Improving the Health of Canadians: Mental Health and Resilience from a Population Health Perspective Jean Harvey Director, Canadian Population Health Initiative Canadian Institute for Health Information Presentation at Canadian Public Health Association 2008 Halifax, Nova Scotia June 2-4, 2008

Canadian Population Health Initiative (CPHI) CPHI’s Mission: To foster a better understanding of factors that affect the health of individuals and communities; and To contribute to the development of policies that reduce inequities and improve the health and well- being of Canadians.

CPHI’s Strategic Functions Knowledge Generation Policy Synthesis Knowledge TransferKnowledge Exchange

CPHI’s Key Themes Promoting Healthy Weights Mental Health and Resilience Place and Health Reducing Gaps in Health

Improving the Health of Canadians Report Series on Mental Health Series of three reports on the theme of mental health and how mental health is linked to the determinants of health Two reports will focus on segments of the population often identified as ‘vulnerable’ Final report will focus on the construct of positive mental health ReportRelease Date Report #1: Mental Health and HomelessnessAugust 30, 2007 Report #2: Mental Health, Delinquency and Criminal Activity April 29, 2008 Report #3: Promoting Positive Mental Health (working title) February 2009 (exact date to be determined)

Improving the Health of Canadians: Mental Health and Homelessness Purpose of Report Examines the links between mental health, mental illness and homelessness Released: August 30, 2007

Improving the Health of Canadians: Mental Health and Homelessness How the Report is Organized Section One Presents compiled estimates of the prevalence of both homelessness and self-reported mental health issues among the homeless across Canada Section Two Looks at the effectiveness of two types of related policies and programs—housing and community mental health programs—and their role in promoting mental health and helping people find a way out of homelessness

Key Findings: Mental Health and Homelessness Relative to comparison groups of non-homeless individuals, recent research involving the homeless indicates a tendency for compromised mental health as measured by: Higher levels of stress, less effective coping strategies, lower self-esteem and lower levels of social support These factors have been associated with various outcomes, including depressive symptoms, substance abuse and suicidal behaviours

Key Findings: Mental Illness and Homelessness Compared to the general population, recent research on the homeless population indicates a higher prevalence of mental illness, substance abuse and suicidal behaviours. In Toronto, 6% of 300 shelter users reported a psychotic disorder, primarily schizophrenia; 68% reported a lifetime diagnosis of substance abuse or dependence Homeless individuals with a concurrent disorder - both a mental illness and a substance abuse disorder - are more likely to remain homeless longer than other homeless individuals A 2006 survey of youth across B.C. indicated that compared to 4% of males and 10% of females in schools, 15% of males and 30% of females who were street-involved reported having attempted suicide at least once in the previous 12 months.

Key Findings: Top Reason for Emergency Department Visits and Inpatient Hospitalizations, Emergency Department Visits Homeless Mental and behaviour disorders35% Others Injury, poisoning and consequences of external causes25% Inpatient Hospitalizations Homeless Mental disease and disorders52% Others Pregnancy and childbirth13%

Policies, Programs and Homelessness: What Studies Show Housing Programs A ‘Housing First’ approach is associated with improved health outcomes and less hospital use among the homeless with mental illnesses and addictions compared to approaches that provide treatment first Community Mental Health Programs A number of community mental health programs with an outreach component are effective at promoting positive mental health among the homeless (for example, Assertive Community Treatment – ACT)

Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity Purpose of Report Examines the links between mental health, delinquency, criminal activity and their various determinants Released: April 29, 2008

Improving the Health of Canadians: Mental Health, Delinquency and Criminal Activity How the Report is Organized Section One Looks at what factors related to mental health within the individual, family, school/peer and community contexts are related to youth delinquency in either a protective or risk capacity Section Two Looks at people with a mental illness who were or are involved with the criminal justice system (that is, in a mental health bed with a criminal history or in a correctional facility with a mental illness)

Mental Health, Delinquency and Criminal Activity: Protective Factors IndividualHigh levels of optimism, life satisfaction and emotional capability; trustworthiness; high self-esteem FamilyNurturing parenting style; high level of parental monitoring; having at least one parent home during at least one of four times during the day; doing activities together as a family; able to discuss problems with parents School/PeerSchool environment in which youth feel involved; Feeling connected with one’s peers; Feeling teachers are fair; Academic achievement CommunityFeeling a positive bond to society; Strong pro-social values

Mental Health, Delinquency and Criminal Activity: Risk Factors IndividualLow self-worth; Hyperactivity; Depression; Victim of assault, threats, theft FamilyHarsh or inconsistent parenting style; Lack of parental supervision; Having a parent who struggles with an addiction or a mental illness and/or had a criminal record School/PeerLack of school involvement; Poor academic achievement; Negative peer influences (older or delinquent friends, friends who committed or tolerated illegal acts); Bullying; Truancy, suspensions CommunityHigh turnover of neighbourhood residents; High rates of violent crimes; Feelings of hopelessness; High levels of marijuana availability; High numbers of youth in trouble with the law; Living in high-poverty neighbourhoods

Preventing Delinquency: Policies and Programs There is a link between various skills-training programs within the family and school contexts with improved mental health outcomes and reduced delinquency among youth. Project Early Intervention The Banyan Community Services SNAP™ Under-12 Outreach Project Syracuse Family Development Research Project Seattle Social Development Project Montréal Longitudinal Experimental Study

Characteristics of Patients with Criminal Involvement Admitted to a Mental Health Bed New analyses of data from CIHI’s Ontario Mental Health Reporting System (OMHRS) database show that from April 2006 to March 2007, of unique patients admitted to a mental health bed 9% cited some current involvement with the justice system as the reason for their admission; 28% reported having a criminal history Compared to non-forensic patients, forensic patients tended to be younger and a higher proportion were male, never married, and had lower education levels and less stable housing Compared to patients without a criminal history, those with a criminal history reported significantly more risk factors at discharge including: lack of medication adherence, not having a support person in place for personal safety, unstable housing

Mental Illness Among Youth and Adults in Correctional Facilities Most people with a mental illness or compromised mental health do not commit crimes However, information from various sources indicates there is a higher prevalence of certain types of mental illnesses among incarcerated youth and adults compared to the general population, including: –Psychotic disorders (schizophrenia) –Major depressive disorder –Anxiety disorders –Substance abuse disorder

Programs for People Involved with the Criminal Justice System Diversion Programs o Intervene during the various points at which persons with a mental illness may come into contact with the criminal justice system o Participants in diversion programs spend less time in jail and have more involvement with mental health professionals and community mental health services than individuals not involved in such programs Many jurisdictions offer mental health-related programming for offenders in institutional settings, such as substance abuse treatment; violence prevention; stress and anger management o Preliminary evaluations speak to the effectiveness of violence prevention and anger management programs offered in correctional facilities o Little is known about the long-term impacts on mental health–related outcomes or the accessibility of programs to offenders, particularly among those with mental health issues

Improving the Health of Canadians: Promoting Positive Mental Health Purpose of Report Examines the construct of positive mental health Looks at the determinants of positive mental health Presents information on the Canadian public’s views of mental health Highlights Canadian and international policies and programs with a focus on positive mental health Release Date: February 2009

Other CPHI Work in the Area of Mental Health Workshops that reflect content of given mental health report –Mental Health and Homelessness workshop: May 27 th Collection of Papers: “What Makes a Community Mentally Healthy?” –Available on CPHI’s website July 2008 Webcast video –Webcast on Mental Health, Delinquency and Criminal Activity held May 6 Methodology papers specific to each report –Literature search methodology –Data and analysis methodology –Policy scanning methodology

It’s Your Turn