WORLD

THE ISSUE IN...

March 17 2008
WORLD

THE ISSUE IN...

March 17 2008

Mending

MINDS

The Alberta Mental Health Board's third annual Research Showcase brought mental health experts from around the world to Banff to shed new light on an illness that afflicts one-in-three Canadians at some point in their lives. Here's what they had to say—and why it matters to you.

IN THIS ISSUE:

THE TRAGIC IMPRINT OF CHILDHOOD ADVERSITY

DEPRESSION AND THE ELDERLY MENTAL HEALTH IN THE WORKPLACE THE CASE FOR EARLY INTERVENTION

ALBERTA MENTAL HEALTH BOARD

. Advancing Mental Health

[ INFORMATION SUPPLEMENT ]

"Sadly, mental illness continues to be cloaked in stigma..."

It's my pleasure to welcome you to this third annual issue of Mending Minds - a summary of information presented at the annual Alberta Mental Health Board Mental Health Research Showcase.

If mental health is not your field of study or work, you might wonder why you should read this. The answer is simple: mental illness affects us all.

Research shows that one in three people in our country will experience a mental illness at some point in their life. So, it's likely that someone you care about will be touched by mental illness—your spouse, your parent, your child, your friend, or your co-worker.

Given that reality, the general public needs to be knowledgeable about mental illness and mental health. That's why our

organization believes so strongly in this Special Report and sharing what was heard at Showcase with Canadians.

Sadly, mental illness continues to be cloaked in stigma created by myths. Believing that nothing can be done for someone with a mental illness is one of those myths. The truth is that treatments have been developed and progress continues to be made. Understanding mental illness and mental health is an important step to recovery and helping others. And it all starts with research.

Showcase brings together leading researchers from our country and around the world. During the three-day conference, researchers have an opportunity to share their experience and expertise with their fellow academics, policymakers, service providers, and those who access mental health services and their families. Bringing together these groups helps us to promote and apply mental health research for the benefit of those with mental illness, which is a key mandate of our organization and one of the priorities in Alberta's Provincial Mental Health Plan.

Collaboration is one of the reasons our conference is so successful. Word about the value of Showcase continues to spread around the world, and that buzz means that, each year, delegate spots fill up faster than the year before.

The annual Special Report you are about to read helps advance mental health through knowledge exchange and by combating the stigma around mental illness.

I hope this report encourages you to learn more about the stigma surrounding mental illness, and how to break it, so we can take the bold next steps needed to make a positive and meaningful difference in the lives of those struggling with mental illness.

Ray Block, PhD

President & CEO of the Alberta Mental Health Board

A M H B

ALBERTA MENTAL HEALTH BOARD

... Advancing Mental Health

The Alberta Mental Health Board (AMHB) is a provincial health authority that oversees and advances Alberta's mental health system, serves in an advisory capacity to government and works with health regions and public and private organizations to address systemwide mental health priority issues that span national, provincial, regional and organizational boundaries.

A research conference is not a rock concert. When a presenter completes an address, the usual response is a polite round of applause. Yet when the University of California's Vincent Felitti finished his hour-long talk at the third annual Alberta Mental Health Board (AMHB) Mental Health Research Showcase conference, the audience spontaneously sprang to their feet and gave him a rousing standing ovation.

How to explain this unusual reception? The fact is that, in a mere 60 minutes, Dr. Felitti shed new light on one of the most profound, and potentially disturbing, aspects of the human condition—that we are all shaped, for good or for ill, by our early childhood experiences.

Dr. Felitti is Co-Principal Investigator of the Adverse Childhood Experiences (ACE) study, an ongoing collaborative research project between the California-based Kaiser Permanente Medical

2007 AMHB Research Showcase

Care Program and the Centers for Disease Control. The ACE study is a long-term evaluation of over 17,000 middle-aged, middle-class Kaiser Health Plan patients. The study matches their current health status against a total of 10 categories of childhood abuse, neglect and family dysfunction that occurred, on average, a half-century earlier.

The ACE study found a devastating link between childhood suffering and subsequent life experiences, including depression, alcoholism and suicide. "Adverse childhood experiences are common, but typically unrecognized," Dr. Felitti told the 400 delegates at the Showcase conference, which annually shines a light on the very best mental health and addictions research worldwide. "The link to problems later in life is strong and logical."

Dr. Felitti described the unusual inspiration for the ACE study.

He and his colleagues had developed a weight-loss program that used the technique of supplemented fasting to help severely obese individuals shed up to 300 pounds of weight without surgery. But the program had a high dropout rate—limited almost exclusively to patients who had successfully lost weight. "The counterintuitive aspects of that really drove me nuts,"

Dr. Felitti told delegates.

In-depth interviews with some of the dropouts began to provide an explanation. Dr. Felitti cited the case of a woman who entered the program in 1984 weighing 408 pounds. Within 51 weeks,

Dr. Felitti's study shows that adversity in childhood leads to much higher rates of depression, substance abuse and suicide later in life.

she lost 276 pounds. She stayed stable for several weeks but then, in a mere two-week period, regained 37 pounds. When Dr. Felitti asked what was going on, the woman said she was "sleep-eating"—she would go to bed and later find dirty pots and pans and other evidence of binge eating. After pressing her on why she might be doing this, the woman told him about a work colleague—a much older, married man—who made sexual advances after her weight loss. Ultimately, she told him about a lengthy history of childhood incest at the hands of her grandfather.

"Suddenly," said Dr. Felitti, "even her job made sense. She was a nurse's aide on the night shift in a convalescence hospital. She was paid to be awake and on her feet all night when the old people were in bed."

The woman soon regained all her lost weight. She disappeared, only to resurface 12 years later, when she underwent stomach surgery. After shedding 98 pounds, she became suicidal and landed in a psychiatric hospital five times over the next year.

After interviewing nearly 300 other weight program dropouts who had similar stories of childhood abuse and neglect,

Dr. Felitti and his colleagues concluded that severe obesity often masked a much deeper problem. They decided to research the prevalence of adverse childhood experiences in a very mainstream population and its impact on subsequent health status. The result was the ACE study—and some truly disturbing findings.

The 10 categories of childhood adversity studied include three sub-groups. Under abuse, there is emotional (recurrent humiliation), physical (beating, not spanking) and sexual. Under household dysfunction, the factors are: mother treated violently; household member was alcoholic or drug user; household member was imprisoned; household member was chronically depressed, suicidal, mentally ill, or in a psychiatric hospital; or the individual was not raised by both biological parents (divorce being the most common reason). Finally, there are the two categories of neglect— physical and emotional.

The ACE score is based on the number of categories of adverse experience during the first 18 years of life, with each category scoring as one point. There is no extra scoring for multiple offenders or offences. Thus, if you grew up with two alcoholic parents, that still scores as one point. The same is true if you were molested multiple times by five different people.

If anything, observed Dr. Felitti, the survey tends to understate the actual level of abuse and neglect.

Dr. Felitti stressed that the people studied are well educated and broadly representative of middle-class America. "In no way can you dismiss this population as strange or aberrant," he told delegates. "The risk is that this is really you and me."

Yet the amount of adversity revealed by the survey is staggering. For example, 28 per cent of participants had been beaten as children, 22 per cent were sexually abused and 27 per cent lived in a household where at least one member was an alcoholic or a drug user.

Only one-third had an ACE score of zero. If any one category was present, there was an 87 per cent likelihood of at least one more category being present. One in six individuals had an ACE score of 4 or more; one in 10 had an ACE score of 5 or higher.

Then there are the links to adult tragedy and trauma. Individuals with an ACE score of 4 were four times more likely to suffer chronic depression than those with a zero score, while their likelihood of attempting suicide increased by a factor of 1,250 per cent. At an ACE score of 4, you were also 550 per cent more likely to become an alcoholic; at a score of 6 or more, you were 4,600 per cent more likely to become an intravenous drug user.

This year's AMHB Showcase included a keynote address by Margaret Trudeau, who became the youngest Prime Minister's wife in Canadian history when she married Pierre Elliot Trudeau at the age of 22. Ms. Trudeau, who raised five children, has suffered from the debilitating effects of bipolar condition all of her adult life. Now, after seeking medical treatment that has given her life balance and happiness, she advocates strongly on the need to promote better mental health and overcome public stigma. She also works with the Royal Ottawa Hospital to raise funds for their new hospital and increase public awareness about mental health issues.

Ms. Trudeau gave delegates a moving account of her personal struggles with mental illness and her journey towards recovery. She credited a comprehensive program of medication, therapy, nutrition and physical exercise with restoring her mental health and helping her find a positive balance of mind, body and spirit. She also urged delegates to continue to reach out and help those who experience mental health problems, but who may be reluctant to seek treatment because of the stigma so often associated with mental illness.

Childhood adversity even appears to impact future physical health. As ACE scores go up, so does the likelihood of liver disease, chronic obstructive pulmonary disease and coronary heart disease.

As Dr. Felitti told delegates, the ACE study helps answer an age-old question: how is it that the golden promise of the newborn can so often turn into the leaden reality ofthat individual's adult life? For medical practitioners, he added, the study underscores the importance of fully exploring and understanding their patients' life history. And for health care planners, it reinforces the need for early intervention.

"The magnitude of the problem is so huge and so complex that it isn't realistic to think we can deal with it in a meaningful way by treatment after the fact," said Dr. Felitti. "The only way it can be done is through primary prevention."

Dr. Felitti's presentation was an

outstanding example of what the AMHB Showcase is all about. Each year, the conference brings top-flight mental health and addictions researchers and clinicians from across Canada and around the world to Banff. For three days, the experts present their latest research findings and interact closely with Showcase delegates, including front-line health workers, policymakers and mental health consumers and their families.

Hosting the Showcase conference flows naturally from the AMHB's ever-evolving mandate. The board is the provincial health authority that oversees and advances Alberta's mental health system. The AMHB is involved in numerous initiatives, including advocacy, policy advice and working with regional health authorities and stakeholders to improve and facilitate mental health research and services.

In 2004, the AMHB helped develop a province-wide mental health plan, which sets out a vision for making Alberta a world-class leader in mental health research. The board is now implementing that plan by focusing on four key themes: the effectiveness of mental health services, child and adolescent mental health, workplace mental health issues, and mental illness and addictions.

The AMHB is also in charge of monitoring a three-year, $75 million Innovation Fund from the Alberta Health and Wellness ministry to advance new ideas for improving the mental health system. Another $7 million has been raised to date to support the Alberta Centennial Mental Health Research program. Through this initiative, the AMHB and its partners plan to attract leading mental health experts to research chair positions at Alberta universities. The objective: to provide strong, credible research that will result in effective mental health treatment and prevention programs.

All of these initiatives, in fact, are about reaching out and making a real difference in the lives of those who struggle with mental illness and addictions. As AMHB Chair Dr. Jean Ference told Showcase delegates in Banff: "Not taking steps to ensure good mental health comes with costs. It costs us as individuals and families. It costs us as a society. And it costs us economically."

The vision being pursued by the AMHB extends far beyond Alberta's boundaries. The AMHB collaborates regularly with inter-provincial, national and international partners.

The B.C. Mental Health & Addictions Services and Saskatchewan Health were co-sponsors of the 2007 Showcase, and researchers from those two provinces figured prominently in conference presentations.

The third co-sponsor of the conference, the Alberta Alcohol and Drug Abuse Commission (AADAC), works closely with the AMHB on a number of fronts. As AADAC Chair Harvey Cenaiko reminded delegates, "Mental health issues and addictions often go handin-hand—and both have a serious impact on our families, communities and economies."

Going forward, the AMHB will also collaborate with the recently established Mental Health Commission of Canada (MHCC), headquartered in Calgary. In a brief address to delegates,

John Service, Executive Director of the MHCC, described the Commission's three key initiatives. They are: a 10-year national anti-stigma campaign, a knowledge exchange centre to help disseminate mental health research, and a national strategy to address mental illness. "Together," said Dr. Service, "I think we can make quite a difference over the next 10 years."

Working with these partners, and others, the AMHB will continue to play a significant role in reforming Canada's mental health system—with the information gleaned from the Research Showcase helping to pave the way. As they had at the two earlier conferences, delegates resisted the lure of the snow-peaked Rockies in favor of marathon presentations and networking.

For three days, November 21 to November 23, 2007, they listened intently to expert speakers and peppered them with probing questions. They pored over more than 100 academic abstracts on everything from eating disorders to meeting the housing needs of people with mental illness. They reached out to each other for advice and expertise and came away more determined than ever to harness the best in research to advance mental health.

What follows are some highlights of what this year's Showcase conference participants learned.

PRIMED TO HEAL: DELIVERING EFFECTIVE MENTAL HEALTH CARE

"If you put five experts in a room, they'd ail want to be perfect. There isn't enough money in our health care system for perfection, but there is enough money for good. He can't let the perfect be the enemy of the good. "

GAVIN ANDREWS, SCIENTIA PROFESSOR, SCHOOL OF PSYCHIATRY, UNIVERSITY OF NEW SOUTH WALES, SYDNEY, AUSTRALIA, AMHB SHOWCASE

One of the biggest challenges facing the mental health system is the gap between the demand for services and the resources available to respond to those needs. Many suffer. Far too few are being helped.

One in three individuals will experience a mental health problem at some point in their lives. In Canada, that translates into more than 10 million people. It's been estimated that mental illness costs the Canadian economy $33 billion each year in disability and lost productivity. We currently spend another $6 billion to $8 billion annually to treat mental disorders. More hospital days are consumed by people with a mental illness than by cancer and heart disease patients combined.

At the same time, research shows that two-thirds of adults who experience mental illness never seek help; for adolescents, the figure is 75 per cent. Of those who do seek treatment, the majority will first report symptoms to family physicians who are often ill equipped to recognize or deal with mental illness.

Delegates to the Showcase conference heard from Canadian and international experts on recent initiatives to improve the delivery of mental health services in primary healthcare. Common themes included the need to innovate, make better use of existing and emerging resources, and enhance the level of contact and collaboration between health care practitioners.

Dr. Gavin Andrews is both a practicing psychiatrist and a leading researcher and mental health reform advocate in his native

Australia. Working with data collected through the exhaustive Australian Survey of Mental Health and Well-Being, Dr. Andrews and a team of experts resolved to identify the number of people in need and calculate the resources required to meet their individual needs. Their conclusion: a 30 per cent increase in mental health spending would reach 60 per cent more people than is currently the case and generate a 90 per cent increase in health gains.

In what was dubbed the Tolkien II project, Dr. Andrews and the other experts looked at a total of 15 mental disorders, the amount of money currently being invested in treating those conditions and the health benefits gained. They then asked, if money were no object, what would an optimum level of treatment entail? In the end, they determined that providing ideal care would cost little more than current care. But it would mean re-allocating resources and committing to do things differently.

"No country in the world can afford all of the health care its citizens want or need,"

Dr. Andrews told delegates. "So we had better understand about setting priorities. As a clinician, it's my moral duty to fight for every dollar I can get for my patients. But as a health care planner, I understand there isn't enough for everyone and that, for every dollar I misspend, I take that away from another human being who warrants treatment."

Dr. Andrews said serious disorders like schizophrenia would require increased funding to achieve an ideal level of care.

But more common conditions, such as social phobia, could actually be treated at a reduced cost.

One of the keys is to harness technology. Dr. Andrews cited two recent studies of Web-based programs that are now being used in Australia to treat individuals with social phobia. "And here's the shock," he said. "The people we got over the Internet are of the same severity as those who come to our anxiety disorder clinic, which is considered world-class. They made the same level of improvement as the ones treated at the clinic—and at a quarter of the cost."

For similar reasons, Dr. Andrews is a strong advocate of using electronic medical records to accurately and efficiently track the progress of patients through the health care system. "We need to use technology to free us up to do what we do best," he said. "There are new advances coming. We should open our minds and use them."

In the wake of the Tolkien II project, governments across Australia significantly increased their mental health care budgets. If spent wisely, Dr. Andrews is confident the new resources will make a real difference in the lives of people coping with mental illness.

Delegates also heard about initiatives in Alberta to help family physicians deal with mental health issues by linking them with psychiatrists and other experts.

Michael Trew, Medical Director, Primary Care & ConsultationLiaison Psychiatry, Department of Psychiatry, for the Calgary

Health Region, described the role played by the Shared Mental Health Care program. Established in 1998, the program sees consultants (psychiatrists or clinicians) go to the primary care offices to either discuss cases or meet jointly with the family physician and patients. Regular times are then set aside for "shared care" sessions involving the consultants (between one and four hours a month).

Dr. Trew said the program is intended to help family physicians detect and treat mental illness—and according to the most recent evaluation, it appears to be working. Based on results from 1,125 patients and 75 family physicians, 72 per cent of the doctors said their skills in managing mental health problems had improved.

The patients meanwhile reported that their mental health problems caused fewer negative effects on their lives and they felt more satisfied with the services being provided by their physician.

Delegates also learned about a Primary Care Network (PCN) recently created to improve mental health services for residents of the City of St. Albert and Sturgeon County, just north of Edmonton. The network includes 40 physicians. Roaming mental health coordinators work with the physicians to help link patients to the proper medical and community services— including psychiatrists, dieticians and social service workers.

"Our role is to help navigate the system," said Holly Brown, a PCN mental health coordinator. "Key to this is figuring out a patient's individual needs, clarifying diagnoses and looking at where they've been and what they've already tried."

Ms. Brown added that, prior to creating the PCN, "patients were falling through the cracks and doctors were feeling very frustrated." After the first year in operation, all 40 physicians reported that the network had improved the quality of patient care while also increasing their own awareness of available resources.

Success, though, created some new challenges. The network resulted in more patients being identified with mental health needs—an increased demand the system is not yet able to accommodate in a timely manner. "We're at capacity right now and three-month wait lists for newly diagnosed patients is typical," said Ms. Brown. "So the question we now face is: how do we bridge that treatment so you are not left floundering for three months?"

When it comes to delivering mental health services one province— Saskatchewan—is a clear pioneer. Tommy Douglas, Saskatchewan's premier and minister of health for almost two decades (19441961), considered mental health a top priority. In 1946, Douglas appointed psychiatrist and academic Donald Griffith McKerracher as the province's first Commissioner of Mental Health. In short order, Dr. McKerracher opened a permanent outpatient clinic in Regina, the first of its kind in North America, and launched the first fully funded province-wide research program in psychiatry. In 1950, Saskatchewan became the first Canadian province to provide universal free health care for people with mental disorders.

Saskatchewan was also a leader in providing community-based treatments for the mentally ill. Between 1963 and 1966, nearly three quarters of the 1,500 patients at the Weyburn Psychiatric Hospital were transferred into the community—the largest and fastest rate of deinstitutionalization attempted to that point.

These landmarks were recounted at the Showcase conference by Raymond Tempier, Head of the Department of Psychiatry at the University of Saskatchewan. Dr. Tempier suggested a similar pioneering spirit might be in order as Saskatchewan grapples with current challenges to provide psychiatric care to large Aboriginal and elderly populations and to rural and remote parts of the province.

"Mental health problems are huge in our society," said Dr. Tempier, "and one thing that's very important is mental health promotion and education. We need to make the public a partner in all that we do so they can work within their own communities and families to help provide the care that's needed."

LIFE LESSONS: MENTAL HEALTH AND AN AGING POPULATION

"When an elderly person has the feeling that life is not worth living, you should always check for depression. Having lost interest in life is not a normal consequence of aging. "

INGMAR SKOOG, PROFESSOR, INSTITUTE OF NEUROSCIENCE AND PHYSIOLOGY, SHLGRENSKA ACADEMY AT G0TEB0RG UNIVERSITY, SWEDEN, AMHB SHOWCASE

The world, quite literally, is getting older.

Today, there are almost 500 million people above the age of 65. By 2050, that number will have increased three-fold. During the same period, the number of people aged 80 or older is expected to climb from 87 million to almost 400 million.

In Canada, the same trend holds true. In 1921, only five per cent of Canadians were 65 years or older. By 2031, it's expected nearly one-quarter of the population will be in this age group.

All of this has significant implications for the health care system. Seniors seek out medical help more frequently than younger people and put more demand on acute care beds and other resources.

But as conference delegates heard, one of the hardest truths is that aging is linked to high rates of two common mental disorders—dementia and depression.

Sweden's Dr. Ingmar Skoog reported on a series of studies that tracked people as they aged over the past four decades. One study looked at a group of 70 year-olds starting in 1971 and followed them through to the age of 100. Another, begun in 1968, involved women between the ages of 38 and 60; the last follow-up of this group occurred in 2005, when they were between 75 and 105. Yet another research project—most likely the largest of its kind in the world—has so far studied 950 people above the age of 95.

These studies show that the prevalence of dementia increases dramatically with age.

At age 70, three per cent suffer from this disorder. The proportion then increases to 11 per cent by age 79, to 30 per cent by age 85, and to 50 per cent by age 95.

While the relationship between aging and dementia is well established, the Swedish studies also suggest depression is more common in older people than previously recognized—and that it often goes undiagnosed.

"It's commonly thought the prevalence of depression may decrease after age 65," said Dr. Skoog. "But that's because earlier studies looked at the whole population over 65 and treated it as one entity."

Dr. Skoog explained that the lowest incidence of depression is in the 10 years after retirement—a period that appears to be the happiest and least stressful time in most people's lives.

But the studies also show the incidence of new depression increases between the ages of 70 and 85. Among those 85 and older who are not suffering from dementia, fully 20 per cent experience depression.

Depression in the elderly can have serious physical consequences. The Swedish studies show that people over 85 who are depressed are twice as likely to suffer a stroke—in fact, depression is a stronger risk factor in this age group than hypertension. Depression is also a key factor in suicide by the elderly.

Dr. Skoog noted that no matter how frail, or even bedridden, a person gets, the will to live persists. Among 85 year-olds who do not suffer from dementia, he found only four percent felt life was not worth living. That's why it's important to look for undiagnosed depression when someone says they have lost interest in life.

Such feelings can, in fact, be a self-fulfilling prophecy. Research shows that 43 per cent of elderly women who felt life was not worth living actually died within three years, compared to 14 per cent who didn't have that feeling. Losing the will to live proved to be more fatal than 20 other analyzed disorders, including cardiovascular disease and cancer. "So when you actually lose

your faith in life, you are also at risk of dying," observed Dr. Skoog. "And this is very unnecessary because the majority of these people have depression."

As for dementia, it's a difficult disorder to predict—and, therefore, to prevent. But one of Dr. Skoog's colleagues,

Goteborg University Associate Professor Deborah Gustafson, told delegates there are some precautions that have at least the potential of delaying or averting the onset of dementia.

The biggest risk factor for dementia, said Dr. Gustafson, is aging itself—a person has to live long enough to enter the age range where dementia becomes commonplace. But there are several other factors that have been linked to a higher risk of dementia, including hypertension, heart disease, stroke, diabetes, obesity and smoking.

What might help protect against dementia? Vitamin supplements, a diet that includes fish or fish oil, and moderate alcohol intake (particularly of red wine) are all shown to have beneficial effects. Controlling high blood pressure and watching one's weight are also helpful.

In the absence of knowing if you are likely to develop dementia, Dr. Gustafson believes the most prudent approach is a lifelong commitment to health and wellness. "I'm just a lifestyle advocate from the get-go," she said. "We have to teach people to stay active, to watch what they eat and to take care of their health. It may have a smaller effect on prevention, but in terms of improving quality of life, it's going to have a big pay-off."

An aging population also means health care planners must be taking steps today to prepare for increased demands on mental health services tomorrow.

Mel Slomp, Director, Information Management for the AMHB, told delegates that, if current trends persist, physicians in Alberta would be seeing an additional 23,000 individuals with dementia by 2030 as compared to 2006. Based on the current average of 12 physician visits per dementia patient, that translates into an additional 250,000 visits. Similarly, the 41,000 patient days in acute care and psychiatric facilities now generated by Albertans with dementia is projected to increase to 104,850 days by 2030.

What's required, said Mr. Slomp, is a range of strategies to improve mental health services for the elderly. These include an increase in the number of psychiatrists and gerontologists, more beds for the elderly in acute and psychiatric hospitals, more support for caregivers and a wider range of home care and outpatient options.

Mr. Slomp concluded his presentation with a question—and a challenge. "The baby boomers are relatively wealthy," he said. "They are politically connected and have high expectations about their health care. So how can some of those characteristics be used to leverage the change that needs to happen?"

BOTTOM LINE BLUES: MENTAL HEALTH AND THE WORKPLACE

"We've got o lot of work to do in creating healthy workplaces because it reguires a huge culture shift. A lot of organizations don't want to do it because of cost. But the new reality is that, if you don't get on top of this, you are going to have trouble recruiting and retaining the employees you need. "

PETER COLERIDGE, VICE PRESIDENT, EDUCATION AND POPULATION HEALTH, BC MENTAL HEALTH & ADDICTION SERVICES, AMHB SHOWCASE

Canadian employers are starting to appreciate the enormous costs—both emotional and financial—of mental illness in the workplace. Research shows that one in four employees struggle with mental health issues, most commonly depression or anxiety. It's estimated that mental illness results in 35 million workdays lost each year in Canada. Mental disorders also account for up to 40 per cent of short-term disability insurance claims and are a secondary diagnosis in more than 50 per cent of long-term claims.

With 72,000 employees, Canada Post is well aware of this phenomenon. Robert Waite, Senior Vice President, Stakeholder Relations and Brand, Canada Post, told Showcase delegates that 37 per cent of the Crown Corporation's disability claims in 2006 were due to depression or anxiety. The third largest cost for the Canada Post drug coverage program related to medications used to treat depression and other mental disorders.

In the autumn of 2007, Canada Post embraced mental health as its "cause of choice"—the first major Canadian company to do so. As part of this effort, Canada Post employees are now attending workshops to raise awareness about the challenges facing those who struggle with mental illness. Employees also have full and immediate access to experienced professionals to help them deal with mental health concerns before these affect their work and family life.

In addition to creating a healthier workplace culture, Canada Post is hoping to boost the public profile of mental health. Among other initiatives, Canada Post is now the title sponsor of Mental Health Awareness Week and, in 2008, plans to issue the first-ever mental health awareness postage stamp.

"Our biggest job/' said Mr. Waite, "is to get people not to be frightened to come forward with their problems or to help their fellow employees. We want to lead the charge to dispel the persistent stigma that prevents millions of sufferers across Canada from getting the help they need. We hope our involvement will raise awareness and perhaps set an example for other companies out there."

In fact, at a time of chronic labour shortages, good mental health in the workplace is becoming critical to corporate survival. That was part of the message brought to Showcase delegates by British Columbia's Peter Coleridge. Young people today, said Coleridge, value employers who understand the importance of work/life balance and who foster positive, respectful relationships among co-workers.

Mr. Coleridge outlined a five-year plan recently launched by the Provincial Health Services Authority (PHSA) to improve mental health work conditions. It began with a comprehensive employee survey to elicit information on current mental and physical health status. The plan also includes initiatives to promote employee mental health through web-based self-assessment programs as well as courses to help managers and directors recognize signs of mental illness and respond in a compassionate and supportive manner.

Moving forward, the PHSA plan will introduce better screening for depression as well as periodic health monitoring for high-risk occupational groups. It will also look at helping workers return to the job following a disability leave and preventing relapses.

In addition to improving the conditions for PHSA workers, said Mr. Coleridge, the plan could provide valuable information for promoting mental health in other public and private sector workplaces. "We need to make sure it's not just talking the talk, but walking the walk," he said. "We are committed to implementing activities that will make a real difference."

About a quarter of Canada's population lives and works in rural areas and small towns. Providing mental health services to the rural workplace presents some unique challenges.

Carl D'Arcy is Professor and Director of Applied Research, Department of Psychiatry, at the University of Saskatchewan. Dr. D'Arcy, who was trained as a sociologist, told Showcase delegates that the popular image of rural Canada as bucolic or idyllic is often misleading when it comes to personal health. Obesity and smoking rates are higher in rural areas and preventative medical procedures are less accessible. There are fewer primary physicians and far fewer specialists, including psychiatrists.

While rural Canada is often associated with farming, forestry and fishing, Dr. D'Arcy noted that the biggest employer is actually the retail and wholesale trade sector. And when it comes to mental disorders and substance abuse, research shows that sales and service workers have some of the highest prevalence rates.

"People who work under much more structured situations, and with more demands on their time, are more likely to experience stress and psychiatric disorders," said Dr. D'Arcy. "It comes down to the degree of control you have over your work life. The less control you have, the more likely you will suffer from these disorders."

Given the expanse of rural Canada, Dr. D'Arcy said we must think more creatively about how to deliver mental health services. He sees great potential for Web-based mental health promotion and treatment programs as well as telephone-based counseling services. He also welcomes initiatives like the Australiandesigned Mental Health First Aid program, which teaches ordinary people how to detect the signs of mental illness in others and to help direct them to proper sources of care (see sidebar, page 11).

Governments have also received the message about the need to encourage healthy workplaces— starting with efforts to build and educate tomorrow's workforce. Iris Evans, Alberta Minister of Employment, Immigration and Industry, told Showcase delegates about two such programs supported by her department.

The first, Roots of Empathy, is a classroom program for kindergarten to Grade 8.

A companion program,

Seeds of Empathy, is being introduced in 2008 for

children three to five years old in early childhood centres. Both programs are aimed at improving social and emotional competence and increasing empathy.

Ms. Evans urged delegates to keep pressing politicians to do more, "I want you all to send an email to your representatives, telling them to pay attention to mental health issues. Because it's too easily something we keep in the closet and treat with shame."

BACK TO THE BASICS: THE CASE FOR EARLY INTERVENTION

"We're realty focusing on universal prevention. We want to promote mental health and appropriate social behaviours in all students. "

LYNN DAMBERGER, AMHB DIRECTOR OF ADVOCACY AND LIASON,

AMHB SHOWCASE

A recurring theme at the Showcase conference was the need to intervene early to promote better mental health starting at a young age. The proverbial ounce of prevention continues to outweigh any pound of cure.

This truism was reinforced in a presentation by Anja Huizink, an Associate Professor with the Department of Child and Adolescent Psychiatry at the Erasmus Medical Centre in Rotterdam, The Netherlands. Dr. Huizink reported on studies that used classroom games to encourage good behaviour among elementary school students who suffer from Attention Deficit Hyperactivity Disorder (ADHD). In addition to reducing the level of disruptive and anti-social behaviour by children with ADHD, followup with the students showed that nine year-olds who received the behaviour management intervention were less likely than other children with ADHD to take up smoking by age 10 or 11.

Early intervention has become a top priority for Canadian health authorities as well. In 2006, Alberta's Health and Wellness ministry provided the AMHB with $38.9 million in new funding over three years to support children's mental health programs. This included $25.8 million for a program known as Mental Health Capacity Building in the Schools, which began with five pilot projects in 2005 and is now being expanded to up to 27 other sites across Alberta.

Showcase delegates received a progress report on the five pilot projects from co-leads Lynn Damberger, Director of Advocacy and Liaison for the AMHB, and Sandra Woitas, a prominent Edmonton-based educator. The initiatives are: a project in elementary schools in the small southern Alberta city of Brooks to help immigrant youth and their families adapt; another in Calgary high schools that reaches out to students from African refugee families; a program at Edmonton's Jasper Place High School aimed at Grade 10 students, many of them Aboriginal, who are at risk of failing or leaving school due to various social, emotional and environmental factors; and two other projects in northern Alberta—one for students in Peace River who exhibit risk-taking behaviours and another for students in High Level who may face difficulties when transitioning between grade levels.

The common theme in all these projects is the need to involve a multidisciplinary team (including educators, therapists, family

Betty Kitchener, Program Director, Mental Health First Aid, Australia

Over the years, Australian Betty Kitchener has been a primary school teacher, a psychological counselor, a coronary care nurse, a trauma research officer and a stay-at-home mother. Ms. Kitchener has also suffered from recurrent major depression, an experience that gave her insight into the sense of helplessness and stigma that is so often associated with mental illness.

"When you're depressed, you feel so rotten, so inadequate, and that just confirms your worst fears," says Ms. Kitchener. "You also have to deal with two types of stigma—the stigma from others and self-stigma. And often the biggest one is self-stigma. I had it. Your thinking is, 'I'm hopeless. I'm helpless. I might as well kill myself because I'm a smudge on the world.' It really is a vicious circle."

Over the past decade, Ms. Kitchener has brought her professional and personal experience to bear on a program that is now helping people with mental illness around the world. Together with her husband, Dr. Tony Jorm, an internationally recognized mental health researcher, Ms. Kitchener developed Mental Health First Aid, which teaches ordinary people how to detect signs of mental illness in others and help them find the care they need.

Since it was launched in 2001, more than 50,000 Australians have been trained in Mental Health First Aid.

The course has since spread to Great Britain, Hong Kong, Finland, and Singapore. In 2006, the Alberta Mental Health

resource workers and public health nurses) to deal with potential mental health concerns before they reach the crisis stage.

The need for early intervention was also the cornerstone of Alberta Health and Wellness Minister Dave Hancock's closing address to the conference. Borrowing a phrase from Australia's Dr. Gavin Andrews, Mr. Hancock told delegates, "We can't afford to mend, so we must prevent." He then added: "No matter how wonderful our health care system is, we're never going to be able to afford it going forward if all of us need it all the time. To preserve and improve our system, we have to learn how to prevent."

Mr. Hancock urged delegates to take back to their home communities what they had learned from the three-day conference and to continue reaching out to help those who struggle with mental illness. "Thank you for making this an important part of your life," he said. "You are doing very important work." ■

Board (AMHB) brought the program to Canada and is now coordinating its roll out across the country as Mental Health First Aid Canada (MHFA Canada).

Ms. Kitchener came to Banff to attend the 2007 AMHB Research Showcase and talk about Mental Health First Aid.

In a presentation to delegates, she described the program's five-point action plan. First, trainees are taught to assess the risk of suicide or harm on the part of those they suspect may be developing or experiencing a mental health problem. Second, they are told to listen non-judgmentally to these individuals. Third, they are asked to provide reassurance and information. Fourth, they encourage those in need to get appropriate professional help. Fifth, they support the use of self-help strategies.

As with physical first aid, the program maintains that it isn't necessary to be a trained health professional to offer initial help or support. "This is not teaching you to be a counselor," Ms. Kitchener told delegates, "just as the regular first aid doesn't teach you to be an ambulance attendant or an emergency room triage nurse. This is just teaching you to be the first responder. It's the very first early intervention"

The 12-hour course has been rigorously evaluated in Australia and found to be effective. For example, surveys show that, six months after taking the course, trainees report they are much more confident about providing help and urging people to seek professional counseling. Another study showed over three-quarters of participants had used the skills they were taught.

Ms. Kitchener told delegates she was frankly amazed at the program's popularity. "It's spread like wildfire, which we never imagined," she said. "I really don't think it's all that clever; we simply brought together the information that was out there. I guess it's just the right thing at the right time."

See the MHFA Canada website at www.mentalhealthfirstaid.ca for additional information, including details about upcoming courses being offered across Canada.

Showcase Partners

The Alberta Mental Health Board gratefully acknowledges the support of the following organizations in presenting this Special Report:

AADAC (the Alberta Alcohol and Drug Abuse Commission) is an agency funded by the Government of Alberta to assist Albertans in achieving freedom from the harmful effects of alcohol, other drugs and gambling.

BC Mental Health & Addictions Services is an agency of the Provincial Health Services Authority. The agency provides a diverse range of mental health services to British Columbians and contributes significantly to research and knowledge exchange in the field of mental health.

The Mental Health Commission of Canada is a non-profit organization created to focus national attention on mental health issues and to improve the quality of life for Canadians with mental illness and their families (for more information, see www.mentalhealthcommission.ca).

Saskatchewan Health supports Saskatchewan residents in achieving their best possible health and well-being. Saskatchewan Health establishes policy direction, sets and monitors standards, provides funding, supports regional health authorities and ensures the provision of essential and appropriate services.

On The Cover

The individuals featured on the cover of Mending Minds were just some of the speakers at this year's AMHB Research Showcase. They are: (Top cover frame, left to right): Gavin Andrews, Scientia Professor, School of Psychiatry, University of New South Wales, Sydney, Australia; Sykes Powderface, Cochair, AMHB Aboriginal Mental Health Wisdom Committee; Lynn Damberger, Director of Advocacy and Liason for the AMHB, and Sandra Woitas, Education Manager, Alberta Education.

(Bottom cover frame, left to right): Jean Ference, Chair, AMHB; Deborah Gustafson, Associate Professor, Goteborg University, Sweden; Peter Coleridge, Vice-President, Education and Population Health, BC Mental Health & Addictions Services; Carl D'Arcy, Professor and Director of Applied Research, Department of Psychiatry, University of Saskatchewan.

For more information about the Alberta Mental Health Board, please see www.amhb.ab.ca

For more information about The Alberta Mental Health Research Partnership Program, please see www.mentalhealthresearch.ca