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Healthy behaviours - promoting physical activity and healthy eating

https://policybase.cma.ca/en/permalink/policy11523
Date
2015-05-30
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2015-05-30
Replaces
Promoting Physical Activity and Healthy Weights
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) supports the promotion of healthy lifestyles in order to improve individual health and well-being and the overall health status of the population. Healthy lifestyles refer to patterns of individual practices and personal behavioural choices that are associated with optimal health. Two of the most important behaviours to create or maintain optimum health are healthy eating and physical activity. For many Canadians, their diet and physical activity levels can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy lifestyle.1 Childhood obesity research tells us that overweight and obese children are more likely to stay the same into adulthood.2 To reverse this trend, determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. Healthy lifestyles are central to successful aging and improving the likelihood of recovery after poor health.3 This policy paper discusses the importance of physical activity and healthy eating, and the role that individuals and families, schools, workplaces, communities, the food industry and all levels of governments can play in promoting healthy lifestyles. We know that collaborative action is required to make it easier for Canadians to incorporate healthy eating and physical activity into their daily lives - to make the healthy choice the easy choice. What are the health impacts of unhealthy diets and physical inactivity Diet is the leading risk factor for death, disability and life-years lost; being estimated to cause over 65,000 deaths and 864,000 life years lost in Canada in 2010.4 Unhealthy diet has been consistently linked with cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and some cancers,5 which constitutes the majority of the disease burden in Canada. An estimated 80% of hypertension, which affects over 7 million Canadians, is directly or indirectly attributed to unhealthy diet.6 An estimated 60% of Canadian adults and close to one-third of children are overweight or obese, largely caused by unhealthy diets.7 Overweight and obesity (and the lifestyle choices associated with them) are contributors to more than 18 chronic conditions.8 This includes diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer. Obesity is a public health issue not unique to Canada as the rates are increasing worldwide. Obesity is generally attributed to the fact that, as a society, we are increasing our calorie intake while at the same time burning less energy in physical activity. While it is difficult to determine how many deaths are directly attributable to obesity, we know that obesity often co-exists with other risk factors such as the lack of physical activity. Exercise is one of the top modifiable risk factor for chronic disease.9 Regular physical activity is associated with a reduced risk of cardiovascular disease, some types of cancer, diabetes, obesity, hypertension, bone and joint diseases, and depression.10 The risk for many of these conditions is reduced by 20 - 40% in adults with the highest levels of physical activity compared to those with the lowest levels of physical activity. Recent research has shown that a sedentary lifestyle is associated with higher risk for chronic conditions such as obesity, diabetes and cancer independent of physical activity levels.11 According to the most recent Canadian Health Measures Study physical activity levels for children and youth are low with 6 out of 10 waking hours devoted to sedentary pursuits. Obesity is rising and physical fitness is declining.12 Canadians who do not achieve adequate levels of physical activity or eat unhealthy foods are vulnerable to preventable chronic diseases, premature death, and contribute to high health care costs. For instance, in 1999, $2.1 billion or 2.5% of the total direct health care costs were attributable to physical inactivity.13 To understand why the rates of obesity and overweight are rising, it may be helpful to look at what we already know about healthy eating and physical activity. What we know about healthy eating While modern science has allowed us to expand our knowledge of the impact of nutrients and food on human health we continue to be beset with illness and disease caused by the foods we consume. Having the right amount and type of food recommended in Canada's Food Guide is a first step towards healthy eating. But Canadians self-reported dietary intakes do not meet national dietary recommendations despite high reliance on public education concerning healthy eating and healthy diets. Children and adults are under-consuming the recommended servings of vegetables and fruits, an established proxy for healthy eating habits, and exceeding daily recommended intakes of sodium.14,15 As the links between nutrition and disease, and the impact on the health of our society are revealed it is more important than ever to understand what influences healthy eating behaviours. Food choices are structured by a variety of individual determinants of behaviour, ranging from one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors. Many processed foods have become popular due to their accessibility and 'convenience factor', but these features have changed the way food and in particular these products are consumed compared to unprocessed foods: increased 'grazing', eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form.16 Growth in the production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower-income countries.17 A number of studies have shown that because less healthy foods are cheaper than healthier food, individuals from lower socioeconomic classes tend to be more dependent on unhealthy foods for nourishment.18 Other determinants for healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.19 What we know about physical activity Canada's Physical Activity Guidelines recommend that children and youth aged 5 to 17 get at least 60 minutes of moderate-to-vigorous physical activity (MVPA) per day; and adults get 150 minutes of physical activity per week.20 In fact, about 94% of Canadian children and youth do not meet minimum physical activity guidelines.21 Furthermore, about 85% of Canadian adults do not meet the minimum guidelines. Physical activity includes but is not limited to sports and recreation. Using active transportation to get to work as well as being active at work is an alternative form of MVPA and can also lead to improved health. For most Canadians, the average day is spent on passive activities such as TV viewing, computer and game-console use, workplace sitting, and time spent in automobiles. Moreover, the sprawling suburban communities, in which many live, do not encourage physical activity. Emerging research suggests that prolonged sitting time is associated with an increased health risk.22 These findings mean that one can meet the minimum physical activity guidelines and still not engage in a healthy lifestyle. Spending a few hours a week at the gym or otherwise engaged in moderate or vigorous activity doesn't seem to significantly offset the risk. Hence too much sitting is a risk distinct from too little exercise. While further research is required to identify which methods of exercise promotions work best for individuals,23 it is clear that supportive environments and infrastructures are essential for Canadians to make physical activity part of their daily lives. CMA's policies about the Built Environment and Active Transportation support the role of the environment on our physical activity patterns. How we can promote physical activity and healthy eating A sedentary lifestyle is a cue for physician advice.24 Physical activity is a vital sign that may require as much attention as other traditional vital signs25 - weight, blood pressure, or smoking history. Physicians are eager to initiate these conversations, especially with patients living with chronic diseases. A message must be repeated many times in order to effect a change in lifestyle. Physicians can reiterate the medical importance of physical activity and healthy eating by reinforcing this message during each office visit, and writing the recommendation on a prescription pad.26 For instance, in British Columbia, physicians are prescribing exercise on specially-designed pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. And in Nova Scotia, physicians have been running a free provincial running program for over 10 years that benefits thousands of kids in elementary school. Nonetheless these clinical interventions alone cannot shape healthier food consumption patterns and lifestyle choices. An obvious starting point to develop a comprehensive policy is to understand the interplay between individual and environmental determinants that influence our behaviours. In this regard, CMA has developed policies on Active Transportation and the Built Environment and Health which recognize the role of neighborhood design and alternative modes for transportation for an active lifestyle. This approach is also at the heart of the Integrated Pan-Canadian Healthy Living Strategy (PCHLS)27, approved in 2005 by all levels of government. CMA commends the efforts put in the PCHLS to prioritize healthy eating and physical activity. What we recommend CMA looks forward to working with others in making options for physical activity and healthy eating more available and accessible to all Canadians. The following recommendations highlight the potential contributions of the following sectors: health professionals, all levels of government, communities, workplaces, schools, the food industry and individuals and families. Health Professionals CMA encourages physicians to promote healthy eating and physical activity inside and outside their office. Physicians are lifestyle change agents and remain the preferred source of information about health for many people. Physicians, who are committed to physical activity, are role models whose advice on healthy living is more likely to be adopted.28 CMA encourages physicians to address any work-imposed limitations - such as the lack of time, motivation, or tiredness - that could also influence their own exercise and eating habits. In clinical practice, physicians can help patients start or maintain a healthy lifestyle by: * assessing nutrition and physical activity as part of routine assessments; * determining the factors that influence individual patient's nutrition and physical activity levels; * assessing patient's readiness to change and tailoring interventions and support to their current situation; * providing an exercise prescription to encourage physical activity to maintain or improve health status, and * working in inter-professional teams to provide patient education with other health care providers such as dieticians. Medical students and residents, while reporting a high level of importance for exercise prescription concede a low level of expertise in this area upon graduation.29,30,31 As knowledge develops, physicians and other health professionals should be kept updated and encouraged to incorporate the most effective interventions into their practices. The CMA encourages the development of continuing medical education courses on issues related to physical activity and healthy eating. Within the healthy living approach, there are multiple opportunities to extend the role of physicians into the community as observed in Nova Scotia, British Columbia and Edmonton area. Physicians can establish strong community norms for a healthy lifestyle by: * establishing and reinforcing healthy food policies in hospital cafeterias or at health-related meetings and conferences * using, facilitating and advocating for the use of active transportation in their communities * working within the community to ensure that recreation centres and other facilities are available and patients can be referred to the services most appropriate to their needs Federal, Provincial, and Territorial Governments CMA calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. In 2005, Canada's federal, provincial, and territorial governments endorsed a 10-year Healthy Living Strategy Framework, whose initial priorities included the promotion of healthy eating and physical activity. The national strategy addressed information and support for Canadians to help them make healthy choices; support for physicians and other health professionals in counselling patients on healthy weight and in treating existing obesity; community infrastructures that make healthy living easier; and public policies that encourage healthy eating and physical activity. The federal and provincial / territorial governments have undertaken a number of activities in the intervening years to promote physical activity and healthy eating but much remains to be done. CMA believes that all levels of governments have a continuous obligation to provide public guidance on healthy eating and to promulgate policies, standards, regulations and legislations that support the availability and accessibility of healthy and affordable food and beverage choices. CMA calls on governments to improve access to nutritious food at affordable prices for all Canadians. The price of milk, fresh produce and other healthy foods can vary greatly across Canada. In many remote areas, they are often more expensive than processed, nutrition-poor foods because of high transportation costs. Governments should implement effective programs to offset the impact of transportation costs on food prices in northern and remote communities. Even in urban areas, nutritious food may be unaffordable for people on low incomes. School meal programs, social assistance rates that take into account the cost of purchasing healthy food, access to urban farmers' markets can help to ensure that all Canadians have access to healthy foods at a reasonable price. CMA calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. The typical Canadian child may be exposed to as many as 40,000 advertisements for food a year.32 This does not include point-of-sale promotions, such as displays of candy bars at convenience-store counters. CMA's policy on marketing of unhealthy foods and beverages to children and youth calls for a ban on marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. CMA calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. Brand-specific advertising is a less than optimal way to provide health information to consumers, who should be encouraged to seek out objective information sources for answers to their questions about physical activity and healthy eating. To improve the quality of information received through commercial channels, the CMA recommends that health claims made for foods be strictly regulated to ensure that they are based on the best available scientific evidence and that they are accurately communicated to consumers. Food advertisements should be pre-cleared before airing in the media, and the provisions against deceptive advertising in the Food and Drug Act should be strengthened. CMA recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. CMA encourages all levels of governments to continue to fund and support research for healthy lifestyles. There is a clear need to invest in research to strengthen the evidence base about physical activity and healthy eating, particularly on:
best measures for assessing overweight and obesity;
the effectiveness of weight management and treatment programs; and
the effect of policy interventions on healthy eating and physical activity on rates of obesity and obesity-related disease. Food Industry CMA encourages governments to continue to work with the food industry to improve the food environment in Canada. The partnership and collaboration of food manufacturers is needed to help Canadians make healthier food choices. The food industry can work with governments to:
reduce the salt, sugar, saturated fat, trans fat and calorie content of processed foods and pre-prepared meals;
provide information about the calorie and nutrition content on restaurant menus;
restrict advertising and in-store promotion of high-sugar, high-salt, high-fat foods, particularly those aimed at children;
provide user-friendly consumer information about their products, including and accurate health and advertising claims;
improve the nutrition fact table to make it more user friendly and increase the amount of information for example, by identifying the amount of free sugars. Communities CMA calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. Communities have an important role to play to promote healthy behaviours for children, youth, and adults. They shape how many Canadians decide to live, work and play in their daily life. Through mixed-use land planning and building design, communities can create walking-friendly environments, and reduce the time people spend in cars. To achieve this, communities should consider:
developing and maintaining a community-wide network of walking and cycling paths;
zoning communities in such a way that amenities are within walking distance of homes; and
revising building codes to make stairs accessible, pleasant and safe, so that people have an alternative to taking the elevator. Canadians are considerably more physically active in the summer than in the winter and this could have an impact on obesity trends.33 Communities could improve pathways to healthy lifestyles year-round by improving access to indoor sport and recreation facilities, especially during winter. Where possible, communities should consider partnering with schools to share the use of gymnasiums, playgrounds, fields, courts, and tracks with the public after school hours and on weekends. In doing so, communities are ensuring the best use of time and resources, but also sharing liability for the development, operation, and maintenance of the facilities. Community food security can happen if local residents have equal access to safe, affordable and nutritious food. Communities have a role to play in advocating for healthier food options in schools and workplaces, encouraging community kitchens to teach cooking skills, and supporting local agriculture and farmers markets. This, in turn, would encourage individuals to eat more healthy foods. Workplaces CMA encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. Prolonged, unbroken time spent sitting in front of a screen is very common in the workplace. In addition, four out of five commuters sit daily in their private vehicles to go to work.34 As Canadians spend most of their adult life at work, it is important to reduce workplace sitting. CMA encourages employers, especially in sedentary occupational groups, to increase opportunities for physical activity. For example, employers can promote healthy behaviours by:
Building on-site fitness facilities or entering into agreements with off-site fitness centres to provide programs for their employees
Providing showers, bike racks and other amenities for employees for those who want to commute to work on foot or by bike. Healthier food options in cafeteria and vending machines can promote and encourage healthy eating by employees. Schools Schools, where children spend most of their time outside of home, present an excellent opportunity to instil healthy behaviours at an early age. They could, for example, provide comprehensive nutrition education, serve nutritious food in their cafeterias and promote physical activity by providing formal instruction and informal recreation time. Schools can provide the most effective and efficient way to reach not only the children themselves, but their parents, teachers, and other community members.35 CMA encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. Only 26% of Canadian schools reported that they had implemented daily physical education classes for their students.36 There is some evidence that school-based physical activity can increase physical activity levels and reduce time spent watching television at home. 37 For instance, schools can promote physical activity through unstructured out-of-home play, structured sports, or active transportation (e.g. walking to school). Children who are physically active and spend less time watching television after school are less likely to become overweight before age 12.38 CMA recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. CMA calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. Fast food restaurants and convenience stores can be an important influence on children's eating habits and food choices.39 Children attending schools within a short distance of fast food restaurants eat fewer fruits and vegetable servings, and drink more soft drinks than others who did not have similar establishments within proximity.40 To encourage effective school-based nutrition interventions, it is therefore important to educate students about the nutrition value of foods, healthy food choices, and provide healthy canteens or cafeterias. Individuals and families CMA recommends that all Canadians work toward achieving and maintaining health by:
educating themselves about their dietary needs and about the caloric and nutrition content of foods; and
engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. Ultimately, healthy eating and physical activity require that individuals take action to make healthy choices in their lives. To inform these choices, Canadians should be supported with appropriate resource materials with consistent information about healthy eating and physical activity. For instance, many young children do not choose what they consume; their parents buy and prepare the food for them. Research suggests that mothers and children appear to have divergent attitudes towards food and mealtimes.41 In this regard, it is important for parents to be well-informed and able to explain the tangible benefits of foods and their nutritional components to their children before they reach adulthood. What we conclude Healthy behaviours are easier to maintain through life if acquired in childhood and encouraged by the family. Therefore Canadian families should be supported in efforts to ensure that both children and adults eat nutritiously and exercise daily. We believe there is a role for everyone in promoting healthy behaviours - including health professionals, individuals, families, schools, workplaces, communities, the food industry and all levels of governments. Popular approaches seek to provide individuals with information and options about healthy lifestyles choices. However, individual choice is not sufficient to ensure healthy behaviours. Many barriers to the adoption of healthy behaviours and lifestyle choices can be met through a targeted population health approach, and evidence-based policy and regulatory controls. A comprehensive change in culture and mindset, political endorsement and multifaceted strategies are needed to promote and facilitate change to improve the dietary practices and physical activity levels of Canadians. Summary of Recommendations 1. The Canadian Medical Association encourages physicians to promote healthy eating and physical activity inside and outside their office. 2. The Canadian Medical Association calls on federal, provincial, territorial and municipal governments to commit to a long-term, well-funded Canada-wide strategy for healthy living beyond 2015. 3. The Canadian Medical Association calls on governments to improve access to nutritious food at affordable prices for all Canadians. 4. The Canadian Medical Association calls on governments to ban marketing of foods and beverages high in salt, sugars and trans fats to those 13 years of age and younger. 5. The Canadian Medical Association calls on governments to set rigorous standards for front of package food labeling and for the advertising of health claims for food. 6. The Canadian Medical Association recommends that governments at all levels invest in evidence-based research on healthy eating and physical activity and share the results of this research with all Canadians. 7. The Canadian Medical Association encourages governments to continue to work with the food industry to improve the food environment in Canada. 8. The Canadian Medical Association calls on municipal governments to create environments that encourage healthy and active living and on federal, provincial and territorial governments to support them in this endeavour. 9. The Canadian Medical Association encourages employers to actively promote the health of their employees by providing opportunities for physical activity, and healthy food choices in cafeterias. 10. The Canadian Medical Association encourages school boards to provide at least 60 minutes of active daily physical education for all primary and secondary grades. 11. The Canadian Medical Association recommends that schools provide access to attractive, affordable, healthy food choices, provide nutrition education, and initiate programs aimed at encouraging healthy food consumption and skills to prepare meals from scratch. 12. The Canadian Medical Association calls for restrictions on the sale of high-calorie, high fats, sugars or salts foods/drinks in recreational facilities frequented by young people. 13. The Canadian Medical Association recommends that all Canadians work toward achieving and maintaining health by: * educating themselves about their dietary needs and about the caloric and nutrition content of foods; and * engaging in physical activity, with the goal of at least 60 minutes of moderate activity per day for children and youth, and 150 minutes per week for adults. References 1 Swinburn B, Egger G. The runaway weight gain train: too many accelerators, not enough brakes. BMJ. 2007;329:736-9. 2 Waters E, de Silva-Sanigorski A, Hall BJ, et al. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2011;(12): CD001871. 3 Shields M, Martel L. (2006). Healthy living among seniors. Ottawa: Statistics Canada; 2005. Available: www5.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=82-003-S20050009086&lang=eng (accessed 2014 Jan 20). 4 Institute for Health Metrics and Evaluation. Global burden of disease arrow diagram. Seattle (WA): The Institute; 2013. Available: www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram (accessed 2010 Mar 15) 5Committee on Public Health Priorities to Reduce and Control Hypertension in the U.S. Population, Institute of Medicine of the National Academies. A population-based policy and systems change approach to prevent and control hypertension. Report, v-173. Washington (DC): National Academies Press; 2010. 6 Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377(9775):1438-47. 7 Roberts KC, Shields M, de Groh M, et al. Overweight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep. 2012;23(3):37-41. 8 Canadian Institute for Health Information, Public Health Agency of Canada. Obesity in Canada. Ottawa: The Agency; 2011. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/index-eng.php (accessed 2014 Jan 20). 9 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease study 2010. Lancet. 2012;380:2224-60. 10Colley, R, Garriguet D, Janssen I, et al. Physical activity of Canadian adults: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1). 11 Statistics Canada. Directly measured physical activity of Canadian adults, 2007-2011. Health fact sheets. Ottawa: Statistics Canada; 2013. 12 Colley R, Garriguet D, Janssen I, et al. Physical activity of Canadian children and youth: accelerometer results from the 2007 to 2009 Canadian Health Measures Study. Statistics Canada Cat. No. 82-003 XPE. Health Rep. 2011 Mar;22(1). 13 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada CMAJ. 2000;163(11):1435-40. 14 Statistics Canada. Fruit and vegetable consumption. Health fact sheets. Statistics Canada Cat. No. 82-625-XWE. Ottawa: Statistics Canada; 2012. Available: www.statcan.gc.ca/pub/82-625-x/2013001/article/11837-eng.htm (accessed 2013 Nov 8). 15 Garriguet D. Canadians' eating habits. Statistics Canada Cat. No. 82-003. Health Rep. 2007;18(2):17-32. Available: www.statcan.gc.ca/pub/82-003-x/2006004/article/habit/9609-eng.pdf (accessed 2013 Jul 10). 16 Monteiro CA. Nutrition and health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. DOI:10.1017/S1368980009005291. 17 Monteiro CA, Levy RB. A new classification of foods based on the extent and purpose of their processing. Uma nova classifi cação de alimentos baseada na extensão e propósito do seu processamento. Cad Saude Publica. 2010;26(11):2039-49. 18 World Health Organization. Obesity the "new norm": day 1 of nutrition and NCDs conference. 2013. Available: www.euro.who.int/en/health-topics/health-policy/pages/news/news/2013/07/obesity-the-new-norm-day-1-of-nutrition-and-ncds-conference 19 Raine KD. Determinants of healthy eating in Canada: an overview and synthesis. Can J Public Health. 2005;96(Suppl 3):S8-14, s18-15. 20 Canadian Society for Exercise Physiology. Canadian physical activity guidelines. Ottawa: The Society; 2011. Available: www.csep.ca/guidelines (accessed 2014 Jan 20). 21 Statistics Canada. Canadian health measures survey: directly measured physical activity of Canadians, 2007 to 2011. The Daily. Ottawa: Statistics Canada; 2013 May 30. Available: www.statcan.gc.ca/daily-quotidien/130530/dq130530d-eng.pdf (accessed 2014 Jan 20). 22 Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105-13. 23 Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2013 (1). Review. 24 Glasgow RE, Eakin EG, Fisher EB, et al. Physician advice and support for physical activity results from a national survey. Am J Prev Med. 2001;21(3):189-96. 25 Salis R. Developing healthcare systems to support exercise: exercise as the fifth vital signs. Br J Sports Med. 2011;45(6):473-4. 26 Andersen RE, Blair SN, Cheskin LJ, et al. Encouraging patients to become more physically active: the physician's role. Ann Intern Med. 1997;127(5):395-400. 27 Public Health Agency of Canada. Overview of the Pan-Canadian Healthy Living Strategy. 2010. Available: www.phac-aspc.gc.ca/hp-ps/hl-mvs/ipchls-spimmvs-eng.php (accessed 2014 Jan 20). 28 Lobelo F, Duperly J, Frank E. Physical activity habits of doctors and medical students influence their counselling practices. Br J Sports Med. 2009;43(2):89-92. 29 Rogers LQ, Gutin B, Humphries MC, et al. Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived Success. Teach Learn Med. 2006;18(3):215-21. 30 Connaughton AV, Weiler RM, Connaughton DP. (May-June 2001). Graduating medical students' exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001;116:226-34. 31 Vallance JK, Wylie M, MacDonald R. Medical students' self-perceived competence and prescription of patient-centered physical activity. Prev Med. 2009;48(2):164-6. DOI: 10.1016/j.ypmed.2008.12.006 32 The Kaiser Family Foundation. The role of media in childhood obesity. Menlo Park (CA): The Foundation; 2004 Feb. Available: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/the-role-of-media-in-childhood-obesity.pdf (accessed 2014 Mar 19). 33 Merchant AT, Dehghan M, Akhtar-Danesh N. Seasonal variation in leisure-time physical activity among Canadians Can J Public Health. 2007;98(3):203-8. 34 Statistics Canada. Commuting to work. National Household Survey. 2011. Available: https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-012-x/99-012-x2011003_1-eng.cfm (accessed 2014 Jan 20). 35 Perez-Rodrigo C. School-based nutrition education: lessons learned and new perspectives. Public Health Nutr. 2001;4(1A):131-9. 36 Canadian Fitness and Lifestyle Research Institute. Policies related to physical activities. 2011 opportunities for physical activity at school survey. 2012 Aug 14. Available: http://www.cflri.ca/sites/default/files/node/1054/files/Schools%202011%20Bulletin%2012%20-%20Policy%20EN.pdf (accessed 2013 Sep 15). 37 Dobbins M, Husson H, DeCorby K, et al. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev. 2013;2:CD007651. 38 O'Brien M, Nader PR, Houts RM, et al. The ecology of childhood overweight: a 12-year longitudinal analysis. Int J Obes (Lond). 2007;31(9):1469-78. 39 Howard PH, Fitzpatrick M, Fulfrost B Proximity of food retailers to schools and rates of overweight ninth grade students: an ecological study in California. BMC Public Health. 2011;11(68). 40 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009;99(3):505-10. 41 Le Bigot Macaux A. Eat to live or live to eat? Do parents and children agree? Public Health Nutr. 2001;4(1A):141-6.
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Joint Canadian Medical Association & Canadian Psychiatric Association Policy - Access to mental health care

https://policybase.cma.ca/en/permalink/policy11890
Date
2016-05-20
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2016-05-20
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
One in five Canadians suffer from a mental health problem or illness in any given year. Mental illness costs Canada over $50 billion annually in health care costs, lost productivity and reductions in health-related quality of life. The social costs of poor mental health are high; a person with serious mental illness is at high risk of experiencing poverty, homelessness and unemployment. Despite the widespread prevalence of mental health disorders, it is estimated that fewer than one-third of people affected by them will seek treatment. This is due in large part to the stigma society attaches to mental illness, which can lead to discriminatory treatment in the workplace or the health care system. In recent years, awareness of mental health issues has risen considerably in Canada. However, much still needs to be done to ensure that Canadians who require mental health care have timely access to the treatment and support they need. The Canadian Medical Association (CMA) and Canadian Psychiatric Association (CPA) recommend that all stakeholders, and governments at all levels, work together toward developing a mental health care system that incorporates the following elements:
Comprehensive, patient-centred care and evidence-based treatment for mental health disorders. This includes enhancing collaboration and teamwork among health professionals, patients and their families; providing education and resources for health professionals; and supporting ongoing research to identify and disseminate best clinical practices.
Timely access to mental health services. The health care system should ensure an appropriate supply, distribution and mix of accredited mental health professionals, ensure equitable coverage of essential mental health care and treatment, and provide appropriate services for populations with unique needs, such as children and older Canadians.
Adequate supports in the community, for example in schools and workplaces, to promote mental health, identify mental health issues in a timely manner and support people with mental illness as they seek to function optimally.
Reduction of stigma and discrimination faced by Canadians with mental health disorders, in the health care system and in society. Summary of recommendations Comprehensive, patient-centred care and evidence-based treatment Governments and health care systems 1. Develop and support a continuum of evidence-based, patient-centred services for the promotion of mental health and treatment of mental illness, in the community and in hospitals, with smooth transitions and linkages between each level. 2. Develop and implement models of collaborative mental health care in the community, with input from key stakeholders including the public, patients and their families, evaluate their effectiveness and encourage the adoption of those that demonstrate success. 3. Develop and implement a national caregiver strategy and expand the financial and emotional support programs currently offered to informal caregivers. 4. Continue to develop, implement and monitor mental health indicators that reflect both health system performance and population health, regularly report the results to the public and use them to improve the delivery of mental health services in Canada. 5. Increase funding for mental health research so that it is proportionate to the burden of mental illness on Canada’s health care system. Medical faculties, professional associations and the health care systems 6. Continue to develop evidence-based guidelines and professional development programs on mental health treatment and management, for all health care providers. 7. Continue to conduct research into best practices in mental health care and treatment and communicate the results of this research promptly to health care providers and the public. Appropriate provision and funding of mental health services Governments and health care systems Address current gaps in access to mental health services in the following ways: 8. Ensure that mental health services are appropriately funded to effectively meet the needs of Canadians. 9. Make mental health a priority with all levels of government and ensure stable and appropriate funding. 10. Establish standards for access to mental health services, including appropriate maximum wait times, and measure and report them on an ongoing basis. 11. Fund and support primary health care delivery models that include mental health promotion and mental illness treatment among the services they provide and identify and address the barriers to their implementation. 12. Increase funding for access to evidence-based psychotherapies and counselling services for mental disorders. 13. Establish a program of comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 14. Continue to develop linkages between remote communities and larger health centres, including telehealth and e-health services, to ensure adequate access to mental health services by people in smaller communities. Health professional associations 15. Work with governments and other stakeholders to develop a mental health human resources plan that optimizes the scope of practice of every health professional, is culturally appropriate and takes into account Canada’s diverse geography. 16. Undertake a national study of ways to optimize the supply, mix and distribution of psychiatrists in Canada and present its findings/recommendations to governments. Adequate community supports outside the health sector Governments 17. Ensure the availability of school-based mental health promotion and mental illness prevention programs, and programs that address school-related problems, such as bullying, that are associated with mental distress. 18. Work with employers and other stakeholders to support mental health programs for workplaces. 19. Provide programs and services to improve the interface between people with mental illnesses and the criminal justice system. 20. Expand programs that provide housing for people with mental illness. Reduction of stigma and discrimination Governments and the health care system 21. Incorporate identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. 22. Implement and evaluate national public awareness and education strategies to counteract the stigma associated with mental illness. 23. Enforce legislation and regulations to guard against discrimination against people with mental illness. Professional education 24. Incorporate effective anti-stigma education into the entire medical education continuum (medical school, residency and continuing professional development) for all physicians and other health professionals. 25. Incorporate effective anti-stigma education into professional development programs at hospitals and other health care facilities. Introduction Mental health disorders impose a heavy burden on Canadians and their health care system. In any given year, one in five Canadians will suffer from a mental health problem or illness. It is estimated that 10% to 20% of Canadian youth are affected by a mental health disorder. By age 40, 50% of Canadians will have had a mental illness. Mental illness can shorten life expectancy; for example, people with schizophrenia die as much as 20 years earlier than the population average. This is due both to higher rates of suicide and substance abuse and to a poorer prognosis for conditions such as heart disease, diabetes and cancer. Suicide is the second leading cause of death (after injuries) for Canadians aged 15 to 34. For people with mental health disorders, the effect on their lives goes beyond their interaction with the health care system; a person with serious mental illness is at high risk of experiencing poverty, homelessness and unemployment. Mental health disorders are costly to Canada’s health care system and to its economy. A third of hospital stays in Canada and 25% of emergency department visits are due to mental health disorders. It is estimated that mental illness costs Canada over $50 billion per year, including health care costs, lost productivity and reductions in health-related quality of life. Despite the widespread prevalence of mental health disorders, it is estimated that only one- quarter to one-third of people affected by them will seek treatment. This could be due in part to the stigma society attaches to mental illness, which deters many people from seeking needed treatment because they fear ostracism by their friends or discriminatory treatment in the workplace or the health care system. Those who do seek treatment may have a difficult time finding it. According to Statistics Canada, in 2012 almost a third of Canadians who sought mental health care reported that their needs were not met or only partially met. Lack of access to family physicians, psychiatrists and other health care providers contributes to this deficit. Though mental illnesses constitute more than 15% of the disease burden in Canada, the country spends only about seven cents of every public health care dollar on mental illness (7%), below the 10% to 11% of spending devoted to mental illness in countries such as New Zealand and the United Kingdom.4 Since 2000, however, Canadians’ awareness of mental health issues has risen considerably. The seminal 2006 report entitled Out of the Shadows at Last by the Standing Senate Committee on Social Affairs, Science and Technology, chaired by Senator Michael Kirby, made a number of recommendations aimed at increasing awareness, improving access to mental health services and reducing the stigma of mental illness. As a result of this report, in 2007 the federal government established the Mental Health Commission of Canada (MHCC) to be a catalyst for improving the mental health system and changing the attitudes and behaviours of Canadians around mental health issues. In 2012, the MHCC released Canada’s first mental health strategy, “Changing Directions, Changing Lives.” As part of her mandate from the prime minister following the 2015 federal election, Canada’s health minister has been asked to “engage provinces and territories in the development of a new multi-year Health Accord [that will] make high quality mental health services more available to Canadians who need them.” Nearly all provincial governments have also developed mental health strategies for their own jurisdictions. Much still needs to be done to translate heightened awareness into improvements in service provision to give Canadians who require mental health care timely access to the evidence-based, patient-centred treatment and support they need. The Canadian Medical Association (CMA) and Canadian Psychiatric Association (CPA) agree it is time to make mental health a high priority in Canada. The CMA and CPA recommend that all stakeholders, and governments at all levels, work together toward developing a mental health care system that is driven by needs-based plans with clear performance measures and that receives an appropriate share of health care funding. This position statement discusses and makes recommendations on issues relating to access to mental health care, with a focus on:
comprehensive, patient-centred care and evidence-based treatment for mental health disorders;
appropriately funded primary, specialty and community mental health treatment and support services;
adequate community supports for people with mental health disorders; and
reduction of the stigma and discrimination faced by Canadians with mental health disorders. Comprehensive, patient-centred care and evidence-based treatment The goal of mental health care in Canada should be to allow patients’ needs to be met in the most appropriate, timely and cost-effective manner possible. Current best practice suggests that care for patients with mental health disorders should be provided using models that incorporate the following principles. Patient-centred care One of the fundamental principles of health care is that it be patient centred. CMA defines patient-centred care as “seamless access to the continuum of care in a timely manner … that takes into consideration the individual needs and preferences of the patient and his/her family and treats the patient with respect and dignity.” For treatment of mental health disorders, it is essential that patients be core members of the health care team, working with health care providers to address their individual needs, preferences and aspirations and to seek their personal paths to well-being. Physicians and other health professionals can help patients make choices about their treatment and can provide information and support to patients and their families as they seek to cope with the effects of their illnesses and live functional lives. A continuum of mental health services Mental health disorders can be complex and can vary in severity. A patient may have short-term coping difficulties that can be resolved with counselling or a severe psychotic illness that requires frequent hospital care and intensive, lifelong support. This range of needs requires that the health care system provide different levels of care, including:
community-based programs to promote and maintain mental health and to facilitate early identification of problems requiring intervention;
community-based primary health care, including collaborative care teams, which focus on providing mental health maintenance programs and on treating high-prevalence conditions such as anxiety disorders, mood disorders and addictions;
specialized services in the community for patients with greater needs, which can be delivered through a variety of means, including community-based psychiatrists, interdisciplinary family health teams that incorporate psychiatric services and specialized interdisciplinary teams such as assertive community treatment (ACT) teams ;
acute-care mental health services including community crisis teams and beds, psychiatric emergency services and inpatient beds in community hospitals, and specialized psychiatric hospitals;
a continuum of residential care services including long-term care facilities;
seamless, integrated transitions from one level of care to another, and across age groups (e.g., from youth to adult to senior mental health services);
appropriate services for special populations, including children and adolescents, and adults with dementia;
specialized psychiatric services for patients with complex mental illnesses such as eating disorders, post-traumatic stress disorder and personality disorders; and
community-based programs that provide housing, vocational support and other services to optimize community integration of people with mental illness. Mental health care should ideally be provided in the context of caring for the patient’s overall health, taking into account any physical conditions for which the patient is receiving or may receive treatment. Collaborative and team-based mental health care Within this continuum, a variety of health care professionals with different skills and education provide mental health services in Canada. They include:
primary care physicians (family physicians and general practitioners);
psychiatrists (hospital and community based);
other specialist physicians (including emergency physicians, paediatricians, geriatricians);
other health professionals (psychologists, nurses, pharmacists, occupational therapists, social workers); and
case managers, peer support workers and system navigators. Collaborative models enable a variety of mental health care providers to work with patients and their families to provide effective, coordinated care according to a mutually agreed plan. Collaborative partnerships in mental health care have demonstrated benefits including symptom and functional improvement, reduced disability days and improved adherence to medication. Elements of a successful collaborative partnership include:
effective linkages among psychiatrists, primary care providers and other mental health professionals, including a seamless process for consultation and referral;
effective communication and information flow;
use of technology, such as electronic health records and telemedicine, to facilitate collaboration among providers in all health care settings;
coordination of care plans and clinical activities to ensure the most effective care and efficient use of resources; and
integration of mental health and primary care providers within a single service or team (in some cases, providers may work in the same practice setting).13 Education and resources for health professionals Since mental health disorders are pervasive and are often associated with other chronic conditions such as heart disease, health care providers of all disciplines and specialties often encounter them while caring for their patients. The Mental Health Core Competencies for Physicians report, prepared collaboratively by the Royal College of Physicians and Surgeons of Canada, the MHCC, the College of Family Physicians of Canada, CMA and CPA, proposes goals, principles and core mental health competencies to provide guidance to physicians of all specialties. The intent is to improve access to mental health services; improve the experience of care, including reducing stigma; recognize and address the interaction between physical and mental health; and provide practice support for physicians. To support physicians and other health care providers in treating mental health disorders, clinical and practice resources should be available to them, including:
early education in medical school and residency on mental health promotion, diagnosis and treatment of mental health conditions, and liaison with other community resources, for all specialties;
clinical practice tools including practice guidelines, clinical pathways and online decision support including prescribing guidelines for the appropriate use of psychiatric drugs;
online continuing professional development (CPD) programs ;
enhanced interprofessional education for all providers (psychiatrists, family physicians, nurses, social workers, occupational therapists, peer support workers, patients, their family members and others as relevant) ; and
evidence-based, user-friendly education and support tools for patients, which physicians can recommend to help them manage their conditions. Support for informal caregivers Often the burden of caring for a person with mental illness falls heavily on family or friends, and the role of the informal caregiver can be demanding financially, physically and/or emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more help is required. A national caregiver strategy, developed by governments and other key stakeholders, could define a national standard of support for informal caregivers and expand the financial and emotional support programs that are currently offered. Research and evaluation Thanks to ongoing research, our knowledge of how to treat and manage mental health disorders is constantly growing and developing. However, there are still gaps in this knowledge, and research needs in the area remain substantial. CMA and CPA encourage a continued commitment to research into best practices in early identification, care and treatment of mental health disorders and to funding this research so that it is proportionate to the burden of mental illness on Canada’s health care system. Results of this research should be communicated to health professionals and the public as quickly and widely as possible, so that it can be rapidly incorporated into clinical practice. Mental health care interventions should also be routinely evaluated for their effectiveness in improving patient care, enhancing the sustainability of the health care system and increasing the overall health and well-being of Canadians. The MHCC has developed a set of 63 mental health indicators that focus on 13 specific areas, including access and treatment, the economy and workplace, and special populations such as seniors, children and youth. Other projects are underway to develop indicators to monitor and report more specifically on mental health system performance, such as use of emergency departments for mental health care, and physician follow-up after hospital treatment. Such indicators should be used on an ongoing basis to monitor the performance of the mental health care system and provide mental health professionals, planners and governments with reliable information that they can use to better meet the needs of Canadians. Recommendations Governments and health care systems 1. Develop and support a continuum of evidence-based, patient-centred services for the promotion of mental health and treatment of mental illness, in the community and in hospitals, with smooth transitions and linkages between each level. 2. Develop and implement models of collaborative mental health care in the community, with input from key stakeholders including the public, patients and their families, evaluate their effectiveness and encourage the adoption of those that demonstrate success. 3. Develop and implement a national caregiver strategy and expand the financial and emotional support programs currently offered to informal caregivers. 4. Continue to develop, implement and monitor mental health indicators that reflect both health system performance and population health, regularly report the results to the public and use them to improve the delivery of mental health services in Canada. 5. Increase funding for mental health research so that it is proportionate to the burden of mental illness on Canada’s health care system. Medical faculties, professional associations and health care systems 6. Continue to develop evidence-based guidelines and professional development programs on mental health treatment and management, for all health care providers. 7. Continue to conduct research into best practices in mental health care and treatment and communicate the results of this research promptly to health care providers and the public. Appropriate provision and funding of mental health services Appropriate provision of mental health services requires that people be able to access the right care in the right place at the right time, in both hospital and community settings. Unfortunately, because of the underfunding of the mental health care system, limited resources are available to accommodate all of those who need such services. The exact extent of lack of access to hospital and community mental health services is not well documented; for instance, provinces do not report wait times for psychiatric services. According to the 2015 Wait Time Alliance Report Card, no jurisdiction is measuring what proportion of patients is being seen within the benchmark time periods. In December 2015 the CPA expressed disappointment that “no visible progress has been made in measuring how well the health system meets the psychiatric needs of Canadians.” In the absence of community-based services, patients may have their discharge from hospital delayed. Once they are back in the community, they may be unable to find appropriate assistance, or assistance may be available but beyond their financial means. They may abandon treatment or rely on emergency departments for episodic crisis care.4 Canada should work to remedy the current deficiencies in access to mental health services so that people with mental health disorders have timely access to seamless, comprehensive care in the most appropriate setting. This includes ensuring an appropriate supply, distribution and mix of accredited mental health professionals, ensuring equitable coverage of essential health services and making appropriate services and supports available to populations with unique needs. Access to physician services Primary care For the majority of patients who seek treatment for a mental health problem, the first (often the only) point of contact is their primary care physician. As part of the comprehensive care they provide to patients, family physicians and general practitioners can provide mental health promotion and wellness counselling, detect and treat mental health disorders in their early stages and monitor the patient’s progress in the context of his or her overall health and well-being, referring to psychiatrists and other mental health professionals as needed.13 CMA has long recommended that every Canadian have an established professional relationship with a family physician who is familiar with his or her condition, needs and preferences. However, some Canadians may have difficulty finding primary medical care, since the proportion of family physicians and general practitioners to the population is not consistent across Canada. All stakeholders should continue working to ensure that every Canadian has access to comprehensive first-point-of-contact medical care. Psychiatric services Psychiatrists are physicians who complete five to seven years of specialty and subspecialty training to diagnose, treat and provide ongoing care for mental illnesses, particularly to people with complex illnesses that cannot be managed within a primary care setting alone. In addition to providing specialty treatment, psychiatrists are also active in the areas of education, research and advocacy about the importance of mental health promotion and mental illness prevention. They provide care across the lifespan, in both hospital and community settings. Patient access to psychiatrists is often limited by long wait times. It has been suggested that this is due to a shortage of psychiatrists, which is more severe in some parts of Canada than others. Recent surveys report that a number of specialists, including psychiatrists, are in the latter half of their careers, and there are concerns that the number of psychiatrists per Canadian population is declining. Though the Royal College notes that the number of psychiatric residency positions has increased in recent years, it is unclear if this is sufficient to meet current and future population needs. The CPA recommends the development of strategies to attract, train and retain practitioners in clinical psychiatry. Access to services not funded by provincial and territorial health systems Though Canada’s public health care system covers many mental health services and treatments, including physician consultations and hospital care, it does not cover all aspects of optimal treatment and care, and access to some therapies may be limited by the patient’s ability to pay. Psychiatric drugs, especially those that must be taken over many years, can pose a heavy financial burden for patients who do not have drug coverage through employer-provided benefit programs or provincial or territorial drug plans. Psychotherapies delivered by non-physician health care practitioners are generally not covered by government health plans and must, therefore, in most cases be paid for out of pocket or through private insurance plans, to which many Canadians do not have access. Federal, provincial and territorial governments should work to increase access to accredited psychological and counselling services that are evidence based and to provide comprehensive coverage of medically necessary prescription drugs for all Canadians. Some primary health care practices, such as family health teams in Ontario, have funding envelopes that they can use to contract with skilled mental health professionals to provide psychotherapy, stress management programs and other services that are not ordinarily funded through provincial health budgets. Models such as these help to make publicly funded mental health care available to patients who might otherwise have been unable to afford it. Access to mental health services for special populations For some populations, access to mental health services may be particularly problematic. For example, stakeholders should consider the needs of the following populations:
Children and youth: As up to 70% of mental health conditions first appear in adolescence or young adulthood, it is important that young people have access to mental health promotion and to appropriate assessment and treatment of mental health disorders. At present only one out of four children who need mental health services receives them.1,3 CMA and CPA particularly recommend increased supports for children in high-risk situations, such as those in foster care. The transition from the youth to the adult mental health service sectors should be smooth and well organized.
Remote areas: People in the North and other remote parts of Canada may have to travel many miles to access mental health and other health care services. This gap should be remedied by using technologies such as telehealth and e-mental health services and by strengthening communication and coordination between small communities and the larger health centres to which their residents travel for care.
Immigrants and refugees: New arrivals to Canada may have problems understanding our language and culture and may also face mental health problems as a result of traumatic experiences in their countries of origin or the stress of relocation.
Indigenous Peoples. Rates of mental health disorders, addictions and suicide are high among Canada’s First Nations, Inuit and Métis. Much of this is linked to past experience of forcible separation from their traditional languages and culture. Health service providers should work with Indigenous communities to address their distinct mental health needs appropriately.
Seniors: An estimated 10% to 15% of seniors report depression, and the rate is higher among those with concomitant physical illness and those living in long-term care facilities. Depression among older people may be under-recognized and under-treated or dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. The majority of older adults in long-term care settings have dementia or another mental health condition. Recommendations Governments and health care systems Address current gaps in access to mental health services in the following ways: 8. Ensure that mental health services are appropriately funded to effectively meet the needs of Canadians. 9. Make mental health a priority with all levels of government and ensure stable and appropriate funding. 10. Establish standards for access to mental health services, including appropriate maximum wait times, and measure and report them on an ongoing basis. 11. Fund and support primary health care delivery models that include mental health promotion and mental illness treatment among the services they provide and identify and address the barriers to their implementation. 12. Increase funding for access to evidence-based psychotherapies and counselling services for mental disorders. 13. Establish a program of comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 14. Continue to develop linkages between remote communities and larger health centres, including telehealth and e-health services, to ensure adequate access to mental health services by people in smaller communities. Health professional associations 15. Work with governments and other stakeholders to develop a mental health human resources plan that optimizes the scope of practice of every health professional, is culturally appropriate and takes into account Canada’s diverse geography. 16. Undertake a national study of ways to optimize the supply, mix and distribution of psychiatrists in Canada and present its findings/recommendations to governments. Adequate community supports outside the health sector People with mental health disorders often require not only treatment and care from the health sector but also support from the community at large to function optimally. Ideally, the community should provide an environment that supports patients as they work toward recovery and well-being. In addition, schools, workplaces and other community agencies can play an important role in promoting mental health and identifying problems that require attention. Schools Education and information should be made available to parents, teachers and health professionals to help them identify signs of mental illness or distress in children and adolescents, so they can intervene early and appropriately. School health education programs should include the promotion of mental health and incorporate self-management techniques such as mindfulness training to help young people develop resilience. Schools should also ensure that they minimize possible threats to children’s mental health, such as bullying, that may occur on their premises. Workplaces Unlike many other chronic conditions, mental illness frequently affects younger people and those in their most productive years, so the burden it imposes on Canada’s economy is high. Mental health disorders account for 30% of short-term workplace disability claims,1 and the Conference Board of Canada has estimated that six common mental health disorders cost the country’s economy more than $21 billion a year and predicts that this cost will increase to $30 billion by 2030. However, often employees do not disclose mental health problems to their employers for fear of losing their jobs, being ostracized by colleagues, or other negative consequences. Workplaces can support the mental health of their employees by:
offering mental health promotion assistance through stress management seminars, employee assistance and other programs;
training managers to identify potential mental health issues in their staff and to intervene early and appropriately;
eliminating stigma and discrimination and providing an environment in which employees feel safe disclosing their mental health issues; and
offering adequate benefits, including supplementary health insurance and supportive leave-of-absence programs. The MHCC’s Standard for Psychological Health and Safety in the Workplace, released in 2013, provides guidance to employers on how to promote the mental health of their staff and intervene in cases of mental distress. Correctional services People with mental illnesses are overrepresented in the criminal justice system. Estimates suggest that rates of serious mental illness among federal offenders upon admission have increased by 60% to 70% cent since 1997.4 This places a heavy burden on corrections and law enforcement staff, who are often inadequately trained to deal with mental illness. Programs and services are needed to ensure that people with mental health disorders who run afoul of the law are identified early, given appropriate treatment throughout their incarceration and followed up on release. These could include:
training for police and other frontline criminal justice and corrections workers in how to interact with people with mental illnesses;
diversion programs, such as mental health courts, to redirect people with mental illnesses who are about to enter the criminal justice system;
comprehensive psychiatric screening, assessment and treatment for incarcerated patients with mental illnesses and common co-occurring conditions such as addiction; and
Careful handover of clinical care at the point of release from custody with engagement by mental health services in the community. Housing Mental illness increases a patient’s risk for poverty and homelessness. It is estimated that two- thirds of Canada’s homeless population have a serious mental illness. Homelessness and poverty can exacerbate existing mental health and addiction problems, hinder access to treatment and reduce life expectancy. Programs such as the MHCC’s Housing First research demonstration project can improve the social and economic circumstances of people with mental illness. The MHCC project provided no-strings-attached supportive housing for people with chronic mental health problems, giving them a secure base from which they could pursue their treatment and recovery goals. Evaluation showed that this approach reduced the rate of homelessness, improved access to treatment and support services and led to cost savings, particularly for the program participants who had the highest service-use costs. Recommendations Governments 17. Ensure the availability of school-based mental health promotion and mental illness prevention programs, and programs that address school-related problems, such as bullying, that are associated with mental distress. 18. Work with employers and other stakeholders to support mental health programs for workplaces. 19. Provide programs and services to improve the interface between people with mental illnesses and the criminal justice system. 20. Expand programs that provide housing for people with mental illness. Reduction of stigma and discrimination Many believe that the primary reason for the underfunding of the mental health care system and for the reluctance of people with mental health disorders to seek treatment is the stigma attached to their conditions. Mental illness is the most stigmatized disease state in Canada, and discriminatory behaviour toward people with mental health disorders is widespread. This can include ostracism and lack of support from peers, discrimination in the workplace and distorted public perceptions, such as the tendency to equate mental illness with violent behaviour. Discriminatory behaviour can also occur in the health care system. Experts acknowledge that stigma affects health care providers’ attitude toward patients with mental health problems.29 Though many health care providers are unaware that their language or actions can be harmful, their attitude may have negative effects on the treatment their patients receive. For example, if a patient who has been treated for a psychiatric condition reports physical symptoms, these symptoms might be attributed to the mental illness rather than to a physical condition, and as a result the patient may not receive necessary treatment. This is known as diagnostic overshadowing. , CMA and CPA recommend comprehensive efforts to change the culture of stigmatization of mental illness, in the health care system and in society. A number of interventions are underway to help reduce stigma and discrimination related to mental illness. These include public awareness programs such as the Bell Let’s Talk campaign, Mental Illness Awareness Week, sponsored by the Canadian Alliance on Mental Illness and Mental Health, and the Opening Minds program of the MHCC, which focuses on specific populations including youth and health care providers. The current consensus among experts is that the most effective interventions are those that:
are aimed at changing behaviour rather than modifying attitudes;
are ongoing rather than time limited;
are targeted to specific groups rather than to the general population; and
involve direct contact with people with mental illness. Within the health care system, professional education is a potentially important means of addressing stigma and discrimination. It has been recommended that anti-stigma education be incorporated into the medical education continuum at all levels (including residency and CPD) and for all specialties and that this education incorporate direct contact with people with mental illness, to share their stories of recovery.27 All health professionals and their associations should be encouraged to address the elimination of stigma in their educational programs. CMA and CPA have worked with partners to provide education to physicians, through workshops, online materials and other means. Recommendations Governments and the health care system 21. Incorporate identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. 22. Implement and evaluate national public awareness and education strategies to counteract the stigma associated with mental illness. 23. Enforce legislation and regulations to guard against discrimination against people with mental illness. Professional education 24. Incorporate effective anti-stigma education into the entire medical education continuum (medical school, residency and CPD) for all physicians and other health professionals. 25. Incorporate effective anti-stigma education into professional development programs at hospitals and other health care facilities. Conclusion Despite increased public awareness about mental illness, ensuring access to effective mental health services and supports remains a challenge in Canada, and the stigma and discrimination associated with mental illness remain high. CMA and CPA believe that change is possible. 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