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What is the Fit between Mental Health, Mental Illness and Ontario’s Approach to Chronic Disease Prevention and Management?

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I Introduction

As the provincial health system is shifting from a focus on acute care to the prevention and management of chronic diseases, the Canadian Mental Health Association, Ontario (CMHA Ontario) has prepared a discussion paper on the fit of mental health and mental illnesses within Ontario's approach to chronic disease prevention and management, and a policy paper to initiate action to address co-existing mental health and physical chronic conditions. We are currently engaging stakeholders to raise awareness of the issues and opportunities, and to discuss our recommendations.

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II Overview

Physical and mental health are intensely intertwined yet health systems tend to address them separately. Nowhere is this more evident a problem than in the area of chronic disease. Poor mental health and mental illness are risk factors for chronic physical conditions and people living with chronic conditions often experience poor mental health.  (Note: Because mental illnesses are sometimes considered to be chronic diseases, the terms "mental illnesses" and "chronic physical conditions" are used in this article rather than "chronic diseases.")

  • Mental health affects chronic disease in several ways.
  • Mental illnesses are sometimes perceived as chronic illnesses.
  • People experiencing poor mental health are at higher risk of developing chronic physical conditions than those with good mental health.
  • People with severe and persistent mental illnesses are at significantly high risk of several chronic physical conditions.
  • People living with chronic physical conditions are at higher risk of developing depression

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Improving the prevention, recognition and treatment of depression

Depression is the leading cause of disability and the fourth leading contributor to the global burden of disease. [1] Just over 12 per cent of Canadians have experienced depression in their lifetimes. [2] The Ministry of Health and Long-Term Care has identified depression as one of the top 10 chronic conditions in terms of disease burden and economic costs. [3] Although not all depression is chronic, it is important for those involved in chronic disease prevention to recognize the significant impact depression has on both the risk of chronic physical conditions and the health status of people living with chronic physical conditions. Early recognition and intervention for depression are an important part of chronic disease prevention and management (CDPM).

There is good evidence that a chronic disease management approach to depression, particularly at the primary care level can reduce the risk of depression, as well as improve its detection and treatment. Structured diagnostic assessments, care plans, evidence-based treatment protocols, multidisciplinary teams, psychiatric consults, relapse prevention planning, proactive follow-up and monitoring, and ongoing training for providers are key success factors in chronic disease management that have been demonstrated to improve depression care. Another key element is the provision of education and support for people experiencing depression, to enhance their self-care. [4, 5, 6, 7, 8]

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Mental illness, chronicity, management and recovery

Consumers of mental health services have advocated for many years to move the mental health system away from thinking of mental illnesses in terms of chronicity to thinking of them in terms of recovery. Serious mental illnesses typically begin in early adulthood, disrupting education, employment and relationships, often resulting in disempowerment, poverty and isolation. Recovery involves restoring self-determination, employment and income, and moving from isolation to inclusion in community life. [9] Improved mental health through management of the illness is part of recovery but recovery is not all about preventing and managing illness.

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Improving the prevention and management of chronic physical conditions in people with serious mental illnesses

The CDPM approach has the potential to improve the integration of mental and physical health care, which can significantly benefit the physical health of people living with serious mental illnesses.

People with serious mental illnesses including schizophrenia and major depression have higher rates of diabetes and heart disease and they are more likely to die from heart disease and stroke than those without a mental illness. [10, 11, 12, 13] Antipsychotic medications have been shown to generate weight gain; obesity rates are up to 3.5 times higher in people with serious mental illnesses in comparison to the general population. [14] In addition to medication, the impact of mental illness on one's life, the stigma of living with mental illness, the living conditions of many people with serious mental illness, and a lack of access to primary health care combine to put people with mental illnesses at high risk of chronic physical conditions. [15, 16, 17, 18]

Primary health care is the cornerstone of CDPM. A lack of access to primary care and a focus on mental health symptoms over physical symptoms [19] are barriers to good physical health for many people living with serious mental illness. Proactive evidence-based care, multidisciplinary teams and strong links with community resources have the potential to improve the quality of care and the integration of mental and physical health care for this population.

It is important, when designing strategies for preventing and living with chronic physical conditions to incorporate strategies that are inclusive and appropriate for people living with serious mental illnesses. For people living in poverty or struggling with stigma, safety and security are higher priorities than whether they are eating enough fruit and vegetables or walking enough. The risk of developing diabetes and heart disease is less immanent than the risk of losing one's housing or one's job if people know you have a mental illness or if you miss too many days at work. Strategies must be designed with the recognition of these barriers. For example, CMHA Ontario's "Minding Our Bodies" project is exploring effective ways to increase physical activity among people living with mental illnesses.

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Poor mental health as a risk factor for chronic disease

In addition to addressing the risk of chronic physical conditions in people with serious mental illnesses, poor mental health is a risk factor for chronic physical conditions.  CMHA Ontario is working with the Ontario Chronic Disease Prevention Alliance to increase attention on the benefits of promoting positive mental health as a protective factor for chronic physical conditions.

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Depression in people with chronic physical conditions

Most major chronic physical conditions in Canada have been associated with higher rates of depression and other mood and anxiety disorders; these include stroke, arthritis/rheumatism, and asthma, as well as migraines, thyroid conditions, respiratory illnesses, cancers and multiple sclerosis. [20] It is three times more likely that a person with heart disease will experience depression when compared to people who do not have cardiac conditions. [21] Diabetes is a risk factor for developing depression, especially among women and people facing socioeconomic challenges. [22] In Ontario, there is almost a three times greater likelihood that people with a chronic physical condition also have a mental health problem than the general population. [23] People with chronic physical illnesses also have poorer self-perceived mental health. [24]

Depression can reduce the motivation for self-care and lead to poorer physical health outcomes. [25] Integrating regular screening for depression into chronic disease management is important to early identification and intervention. Chronic disease self management programs can reduce the risk of depression by offering social support, improve coping skills and reducing stress. Linking people with community resources that create supportive environments can also reduce the risk of depression. The CDPM framework prescribes collaboration between primary care providers and others in the community to create an integrated approach to chronic disease prevention and management. In British Columbia, CMHA BC's "Bounce Back" program is a partnership between community mental health organizations and primary care providers to support self-care for people with chronic conditions who are experiencing mild to moderate depression symptoms.

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The social determinants of physical and mental health

The CDPM framework also presents an opportunity to address the preventable risk factors common to both mental illnesses and chronic physical conditions. Income, employment and housing are important to recovery from mental illness. Poverty is also an underlying risk factor for both mental health problems and physical illness. The CDPM framework's focus on community action, supportive environments and creating healthy public policy recognizes the socioeconomic issues that impact mental health, mental illness and physical health.

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III Opportunities for Mental Health: A Summary

  • Improve depression prevention and treatment.
  • Improve physical health of people with serious mental illness.
  • Prevent and manage chronic physical conditions in people with mental illness.
  • Prevent and treat mental health problems in people with chronic conditions.
  • Take coordinated action on socio-economic factors that affect mental and physical health.

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IV Next Steps

CMHA Ontario is engaged in discussions with policy-makers, decision-makers and providers in the health system to raise awareness of the relationship between mental health and chronic disease, and encourage the development of policies and strategies to address these issues. A specific opportunity we are focusing on is offering advice on how to incorporate strategies to address mental health and mental illness in the implementation of the provincial diabetes strategy. As a member of the Ontario Chronic Disease Prevention Alliance, we are also working with our partners in the Alliance to integrate mental health into chronic disease prevention across Ontario.

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V Taking Action

What you can do

Refer to the resources section for more information on any of the resources referenced in this section.

1. Work with Local Health Integration Networks (LHINs), non-government organizations and health system providers to improve the integration of mental and physical health into chronic disease prevention and management strategies for Ontario.

Develop new initiatives that specifically address the high prevalence of chronic physical conditions among people with mental illnesses. Address the specific needs and barriers experienced by this population.

Ensure that people with chronic physical conditions are routinely screened for depression; and provide support and treatment for people with chronic physical conditions that are experiencing depression.

For specific ideas, see the two papers written by CMHA Ontario on chronic disease, mental health and mental illness.

2. Integrate mental health promotion into your chronic disease prevention work.

Promoting good mental health can be integrated into all health promotion and chronic disease prevention. One way to do this is to promote the Ontario Chronic Disease Prevention Alliance's (OCDPA) common messages about poor mental health as a risk factor for chronic disease and to use the Alberta Healthy Living Network's information about the mental health benefits of healthy behaviours. More ideas about mental health promotion and chronic disease prevention can be found in the proceedings from the OCDPA mental health think tank.  

3. Educate yourself and the populations you work with about mental health and mental illness.

Improve knowledge and understanding of mental health, mental illness and information on available resources to encourage earlier help-seeking behaviour. Strategies to improve mental health literacy can be incorporated into health promotion programs and provision of health care.  

4. Involve people with chronic diseases in decision-making and support them to manage their illnesses.

Ensure that people with chronic conditions are an active part of the decision-making and planning process for their care, that they learn about their illness and how to manage it and that they are provided with support to do so. This can also reduce depression.

5. Take action on the social determinants of health.

Health Nexus and the Ontario Chronic Disease Prevention Alliance (OCDPA) have produced a tool for health care workers on how to take action on the social determinants of health in order to reduce the impact of chronic disease. Do what you can to improve social inclusion, to reduce the impact of violence and discrimination and to reduce poverty. There is good evidence that these factors promote positive mental health.
 
6. Encourage the provincial government to develop and implement additional related strategies.

A provincial depression strategy has been prepared, but not yet implemented.

The Ministry of Health Promotion includes mental health promotion as a key strategic direction. CMHA Ontario has collaborated with four other provincial organizations and prepared a paper which identifies how the broad determinants of health impact mental health. The paper recommends next steps for Ontario to promote mental health.

The Ministry of Health and Long-Term Care is currently developing a new mental heath and addiction strategy.  Directions to address chronic physical conditions among people with serious mental illness should be included.

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VI References

1. World Health Organization, "The World Health Report 2001, Mental Health: New Understanding, New Hope" (2001), http://www.who.int/whr/2001/en/whr01_en.pdf.
2. Canada, "The Human Face of Mental Health and Mental Illness in Canada 2006," p. 59.
3. Meera Jain, PowerPoint presentation retrieved at http://www.omgma.ca/attachments/OntariosChronicDisease.ppt#31
4. Nick Kates and Michele Mach, "Chronic Disease Management for Depression in Primary Care: A Summary of the Current Literature and Implications for Practice," Canadian Journal of Psychiatry 52, no. 2 (2007): 77-85, http://publications.cpa-apc.org/media.php?mid=324.
5. S. Gilbody, P. Bower, J. Fletcher and D. Richards, "Collaborative Care for Depression: A Cumulative Meta-Analysis and Review of Longer-Term Outcomes," Archives of Internal Medicine 166, no. 21 (2006): 2314-2321, http://archinte.ama-assn.org/cgi/reprint/166/21/2314.
6. S. Gilbody, P. Whitty, J. Grimshaw and R. Thomas, "Education and Organizational Interventions to Improve the Management of Depression in Primary Care: A Systematic Review," Journal of the American Medical Association 289, no. 23 (2003): 3145-3151, http://jama.ama-assn.org/cgi/content/abstract/289/23/3145.
7. David J. Katzelnick et al., "Applying Depression-Specific Change Concepts in a Collaborative Breakthrough Series," Journal on Quality and Patient Safety 31, no. 7 (2005): 386-396. Retrieved at http://www.ingentaconnect.com/content/jcaho/jcjqs/2005/00000031/00000007/art00004.
8. A. Neumeyer-Gromen et al., "Disease Management Programs for Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials," Medical Care 42, no. 12 (2004): 1211-1221. Retrieved at http://www.lww-medicalcare.com/pt/re/medcare/abstract.00005650-200412000-00008.htm.
9. John Trainor, Ed Pomeroy and Bonnie Pape, A Framework for Support, Third Edition (Canadian Mental Health Association, National Office, 2004), p. 23. Retrieved at http://www.cmha.ca/data/1/rec_docs/120_Framework3rdEd_Eng.pdf.
10. David P. J. Osborn et al., "Relative Risk of Cardiovascular and Cancer Mortality in People with Severe Mental Illness from the United Kingdom's General Practice Research Database," Archives of General Psychiatry 64 (2007): 242-249. Retrieved at http://archpsyc.ama-assn.org/cgi/reprint/64/2/242.
11. Mythily Subramaniam, Siow-Ann Chong and Elaine Pek, "Diabetes Mellitus and Impaired Glucose Tolerance in Patients with Schizophrenia," Canadian Journal of Psychiatry 48, no. 5 (2003): 345-347. Retrieved at http://ww1.cpa-apc.org:8080/publications/archives/CJP/2003/june/subramaniam.pdf.
12. Mercedes R. Carnethon et al., "Longitudinal Association between Depressive Symptoms and Incident Type 2 Diabetes Mellitus in Older Adults: The Cardiovascular Health Study," Archives of Internal Medicine 167 (2007): 802-807. Retrieved at, http://archinte.ama-assn.org/cgi/reprint/167/8/802.
13. D. C. Goff et al., "A Comparison of Ten-Year Cardiac Risk Estimates in Schizophrenia Patients from the CATIE Study and Matched Controls." Schizophrenia Research 80 no. 1 (2005): 45-53.
14. S. Coodin. "Body Mass Index in Persons with Schizophrenia." Canadian Journal of Psychiatry 46 no. 6 (2001):549-555.
15. Vincent Woo, Stewart B. Harris and Robyn L. Houlden, "Canadian Diabetes Association Position Paper: Antipsychotic Medications and the Associated Risks of Weight Gain and Diabetes," Canadian Journal of Diabetes 29, no. 2 (2005): 111-112.  Retrieved at http://www.diabetes.ca/Files/CDAPositionPaper-FINAL.pdf.
16. Tony A. Cohn and Michael J. Sernyak, "Metabolic Monitoring for Patients Treated with Antipsychotic Medications," Canadian Journal of Psychiatry 51, no. 8 (2006): 492-501. Retrieved at http://ww1.cpa-apc.org:8080/publications/archives/CJP/2006/july/cjp-july-06-cohn-sernyak-IR.pdf.
17. Chronic Disease Prevention Alliance of Canada, "Poverty and Chronic Disease: Recommendations for Action" (April 2008). Retrieved at http://www.cdpac.ca/media.php?mid=457.
18. Stephen Kisely et al., "Inequitable Access for Mentally Ill Patients to Some Medically Necessary Procedures," Canadian Medical Association Journal 176, no. 6 (2007): 779-784. Retrieved at http://www.cmaj.ca/cgi/reprint/176/6/779.pdf.
19. Disability Rights Commission. Equal Treatment: Closing the Gap A formal investigation into physical
health inequalities experienced by people with learning disabilities and/or mental health problems (2006). Retrieved at http://83.137.212.42/sitearchive/DRC/library/publications/health_and_independent_living/health_formal_investigation.html
20. T. Gadalla. "Association of comorbid mood disorders and chronic illness with disability and quality of life in Ontario, Canada." Chronic Diseases in Canada 28 no. 4 (2008):148-154; Kessler (Kessler; Patten sources; Gadalla 2008).  
21. H. Johansen. "Living with Heart Disease - The Working-Age Population." Health Reports. Statistics Canada, Catalogue 82-003. 10 no. 4(Spring 1999): 33-45.
22. D.L. Evans et al., "Mood Disorders in the Medically Ill: Scientific Review and Recommendations," Biological Psychiatry 58, no. 3 (2005): 175-89.
23. T. Gadalla. "Association of comorbid mood disorders and chronic illness with disability and quality of life in Ontario, Canada." Chronic Diseases in Canada 28 no. 4 (2008): 148-154.
24. Government of Canada. The Human Face of Mental Health and Mental Illness in Canada. (2006). Catalogue No. HP5-19/2006E.
25. D. McIntosh and Diane Hammond. "Diabetes and Depression: What is the Association between these Common, Chronic Illnesses?" Canadian  Diabetes 1 no.1 (2008): 3-7.