental Health, “Full-Time Employees in Canada Losing 35 Million Days of Work a Year Due to Mental Disorders; Half of All Days Lost to Illness and Disability”, Press Release, 14 July 2004.

[291]   Watson Wyatt Worldwide, Addressing Mental Health in the Workplace, June 2003.

[292] Canadian Psychiatric Association (1988), op. cit.

[293]   Bill Wilkerson, Notes for Remarks, 55th Annual Meeting of the Canadian Life Insurance and Medical Officers Association, 17 May 2004, p. 9.

[294]   Association of Workers’ Compensation Boards of Canada, Occupational Disease and Occupational Stress Legislation and Policies, 1998.

[295]   Carolyn S. Dewa, Alain Lesage, Paula Goering and Michèle Caveen, The Nature and Amplitude of Mental Illness in the Workplace, discussion paper commissioned by the workshop supported by the Institute of Population Health and the Institute of Neurosciences, Mental Health and Addiction of the Canadian Institutes of Health Research, April 2004, pp. 2-19.

[296]   Office of the Chief Actuary, Canada Pension Plan – Experience Study of Disability Beneficiaries, Actuarial Study No. 1, November 2002.

[297]   Wendy Steinberg, Position Paper on Federal Income Security Programs, prepared for the Canadian Mental Health Association, December 2001.

[298]   Subcommittee on the Status of Persons with Disabilities (Dr. Carolyn Bennett, Chair), Listening to Canadians: A First View of the Future of The Canada Pension Plan Disability Program, June 2003.

[299]   Human Resources Development Canada, Government of Canada’s Response to “Listening to Canadians: A First View of the Future of the Canada Pension Plan Disability Program”, November 2003, p. 22.

[300]   Dr. Sunil V. Patel, President, CMA, Brief to the Committee, 31 March 2004, p. 5.

[301]   Bill Wilkerson (6 February 2002), p. 6.

[302] Bill Wilkerson (6 February 2002), p. 8.

[303] Rod Phillips (18:9).

[304] Watson Wyatt Worldwide, Addressing Mental Health in the Workplace, June 2003.

[305]   Ibid.

[306]   Ash Bender et al., Mental Health and Substance Use at Work : Perspectives from Research and Implications for Leaders, background paper prepared for the Global Business and Economic Roundtable on Addiction and Mental Health, 14 November 2002.

[307]   Ibid.

[308]   Lana M. Frado, Diversity at Work: Accommodations in the Workplace for People with Mental Illness, Canadian Mental Health Association, 1993, p. 8.

[309]   Lana M. Frado (1993), p. 10.

[310] Canadian Psychiatric Association, op. cit.

[311] Mental Health Works (2003), op. cit.

[312] Gaston Harnois and Phyllis Gabriel (2000), op. cit., p. 47.

[313] Global Business and Economic Roundtable on Addiction and Mental Health (25 June 2004), p. 11.

[314] Ibid., p. 23.

[315]   Warren Shepell, “Warren Shepell Calls for Tax Incentives to Support Employer Mental Health Programs”, Press Release, 12 June 2003.

[316]   Canadian Mental Health Association (Ontario Division), Brief to the Committee, 12 June 2003, pp. 6-7.

[317] Additional information can be found at http://www.icomm.ca/ocab/.

[318] Heather Stuart (April 2004), p. 84.

[319] Honorable Michael Wilson, Text of Remarks, CIHR IRSC Workshop, 28 April 2004.


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