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ARCHIVED - The Human Face of Mental Health and Mental Illness in Canada 2006

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CHAPTER 2 MENTAL ILLNESS IN CANADA: AN OVERVIEW

What Is Mental Illness?

Mental illnesses are characterized by alterations in thinking, mood or behaviour—or some combination thereof—associated with significant distress and impaired functioning. The symptoms of mental illness vary from mild to severe, depending on the type of mental illness, the individual, the family and the socio-economic environment. Mental illnesses take many forms, including mood disorders, schizophrenia, anxiety disorders, personality disorders, eating disorders, and addictions such as substance dependence and gambling.

During his or her lifetime, every individual experiences feelings of isolation, loneliness or disconnection—some of the symptoms of mental illnesses. If these symptoms begin to interfere with everyday functioning, however, the individual may need help to regain balance and restore optimal functioning.

Mental and physical illnesses are often intertwined. Individuals with physical health problems often experience anxiety or depression, which affects their response to the physical illness. Individuals with mental illnesses can develop physical symptoms and illnesses, such as weight loss and the biological disturbances associated with eating disorders, or depression contributing to diabetes or a heart attack.

Mental illnesses often occur together. An individual may experience both depression and an anxiety disorder, for example. Some individuals may attempt to manage symptoms through alcohol or drugs, leading to problematic substance use.

How Common Are Mental Illnesses in Canada?

Several research projects in the past 15 years in Canada and the United States have estimated the prevalence of mental illness.1 2 3 4In 2002, Statistics Canada conducted the 2002 Mental Health and Well-being Survey (Canadian Community Health Survey (CCHS), Cycle 1.2), which provided for the first time national and provincial level data on mental illness in Canada.5

According to the survey, at some time during the twelve months prior to the interview (Table 2-1):

  • 1 out of every 10 Canadians aged 15 and over, or about 2.7 million people, reported symptoms consistent with a mood or anxiety disorder, or alcohol or illicit drug dependence.
  • 1 in 20 met the criteria for a mood disorder, either major depression or bipolar 1 disorder (see Chapter 2);
  • 1 in 20 met the criteria for an anxiety disorder, either panic disorder, agoraphobia or social phobia (see Chapter 5);
  • 1 in 50 met the criteria for moderate-risk or problem gambling (see Chapter 9); and
  • 1 in 30 met the criteria for substance dependence associated with either alcohol or illicit drug use (see Chapter 10).

Other than those who met the criteria for a mood or anxiety disorder or substance dependence, 5.3% of the Canadian population either sought help for mental health problems or felt a need for help but did not receive it.

One in 5 participants (20.6%) in the 2002 Mental Health and Well-being Survey (CCHS 1.2) met the criteria for a mood or anxiety disorder or substance dependence at some point during their lifetime—24.1% of women and 17.0% of men.

Table 2-1 Twelve-month Prevalence of Mental Disorders and Substance Dependence Measured in the 2002 Mental Health and Well-being Survey (CCHS 1.2), Canada
Mental Disorder or Substance Dependence Total** Men Women
Number % Number % Number %
*Respondents could have reported symptoms that met the criteria for more than one condition.
**Numbers have been rounded to the nearest 10,000.
Source: Statistics Canada, Canadian Community Health Survey, 2002, Mental Health and Well-being, Cycle 1.2
Any measured mood disorder, anxiety disorder or substance dependence* 2,660,000 11.0 1,220,000 10.2 1,440,000 11.7
Any mood 1,310,000 5.3 510,000 4.2 800,000 6.3
  • Major depression
1,200,000 4.8 450,000 3.7 740,000 5.9
  • Bipolar disorder
240,000 1.0 120,000 1.0 120,000 1.0
Any anxiety 1,160,000 4.8 430,000 3.6 730,000 5.9
  • Panic disorder
380,000 1.5 130,000 1.0 250,000 2.0
  • Agoraphobia
180,000 0.7 40,000 0.4 140,000 1.1
  • Social anxiety disorder (Social phobia)
750,000 3.0 310,000 2.6 430,000 3.4
Any substance dependence 760,000 3.1 550,000 4.5 210,000 1.7
  • Alcohol dependence
640,000 2.6 470,000 3.9 170,000 1.3
  • Illicit drug dependence
190,000 0.8 130,000 1.1 60,000 0.5
Eating Attitude Problems 430,000 1.7 60,000 0.5 360,000 2.9
Moderate Risk for / or Problem Gambling 490,000 2.0 320,000 2.6 170,000 0.5
  • Problem Gambling
120,000 0.5 70,000 0.6 50,000 0.4
  • Moderate Risk for Problem Gambling
370,000 1.5 250,000 2.0 130,000 0.1

Respondents to the survey were also asked to report whether they had dysthymic disorder, schizophrenia or an eating disorder that had been diagnosed by a health professional and lasting six months or more.

  • 0.3% of survey participants reported that they had a dysthymic disorder or suffered from dysthymia (0.3% of men and 0.4% of women) (see Chapter 3);
  • 0.3% reported schizophrenia (0.3% of men and 0.2% of women) (see Chapter 4); and
  • 0.5% reported an eating disorder (0.2% of men and 0.8% of women) (see Chapter 7).

These self-reported estimates may under- represent the true picture in the population since many people with mental illness remain undiagnosed. In addition, people with severe mental illness were likely missed by the study.

Other studies have reported a prevalence of approximately 1% for schizophrenia in contrast to the 0.3% found in this survey.

Impact of Mental Illnesses

Who Is Affected by Mental Illnesses?

Mental illnesses affect people in all occupations, education levels, socio-economic conditions and cultures. At some point in their lives, mental illness will affect most Canadians through a family member, friend or colleague.

Men and Women

According to the 2002 Mental Health and Well- being Survey (CCHS 1.2), 10.2% of men and 11.7% of women met the criteria for a mood or anxiety disorder or substance dependence during the previous 12 months. (Table 2-1) While the overall proportions are similar, women were 1.5 times more likely than men to meet the criteria for a mood or anxiety disorder, while men were 2.6 times more likely than women to meet the criteria for substance dependence. For some specific disorders gender differences were even more evident: eating disorders and agoraphobia were 6 times and 3 times more common among women than men.

These gender differences may reflect biological differences between men and women or cultural and social differences, such as norms of expressing or framing health problems, and life experiences.6 7 Societal attitudes encourage stoicism and an illusion of immunity from mental illness. As a result, men may focus on physical symptoms and disregard an underlying mental illness or they may use drugs and alcohol to cope with anxiety or depression.

Age

According to the 2002 Mental Health and Well- being Survey (CCHS 1.2), between 1 in 4 and 1 in 5 adults in the age groups between 15–64 years reported symptoms that met the criteria for a mood or anxiety disorder or substance dependence during their lifetime: 19.8% of those 15–24 years of age, 22.7% of those 25–44 years of age, 23.4% of those 45—64 years of age. (Figure 2-1)

Seniors were less likely than other age groups to report symptoms consistent with a mood or anxiety disorder or substance dependence during their lifetime. This may be an underestimate of mental illness, because the survey did not include those individuals living in nursing homes, retirement homes or chronic care hospitals where depression is common. It is estimated that 80%–90% of residents of long-term care facilities have a mental disorder.8 In addition, seniors may not have remembered past episodes or the questions may not havebeen sensitive enough to identify symptoms of mental illness specific to seniors.

Figure 2-1 Proportion of population with a measured: disorder1 during lifetime, by age and sex, Canada, 2002

Seniors do, however, have a high prevalence of dementia. The Canadian Study of Health and Aging found that 8% of individuals over age 65 years and 34.5% of those over age 85 years had dementia.9 Depression was higher among individuals with dementia than among those without (9.5% versus 2.1%).10 This combination of neurodegenerative and mental illness is very challenging to diagnose and treat. However, anti-depressants have been found to be effective for treating depression among seniors living with Alzheimer's disease.11

The highest prevalence of a mood or anxiety disorder or substance dependence in the previous 12 months was among young adults aged between 15 and 24 years: 19.8% of women and 17.5% of men. (Figure 2-2)

Among adults aged 25–44 years, more than 1 in 10 (12.2%) reported symptoms that met the criteria for one of these conditions in the previous 12 months. The twelve-month prevalence was slightly lower among individuals aged between 45 and 64 years (8.8%).

Figure 2-2 Proportion of population with a measured: disorder in past 12 months, by age and sex, Canada, 2002

Mental illnesses often develop during adolescence and young adulthood. According to the 2002 Mental Health and Well-being Survey (CCHS 1.2), two-thirds (68.8%) of young adults aged 15–24 years with a mood or anxiety disorder reported that their symptoms had started before the age of 15. (Figure 2-3) Almost one-half of those aged 45–64 years (47.9%) and one-third of seniors (34.1%) stated that their mental illness started before the age of 25 years.

Mood or anxiety disorders continue to develop during each life stage: 30.7% of individuals aged 25–44 years; 16.7% of 45–64 year-olds, 13.9% of seniors developed their disorder while in that age group. Patterns were similar among both men and women.

Figure 2-3 Age at onset of symptoms among individuals: Percent - Age at Onset with a measured disorder1, by age, Canada, 2002

Immigrants

Eighteen percent of people living in Canada were born elsewhere—many have been here for years. Some come to Canada through the formal immigration system that assesses their potential to contribute to the economic productivity of the country. Others—about 10%—are refugees in need of refuge and protection.12

In general, immigrants are very healthy because the pre-entry process screens out individuals with health problems. The 2002 Mental Health and Well-being Survey (CCHS 1.2) found that immigrants had lower rates of depression and alcohol dependence than those born in Canada (6.2% versus 8.3% for depression; and 0.5% versus 2.5% for alcohol dependence).13

This difference may reflect either the influence of the new country or the change in origin of immigrants over time, or both. While in the past, immigrants came from Europe or North America, more recently they have arrived from Asia and Africa, from countries with low reported rates of depression and alcohol dependence.

All immigrants face resettlement stress, or the challenge of settling in a new country. Possible stressors include unemployment, poverty, isolation, language barriers, differing societal values, racism and, in general, knowing how various systems—such as credentialing, employment, workplace, education and health— function. Whether or not these stressors lead to mental illness is likely the result of the interaction between vulnerabilities, stressors, social resources and personal strengths.

Pre-immigration trauma, such as internship in refugee camps, torture or witnessing violence, increases the risk of mental illness, particularly post-traumatic stress disorder and depression, in the first six months after arrival in Canada.14 (See Chapter 5 – Anxiety Disorders). The higher the degree of trauma, the more likely a mental illness will develop. The diagnosis of post-traumatic stress disorder can be a challenge. Programs for assisting refugees need to recognize this reality and provide the necessary support.

Immigrants show a strong desire to be productive and independent—it is a motivation for coming to Canada.15 However, more than 30% of immigrant families live below the poverty level during their first ten years in Canada. Mental illness such as depression can arise when immigrants are unable to find meaningful and economically sustaining employment.

Preventing mental illness among immigrants requires societal, community and individual interventions.

Inmates in Correctional Facilities

Inmates in correctional facilities are more likely than the community population to have present or past mental illness. This is, in part, because the nature of some mental illnesses, such as bipolar disorder, personality disorders or problematic substance use, is highly associated with participation in illegal acts such as theft and violence. Another health condition, foetal alcohol syndrome caused by heavy alcohol intake during pregnancy, contributes to behaviour problems in adolescents and adults that can result in conflict with the law. A correctional facility is by definition a restrictive, coercive environment that could contribute to anxiety and depression.

An analysis of offender intake assessments to the federal corrections system between 1996/97 and 2004/05 showed an increase in the proportion of individuals who were diagnosed as having a current mental disorder and who were prescribed medication for a current mental disorder. (Figure 2-4)

Figure 2-4 Proportion of admissions to federal corrections: system with current or history of mental health diagnosis, Canada, 1996/97-2004/05

A 2004 review of mental health and illness in federal correctional facilities (where sentences were of two years or more) summarized Canadian literature and studies.16

  • Most inmates in Canadian federal correctional facilities are male (97%) and under 50 years of age (86.1%).
  • About 1–2% of inmates have an intellectual disability and a high proportion of these individuals also have a mental illness.
  • In 2002, about one-third (31%) of female inmates and 15% of male inmates reported emotional or mental health problems at the time of intake.
  • In 1999, more than 4 out of 5 inmates entering prisons in British Columbia (84%) reported symptoms that met the criteria for at least one current or lifetime diagnosis of a mental disorder, including problematic substance use. Forty-three percent met the criteria for one lifetime mental disorder: 18.3% for an anxiety disorder, 30.2% for a mood disorder and 1.5% for schizophrenia. Over 90% of inmates diagnosed with either a mood, anxiety or psychotic disorder had at least one other disorder, including substance abuse. Almost one-half of those with substance abuse had another mental disorder.
  • In 2002, substance abuse was identified as a problem among a high proportion of inmates at the time of intake. Among men, 34.3% in minimum- 45.8% in medium- and 42.1% in maximum-security facilities had an alcohol problem. The proportion was even higher for drug problems: 36.4% in minimum-, 51.2% in medium- and 51.4% in maximum-security facilities. Among women, the proportions were 29.3%, 49.4% and 69.6%, for alcohol, and 40.1%, 67.5% and 78.3% for drugs in minimum-, medium- and maximum-security facilities, respectively.
  • In 2000/01 the suicide rate in correctional facilities was 3.7 times higher than in the general public for similar age groups.
  • A 1995 survey of federal inmates reported stresses associated with relationships among inmates and staff, getting parole, getting transferred, release dates, double bunking, getting enough tobacco, and physical safety.
  • A survey of women conducted at a psychiatric hospital in British Columbia found that 58% had been sexually abused as children.17 Another study found that 83% of women in an inpatient setting had experienced physical or sexual abuse.18

The high prevalence of mental illnesses and problematic substance use underscores the need for effective assessment and treatment services within correctional services. It also points to the importance of policies, programs and services directed at the prevention and early recognition of mental illness and problematic substance use, particularly among youth, to reduce the risk of criminal activity.

Armed Forces Personnel

Mental health has special significance in the military. Service is demanding both physically and emotionally, and mental illness may be a consequence of military service. In addition, poor mental health may put both the individual and others at risk.

Mental illnesses among Regular Force service members, particularly depression and post- traumatic stress disorder (PTSD) contribute heavily to long-term sick leave medical releases. PTSD has been an important cause of service- related disabilities following peacekeeping and other deployments since the Persian Gulf conflict of 1990/91.

At the request of the Canadian Forces, Statistics Canada administered a slightly modified version of the 2002 Mental Health and Well-being Survey. Survey respondents who were in the Regular Forces were more likely than the general population of similar age and sex to meet the criteria for panic disorder and depression, but not for social phobia. (Figure 2-5) The prevalence of these conditions in the Reserve Forces was very similar to those of the general population.

Whether the difference in prevalence of mental disorders is due to practices associated with military service, recruitment and selection practices, or other factors is unknown.

Figure 2-5 Proportion of DND* Regulars and Reservists: and general population with and without selected disorders in the previous 12 months, age- and sex-adjusted, Canada, 2002

How Do Mental Illnesses Affect People?

Quality of Life

Mental illness affects every aspect of an individual's life—personal and family relationships, education, work and community involvement. Too often, life closes in and the individual's world becomes narrow and limited.

The greater the number of episodes of illness experienced by an individual, the greater the degree of lasting disability. Receiving and complying with effective treatment and the security of strong social supports, adequate income, housing and educational opportunities are essential elements in minimizing the impact of mental illness.

Worldwide, mental illnesses (major depression, bipolar disorder, schizophrenia, alcohol use, PTSD, obsessive-compulsive disorder, and panic disorder) accounted for 9.4% of the disability-adjusted life years (DALYs) in 2002.19 This is comparable to 9.9% for cardiovascular disease and almost twice as high as DALYs attributed to cancer (5.1%).

According to the 2002 Mental Heath and Well- being Survey, 75.5% of individuals with a mood or anxiety disorder or substance dependence in the previous 12 months, reported that the condition interfered with their lives (71.2% of men and 79.2% of women). Nearly 1 in 3 individuals (32.7%) reported that they had to reduce activities at home. One in 6 (18.4%) reported that they had "often" or "sometimes" found it necessary to reduce their activities at work. This percentage does not include people who had to leave the workplace because of their mental illness.

Under the age of 45 years, more women than men reported that their condition interfered with their lives, but this pattern was reversed among seniors. (Figure 2-6) The greater impact among women than men under the age of 45 years could reflect their wider range of responsibilities (work, family, school) and caregiving burdens. For men, the loss of structure and role after retirement may contribute to the impact of mental illness on their life.

Figure 2-6 Proportion of population with a measured: disorder in past 12 months who stated it interfered with life, by age and sex, Canada, 2002

Young Adults

Adolescence and early adulthood involve important developmental changes, including completing school and developing a career, developing self-confidence and finding their place within the community. The enormity of the changes associated with this life stage likely contributes to the development of mental illness and substance dependence among young adults who are predisposed to mental illness.

Young adults with a mental illness face greater developmental challenges compared to their peers who do not have a mental health or substance dependence problem. Few other health problems affect so many people in this age group. Without help, young adults with a mental illness may not develop the life skills, independence and self-confidence that they need for not only at this point in their lives, but also in the future.

Seniors

It may be difficult to diagnose mental illness among seniors because they have multiple physical problems that may be confused with or masked by an underlying mental illness. Symptoms of mental illness in seniors may differ from those experienced by younger people, which can make accurate diagnosis and treatment difficult. 20 In addition, symptoms of anxiety or depression may be incorrectly considered part of the aging process and not be recognized as a treatable condition. Dementia also makes it difficult to identify underlying mental illness. Health care providers without specialized training in seniors' mental health may not be able to effectively diagnose or treat seniors' problems.

Family

Mental illnesses have a major impact on the family, in part because the symptoms of mental illness have a major impact on interpersonal relationships. For example, undiagnosed and untreated depression among men may contribute to hostility, irritability, verbal abuse and violence, or excessive drinking that affects the family.

Families may face difficult decisions about treatment, hospitalization, housing, and contact with and support of family members. Both the individuals and their families face the anxiety of an uncertain future and the stress of a potentially severe and limiting disability. Families sometimes live with the unnecessary, self-induced guilt that they caused the illness.

The cost of medication, time off work and extra support can create a severe financial burden for families. With these burdens, along with the stigma attached to mental illness, family members often become isolated from the community and their social support network. This isolation may even contribute to the suicide of a family member.

A 2004 caregiver survey21 commissioned jointly by the Women's Health Bureau and the Primary and Continuing Health Care Division of Health Canada found that 70% of those caring for individuals with mental illness are women. Almost one-half (47%) of all caregivers are between the ages of 45 and 64 years. About one-third juggled full-time work with caregiving. Most lived with their care recipient (69%).

For most caregivers, caregiving was a family responsibility (86%) and they chose to provide the care (81%). In more than one-half of the situations (58%), no one else was available to provide the care—the lack of adequate mental health (58%) or home care services (42%) had thrust them into the role of caregiver. The heavy demands of care may lead to burnout. Caregiving for people with dementia is particularly challenging. While it can be rewarding, it may also cause significant stress.

The caregivers responding to the survey expressed a need for more home and community services, including access to psychologists, social workers, nutritionists and psychiatrists, homemaking, support programs and groups, nursing visits, personal care workers, occupational therapy and psychiatric day programs.

Chronic Conditions

Depression often accompanies chronic illnesses such as heart disease, stroke, Alzheimer's disease, Parkinson's disease, epilepsy, diabetes, cancer and HIV/AIDS.22 This is a particular problem among seniors where chronic disease is very common. Detecting and treating the depression is as important as treating the physical illness for maintaining quality of life and helping the individual cope with and manage the physical illness.

According to the 2002 Mental Health and Well- being Survey (CCHS 1.2), an individual with a chronic physical condition was more likely than an individual without such a condition to have met the criteria for one of the mental illnesses during the previous 12 months. (Figure 2-7) Individuals with a chronic physical condition were twice as likely as those without such a condition to have a mood disorder and almost twice as likely to have an anxiety disorder.

Figure 2-7 Proportion of among adults aged 15+ years: with and without a chronic physical condition who met the criteria for a mental illness in the previous 12 months, Canada, 2002

Suicide

Suicide is a major risk for individuals with schizophrenia. With other mental illnesses, such as major depression, bipolar disorder, and borderline personality disorder, the risk of suicide is also higher than in the general population. (See also Chapter 7 – Suicidal Behaviour.)

Hospitalizations

In the 2002 Mental Health and Well-being Survey (CCHS 1.2), 4.9% of individuals (4.3% of men and 5.4% of women) reported that they had been hospitalized for a mental health problem or substance abuse during their lifetime. The proportion increased with age until 65 years. (Figure 2-8) The proportions of men and women who reported being hospitalized were similar in all age groups, except among those aged 15–24 years, where women were twice as likely as men to report being hospitalized. (See also Chapter 11 – Hospitalization and Mental Illness)

Figure 2-8 Hospitalization during lifetime for self-: reported problems related to emotions, mental health or use of alcohol or drugs, by age and sex, Canada, 2002

Economic Impact

Mental illnesses have a major impact on the Canadian economy in terms of both lost productivity and health care costs. Measuring the economic impact of mental illnesses in Canada is hampered by a lack of comprehensive data, not only on the use and cost of services, but also on the economic impact of lost productivity through, for example, absence from work.

Health Canada's 2002 report, Economic Burden of Illness in Canada, 23 using 1998 data, identified $4.7 billion dollars in direct costs associated with hospital costs ($2.7 billion), drug use ($1.1 billion) and physician care ($0.9 billion), and $3.2 billion in indirect costs associated with short ($0.5 billion) and long term disability ($2.2 billion) and premature mortality ($0.5 billion) for mental disorders. This represents only a small part of the economic burden: it does not include workplace costs, third-party insurance costs or the cost of all the mental health professionals who are not covered by the health insurance plans.

The impact of mental illness on the workplace comes from both lost productivity and disability claims.24 In 2003, mental illness accounted for 30% of disability claims and 70% of the total costs—$15 billion to $33 billion annually.25

Participants in the 2002 Mental Health and Well- being Survey (CCHS 1.2) reported that on average they had spent $202.63 on mental health services and products in the previous 12 months. Among individuals 25–44 years of age, women spent more than men. (Figure 2-9) This pattern was reversed among adults aged 45–64 years. Given women's lower wages and less access to economic resources, this represents a significant additional financial pressure due to mental illness.

Figure 2-9 Average amount spent on mental health services: and products in past 12 months, by age and sex, Canada, 2002

Stigma Associated with Mental Illnesses

Stigma… is externally imposed by society for an unacceptable act and internally imposed by oneself for unacceptable feelings.26

According to the 2002 Mental Health and Well- being Survey (CCHS 1.2), many people were embarrassed about and faced discrimination because of their mental illness or mental health problem. Of respondents who met the criteria for a mood or anxiety disorder or substance dependence in the previous 12 months and reported some activity restriction:

  • 53.5% felt embarrassed about their mental health problems (58.5% of men and 53.4% of women); and
  • 54.3% reported facing discrimination due to mental health problems (55.9% of men and 52.8% of women).

The serious stigma attached to mental illnesses is one of the most tragic realities of mental illness in Canada. Arising from superstition, belief systems and lack of knowledge, this stigma has existed throughout history and results in stereotyping, fear and discrimination. Symptoms of mental illness remain strongly connected with public fears about potential violence and with a desire for limited social interaction.27 Yet very few people with mental illness are violent.

Stigma also results in anger and avoidance behaviours among those with a mental illness. By forcing people to remain quiet about their mental illnesses, stigma often causes them to delay seeking health care, avoid following through with recommended treatment, and avoid sharing their concerns with family, friends, co- workers, employers, health service providers and others in the community.

Stigma in the workplace has a profound impact on people with serious mental illnesses. This includes

"... diminished employability, lack of career advancement, and poor quality of working life. People with serious mental illnesses are more likely to be unemployed or to be under- employed in inferior positions that are incommensurate with their skills or training. If they return to work following an illness, they often face hostility and reduced responsibilities. The results may be self- stigma and increased disability."28

A high degree of stigmatization of pregnant women and mothers who are substance users, mothers who are abused by their partners, and mothers with mental illnesses is created by media and public discourse. Mothers who use substances experience greater stigma than mothers with mental illness. Stigma also has a great impact on mothers who are marginalized by poverty and racism.29

Seniors with mental illness carry a double burden stemming from the stigma associated with both mental illness and old age. As a result, seniors mental health problems are under diagnosed and under treated. Stigma also affects seniors suffering from dementia, sometimes causing alienation from their familiar supports.

Addressing stigma about mental illnesses is one of the most pressing priorities for improving the mental health of Canadians. Educating the public and the media about mental illness is a first step toward reducing stigma and encouraging greater acceptance and understanding. Developing and enforcing policies that address discrimination and human rights violations provide incentives for change.

In May 2006, the Standing Senate Committee on Social Affairs, Science and Technology released the final report of their consultations called "Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addiction Services in Canada".30

Causes of Mental Illnesses

Mental illnesses are the result of a complex interaction of genetic, biological, personality and environmental factors with the brain as the final common pathway for the control of behaviour, cognition, mood and anxiety. At this time, the links between specific brain dysfunction and specific mental illnesses are not fully understood.31

Most mental illnesses are found to be more common among close family members, suggesting a genetic basis to the disorders. Personal factors such as age, sex, lifestyle and life events can contribute to the onset of mental illnesses.

Environmental factors, such as family situation, workplace and socio-economic status of the individual, can precipitate the onset or recurrence of a mental illness.

Depression can contribute to or have a common pathway with physical illnesses such as cancer, heart disease and diabetes.32

Genetics

Current research suggests that the risk of developing a mental illness may be related to defects in multiple genes rather than in any single gene. The development of a mental illness is likely the result of an interaction between genetic and environmental factors. This offers hope that in the future modifiable environmental risk factors will be identified and become targets of prevention.33

Poverty and Mental Illnesses

The relationship between poverty and mental illnesses is complicated. Many studies have found that socio-economic status is inversely related to the development of mental illnesses. Two frameworks34 have been proposed to explain this relationship.

Indirect Association: Selection and Drift

The concept of selection proposes that certain individuals may be predisposed both to a mental illness and to lower expectations and ambition, which in turn result in lower levels of educational and occupational achievement. On the other hand, a milder undiagnosed mental illness makes it difficult for individuals to achieve success in the complex post-industrial society. Poverty is associated with a lower level of achievement in formal education. In this situation, then, there is an indirect association between poverty and mental illnesses.

"Drift" refers to the likelihood that those with a mental illness may drift into poverty as they have difficulty achieving and maintaining regular employment. This indirect association between poverty and mental illness may be mitigated by the "class" effect, whereby the networks of support around people in higher socio-economic classes prevent their drift into poverty.

Direct Association: Social Causation

Direct association between poverty and mental illnesses implies that the social experience of individuals who are poor increases the likelihood of developing a mental illness. For example, living in poverty may lead to a lack of opportunity and consequently to hopelessness, anger and despair. When combined with a genetic predisposition, poverty can contribute to the development of mental illnesses. Most people who are poor do not have mental illnesses, however.

Violence Contributing to Mental Illness
Childhood Maltreatment

Childhood maltreatment refers to "the harm, or risk of harm, that a child or youth may experience while in the care of an adult whom they trust or depend on, including a parent, sibling, other relative, teacher, caregiver or guardian. Harm may occur through actions by the adult (an act of commission) or through the adult's neglect to provide a component of care necessary for healthy child growth and development (an act of omission)" 35

According to the Canadian Incidence Study of Reported Child Abuse and Neglect 2003, the estimated incidence of substantiated child maltreatment was 21.7 cases for every 1,000 children. Of the over 100,000 substantiated cases in this study, 30 % involved child neglect, 28% exposure to domestic violence, 24% physical abuse, 15% emotional maltreatment, and 3% sexual abuse.36

A unique set of symptoms, such as feelings of powerlessness, dissociative symptoms and self- blame, arises from early and chronic sexual abuse. Early childhood trauma has been linked to later depression, borderline personality disorder, multiple personality disorder, problematic substance use, and post-traumatic stress disorder.37 38 39 40

In one long-term study, almost 80% of young adults who had been abused as children met the diagnostic criteria for at least one psychiatric disorder at age 21. These young adults exhibited numerous conditions including depression, anxiety, eating disorders, and suicide attempts.41

A survey of women conducted at a psychiatric hospital in British Columbia found that 58% had been sexually abused as children.42 Another study found that 83% of women in an inpatient setting had experienced physical or sexual abuse.43

The powerful impact of childhood maltreatment emphasizes the need for early intervention and prevention strategies to prevent or minimize serious consequences.

Bullying

"Bullying is a relationship problem—it is the assertion of interpersonal power through aggression. Bullying has been defined as negative physical or verbal actions that have hostile intent, cause distress to victims, are repeated over time, and involve a power differential between bullies and their victims."44

According to the Health Behaviour of School- Aged Children Survey (HBSC), 2002,45 39% of boys and 37% of girls in Grades 6–10 reported being bullied at school at least once in the previous term. Between 7% and 10% of students in each grade reported being bullied once a week or more. Overall, the prevalence of being bullied was highest in Grades 7 and 8.

All young people involved in bullying—the bully, the victim and the witnesses—are affected by it. It most frequently occurs at school and at places where there is little adult supervision. Children and youth who bully are more likely to engage in other forms of aggression, including sexual harassment and dating violence in adolescence. They are also more likely to engage in school delinquency and substance use. Childhood bullying is also associated with adult anti-social behaviour.

Victims of bullying are more likely to experience depression and anxiety and, in extreme cases, to commit suicide. Some express their anger about the abuse by becoming aggressive and bullying others themselves.

Violence against Women

Violence against women encompasses a wide range of abuses and harms, including, but not limited to

"... physical, sexual and psychological violence occurring in the family, including battering, sexual abuse of female children in the household, dowry-related violence, marital rape, female genital mutilation and other traditional practices harmful to women, non-spousal violence and violence related to exploitation: physical, sexual and psychological violence occurring within the general community, including rape, sexual abuse, sexual harassment and intimidation at work, in education institutions and elsewhere, trafficking in women and forced prostitution; and physical, sexual and psychological violence perpetrated or condoned by the state wherever it occurs."46

The health care costs of violence against women have been estimated at over $1.5 billion annually.47

Many women's psychological and physical problems are responses to multiple traumas over their lifetime.48 The impact associated with violence is compounded if a woman is socially marginalized, is living in poverty, or has serious mental illness.

All women are vulnerable to violence, regardless of their race, ethnicity, culture, physical and mental ability, age, sexuality or economic status. Canadian statistics suggest that 50% of women have experienced at least one incident of sexual or physical violence.49 Over one-quarter (29%) of women ever married have been sexually or physically assaulted by a current or former partner since the age of 16 years.50 51

The estimates of abuse during pregnancy vary.52 The Society of Obstetricians and Gynecologists states that the incidence may range from 4% to 17%. The problem is most likely under- estimated because most women do not report it, likely for a variety of reasons, including fear that their child will be removed. For many women the abuse begins during pregnancy.

A minimum of 1 million Canadian children have witnessed violence against their mothers either by their fathers or their father-figures.53

Severe and chronic mental illness also puts women at risk for violence and abuse. This increased risk can be a direct result of a woman's illness and/or the medications she takes for her illness which may impair her judgment, making it difficult for her to protect herself against sexual assault.

At the most extreme end, violence results in serious physical injury and death.54 Many other mental and physical health problems—including anxiety, depression, central nervous system damage, sleep disorders, migraines, respiratory- related problems, cardiovascular system problems, endocrine problems, gastrointestinal and genito-urinary problems, reproductive and sexual problems—have been linked to experiences of abuse and trauma. Women may use substances to self-medicate the psychological symptoms arising from trauma.

Any treatment and program planning requires an understanding of the interconnection between violence, mental health and substance use problems. Promising models for treatment include the application of techniques such as trauma-focused cognitive behavioural treatment, as well as psycho-education and work to help women establish secure attachments.

The manner in which services are provided to trauma survivors with a mental illness needs to be carefully planned. The use of physical and chemical restraints, for example, can trigger feelings of powerlessness.

Prevention and Recovery

Prevention

Addressing the psychological and social determinants of mental health can not only promote mental health but may also prevent some mental illnesses. For the individual, such factors as secure attachment, good parenting, friendship and social support, meaningful employment and social roles, adequate income, physical activity and an internal locus of control will strengthen mental health and help to reduce the impact or incidence of some mental health problems. (See Chapter 1 – Mental Health for more detail.)

Strategies that create supportive environments, strengthen community action, develop personal skills and reorient health services can give the population some control over the psychological and social determinants of mental health.

Primary prevention of most mental illness is still in the early stages of development. Early teaching of cognitive-behavioural strategies may prevent or reduce the impact of anxiety disorders.

Given the correlation between a history of severe trauma (such as physical or sexual abuse) and various mental illnesses (dissociative disorders, personality disorders, addictions, post-traumatic stress disorder), preventing such traumas could prevent mental health problems.

Recovery from Mental Illness

Most mental illnesses can be treated in order to reduce symptoms. Placing treatment within a recovery model, however, helps individuals go beyond symptom reduction toward improving their quality of life.

"Recovery does not refer to an end product or result. It does not mean that one is "cured" nor does it mean that one is simply stabilized or maintained in the community. Recovery often involves a transformation of the self wherein one both accepts one's limitation and discovers a new world of possibility. This is the paradox of recovery, i.e., that in accepting what we cannot do or be, we begin to discover who we can be and what we can do. Thus, recovery is a process. It is a way of life. It is an attitude and way of approaching the day's challenges. It is not a perfectly linear process. Like the sea rose, recovery has its seasons, its time of downward growth into the darkness to secure new roots and then the times of breaking out into the sunlight. But most of all recovery is a slow, deliberate process that occurs by poking through one little grain of sand at a time." 55

Treatment to assist in recovery from mental illness must reflect its complex origins. A variety of interventions such as psychotherapy, cognitive-behavioural therapy, medication and occupational therapy can improve an individual's functioning and quality of life. Since mental illnesses arise from disorders of brain functioning, medication is often an important part of treatment.

Making the correct diagnosis and tailoring effective treatment to the individual's needs are essential components of an overall management plan. The active involvement of the individual in the choice of therapy and his/her adherence to the chosen therapy are critical to successful treatment. Sometimes, protecting the health of the individual may require the involvement of alternate decision makers.

Recovery requires a variety of health and social service providers and volunteers organized into a comprehensive system of services. Service providers need to work as a team to ensure continuity of care.

An effective recovery system requires that all individuals have access to appropriate services where needed, such as in the community. Self- help organizations and programs connect individuals to others facing similar challenges and provide support to both individuals and family members.

A comprehensive, effective mental health care system to support recovery would include the following components:

Assumptions about Recovery

Factors/Items

Reasons

1. The task of consumers is to recover.

Professionals do not hold the key to recovery: consumers do. The task of professionals is to facilitate recovery; the task of consumers is to recover. Recovery may be facilitated by the consumer's natural support system.

2. A common denominator of recovery is the presence of people who believe in and stand by the person in need of recovery.

Seemingly universal in the recovery concept is the notion that critical to one's recovery is a person or persons in whom one can trust to "be there" in times of need.

3. A recovery vision is not a function of one's theory about the causes of mental illness.

Recovery may occur whether one views the illness as biological or not. The key element is understanding that there is hope for the future, rather than understanding the cause in the past.

4. Recovery can occur even though symptoms reoccur.

The episodic nature of severe mental illness does not prevent recovery. As one recovers, symptoms interfere with functioning less often and for briefer periods of time. More of one's life is lived symptom-free.

5. Recovery is a unique process.

There is no one path to recovery, nor one outcome. It is a highly personal process.

6. Recovery demands that a person has choices.

The notion that one has options from which to choose is often more important than the particular option one initially selects.

7. Recovery from the consequences of the illness is sometimes more difficult than recovering from the illness itself.

These consequences include discrimination, poverty, segregation, stigma and iatrogenic effects of treatment.

 

Education

Individuals and families directly affected by the disorders need information about signs and symptoms of mental illnesses, sources of help, medications, therapy and early warning signs of relapse. Booklets, videotapes and family consultations can help to raise awareness. Outcomes may be improved by educating people in order to enhance their abilities to identify episodes in their earlier stages and to respond with appropriate actions.

Community Education

Dispelling the myths surrounding mental illnesses requires community education programs, including programs in schools. Such programs could help reduce the stigma associated with mental illnesses and improve the early recognition of a problem. They may also be instrumental not only in encouraging people to seek care, but also in creating a supportive environment for the individual.

Primary and Specialty Care

For most Canadians, their primary care physician is their first and often only contact with the health care system. According to the 2002 Mental Health and Well-being Survey (CCHS 1.2), only 37.1% of individuals who met the criteria for an anxiety or mood disorder or substance dependence in the previous 12 months consulted with a professional. (Figure 2-10) Family physicians were the most frequently consulted health professional. Psychiatrists, social workers and psychologists were the next most frequently consulted. A small proportion consulted with either a religious advisor or a nurse.

Under-diagnosis, misdiagnosis and under- treatment of mental illnesses can result in poor outcomes. As a result, educating primary care physicians to properly recognize, diagnose and treat most mental illnesses within a recovery model and to know when to refer to others is a crucial factor in optimizing the care that they provide. Training of family medicine residents in these topics is also essential. Creating and distributing consensus treatment guidelines is a first step to increased knowledge about mental illnesses, their diagnosis and treatment. Encouraging the use of these guidelines requires attention to the predisposing, enabling and reinforcing factors that exist in the clinical setting.

In the Shared Care Model of mental health care delivery described by a Canadian Psychiatric Association and College of Family Physicians of Canada collaborative working group56, psychiatrists and mental health care workers work with family physicians, providing support and counselling assistance in the daily clinic setting. Care providers and individuals requiring service have found this to be an effective model.

Figure 2-10 Proportion of adults aged 15+ years with a: measured disorder1 in past 12 months who consulted with a professional in past 12 months, Canada, 2002

Other health professions, such as psychology and social work, also provide essential services to those with mental illness. An ideal primary care model would involve family physicians, psychologists, nurses, social workers, psychiatrists, occupational therapists, pharmacists and others, all working in a collaborative and integrated system.

Hospitals

The hospital emergency department is a valuable resource for crisis interventions and may be an individual's first point of contact with the health care system.

Hospitalization for a mental illness can assist in diagnosing the illness and stabilizing symptoms. It can provide a critical respite from the sometimes overwhelming challenges of daily living. The hospital can also serve as a safe and supportive environment when the risk of suicide is high or judgement is severely compromised by the presence of mental illness.

Multidisciplinary teams of physicians, nurses, occupational therapists, pharmacists, social workers and case managers work with the individual and family to identify and respond to the factors that influence symptoms. They also help the individual and family understand and cope with their personal response to the mental illness.

While hospitalization provides important short term respite and care, prolonged periods of hospitalization can remove the individual from their normal environment and weaken social connections, making re-integration into community living more challenging.

Hospital-based programs targeted at improving independent living skills can help individuals acquire social, communication and functional living skills that improve their ability to cope with the demands of living.

Reforms of the mental health system of the 1960s and 1970s reduced the number beds in psychiatric institutions. Many individuals with a mental illness moved from chronic care facilities back into the community. Communities have faced major challenges in helping both these individuals and those newly diagnosed with severe mental illness to create a reasonable quality of life in the community. (See Chapter 11 – Hospitalization)

Community Outreach Programs

Community mental health programs are varied and range from psychotherapeutic interventions to programs of assertive community treatment, such as mobile crisis teams, crisis stabilization units, community mental health workers in both rural and urban areas, early prevention and intervention programs, programs in schools, safe houses run by consumers, and clubhouse programs.

An investment in community outreach programs that support individuals to live productive, meaningful, and connected lives is an essential, cost-effective alternative to hospital-based care.

Some community outreach programs consist of multidisciplinary teams that share the clinical responsibility for each individual. A team aims to ensure adherence with treatment (particularly for those with schizophrenia and other psychotic illnesses) and, consequently, improve functioning in order to reduce the need for hospital readmission. The community outreach program also focuses on social skills training to improve social functioning and to resolve problems with employment, leisure, relationships and activities of daily living.

The elderly with mental illness are a prime example of the need for community outreach programs. It is difficult for them to move from service to service and the complexity of their needs requires a team approach.

Workplace Supports

The workplace can play a critical role in the prevention of mental illness and in the recovery process through the development of a healthy work environment, education of employers and employees on mental health and mental illness, counselling and support, and supportive reintegration into the work environment for those experiencing mental illness. Vocational rehabilitation supports permanent competitive employment or the ability to hold a regular job in the community.

It is important to address the high levels of unemployment and poverty found among people with mental illness and support their desire for work. Consumer- or survivor-run businesses have proven effective in restoring employment among individuals with mental illnesses.

Other Supports

A variety of other programs and services—such as long-term care residences, community rehabilitation, special needs groups, specialty services (sleep laboratory, psycho- pharmacological consultation) and community crisis centres—can contribute to the diagnosis and recovery of individuals with mental illness and support their integration into the community. Support is also required to ensure adequate income and safe housing for individuals with mental illnesses.

Older homeless persons require long-term case management and help and would benefit from joint action by the gerontological service sector and the homeless sector. Further, increased supportive housing would serve older homeless persons for whom mainstream housing is not an option. Institutional care specific to the needs of the older homeless people is also required along with additional shelter options, particularly for older homeless women.57

It is estimated that at least 75% of residents in nursing or personal care homes have a cognitive difficulty, a diagnosed mental illness, or both.58 Some of these facilities now hire a psychiatric nurse as a mental health resource for the facility to develop programs to meet the specific needs of the patient and to educate staff and train them to follow through with the program.

Unmet Service Needs

According to the 2002 Mental Health and Well- being Survey (CCHS 1.2), 21.6% of individuals (22.9% of women and 20.0% of men) whose reported symptoms met the criteria for an anxiety or mood disorder or substance dependence in the previous 12 months reported that they wanted help for mental health problems but could not get it. (Figure 2-11)

Young women (15–24 years) were more likely than young men to report unmet needs. The proportion who reported unmet needs was higher among those 25–44 years of age than among those 45–64 years of age.

As the level of family income increased, fewer individuals who met the criteria for a mood or anxiety disorder of substance dependence reported that they had unmet needs related to their mental illness. Individuals in the lowest income category were 1.5 times more likely than those in the highest income category to report unmet needs. (Figure 2-12)

Among those who had unmet needs, the type of care most commonly felt to be required was therapy or counselling, help for personal relationships and information on mental illness or treatment.59

Figure 2-11 Proportion of adults with a measured disorder1: in past 12 months who had unmet needs related to emotions, mental health or use of alcohol or drugs, by age and sex, Canada, 2002

Figure 2-12 Proportion of adults aged 15+ years with a: measured disorder1 in past 12 months who had unmet needs related to emotions, mental health or use of alcohol or drugs, by income adequacy, Canada, 2002

Legal Issues Regarding Treatment of Mental Illness

"Without compulsory admission (to hospital) and psychiatric treatment, people who cannot accept voluntary treatment are abandoned to the consequences of their illness. Untreated ... these illnesses can cause great personal suffering including despair to the point that people, for no reason apparent to others, kill themselves to escape the torment of feelings of worthlessness or because a voice (hallucination) commands them to."60

Severe mental illnesses may affect personal insight to the degree that individuals are unable to recognize how seriously ill they are and voluntarily seek help, or even to accept help when it is offered. Mental health laws have been put in place to address situations in which an untreated mental illness is likely to cause significant harm to the person or others. These laws are only effective if there is effective service available to treat the individual involved, however.

While mental health laws are specific to each province and territory, they revolve around the following common societal values:61

  • The need to provide protection and assistance to those who, through no fault of their own, cannot assist themselves;
  • The need to protect other members of society from the conduct of those whose mental illness overrules their capacity for self-control;
  • The need for individuals in a civilized democratic society to be as unfettered as possible by legal intrusions.

The balance accorded to each value changes over time. In the past, greater emphasis has been placed on ensuring that people are not kept in hospital against their will. This has the potential to leave seriously ill people without treatment, however.

Recent changes to mental health acts are redressing this imbalance. Innovative practices—such as encouraging an individual to write explicit instructions about the treatment that he or she would like to receive if too ill to decide at a specific time—keep the individual rights at the forefront of substitute decision- making.

The mental disorder sections of the federal Criminal Code can be used by a judge to require a person who is found unfit to stand trial to receive compulsory psychiatric treatment. This requires, however, that adequate resources be available within the forensic hospital setting in order to receive the individual from the prison setting. Other parts of the Criminal Code that address conditional discharge or probation can encourage but not force psychiatric treatment.

Endnotes

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  61. Ibid. p. 5.

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