CHAPTER NINE MENTAL HEALTH KEY FINDINGS Mental health status is a significant contributor to overall health and well being. Seventy-two percent of SDH adult residents report themselves to be happy and interested in life, suggesting good overall mental health. Positive perceptions of self-worth and control over one's own life are important determinants of mental health status. Social support is a key health resource for individuals and overall communities. Ninety percent of SDH adults reported having adequate social support available to them when they needed it. Across Canada, youth are much more likely to report poor mental health and high levels of distress. Seniors are five times more likely to report positive mental health than are older adolescents. This is a complete reversal from twenty years ago and believed to be linked to a similar corresponding change in socioeconomic well being of the two social groups. Economic and employment trends over the past decade suggest that today's youth may experience long term poor health. According to national data, single parents score lower than any other group on every measure of mental health. Single parents are more likely to report childhood stressors and depression, and experience higher levels of distress than other groups. These factors play a substantial role in both family and child well being. The social and economic costs of poor mental health are substantial and predicted to increase. Hospitalizations for mental disorders comprise a significant portion of all hospital stays by SDH residents. SDH rates are substantially lower than provincial rates. 145
INTRODUCTION Mental health 1 is clearly an important part of overall health and quality of life for individuals and communities. Research consistently shows the interplay between mental health and physical health, addictions, family well being, suicides, educational success and the loss of productivity. Positive mental health is strongly related to social and economic well being. A recent study estimates that the annual cost of treated and non-treated mental health problems in Canada is $14.4 billion. 2 The study indicates that mental health problems rank first regarding the cost of health care by professionals and the loss of short term productivity, when compared with other conditions such as respiratory and cardiovascular diseases, injury and cancer. The authors conclude that the costs of mental health problems are likely to increase in the years to come, based on current social and economic trends. 3 Social conditions, childhood stressors, recent life events, and current stressors are strongly associated with mental health status. The ability to manage stress (along with the availability of social support) is important to good health including physical health. Other significant factors that influence mental health are individual perceptions of self-worth or self-esteem and the feeling that one's life chances are under one's own control (sense of mastery). These attributes have been viewed in the literature both as indicators and determinants of positive mental health. Social support is a significant resource to the population's health and well being. Social relationships contribute to well being by acting both as a buffer to stressors and by providing main or additive effects on health. Some research suggests that social relationships have effects on mortality, and perhaps morbidity, that rival those of most other known biomedical and psychosocial risk factors. 4 Social integration has been shown to have a strong predictive impact on health. The National Population Health Survey (NPHS) 5 utilizes positive and negative mental health indicators and psychosocial health determinants such as social support, measures of self-esteem and control over stress to measure and understand 'population' mental health. The NPHS has provided further evidence that social support is a primary contributor to the health of Canadians. Communities reporting high levels of social support also reported high levels of psychological well being despite being economically disadvantaged. Social support ranked second behind current stress as a contributor to mental health status. 1 It is important to differentiate between mental health and mental illness. Mental illness refers to specific diseases while mental health fits closer with notions of well being along psychological dimensions such as the perception that life is manageable and meaningful and considers social attributes such as positive perceptions of self and the availability of social support. 2 Stephens, T. and N. Joubert. (2001) The economic costs of mental health problems in Canada. Chronic Diseases in Canada, submitted for publication. 3 Joubert, N. (2001) Promoting the Best of Ourselves: Mental Health Promotion in Canada. International Journal of Mental Health Promotion 3(1): 36. 4 House, J.S. et al. (2000) Social Relationships and Health. Science 241: 540-545. 5 The NPHS is a longitudinal study that began with its first cycle in 1994/95. 146
The NPHS also highlighted inter-provincial differences in positive mental health indicators such as self-esteem and sense of mastery. Along with the Atlantic provinces and Manitoba, Saskatchewan residents reported generally lower than the national average in both self-esteem and self-mastery. Researchers suggest that this relationship at a provincial level may point to a link between mental health and a less than 'healthy' economy though admittedly other variables are also involved. 6 Aside from Canada's generally good economic performance over recent years, certain social and economic conditions that foster positive mental health continue to deteriorate for specific groups. Increases in child and youth poverty, income disparities, involuntary part-time work, young single parent families, and declining labour force participation by youth point to long term poor health for this current cohort of youth. There has been a complete reversal in the reporting of depression between seniors and youth. Twenty years ago seniors were more likely to report being unhappy and in distress and now are the least likely to do so. 7 This reversal coincides with the improvement in the standard of living for seniors, increased in part through improved government social transfer payments. Currently, seniors are one of the least likely groups to experience poverty. On the other hand, youth now are most likely to report poor mental health and high levels of current stress and are one of the groups most likely to be poor. Youth represent over 35% of the poor in Saskatoon. Single parents report the lowest levels on every measure of mental health as compared to others. Single parent families, most often headed by women, reported higher levels of depression, distress and childhood stressors, and were most lacking in social support when compared to any other group. 8 These factors play a substantial role in both family and child well being. Single parents face stresses similar to other families, but at levels of higher intensity. Single parent families are also more vulnerable economically than any other group due to reliance on one income and the often-limited education of the parent due to child-care responsibilities. Income levels (correlated with education) often govern what resources are available to help parents cope or obtain assistance with problem behavior in children. In one Saskatoon neighbourhood, over 50% of families are led by a single parent. This suggests the need to provide support to these parents to allow them to continue their education, including better income supports, increased access to high quality, affordable childcare and improved social services. At the same time, additional supports are needed for local schools and other learning environments such as child/youth centres to help children and youth deal effectively with stress. Opportunities to experience the arts, music, culture and the community have been identified as an important health determinant for children, youth and adults. Recreation is believed to be a 6 Statistical Report on the Health of Canadians, 2000, p. 220. 7 Stephens, T. (1998) Population Mental Health in Canada: Working Towards a National Plan for Promoting Mental Health. 8 Joubert, p. 36. 147
key health resource as it promotes social inclusion and positively influences both physical and psychological well being. Economically disadvantaged children have lower rates of participation in recreation-based activities, often due to fees attached to coached or supervised activities and the lack of access to good playgrounds, parks and other play spaces. The interaction between the social environment and mental health status signals that strategies that promote resilience and other psychological resources will also contribute to problem reduction or even prevention. 9 MEASURES OF MENTAL HEALTH Two measures of positive mental health are taken from the 1998 SDH Adult Health Survey; self reported level of happiness and the availability of adequate social support. Better data on population mental health will be forthcoming with the availability of cross-sectional data (every second year) from two ongoing studies, the Saskatchewan Population Health and Dynamics Survey and the Canadian Community Health Survey. These surveys will provide local data that will allow for more targeted planning as well as the opportunity to compare SDH health status and programming performance with other regions across Canada. Suicide rates and hospital stays due to suicide/self-inflicted injuries are also presented below. Measures of mental illness in this report include only service utilization data (hospital stays) for mental disorders and mortality statistics. Service utilization rates should be interpreted with caution as the availability and integration of services, practice patterns and accessibility influence these rates. HAPPINESS Happiness or a positive attitude toward one's self and life is strongly associated with health and well being. 72% of SDH residents reported being happy, suggesting good mental health. However both Saskatchewan and Canada reported higher levels, 80% and 79% respectively. SOCIAL SUPPORT Saskatoon adults reported high levels of social support, with over 90% reporting that they had someone to confide in, someone to turn to if they were in a crisis situation, and someone to discuss important personal decisions with. 96% of those surveyed reported that they felt loved or cared for. Individuals who do not have adequate social networks or relationships (family and friends) have 2 to 4 times the risk of mortality, independent of all other known risk factors. 10 9 Stephes, T. and N. Joubert. Mental Health of the Canadian Population: A Comprehensive Analysis. Chronic Diseases in Canada 20(3): 118-126. 10 House, J.S. et al. (2000) Social Relationships and Health. Science 241: 540-545. 148
SUICIDE Suicide is a deliberate act to end one's life and therefore an important preventable cause of death. However suicide rates should be interpreted with caution because of the potential for underreporting due to misclassifications of cause (i.e. death being defined as unintentional or an accident) or hidden for social or cultural reasons. 11 In Canada, suicides are concentrated in youth, with youth suicide rates surpassed only by Australia and the New Russian Federation among ten industrialized countries. In Canada, suicide rates among Aboriginal youth are reportedly two to seven times higher than that of the general population, with rates varying among regions and communities. 12 However, SDH suicide rates differ somewhat from both provincial and Canadian statistics. When comparing age-standardized mortality rates for both sexes combined, SDH has slightly lower rates than both Saskatchewan and Canada. For all ages, Saskatchewan has a higher overall suicide rate of 13.4/100,000 as compared to the SDH overall rate of 10.2/100,000. 13 (See Figure 9.1) 18.0 16.0 14.0 Mortality Rate (per 100,000) 12.0 10.0 8.0 6.0 4.0 2.0 0.0 1992 1993 1994 1995 1996 1997 1998 1999 SDH 15.1 11.9 13.5 12.2 11.0 11.4 6.0 10.2 Saskatchewan 15.0 13.0 15.6 14.3 14.5 14.2 11.7 12.3 Canada 13.0 13.0 14.0 13.0 12.0 Source: Saskatchewan Health Vital Statistics Data, Covered Population Data, 1992-1999; Statistics Canada Data, 1993-1997 Figure 9.1: Age-standardized mortality rates for suicides, both sexes combined, SDH, Saskatchewan, and Canada, 1992-1999 11 Rates for the underestimation of suicide are estimated to be approximately 18% for females and 12% for males. Speechley, M. and K.M. Stavraky. (1991) The adequacy of suicide statistics for use in epidemiology and public health. Canadian Journal of Public Health 82: 38-42. 12 Federal, Provincial and Territorial Advisory Committee on Population Health. (1999) Toward a Healthy Future: Second Report on the Health of Canadians. 13 The overall Canadian rate in 1996 was 13.2%. (Statistics Canada Health Statistics Division. (1999) Health Indicators 1999. Catalogue No. 82-221-XCB. 149
SDH suicide rates peak in the 35 to 39 year age group with a rate of 23/100,000. Suicide rates for youth and young adults are lower at approximately 14/100,000 across the ages of 20 to 34 years. SDH suicide rates among younger adults, while lower than Saskatchewan, are still disturbing. (See Figure 9.2) 25.0 20.0 Mortality Rate (per 100,000) 15.0 10.0 5.0 0.0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ SDH 2.3 9.6 14.7 14.5 14.3 23.0 9.4 10.7 14.5 4.6 12.6 7.7 Saskatchewan 0.3 2.5 14.8 23.1 20.0 16.6 19.5 18.0 15.3 18.9 8.5 15.5 11.1 Age group Source: Saskatchewan Health Vital Statistics Data and Covered Population Data, 1995-1999 Figure 9.2: Age-specific mortality rates for suicides by age group, both sexes combined, SDH and Saskatchewan, 1995-1999 Average Age-specific suicide rates for Saskatchewan differ somewhat from corresponding SDH rates. There are higher levels of suicide in the 20 to 24 and 25 to 29 year age groupings, with rates of 23/100,000 and 20/100,000, respectively. Similar to other regions, males in SDH are much more likely to commit suicide than females, with rates of 15.7/100,000 and 4.8/100,000 respectively. The peak suicide rate for males occurs in the 35 to 39 year age group with a rate of 34.9/100,000. Female suicide rates also peak at the age group of 35 to 39 years olds at a rate of 11.3/100,000. (See Figure 9.3) In contrast to SDH, suicide rates for Saskatchewan males peak at a younger age group (20 to 24 years) at a rate of 38.9/100,000. Suicide rates for Saskatchewan females reach their highest levels among 50 to 54 year olds, with a rate of 9.8/100,000. Gender differences in suicide rates are more pronounced at the provincial level, with suicide rates of 22.2/100,000 for males as compared to 4.6/100,000 for females. 150
40.0 35.0 Mortality Rate (per 100,000) 30.0 25.0 20.0 15.0 10.0 5.0 0.0 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Male 4.5 16.6 22.8 22.4 22.3 35.0 12.7 18.5 18.8 9.2 15.7 13.0 Female 2.5 6.7 6.6 6.3 11.3 6.1 2.9 10.2 9.8 4.0 Source: Saskatchewan Health Vital Statistics Data and Covered Population Data, 1995-1999 Age Group Figure 9.3: Age-specific mortality rates for suicide by sex and age group, SDH, 1995-1999 Average Unlike deaths from suicides, females have higher rates of hospitalization for suicide / selfinflicted injuries (127.5/100,000) than do males (80.9/100,000). Furthermore, suicide attempts peak in a younger age bracket than deaths. The highest rates of suicide-related hospitalization are found in the 15 to 19 year old age group in both SDH (242/100,000) and Saskatchewan (273/100,000). For the entire population, rates for hospital separations related to suicide /selfinflicted injury show a marked decrease between 1992/93 and 1999/00 in SDH, declining from 123/100,000 in 1992/93 to 84.6/100,000 in 1999/00. During the same time period the provincial hospitalization rate for both sexes combined rate declined only slightly from 103.1/100,000 to 98.7/100,000. (See Figure 9.4) 151
140 120 t Rate (per 100,000) 100 80 60 40 20 0 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-00 SDH 123.0 111.2 108.6 112.2 116.8 100.3 107.0 84.6 Saskatchewan 103.1 107.6 96.6 115.8 112.0 111.7 106.9 98.7 Source: Saskatchewan Health Hospital Separation data (1992/93-1999/00), Covered Population data (1992-1999), Figure 9.4: Age-standardized hospital separation rates related to suicide/self-inflicted injury, both sexes combined, Saskatoon District (SDH) and Saskatchewan, 1992/93-1999/00 HOSPITALIZATIONS FOR MENTAL DISORDERS In SDH, hospitalizations for mental disorders make up a small but significant proportion of all hospital stays with a rate of 590 per 100,000, as compared to an overall hospitalization rate of 10,434/100,000. 14, 15 Hospital stays are typically for more acute mental disorders. Hospitalizations for mental disorders have remained relatively constant over the past decade with a five-year average rate of 590/100,000 for the years 1994/95 to 1998/99, with the exception of 1999/00 when rates dipped to 479. In comparison, Saskatchewan rates are substantially higher, with a five-year average rate of 737/100,000. Saskatchewan rates have declined gradually since 1992 from a high of 833.8/100,000 to a low of 642.1/100,000 in 1999/00. 16 (See Figure 9.5) These trends should be interpreted cautiously as they may be influenced by a complex set of factors, of which need is only one of many. Some of these influential factors include the availability and integration of services, practice patterns and other community support services and resources. There is a need to gain a better understanding of this data and its usefulness for measuring and monitoring population mental health and the planning and evaluation of mental health services within the district. 14 Based on a 5 year average (1994/95-1998/99) 15 Using a methodology for estimating the prevalence of mental health disorders in Ontario suggests that 19% of SDH residents age 15 to 64 years would meet the criteria for a mental disorder. (Offord, D. et al. (1996) One year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Canadian Journal of Psychiatry 41(9): 559-563. 16 These rates do not include data from the Battleford and Weyburn psychiatric hospitals. 152
900 800 700 Rate (per 100,000) 600 500 400 300 200 100 0 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-00 SDH 577.0 630.7 583.6 578.9 612.0 595.7 581.7 479.3 Saskatchewan 833.8 806.8 770.5 747.9 742.0 733.2 691.6 642.1 Canada 577.6 571.6 567.2 559.9 531.1 Source: Saskatchewan Health Hospital Separation data (1992/93-1999/00), Covered Population data (1992-1999), CIHI Hospital Morbidity data (1994/95-1998/99), Statistics Canada post-censal population estimates Figure 9.5: Age-standardized hospital separation rates related to mental disorders, both sexes combined, Saskatoon District (SDH), Saskatchewan and Canada, 1992/93-1999/00 MORTALITY RATES FOR MENTAL DISORDERS Based on a five year average (1995-1999), the age standardized mortality rate for both sexes combined is 16.5/100,000. Females had slightly higher rates than males with rates of 18.1/100,000 and 14.1 /100,000 respectively. 153
154