Population Health 8910 Term Paper The Mental Health Frontier: opportunities for Population Health in addressing the mental health concerns of children and youth.

Peter Levesque, BSocSc, MA, PhD (student)

Institute of Population Health, University of Ottawa

Mailing Address
1961 Caprihani Way
Ottawa, Ontario, Canada
K4A 4R6

Contact
T: (613) 841-0858
E: peterlevesque@yahoo.ca

Citation
Levesque, P. The Mental Health Frontier: opportunities for Population Health in addressing the mental health concerns of children and youth. Ottawa: PhD Working Paper 1, 2005.


Introduction

Mental health is an underdeveloped area of health care in Canada - a frontier. For children and youth mental health, the frontier is especially wide open. As such, there are significant opportunities, for researchers, practitioners, advocates, and policymakers, to increase their involvement in addressing the complex nature of mental health and the problems associated with mental functioning, whether in children and youth or adults. The utilization in population health of complex, holistic models that include the social determinants of health, multiple disciplinary perspectives, and multiple sources and forms of data, is well suited to addressing mental health problems that often create economic and social burdens, not only for individuals directly affected, but also for their families, communities and countries.1

One of the groundbreaking documents in the creation of the health field concept, "A new perspective on the health of Canadians"2, otherwise known as the Lalonde Report, includes a chapter on mental health. This chapter consists of 2 pages. The information provided in this chapter, the shortest of the report, is almost as relevant today as when it was written in 1974. Few still "want to admit to the parenthood of a child with an emotional disorder"3. The statement, "much needs to be done in providing the mentally ill with adequate protection, care and readaptation opportunities and in informing the public and modifying attitudes towards mental illness"4 could have been written in 2005 rather than over three decades ago.

Yet, mental health continues to be the "orphan child" of health5 and one of the least integrated aspects of health care6. The new reality of mental health care, post deinstitutionalization, is that most care is home based, with many mental health patients discharged with insufficient resources and networks to support their ability to live at home.7

The situation for children and youth with mental health issues is even more difficult than that of adults. Senator Michael Kirby said, "If mental health services generally are the orphan of the health care system, then children's services are the "orphan of the orphan."8

The purpose of this paper is to describe the situations of both the "orphan" and the "orphan of the orphan" and to suggest how they may find a home within a population health perspective. Definitions of mental health and mental illness are provided as well as an introduction to some of the conditions that may be prevented or treated. The prevalence of these conditions is presented from global and Canadian perspectives. Several examples of mental health initiatives that have adopted complex, multidisciplinary approaches are presented. These are followed by a discussion of how the mental health of children and youth is better served by adopting a population health perspective. The conclusion is a series of research questions that may help provide direction for new or modified program development at the three levels presented.

For the purpose of this paper, a child refers to a young person between the ages of 1 and 12. A youth (commonly referred to as an adolescent in the United States) generally refers to someone between the ages of 13 and 18 or 19. Age subgroups are often created as a function of interaction with important social institutions such as daycare and school, thus common groupings are found for children under the age of one, ages 1 to 4, ages 5 to 12, for early teens (13 to 15) and late teens (16 to 19). The term youth sometimes extends to young adults under the age of 25. As such, some sources will provide data for age groups such as 15-24. In general, children are more dependent on a parent or caregiver than a youth, however both children and youth have some level of dependence on a parent or caregiver, and all ages fall along a continuum of social, neurological and physiological development.

Mental health and mental illness

Mental health is one aspect of the holistic health of a human being. One way to think of mental health is that humans are "mental beings" as much as they are "physical beings".9 The World Health Organization's definition of health, endorsed by 191 member states, includes mental health: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."10 The WHO further defines mental health "as a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community."11

The Surgeon General of the United States has adopted a lifespan approach to mental health and mental illness: "Mental health and mental illness are dynamic, ever-changing phenomena. At any given moment, a person's mental status reflects the sum total of that individual's genetic inheritance and life experiences. The brain interacts with and responds-both in its function and in its very structure-to multiple influences continuously, across every stage of life. At different stages, variability in expression of mental health and mental illness can be very subtle or very pronounced." 12

As per the Surgeon General's report, health should be viewed as a continuum over a life span, with greater or lesser health necessitating health care of an appropriate nature. The relationship of the physical and mental components of health cannot be separated. As an example, a physically healthy person may suffer from depression, which if left untreated, may lead to suicide. The disorder in this case is mental rather than physical but may lead to the end of a life in a manner that is no less significant than cancer, heart disease, or infection.

Mental illness is illness. Although manifested differently, the effects of mental illness on overall health, are no less dramatic. There is considerable confusion about the difference between mental health and mental illness. This confusion is similar to that shown in understanding the difference between health and medicine, or the production of health and the consumption of health care services.

Given that mental health is broader than mental illness, one may argue that the production of mental health is not the primary function of most mental health practitioners - psychologists, psychiatrists, social workers, and speech language pathologists, among other professional groupings. While they are an important part of a complex system that builds mental health, they most often deal with the downstream effects of upstream opportunities to prevent or treat, which were missed or ignored. Despite a growing anti-psychiatry movement, mental health workers are neither the cause of nor the final cure for mental illness. Many mental health professionals follow the Western medical model that relies primarily upon the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), produced by the American Psychiatric Association, to diagnose and treat the symptoms associated with mental illnesses and disorders, in a manner similar to how a general practitioner, medical specialist, nurse, or physiotherapist may use guidelines, trials and experience from clinical practice, or various compendia to assist in the creation of health by treating the symptoms, illnesses, and disorders which affect physical health. As with all of these practices, there are things that are working quite well and there is much room for improvement. It is important to recognize that health, health care, medicine, mental health, are all connected parts of a larger enterprise of human activity which happens over time and space.

The above is not a criticism of mental health professionals. Rather, by stating the limits of the current professionals, the door is open to serious conversation of how to best approach mental health from a broad population health perspective that includes social determinants, cultural factors, historical biases, and other factors not part of the "normal" mental illness treatment system. In reality, the exisitng system is suffering and there are too few professionals available to provide treatment when needed. The Canadian Academy of Child and Adolescent Psychiatry estimates the need for child and adolescent psychiatrists at 1 per 4000 youth. That means there should be nearly 2000 psychiatrists to serve the 7.8 million Canadians age 19 and under. In reality, there are about 480. In Ontario in 2002, the latest year for which the Academy has figures, there was 1 psychiatrist for every 32 000 youth. Quebec has 1 for every 11 000.13

Mental illness generally include disorders of the brain that disrupt a person's thinking, feeling, moods, and ability to relate to others, to work, and in the case of children, to play. The WHO states that mental illnesses "affect the functioning and thinking processes of the individual, greatly diminishing his or her social role and productivity in the community. In addition, because mental illnesses are disabling and last for many years they take a tremendous toll on the emotional and socio-economic capabilities of relatives who care for the patient."14

These disorders include, but are not limited to the following:


Alcoholism and Alcohol Abuse,
Alzheimer's Disease,
Anankastic Personality Disorder,
Anorexia Nervosa,
Anti Social Personality Disorder,
Anxiety,
Anxious Personality Disorder,
Attention Deficit Hyperactivity Disorder (ADHD),
Autism,
Avoidant Personality Disorder,
Bipolar Affective Disorder,
Body Dysmorphic Disorder,
Borderline Personality Disorder,
Bulimia Nervosa,
Dementia,
Dependent Personality Disorder,
Depression,
Dissocial Personality Disorder,
Eating Disorders,
Gender,
Grief,
Hearing voices,
Histrionic Personality Disorder,
Hyperactivity,
Impulsive Personality Disorder,
Insomnia,
Mania,
Manic Depression,
Munchausen Syndrome,
Narcissistic Personality Disorder,
Narcolepsy,
Neurosis,
Obsessive-compulsive disorder (OCD), Panic Attacks,
Paranoia,
Paranoid Personality Disorder,
Personality Disorders,
Phobias,
Post Natal Depression,
Posttraumatic stress disorder,
Psychopathy,
Psychosis,
Schizoaffective Disorder,
Schizoid Personality Disorder, Schizophrenia,
Schizotypal Personality Disorder, Seasonal Affective Disorder (SAD),
Self harm,
Sleep Disorders,
Stress,
Substance Abuse,
Suicide,
Tourette's Syndrome


According to the WHO, 25% of individuals develop one or more mental or behavioral disorder at some stage in life. This applies for both developed and developing countries. Some disorders can be prevented; all can be successfully managed and treated.15 The UK's Mental Health Foundation states that on average one in four individuals will experience a mental health problem in the course of a year.16 The Canadian context is similar according to the Canadian Mental Health Association.17


Mental health of children and youth

The "orphan of the orphan" statement by Senator Kirby emerged from the cross-Canada hearings by the Standing Senate Committee on Social Affairs. His observation was that children's mental health services are the "most neglected piece" of the Canadian health care system.18 The stigma accurately noted by Lalonde continues to present day.

The Canadian Psychiatric Research Foundation, in the 1992 Canadian Youth and Mental Health & Illness Survey found that one in five (20%) children and youth have a mental health problem and that this number may be higher due to under-reporting.19, 20. Yet only about one in six of these children and youth receive any service from a mental health professional, whether this is a child and youth worker, psychologist, psychiatrist, nurse, or social worker.

Given the dependence of children and youth on their parents and caregivers, it may not be surprising to some that even childhood accidents can be related to the psychosocial states of parents and to their socio-economic context. Wilkinson points to the Brown study that demonstrated that "psychiatric difficulties in the mother appear to account for much of the class differences in childhood accidents"21 Rates of depression were four times as high among the working-class as middle-class mothers. Because the study followed mothers over a period, it was able to show that accident rates were only higher while the mothers were depressed.22

The definitions of mental health provided above relate to active involvement in society, community, family, while maintaining a sense of individual identity - in other words, a balancing of individual and collective life. The Mental Health Foundation states that individuals with good mental health: should develop emotionally, creatively, intellectually and spiritually; initiate, develop and sustain mutually satisfying personal relationships; face problems, resolve them and learn from them; are confident and assertive; are aware of others and empathize with them; use and enjoy solitude; play and have fun, and; laugh, both at themselves and at the world. 23

With regards to children and youth, much of what constitutes good mental health is found in a balance between actual and potential, between existing conditions and development for future use. The good mental health of children and youth is largely dependent on contexts wider than an individual's genetics or their family situation. As early as 1897, Emile Durkheim wrote about social integration and how it was related to patterns of mortality, especially suicide.24

It is from the perspective of a broader societal view of health that the "orphan of the orphan" statement clearly takes on meaning. Given that mental health is a complex, dynamic process, if the conditions that lead to good mental health in adults are not supported (access to professional support when needed, good living conditions, good working conditions, adequate social networks, etc.) then it follows that the children and youth in families under stress, are more at risk of developing mental health problems. The relationship between unemployment, mental health and well-being has been demonstrated in longitudinal studies.25 Adults with mental health problems are often orphans in the health care system and their offspring are often even further removed from adequate supports. Children and youth appear to be in a state of double jeopardy - affected by their own individual genetic make-up and experience, as well as being directly impacted by the mental state of those upon whom they depend the most. This is despite, in at least developed countries, almost universal access to a health care system and an early-education/school system, which has consistently been identified as important locales of early identification of mental health issues.26 27

The cost of not adequately treating mental illness and mental health problems in children and youth is hard to measure, however some indicators point us to a massive sum. In 1992, Lafleur 28 calculated, using actuarial methods, the cost to Canadians of all children dropping out of school in 1989 would, over their lifetimes, total $4 billion. This is the total from one year's dropouts. Think of the total over a decade or a generation. The costs and loss to Canadian society are extraordinary, yet this has become the norm. While not all cases of dropping out of school are due to mental health problems, there is a strong relationship between the effects of mental health problems and the ability to stay in school.29 30

Mental health problems, such as stress, anxiety, and depression, contribute significantly to youth dropping out of school every year. The effects are not limited only to dropouts however, since students cannot optimize their learning if their mental health needs are not met. This often leads to other behaviors that are then manifested in other areas such as physical health, youth justice, and child welfare.31 More troubling still is when youth take this to another level, not just removing themselves from school but from life, by committing suicide. Statistics Canada 32 reports suicide as the second leading cause of youth death, after fatal motor vehicle accidents.

Continuing with the example of school, school has been identified by youth as both the most positive aspect of their life as well as the most stressful. The 1992 Canadian Psychiatric Association's survey, noted above, demonstrated that for youth, school was seen as the most positive aspect of their life (28.1%), followed by friends/relationships (23.5%), family (15.1%), sports, music, and culture (11.1%), other (12.1%), or none (10.1%). The same survey also identified school as the most stressful aspect of their life (64.6%), followed by home and parents (10.6%), friends and relationships (7.9%), money and work (4.3%), with other or no opinion responses comprising 12.6% of responses.

When it comes to discussing mental health concerns however, teachers, principals, school health workers, appear to be left out of the loop. The first line of discussion is with a friend (43%), followed by a parent or family member (23.9%) or other (1.3%). What is troubling however is that over a third of youth are discussing their mental health concerns with no one (31.8%). 33

When youth are ready to seek help, they go to their family doctor first (32 %). The next most common choices are a mental health professional in a quarter of cases (child and youth worker, psychologist, psychiatrist, social worker) or a counselor (21%). Friends and family (4%), hot lines or teen-health clinic (8%), or other (3%), is how the minority seek help. Seven percent seek help from no one.

Given the central role that school plays in the lives of children and youth, and the prevalence of mental health problems faced by children and youth, it is significant that schools do not generally play a more active role in promoting good mental health, of reducing stigma, of developing help-seeking behaviors, and of providing good data and information into the streams where youth seek advice and help. As indicated above, the challenge of child & youth mental health is not being met. Alternative approaches must be found which build on what works, to eliminate what does not work, and to implement activities that are based on evidence.34


Global context on mental health

There is considerable debate as to whether mental health problems and mental illnesses can accurately be described as epidemics.35 36 Measurement and evaluation is often inadequate and the longitudinal data is often flawed due to changing diagnoses. Despite the debates and the ongoing disagreements, the World Health Organization provides some global estimates on the prevalence of mental health problems that are useful to outlining the scope of the number of individuals affected: 37

* 450 million people worldwide are affected by mental, neurological or behavioral problems at any time.

* About 873,000 people die by suicide every year.

* Mental illnesses are common to all countries and cause immense suffering. People with these disorders are often subjected to social isolation, poor quality of life and increased mortality. These disorders are the cause of staggering economic and social costs.

* One in four patients visiting a health service has at least one mental, neurological or behavioral disorder but most of these disorders are neither diagnosed nor treated.

* Mental illnesses affect and are affected by chronic conditions such as cancer, heart and cardiovascular diseases, diabetes and HIV/AIDS. Untreated, they bring about unhealthy behavior, non-compliance with prescribed medical regimens, diminished immune functioning, and poor prognosis.

* Cost-effective treatments exist for most disorders and, if correctly applied, could enable most of those affected to become functioning members of society.

* Barriers to effective treatment of mental illness include lack of recognition of the seriousness of mental illness and lack of understanding about the benefits of services. Policy makers, insurance companies, health and labor policies, and the public at large - all discriminate between physical and mental problems.


* Most middle and low-income countries devote less than 1% of their health expenditure to mental health. Consequently mental health policies, legislation, community care facilities, and treatments for people with mental illness are not given the priority they deserve.

With specific regard to children and youth mental health globally, the World Health Organization's, Atlas: child and adolescent mental health resources: global concerns, implications for the future, outlines the need for services 38:

* Worldwide prevalence of child and adolescent mental disorders of approximately 20%. Of this 20% it is recognized that from 4 to 6% of children and adolescents are in need of a clinical intervention for an observed significant mental disorder.39

* Half of all lifetime cases of mental disorders start by age 14.40

* Nowhere in the world is the documented need for child and adolescent mental health services fully met.

* In high-income countries child and adolescent mental health service need is identified for between 5 and 20% of the population. This is comparable to the range of estimated service need in the lowest income countries.

* In a European survey of 36 countries (70.5% of all European countries) showed that the degree of coverage and quality of services for the young were generally worse in comparison with adults.41

* In high-income countries the service gap, while substantially less than in low-income countries is still very high.

* European countries, particularly in the Scandinavian region and certain countries, such as Israel with highly developed mental health services approach 80% provision, but others among the high income countries report as low as 20% provision of services.

* The Mental Health Atlas - 2005 showed that 23% of countries in Europe lacked specific programs for child mental health.

* While a services gap exists in all countries in the Americas, 26% of countries lacked basic clinical mental health services for children and adolescents.42

* The Child and Adolescent Mental Health ATLAS documents that countries with the higher proportion of children in the world are the ones that lack both mental health policy addressing the needs of children and adolescents and services for the population.

* In Africa and other countries with a high rate of HIV/AIDS deaths the population of young people will increase disproportionately in the coming years. (UNICEF, 2005) The number of AIDS orphans is currently estimated to be 14 million, and anticipated to rise to 20 million by 2010 (UNICEF).

The WHO, as mentioned earlier, has identified mental health as carrying both an undefined burden of economic and social hardship for families, communities and countries as well as a hidden burden of stigma and violations of human rights and freedoms. These burdens are not effectively or efficiently measured and there are significant difficulties in measuring and evaluating the state of mental health and access to needed services.43

Even in one of the wealthiest nations of the world, the United States of America, the Surgeon General states that: "Tragic and devastating disorders such as schizophrenia, depression and bipolar disorder, Alzheimer's disease, the mental and behavioral disorders suffered by children, and a range of other mental disorders affect nearly one in five Americans in any year, yet continue too frequently to be spoken of in whispers and shame."44

Canadian context on mental health

The Canadian context is similar to that described in the United States and European countries. The Health Canada Report on Mental Illnesses in Canada45 provides an overview of mental health in Canada:

* Mental illnesses indirectly affect all Canadians through illness in a family member, friend or colleague.

* Twenty percent of Canadians will personally experience a mental illness during their lifetime.

* Mental illnesses affect people of all ages, educational and income levels, and cultures.

* The onset of most mental illnesses occurs during adolescence and young adulthood.

* A complex interplay of genetic, biological, personality and environmental factors causes mental illnesses.

* Mental illnesses can be treated effectively.

* Mental illnesses are costly to the individual, the family, the health care system and the community.

* The economic cost of mental illnesses in Canada was estimated to be at least $7.331 billion in 1993.

* Eight-six percent of hospitalizations for mental illness in Canada occur in general hospitals.

* In 1999, 3.8% of all admissions in general hospitals (1.5 million hospital days) were due to anxiety disorders, bipolar disorders, schizophrenia, major depression, personality disorders, eating disorders and suicidal behavior.

* The stigma attached to mental illnesses presents a serious barrier not only to diagnosis and treatment but also to acceptance in the community.

The Canada section of the World Health Organization's Mental Health Atlas provides a synthesis of mental health services.46 Canada has no national mental health program. There is no national therapeutic drug policy or essential list of drugs. Given the context of federal, provincial, and territorial government relations on health, each province frames mental health legislation independently. There are no federal budgets for mental health. Each province has its own health and mental health budgets. The Medicare system pays basic medical and hospital bills however the direct and indirect costs related to mental health problems are estimated be among the costliest of all conditions and represent nearly one-sixth of the national corporate net operating profits.47 Provincial health insurance plans fund general practitioners but do not usually cover services provided by other mental health professionals. There are thirteen interlocking health insurance plans and thirteen separate delivery systems. Mental health services are provided through an often confusing mix of sources: primary care, general hospital care, community service, specialized treatment facilities, psychiatric hospitals, community providers, non-governmental organizations, and consumer-run organizations.48

On a positive note, Canada has disability benefits (although limited, even General Romeo Dallaire, post Rwanda, had difficulty receiving benefits49) for persons with mental disorders, if they can receive proper diagnosis and ongoing treatment. There are specific programs for mental health for minorities, refugees, disaster-affected populations, indigenous populations, elderly and children, and there are services available for mentally disordered offenders. With regards to offenders, one of the few coherent national policy documents, is the 1991 "Report on the Task Force on Mental Health" published by Correctional Services of Canada.

Given the complexity of the legislative, financing, and service-delivery systems for mental health, Dickinson has argued that there is an on-going tension between the medical-scientific model of practice and the multidisciplinary, community-based model of mental health promotion and mental illness prevention originating in the mental hygiene movement.50 This tension is perhaps one reason why mental health services tend to be under-developed.

In the Romanow Report, there is the repeated recommendation that the quality of care and support available to people with mental illnesses be improved by including home mental health case management and intervention services as part of the Canada Health Act.51

Complex, multidisciplinary approaches

Given the prevalence of mental health problems and mental illnesses globally, as well as the gaps in services, access to professionals, competing systems, inconsistent policies, and inadequate financial resources, it is not surprising that a significant number of initiatives have been created in an attempt to leverage existing scarce resources. It is also not surprising that given these scarce resources, there have been few successes in bringing these initiatives together into a comprehensive framework.

The Ontario provincial government has recently begun putting more resources into mental health care, and into child and youth mental health in particular. According to ICES, an under-funding of mental health is consistent with historical perceptions of the mental illness. "Mental illnesses are often perceived as rare conditions and have been characterized historically as afflicting primarily people who are weak or lack moral fibre. These illnesses do not have clear-cut causal agents (such as bacteria or viruses) that are easily identifiable and treatable. Furthermore they are seen as less debilitating..."52

The creation in June 2004, of the Provincial Centre of Excellence for Mental Health53, located at the Children's Hospital of Eastern Ontario, is an example of the adoption of a multidisciplinary approach. With a budget of approximately $6 million per year, this Centre has adopted a four-prong approach to assisting the process of building an integrated mental health system for children and youth in Ontario. The stated strategic directions include:

* Networks and Partnerships
o Create and maintain partnerships and networks among and between mental health stakeholders
o Identify potential partners including parents, children, youth and their families
o Facilitate partnership building as well as provincial and province-wide activities
o Advocate for capacity building

* Research and Development
o Scan mental health research to consolidate and identify gaps
o Undertake leading edge research to fill the gaps
o Support researchers through consultation
o Fund new research

* Intervention
o Champion a fully integrated and collaborative system across the full continuum of needs in child and youth mental health
o Provide interventional consultation
o Ensure cultural and linguistic diversity
o Develop best practices guidelines

* Education and Training
o Scan education and training activities
o Provide mentorship and educational consultation
o Develop web-based training
o Target community awareness of the importance of child and youth mental health

While it is too early to determine whether the activities of the Centre will have the desired effect, there is already clear indication of a shift away from the more traditional hiring patterns of those involved with mental health care. Employees of the Centre come from a range of disciplines: psychology, education, psychiatry, sociology, epidemiology, communications, administration, knowledge exchange, and computer science, among others. The introduction of diverse professional perspectives, as well as the utilization of multiple sector advisory committees (service providers, researchers, consumers and caregivers, etc.), is a strong indicator of the recognition that if one involves only those involved in treating the symptoms of mental illness, it will be difficult to build a system that supports overall mental health.

The co-director of the Centre of Excellence, Drs. Ian Manion and Simon Davidson, were founders, over ten years ago, of a successful program supporting youth mental health. "Youth Net", was started at the Children's Hospital of Eastern Ontario and is now operating in the Ontario communities of Hamilton, Halton, Peel, and Grey Bruce, in the Quebec communities of Montréal, Montéregie, and Montmagny, in Delta, British Columbia and in Newcastle, United Kingdom. This bilingual program is run by youth for youth with an aim to: 1) increase communication and promote awareness among youth regarding mental health and illness issues, 2) identify those youth who are at risk for mental illness and bridge them to appropriate, youth friendly mental health services, 3) reduce the stigma surrounding mental health and illness through education and communication, and 4) attend to what youth are saying in order to make current mental health services more youth appropriate. The program is supported by a safety net of mental health professionals. 54

Another youth oriented program, HealthNet, based in Halifax, "is comprised of a range of programs, workshops, and health materials for young people, parents and teachers. Materials for youth are distributed online through (an) interactive health magazine for youth. Materials for parents and teachers are located and maintained through separate websites." These websites provide "both content and infrastructure that allow young people, teachers and parents to enhance health literacy using novel and interactive technologies as well as to track health needs, outcomes and risk behaviors as required." 55 Combining psychology, computer science, education, sociology, and psychiatry; the stated goal of the websites is "to promote health literacy in youth. Health literacy is a key component of making good choices for health and well-being." 56

As discussed above, schools can play a leadership role in the development of better parenting of children and youth. Programs such as COPE (Community Parent Education Program)57 developed at McMaster University and now operating in cities across Canada (Calgary, Regina, Toronto, Hamilton, and various places in Nova Scotia), the United States (Buffalo and ten sites in Orange County, California), in five cities in Sweden, and Istanbul, Turkey, uses active learning models to develop better parenting skills that have a direct effect on the mental health of families and children. This allows for better school performance as a result of better mental health.

A related program, from Australia, Triple P - Positive Parenting Program58 is an evidence-based parenting program based on over 25 years of clinical and empirical research. The program provides parenting and family support strategies that aim to prevent severe behavioral, emotional and developmental problems in children by enhancing the knowledge, skills and confidence of parents. This program has led to the development of a hit television show in the United Kingdom, "Driving Mum and Dad Mad"59.

Also from Australia, the Australian Broadcasting Corporation's youth radio station, "Triple J" 60, is using podcasts as a method to enable youth to listen to information pieces in a format they want (on their portable devices) and at a time they choose. Recent episodes include a pharmacist's investigation of Australia's depression epidemic. She wonders why over a million Australians now take antidepressant drugs? Other podcasts available include why it's not easy getting off anything that you are addicted to. This podcast includes stories of people who have kicked their drug habits and how they managed it. It was part of a promotion of "Positive Stories" by the Australian National Council on Drugs.

While the relative effectiveness and efficiency of any of the above examples is the subject for another paper, there does seem to be an international trend in dealing with mental health problems that recognizes their complex nature and the need to include a diverse set of perspectives and expertise. The challenge faced by mental health is similar to that faced by many areas of study and treatment: knowledge exchange - how do we know what we know and how do we move this knowledge into policy, practice, and perspectives.

The Centre of Excellence for Child and Youth Mental Health, provided as an example above, has recognized the challenge of knowledge exchange and has created a dedicated Knowledge Exchange Centre to help build the processes and tools to essentially "Do more with what we know."61 The emphasis on knowledge exchange within health care has also been emphasized by many organizations internationally, including in Canada by the Canadian Health Services Research Foundation62 and the Canadian Institutes of Health Research63, among others.

Population health perspective on child and youth mental health

"When people talk about health and health care, they usually think in terms of physical illness and medical treatments. Mental health is usually ignored or added only as an after thought."64 For a population health perspective to be truly adopted in Canada, mental health should be an integrated component of a complex, emergent process that looks at health over the lifespan. Given where we are, how do we do this?

The World Health Organization suggests that the federal government in Canada plays an important role in consensus building and setting priorities for policies, such as health care, including mental health care.65 With regards to mental health, the Public Health Agency of Canada's, Mental Health Promotion Unit appears to have been given the mandate to manage this role of "consensus builder".

The MHPU was created in 1995, as a unit of Health Canada. Their website states that the: "MHPU addresses mental health promotion from a population health perspective that takes into account the broad range of determinants of mental health... the mandate of the unit is to promote and support mental health and reduce the burden of mental health problems and disorders, by contributing to the development, synthesis, dissemination and application of knowledge; the development, implementation and evaluation of policies, programs and activities designed to promote mental health and address the needs of people with mental health problems or disorders."66

While the MHPU's mandate may state that they have adopted a population health perspective, a reading of their research documents and website pages, clearly identifies their activities as health promotion. While an important part of population health, health promotion has a focus on individual behavior: "mental health promotion is the process of enhancing the capacity of individuals and communities to take control over their lives and improve their mental health...our unit emphasizes the following elements: By working to increase self-esteem, coping skills, social support and well-being in all individuals and communities, mental health promotion empowers people and communities to interact with their environments in ways that enhance emotional and spiritual strength. It is an approach that fosters individual resilience and promotes socially supportive environments. Mental health promotion also works to challenge discrimination against those with mental health problems. Respect for culture, equity, social justice, interconnections and personal dignity is essential for promoting mental health for everyone."67

The MHPU clearly has an important role to play in developing a population health perspective for Canadian but it cannot be successful if it is the only section charged with doing this. This "modern" form of organization is often where the intention to action falls apart - how can one manage something that is complex?

Kindig and Stoddart state that a hallmark of the field of population health "is significant attention to the multiple determinants of health outcomes, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and the physical environment (urban design, clean air and water), genetics, and individual behavior."68 They further state "no one in the public or private sectors currently has responsibility for overall health...the importance of population health ...is that it forces review of health outcomes across determinants."

The Ottawa Charter for Health Promotion outlined the prerequisites for health as: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.69

Looking to Graham70, it appear that certain prerequisites need to be met before we can truly have an integrated population health system - one that includes mental health, including the mental health of children and youth. She suggests that the complexity of looking at macro determinants of health inequalities requires new methods and theories. The linking of epidemiology with social policy research may be helpful if one takes into account cumulative exposure over the life course and the effect of state policies to help or hinder health. This is keeping with the perspective that the US Surgeon General has recommended.

New health strategies recognize that the roots of health inequalities "run deep" and there are movements in many jurisdictions from a focus on disease and individuals to the wider determinants of health but clearly building science into policy is not straightforward. Marmot71 states that we cannot ignore how people got where they are and we always need to look upstream. In times of rapid social change, the dynamics of inequality also change. Tax and social security are only two of the measure by which governments can reduce inequalities in living standards - the third is the broad set made of things like education, health care, housing, personal social services, and public transport. This is one reason for the emphasis on the school system as an integral part of the health system that supports good mental health for children and youth. It also supports the emphasis on helping parents become better parents.

The tax system, the social security system, and the welfare system combine in ways that temper the life course effects of social and economic change. Social capital may not be the underlying determinant of the relationship between income inequality and health, although it may be a marker and outcome of the level of investment in systems that redistribute wealth. This is one of the reasons Graham argues for the need for an interdisciplinary science - one capable of capturing both the dynamics and the health consequences of social inequality.

This interdisciplinary perspective is partially captured by the Public Health Agency of Canada.72 They list the key social determinants of health as: income and social status, social support networks, education and literacy, employment/working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender, and culture. However, they miss many of the connections of these determinants to mental health.

Mental health is linked explicitly to employment/working conditions by stating, "Employment has a significant effect on a person's physical, mental and social health... (a) major review done for the World Health Organization found that high levels of unemployment and economic instability in a society cause significant mental health problems and adverse effects on the physical health of unemployed individuals, their families and their communities." 73

It is also linked to healthy child development: "New evidence on the effects of early experiences on brain development, school readiness and health in later life has sparked a growing consensus about early child development as a powerful determinant of health in its own right. At the same time, we have been learning more about how all of the other determinants of health affect the physical, social, mental, emotional and spiritual development of children and youth."74

The link to health services shows that access to mental health services is inadequate: "Access to universally insured care remains largely unrelated to income; however, many low- and moderate-income Canadians have limited or no access to health services such as eye care, dentistry, mental health counseling and prescription drugs."75 The obvious link to income and social status is not explicitly made in the PHAC materials.

No direct links are made to: income and social status, social support networks, education and literacy, social environments, physical environments, personal health practices and coping skills, biology and genetic endowment, gender, and culture.

All of these have an effect on mental health. The mental health of individuals has an effect on each of the environments encompassed by the social determinants - 20 to 25% percent of people suffering some sort of mental health problem is going to have an impact on social environments, on culture, on gender relationships, on education and the ability to develop literacy.

While the PHAC appears to be moving in the direction of adopting a population health framework, it is too slow given what "we", as a society "know" about the effects of mental health problems, and more importantly, on what we know about the positive impact of early prevention and treatments on children and youth.

Another example, "The Population Health Template: Key Elements and Actions that define a Population Health Approach" from Health Canada76 has no reference to mental health. Two competing assumptions can be made. Either it is included as part of their concept of health or is it completely ignored, as described by Goel and colleagues, either way, it is not clear.

Two examples that demonstrate a movement to adopt a population health perspective for mental health come from the provinces of British Columbia and Quebec.

The Province of British Columbia's, Child and Youth Mental Health Plan77 adopts a long-term view, in which the Ministry of Children & Family Development has applied a population health framework that includes mental health: "Children are British Columbia's most important investment in the future. Families and communities share the responsibility to ensure that children in British Columbia have access to the resources that promote health, well-being and optimal human development. It is our common goal - and in our common interest - to see that children thrive...Mental illnesses now constitute the most important group of health problems that children suffer - superceding all other health problems in terms of the number of children affected and the degree of impairment caused. Currently, one in seven (more than 140,000) children in British Columbia are estimated to have a mental illness serious enough to cause significant distress and impair their development and functioning at home, at school, and in the community. The majority of these children (and their families) do not receive the services they need, with the result that impairments often continue, causing increased suffering and affecting productivity and functioning in adulthood."

In Quebec, recognizing that mental health is an issue of growing importance: "La santé mentale, la violence et le suicide sont devenus des préoccupations de première importance dans notre société. En 1998, 20 % de la population québécoise de 15 ans et plus se situait au niveau de détresse le plus élevé selon l'Enquête Santé Québec. De 1976 à 1999, on a observé une augmentation du taux de suicide de 62 % dans la population en général, plus particulièrement de 25 % chez les femmes et de 78 % chez les hommes. Avec ses 1 500 décès par année, le Québec se retrouve dans le peloton de tête des pays industrialisés pour son taux de suicide." the Institut national de santé publique78, has partnered with the Observatoire pour la promotion de la sécurité et la prévention des traumatismes, to provide expertise, research, and capacity building for a range of stakeholders involved in addressing mental health problems from a population health perspective.

Both of these examples include broad partnerships between diverse actors. Again, they are both too newly implemented to determine whether their approaches will be successful.

Research questions

Population health and mental health are both complex emergent concepts that are not fully defined. As such, there appears to be no silver "implementation strategy" bullet. This however, provides many opportunities to build on what is already known and to venture into the frontier.

The main questions that emerge from the above discussion are the following:

* How to change the culture of stigma against mental health problems and mental illness? What can be learned from other campaigns to reduce stigma? Why is mental health such a difficult issue around which to mobilize?

* How to bridge what is known with what is practiced? What does knowledge exchange and knowledge mobilization look like for mental health presented from a population health perspective? Can the diverse federal, provincial, territorial infrastructures be brought together into a mutually beneficial community of practice? Can organizations such as the WHO improve on their international efforts and what are the responsibilities of member nations to each other and non-member nations, with regards to the mental health of children and youth? What is the role of multinational corporations in developing the conditions for good mental health, both in their workers and the communities where they live?

* Which models are more effective than others? Given that no society appears to be completely addressing mental health issues - is there a fundamental flaw in current endeavors? Do we have the methods and theories to properly address the upstream issues that affect mental health in children and youth?

* The artist and child advocate, Raffi, once asked at a conference79: "Do we have the courage to be a healthy society?" Given that existing incentives in schools and workplaces often run counter to the conditions for good mental health, what is needed to shift the focus from profits and efficiencies, to people and long-term effectiveness? Is this shift possible and if so, what are the timeframes and infrastructure adjustments needed to support such a movement?

* Given the complexity of interactions of the social determinants of health, is it possible for a society to become healthier, both physically and mentally, without first dealing with the power and structural issues of social class and economic inequities?

* What is the role of "community" in causing mental health problems or in creating the conditions for good mental health?

Final Remarks

Health, including mental health, is a continuum over the life course. The ideal of perfect health, physically and mentally, is just that, an ideal: something desired yet almost impossible to attain. This seeming impossibility however, is the very reason to venture forward with the development of further understanding, better tools, creative theories, and resilient practices. Population health is a study of how to live better, with what we have, where we are, and with whom we interact. Health is never complete: it changes as people change, as they move, grow, breathe, interact, and become, whatever they are becoming. This "reality" is a source of frustration in a world where "ends" are rewarded and the "means" or processes are of a secondary importance.

The mental health of children and youth, worldwide, says much about the societies we have built. The rising rate of depression, suicide, anxiety, eating disorders, self-harm, among our children and youth, may simply be a result of better measurement and diagnosis. It may also be that we are creating the conditions that cause more children and youth, to consider suicide and self-harm, as reasonable options to the life that is offered to them.

These questions are only of importance if one considers life, important.

____________________________________________________


Endnotes

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5 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 32.

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7 Romanow, R. Building on Values: The Future of Health Care in Canada - Final Report. Ottawa: Commission on the Future of Health Care in Canada; 2002. p. 214.

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