Chapter 6 Eating Disorders

From: Public Health Agency of Canada

Highlights

• Approximately 3% of women will be affected by an eating disorder during their lifetime.
• Eating disorders affect girls and women more than boys and men.
• Factors believed to contribute to eating disorders include biological and personal factors as well as society's promotion of the thin body image.
• Eating disorders carry with them a high risk of other mental and physical illnesses that can lead to death.
• Since 1987, hospitalizations for eating disorders in general hospitals have increased by 34% among young women under the age of 15 and by 29% among 15-24 year olds.

What Are Eating Disorders?

Eating disorders involve a serious disturbance in eating behaviour - either eating too much or too little - in addition to great concern over body size and shape.¹ This chapter addresses anorexia nervosa, bulimia nervosa and binge eating disorder (BED).

Eating disorders are not a function of will but are, rather, unhealthy eating patterns that "take on a life of their own." The voluntary eating of smaller or larger portions of food than usual is common, but for some people this develops into a compulsion and the eating behaviours become extreme.

Individuals with anorexia nervosa refuse to maintain a minimally normal body weight, carry an intense fear of gaining weight and have a distorted perception of the shape or size of their bodies.²

Individuals with bulimia nervosa undertake binge eating and then use compensatory methods to prevent weight gain, such as induced vomiting, excessive exercise or laxative abuse. They also place excessive importance on body shape and weight. In order for a diagnosis of bulimia nervosa to be made, the binge eating and compensatory behaviours must occur, on average, at least twice a week for 3 months.²

A diagnosis of binge eating disorder (BED) is made if the binge eating is not followed by some compensatory behaviour, such as vomiting, excessive exercise or laxative abuse. This disorder is often associated with obesity.

Symptoms Eating Disorders
General
Distorted perception of the shape or size of one's own body
Anorexia	Bulimia	Binge Eating Disorder (BED)
Resistance to maintaining body weight at or above a minimally normal weight for age and height with an intense fear of gaining weight or becoming fat, even though underweight.	Recurrent episodes of binge eating, accompanied by inappropriate compensatory behaviour in order to prevent weight gain, such as selfinduced vomiting, use of laxatives, or excessive exercise.	Binge eating without compensatory behaviours, such as vomiting, excessive exercise or laxative abuse Individuals are often obese.

How Common Are Eating Disorders?

It is estimated that 3% of women will be affected by eating disorders in their lifetime.³ Approximately 0.5% to 4% of women will develop anorexia nervosa during their lifetime, and about 1 to 4% will develop bulimia.¹ BED affects about 2% of the population.⁴

Impact of Eating Disorders

Who Is Affected by Eating Disorders?

Anorexia nervosa and bulimia predominantly affect young women. Some studies have found that young men represent only about 10% of individuals with the disorder.¹ An Ontario study found that 0.3% of men ages 15-64 and 2.1% of women had anorexia nervosa or bulimia.⁵ In most cases, BED starts during adolescence or young adulthood. Men are more likely to be affected by BED than by other eating disorders.

Although most of the treatment of an eating disorder is provided in the community, occasionally hospitalization is needed. Hospitalization data provide a partial description of who is affected by severe eating disorders. The results must be viewed with caution, however, since this is only a subset of those with eating disorders.

In 1999, women in all age groups had higher rates of hospitalization than men for eating disorders (Figure 6- 1). Females accounted for 94% of all hospital admissions for eating disorders. Adolescents of both sexes between the ages of 10 and 19 years had the highest rates of hospitalization.

Figure 6-1 Hospitalizations for eating disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000.

How Do Eating Disorders Affect People?

Individuals with anorexia and bulimia may recover after a single episode of the disorder. Others may have a fluctuating pattern of weight gain and relapse. Still others will continue to have issues with food and weight throughout their lives. A lifetime history of substance use disorders, drug or alcohol problems at the time of diagnosis and longer duration of symptoms before diagnosis are associated with poorer long-term outcomes.⁶

Individuals with anorexia and bulimia may develop serious physical problems such as heart conditions, electrolyte imbalance and kidney failure that can lead to death. Eating disorders may cause long-term psychological, social and health problems even after the acute episode has been resolved.⁷

Anorexic individuals are more susceptible to major depression, alcohol dependence and anxiety disorders, either at the time of their illness or later in life.^8,9 Suicide is also a possible outcome.

An eating disorder causes young people to miss school, work and recreational activities. The physical weakness associated with the illness also seriously affects their social interaction with friends and their involvement in life in general. Friends also have difficulty knowing how to react and how to help.

Families of individuals with eating disorders also live under great stress. They may blame themselves, feel anxious about their loved one's future, worry that the family member will die, and face the stigma associated with having a child with a mental illness. Parents especially experience the tension between their natural protective instinct to force healthy behaviours on the child (which can often make the situation worse) and the child's need to take control over his/her illness and health.

Stigma Associated with Eating Disorders

Anorexia nervosa and bulimia nervosa do not have the same public manifestation as other mental illnesses. In general, public embarrassment due to unusual behaviour is not an issue. Essentially, these illnesses are a private family affair. As a result, the stigma associated with eating disorders comes from the mistaken impression that others (parents in particular) are to blame for the illness. The stigmatization isolates parents from their peers and other family members.

Individuals with BED who are obese must contend with negative societal attitudes toward obesity. These attitudes isolate them, and the loss of self-esteem exacerbates the illness.

Causes of Eating Disorders

Eating disorders are complex syndromes strongly associated with other mental illnesses, such as mood, personality and anxiety disorders. This suggests that the development of the disease results from a combination of biological, psychological and social factors. In addition, the secondary effects of the maladaptive eating practices themselves likely contribute to the disorder. Steiger and Séguin have written an excellent in-depth discussion of the etiology of eating disorders.¹

Table 6-1 Summary of Possible Risk Factors for the Development of Eating Disorders

	Eating-Specific Factors (Direct Risk Factors)	Generalized Factors (Indirect Risk Factors)
Biological Factors	ED-specific genetic risk Physiognomy and body weight Appetite regulation Energy metabolism Gender	Genetic risk for associated disturbance Temperament Impulsivity Neurobiology (e.g., 5-HT mechanisms) Gender
Psychological Factors	Poor body image Maladaptive eating attitudes Maladaptive weight beliefs Specific values or meanings assigned to food, body Overvaluation of appearance	Poor self-image Inadequate coping mechanisms Self-regulation problems Unresolved conflicts, deficits, posttraumatic reactions Identity problems Autonomy problems
Developmental Factors	Identifications with body-concerned relatives, or peers Aversive mealtime experiences Trauma affecting bodily experience	Overprotection Neglect Felt rejection, criticism Traumata Object relationships (interpersonal experience)
Social Factors	Maladaptive family attitudes to eating, weight Peer-group weight concerns Pressures to be thin Body-relevant insults, teasing Specific pressures to control weight (e.g., through ballet, athletic pursuits) Maladaptive cultural values assigned to body	Family dysfunction Aversive peer experiences Social values detrimental to stable, positive self-image Destabilizing social change Values assigned to gender Social isolation Poor support network Impediments to means of self-definition

Treatment of Eating Disorders

Eating disorders can be treated and a healthy weight restored. Earlier diagnosis results in improved outcomes. Treatment is most effective if started in the early stages of the disorder. Therefore, routine assessment of teenaged girls for the early signs of an eating disorder can help identify those who would benefit from treatment.

Success of treatment depends on a comprehensive plan,¹⁰ including the following:

• Monitoring of physical symptoms
• Behavioural therapy
• Cognitive therapy
• Body image therapy
• Nutritional counselling
• Education
• Medication, if necessary

Treatment has changed dramatically over time.¹¹ The previous emphasis on long-term psychotherapy and potentially harmful medications has been replaced with nutritional stabilization as the initial approach. Once the nutritional status has improved, then a variety of psychotherapy methods (cognitive/analytical, family and cognitive/ behavioural) are used to improve functioning. Unfortunately, a recent review of psychological treatments of anorexia nervosa found that much more research needs to be done in this area.¹²

According to a recent review of the pharmacological treatment of eating disorders, numerous studies have shown that anti-depressants are useful in the treatment of bulimia nervosa.³ Some medications are also useful in treating BED. Unfortunately, studies have not identified any effective drugs in treating anorexia nervosa. The treatment of coexisting mental illnesses, such as depression, anxiety and alcoholism, is essential.

For people who have been ill for many years with anorexia nervosa, brief time-limited admissions to hospital to stabilize weight loss and treat metabolic complications, combined with supportive psychotherapy, are more effective than coercive hospital treatment with overly ambitious goals.

Most treatment of eating disorders takes place in the community, but hospitalization data give some indication of serious disease in the population.

In 1999, among teenagers, an eating disorder was the diagnosis most responsible for determining the length of stay in hospital, likely associated with the life threatening biochemical changes in the body (Figure 6- 2). Among older individuals, eating disorders were more likely to be an associated condition.

Figure 6-2 Hospitalizations for eating disorders in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000.

Rates of hospitalization for eating disorders among women increased by 20% between 1987 and 1999 (Figure 6-3). Rates among men remained stable.

Figure 6-3 Rates of hospitalization per 100,000 for eating disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

From 1987 to 1999, women aged <15>

Figure 6-4 Rates of hospitalization per 100,000 for eating disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Rates of hospitalization for eating disorders among men between 1987 and 1999 were very unstable because of small numbers (Figure 6-5).

Figure 6-5 Rates of hospitalization per 100,000 for eating disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to eating disorders decreased in the mid-1990s and in 1999 was 27.5 days (Figure 6-6).

Figure 6-6 Average length of stay in general hospitals due to eating disorders*, Canada, 1987/88-1999/2000.

Discussion of Hospitalization Data

The hospitalization data support clinical findings that more women than men are affected by eating disorders. In general hospitals, 93% of individuals hospitalized for eating disorders are women. Hospitalization rates are very high among adolescents, consistent with the onset of eating disorders in this age group.

Among older individuals, eating disorders are more likely to be an associated, rather than primary, condition as the reason for the length of stay in hospital. This may reflect the more severe complications associated with the condition that appear once the disease has been present for a period of time.

Rates of hospitalization for eating disorders in general hospital are increasing among young women. Whether this signals an increase in the disorder or rather an increase in the use of hospitalization in treating the disorder requires further research.

Future Surveillance Needs

Eating disorders are common among young women and they can lead to death. They are difficult to treat, but early diagnosis results in improved outcomes.

Existing data provide a very limited profile of eating disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

• Incidence and prevalence of each of the eating disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity).
• Impact of eating disorders on the quality of life of the individual and family.
• Access to and use of primary and specialist health care services and community programs.
• Stigma associated with eating disorders.
• Attitude toward body image in the general population.
• Access and use of public and private mental health services.
• Access and use of mental health services in other systems, such as schools.
• Treatment outcomes.
• Exposure to known or suspected risk and protective factors.

References

1. Steiger H, Séguin JR. Eating disorders: anorexia nervosa and bulimia nervosa. Million T, Blaneyu PH, David R, ed., Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999: 365-88.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
3. Zhu AJ, Walsh BT. Pharmacologic treatment of eating disorders. Can J Psychiatry 2002;47:3:227- 34.
4. Bruce, B., & Agras, S.. Binge eating in females: A population-based investigation. Int J Eat Disord 1992;12:365-373.
5. Woodside DB, Garfinkel PE, Lin E, Goering P, Kaplan AS, Goldbloom DS et al. Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 2001;158:570-574.
6. Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ. Long-term outcome of bulimia nervosa. Arch Gen Psychiatry 1999;56:63-69.
7. Lewinsohn PM, Striegel-Moore RH, Seeley JR. Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2000;39:1284-1292.
8. American Psychiatric Association Work Group on Eating Disorders. Practice guidelines for the treatment of patients with eating disorders. Am J Psychiatry 2000;157:1suppl:1-39.
9. Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcome of anorexia nervosa: a case-control study. Am J Psychiatry 1998;155:939-946.
10. Steiger H, Champagne J. Les troubles d l'alimentation : l'anorexie nerveuse et la boulimie. Habimana E (ed.), Psychopathologie de l'enfant et de l'adolescent: approche intégrative. Paris: Christian Morin, 1999.
11. Garfinkel PE. Eating disorders (guest editorial). Can J Psychiatry 2002;47:3:225-6.
12. Kaplan AS. Psychological treatments for anorexia nervosa: a review of published studies and promising new directions. Can J Psychiatry 2002;47:3:235-42.

Chapter 5 Personality Disorders

From: Public Health Agency of Canada

Highlights

• Based on US data, about 6% to 9% of the population has a personality disorder.
• Personality disorders exist in several forms. Their influence on interpersonal functioning varies from mild to serious.
• Onset usually occurs during adolescence or in early adulthood.
• Anti-social personality disorder is frequently found among prisoners (up to 50%).
• Of hospitalizations for personality disorders in general hospitals, 78% are among young adults between 15 and 44 years of age.

What Are Personality Disorders?

Personality disorders cause enduring patterns of inner experience and behaviour that deviate from the expectations of society, are pervasive, inflexible and stable over time, and lead to distress or impairment.¹

"Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non-conscious and not easily altered, which express themselves automatically in almost every area of functioning."²

Personality characteristics or traits are expressed on a continuum of social functioning. Personality disorders reflect personality traits that are used inappropriately and become maladaptive.² To some degree, this classification is arbitrary.

Some deviations may be quite mild and interfere very little with the individual's home or work life; others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with personality disorders have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.

Symptoms
Personality Disorders
Difficulty getting along with other people. May be irritable, demanding, hostile, fearful or manipulative. Patterns of behaviour deviate markedly from society's expectations and remain consistent over time. Disorder affects thought, emotion, interpersonal relationships and impulse control. The pattern is inflexible and occurs across a broad range of situations. Pattern is stable or of long duration, beginning in childhood or adolescence.

Personality disorders exist in many forms.¹ Classification of personality disorders is arbitrary. Each person is unique, however, and can display mixtures of patterns.

Table 5-1 Types of Personality Disorders

Type	Patterns
Borderline Personality Disorder	Instability in interpersonal relationships, selfimage and affects, and marked impulsivity.
Antisocial Personality Disorder	Disregard for, and violation of, the rights of others.
Histrionic Personality Disorder	Excessive emotionality and attention seeking.
Narcissistic Personality Disorder	Grandiosity, need for admiration, and lack of empathy.
Avoidant Personality Disorder	Social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent Personality Disorder	Submissive and clinging behaviour related to an excessive need to be taken care of.
Schizoid Personality Disorder	Detachment from social relationships and a restricted range of emotional expression.
Paranoid Personality Disorder	Distrust and suspiciousness in which others' motives are interpreted as malevolent.
Obsessive-Compulsive Personality	Disorder Preoccupation with orderliness, perfectionism and control.
Schizotypal Personality Disorder	Acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.

How Common Are Personality Disorders?

Canadian data on the prevalence of personality disorders are lacking. United States estimates of the prevalence of diagnosis of any personality disorder, however, range from 6% to 9%, depending upon the criteria used for definition.³

Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the 1- year prevalence rate of antisocial personality disorder in the general population was 1.7%.⁴ According to the Edmonton study in the 1980s, 1.8% of the population had an antisocial personality disorder in the 6-month period before the survey, and 3.7% reported a personality disorder at some point in their lives.^5,6 Estimates of the prevalence of other personality disorders range from 1% to 10% of the population.

Impact of Personality Disorders

Who Develops a Personality Disorder?

There is a sex difference in the personality disorder types. For example, antisocial personality disorder is more common among men, while borderline personality disorder is more common among women. The dependent and hysterical personality disorders are also more common among women. Labelling biases among health professionals may lead to some of the sex differences.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with personality disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide prevalence of self-reported obsessivecompulsive personality disorder in the future.

At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however, because most people with personality disorders, unless they show suicidal behaviour, are treated in the community rather than in hospitals. Many are never diagnosed or treated. Individuals with borderline personality disorder have higher rates of admission than individuals with other disorders because of their high rate of suicidal behaviour. These limitations must be kept in mind, then, when interpreting the data presented in this report.

Among both women and men, the highest rates of hospitalization for personality disorders were among individuals between the ages of 15 and 44 years (Figure 5-1). Over three-quarters (78%) of all admissions were between these ages and rates were higher among women than men.

Figure 5-1 Hospitalizations for personality disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000

What Are the Effects of Personality Disorders?

Although the onset of personality disorders usually occurs in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, the timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood, and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.

Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, obtain education, establish careers and generally "build equity" in their lives. The use of maladaptive behaviours during this life stage has implications that extend for a lifetime.

A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive-compulsive disorder, depressive disorder, eating disorder, and suicidal thoughts or attempts often accompany personality disorders.³ Up to onehalf of prisoners have antisocial personality disorder because its associated behavioural characteristics (such as substance abuse, violence and vagrancy) lead to criminal behaviour.³ Other social consequences of personality disorders include:

• Spousal violence
• Child maltreatment
• Poor work performance
• Suicide
• Gambling

Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to them. This creates a major strain on all relationships among family and close friends and in the workplace. At the same time, when other people do not adjust, the individual with the personality disorder can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.

Stigma Associated with Personality Disorders

Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is not well understood by others.

Causes of Personality Disorders

Personality disorders likely result from the complex interplay of early life experience, genetic and environmental factors. In principle, genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.

Although little is known to date about possible biological correlates of personality disorder, individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.

For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood - separation from family, selfi-dentity, and independence - may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually begin in these years.

Treatment of Personality Disorders

Personality disorders are difficult to treat because of self-denial about the presence of the problem and the pessimism of health professionals based on a lack of success in previous efforts.

Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.

Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders.⁷

In 1999, in all age groups, personality disorders were more likely to be a contributing rather than the main factor determining length of stay in hospital (Figure 5-2). This reflects the fact that personality disorders are associated with other conditions, such as suicidal behaviour, that may need hospitalization.

Figure 5-2 Hospitalizations for personality disorders in general hospitals per 100,000 by by contribution to length of stay and age group, Canada, 1999/2000

Rates of hospitalization for personality disorders among both men and women increased during the early 1990s and decreased in the later years of the decade (Figure 5-3).

Figure 5-3 Rates of hospitalization for personality disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

The increase in hospitalization rates for personality disorders in the early 1990s was due to an increase among women in the 15-24 and 25-44 year age groups (Figure 5-4). These same age groups, along with those 65 years of age and older, showed a decline in the later 1990s.

Figure 5-4 Rates of hospitalization for personality disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Between 1987 and 1999, men aged 15- 24 years showed the greatest decrease in hospitalization rates for personality disorders (Figure 5- 5). During the early 1990s, rates of hospitalization increased slightly among men aged 25-44 years, and this was followed by a slight decrease later in the decade.

Figure 5-5 Rates of hospitalization for personality disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to personality disorders was 9.5 days in 1999, a decrease of nearly 50% since 1991 (Figure 5-6).

Figure 5-6 Average length of stay in general hospitals due to personality disorders*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

Most personality disorders are treated outside of the hospital. Thus, the hospitalization data provide a very limited picture of personality disorders in Canada.

The higher rates of hospitalization for personality disorder in general hospitals among young women than men supports the clinical experience that women are more likely to have borderline personality disorder with its associated suicidal behaviour, leading to hospitalization.

High rates among adolescents and young adults support the negative impact of these disorders on young people at a critical time in their lives.

The length of stay in hospital associated with personality disorders decreased during the 1990s. Further research is needed to determine the reason for this trend: What has been the impact on hospital bed closures on length of stay and treatment outcome? Have treatment methods changed and have outcomes improved?

Future Surveillance Needs

Personality disorders are common in the general population, causing not only a great deal of personal and family distress but also impairment of social functioning.

Existing data provide a very limited profile of personality disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

• Incidence and prevalence of each of the personality disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity)
• Impact of personality disorders on the quality of life of the individual and family
• Access to and use of primary and specialist health care services
• Impact of personality disorders on the workplace and the economy
• Impact of personality disorders on the legal and penal systems
• Stigma associated with personality disorders
• Access to and use of public and private mental health services
• Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs
• Treatment outcomes
• Exposure to known or suspected risk and protective factors

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
2. Millon T, Blaneyu PH, Davis R, ed. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999:510.
3. Samuels JF, Nestadt G, Romanoski AJ, Folstein MF, McHugh PR. DSM-III personality disorders in the community. Am J Psychiatry 1994;151:1055-1062.
4. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, Racine YA. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559-563.
5. Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):33-42.
6. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):24-32.
7. Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG. Treatment utilization by patients with personality disorders. Am J Psychiatry 2001;158:295-302.

Chapter 4 Anxiety Disorders

From: Public Health Agency of Canada

Highlights

• Anxiety disorders affect 12% of the population, causing mild to severe impairment.
• For a variety of reasons, many individuals may not seek treatment for their anxiety; they may consider the symptoms mild or normal, or the symptoms themselves may interfere with help-seeking.
• Anxiety disorders can be effectively treated in the community setting.
• Hospitalization rates for anxiety disorders in general hospitals are twice as high among women as men.
• The highest rates of hospitalization for anxiety disorders in general hospitals are among those aged 65 years and over.
• Since 1987, hospitalization rates for anxiety disorders in general hospitals have decreased by 49%.

What Are Anxiety Disorders?

Individuals with anxiety disorders experience excessive anxiety, fear or worry, causing them either to avoid situations that might precipitate the anxiety or to develop compulsive rituals that lessen the anxiety. Everyone feels anxious in response to specific events - but individuals with an anxiety disorder have excessive and unrealistic feelings that interfere with their lives in their relationships, school and work performance, social activities and recreation.

Symptoms
Anxiety Disorders
Intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger Feelings of fear and distress that interfere with normal daily functioning

Types of Anxiety Disorders ¹

Generalized Anxiety Disorder (GAD)

Excessive anxiety and worry about a number of events or activities occurring for more days than not over a period of at least 6 months with associated symptoms (such as fatigue and poor concentration).

Specific Phobia

Marked and persistent fear of clearly discernible objects or situations (such as flying, heights and animals).

Post Traumatic Stress Disorder

Flashbacks, persistent frightening thoughts and memories, anger or irritability in response to a terrifying experience in which physical harm occurred or was threatened (such as rape, child abuse, war or natural disaster).

Social Phobia, also known as Social Anxiety Disorder

Exposure to social or performance situations almost invariably provokes an immediate anxiety response that may include palpitations, tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing or confusion, and which may meet criteria for the panic attack in severe cases.

Obsessive-Compulsive Disorder

Obsessions : Persistent thoughts, ideas, impulses or images that are intrusive and inappropriate and that cause marked anxiety or distress. Individuals with obsessions usually attempt to ignore or suppress such thoughts or impulses or to counteract them by other thoughts or actions (compulsions).

Compulsions : Repetitive behaviours (such as hand washing, ordering or checking) or mental acts (such as praying, counting or repeating words) that occur in response to an obsession or in a ritualistic way.

Panic Disorder

Presence of recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about having additional attacks, worry about the implication of the attack or its consequences, or a significant change in behaviour related to the attacks. There are three clusters of symptoms: reexperiencing, avoidance and numbing, and arousal.

Panic disorders are sometimes associated with agoraphobia - anxiety about, or the avoidance of, places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of a panic attack or panic-like symptoms.

The essential feature of the panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical symptoms, such as:

• Palpitations, increased heart rate or pounding heart
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, unsteadiness, lightheadedness or fainting
• De-realization or de-personalization
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness or tingling sensation)
• Chills or hot flashes

How Common Are Anxiety Disorders?

Combined anxiety disorders affect approximately 12% of Canadians: about 9% of men and 16% of women during a one-year period.² As a group, anxiety disorders represent the most common of all mental illnesses.

Table 4-1 One-Year Prevalence of Anxiety Disorders in Canada.

Type of Anxiety Disorder	Canada (Ages 15-64 years)
	% with anxiety disorder 2-4
Generalized Anxiety Disorder	1.1
Specific Phobia	6.2 - 8.0
Post Traumatic Stress Disorder	---
Social Phobia	6.7
Obsessive Compulsive Disorder	1.8
Panic Disorder	0.7

Impact of Anxiety Disorders

Who Is Affected by Anxiety Disorders?

Women report and are diagnosed with some anxiety disorders more frequently than men. This may reflect the differences between men and women in their health-service-seeking behaviours, however, rather than true differences in prevalence.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with anxiety disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide these data in the future.

At the present time, hospitalization data provide the best available description of individuals with anxiety disorders. These data have limitations, however, because most people with anxiety disorders are treated in the community rather than in hospitals, and many do not receive treatment at all. As a result, the data represents only a subset of all those with anxiety disorders, and the results must be interpreted with caution.

In 1999, women were hospitalized for anxiety disorders at higher rates than men in every age category (Figure 4-1). Young women aged between 15 and 19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women and men over the age of 65 had the highest rates of hospitalization.

Figure 4-1 Hospitalizations for anxiety disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000

How Does It Affect Them?

Symptoms of anxiety disorders often develop during early adulthood. Although the majority of people have mild or no impairment, anxiety disorders can seriously restrict an individual's education, work, recreation and social activities because he / she avoids situations that precipitate the symptoms.

Individuals severely affected by anxiety disorders are also more likely to have either another type of anxiety disorder, major depression or dysthymia, alcohol or substance abuse, or a personality disorder.⁵ This compounds the impact of the anxiety disorder and presents challenges for effective treatment.

Economic Impact

Because they are so common, anxiety disorders have a major economic impact.⁶ They contribute to lost productivity due to both time away from work and unemployment. Other associated costs include claims on disability insurance.

Heavy use of the emergency department and primary care system in reaction to physical symptoms also contributes to significant health care costs.

Stigma Associated with Anxiety Disorders

Because anxiety disorders are the extension of what most people perceive as normal worry and concern, those who experience them may fear that others would label their excessive worry and fear as simply a weakness. As a result, they may try to ignore the seriousness of their condition and deal with it themselves. They often avoid seeking help and suffer in silence.

Causes of Anxiety Disorders

The development of anxiety disorders appears to result from a complex interplay of genetic, biological, developmental and other factors such as socio-economic and workplace stress. A variety of theories have been proposed to explain how these factors contribute to the development of the disorder.⁷

The first is experiential: people may learn their fear from an initial experience, such as an embarrassing situation, physical or sexual abuse, or the witnessing of a violent act. Similar subsequent experiences serve to reinforce the fear.

A second theory relates to cognition or thinking, in that people believe or predict that the result of a specific situation will be embarrassing or harmful. This may occur, for example, if parents are over-protective and continually warn against potential problems.

A third theory focuses on a biological basis. Research suggests that the amygdala, a structure deep within the brain, serves as a communication hub that signals the presence of a threat and triggers a fear response or anxiety. It also stores emotional memories and may play a role in the development of anxiety disorders. The children of adults with anxiety disorders are at much greater risk of an anxiety disorder than is the general population,⁴ which may imply a genetic factor, an effect of parenting practices, or both.

Treatment of Anxiety Disorders

Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol.

The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, a lack of human resources, restrictive government funding systems and lack of knowledge. In addition, family physicians may not always recognize the pattern in an individual's symptoms that would lead them to a correct diagnosis. Too often, the symptoms are not taken seriously and an individual with an anxiety disorder is labelled as being emotionally unstable. Education of both the public and family physicians would help to solve this problem.

A recent review of anxiety disorders suggests that effective treatments include drug therapy (with anti-depressants or anti-anxiety drugs) and cognitive-behavioural therapy, which helps people turn their anxious thoughts into more rational and less anxietyproducing ideas.⁸ Support groups for individuals and families can also help develop the tools for minimizing and coping with the symptoms.

Anxiety disorders can be well managed in the primary care setting. Creating access to experts in cognitive-behaviour therapy through a shared-care model can help family physicians provide optimal care for the individuals they are treating.

When individuals with anxiety disorders are hospitalized, another associated condition is usually responsible for determining their length of stay (Figure 4-2).

Figure 4-2 Hospitalizations for anxiety disorders in general hospitals per 100,000 by by contribution to length of stay and age group, Canada, 1999/2000

Overall, hospitalization rates for anxiety disorders decreased dramatically between 1987 and 1999, by 50% among women and 46% among men, with a combined reduction of 49% (Figure 4-3).

Figure 4-3 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

Between 1987 and 1999, hospitalization rates for anxiety disorders decreased by 45% among women aged 25-44 years, and by 62% in both the 45-64 and 65+ year age groups (Figure 4-4). Among girls under 15 years of age, even though hospitalization rates remained low, there was a 52% increase over the time period.

Figure 4-4 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Among men, the reduction in hospitalization rates for anxiety disorder in each age group reflected the reduction reported by women: a reduction of 42% among men aged 25-44 years; 58% among men aged 45-64 years; and 61% among those 65+ years of age (Figure 4-5). For boys under the age of 15 years, rates increased by 49%.

Figure 4-5 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to anxiety disorders changed very little between 1987 and 1999 (Figure 4-6).

Figure 4-6 Average length of stay in general hospitals due to anxiety disorders*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

Since most anxiety disorders are treated outside of hospitals, hospitalization data provide a very limited picture of these disorders in Canada. The data do support the view that anxiety disorders are associated with other health problems and it is usually these, rather than anxiety disorders, that lead to hospitalization.

The decrease in hospitalization rates for anxiety may be due to bed closures and a refocusing of hospital services to ambulatory services. Hospitalizations for anxiety disorders in general hospitals among seniors have shown a dramatic decrease (much greater than any other age group) since 1987. This trend reflects the pattern for the same age group for major depression. Further research is needed to determine the reason for this trend: Is the prevalence of the disorders decreasing? Have treatment methods changed? Have outcomes improved?

The higher rates of hospitalization for anxiety disorders in general hospitals among women than men prompt several research questions: Are anxiety disorders really more common among women? Are women more likely to seek treatment than men? Are women treated differently than men, with greater use of hospitalization?

Hospitalization rates for anxiety disorders have a pronounced peak among women between 15 and 19 years of age. This peak is also found in hospitalization rates for depression and personality disorders. This suggests that women in this age group are vulnerable to mental illnesses. The reasons for this phenomenon require further clarification through research.

Future Surveillance Needs

Anxiety disorders are common among Canadians, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Anxiety disorders can be effectively treated with a combination of medication and cognitive behavioural therapy.

Existing data provide a very limited profile of anxiety disorders in Canada. The available hospitalization data need to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

• Incidence and prevalence of each of the anxiety disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity).
• Impact of anxiety disorders on the quality of life of the individual and family.
• Access to and use of primary and specialist health care services.
• Impact of anxiety disorders on the workplace and the economy.
• Stigma associated with anxiety disorders.
• Access to and use of public and private mental health services.
• Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs.
• Treatment outcomes.
• Exposure to known or suspected risk and protective factors.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
2. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M et al. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559-563.
3. Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):33-42.
4. Dick CL, Bland RC, Newman SC. Epidemiology of psychiatric disorder in Edmonton: panic disorder. Acta Psychiatr Scand 1994;Suppl 376:45-53.
5. Eaton WW, Kessler RC, Wittchen HU, Magee WJ. Panic and panic disorder in the United States. Am J Psychiatry 1994;151:413-420.
6. Adult Mental Health Division, British Columbia Ministry of Health. The Provincial Strategy Advisory Committee for Anxiety Disorders. A Provincial Anxiety Disorders Strategy, 2002.
7. Millon T, Blaneyu PH, Davis R, ed. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999.
8. Antony MM, Swinson RP. Anxiety disorders and their treatment: a critical review of the evidencebased literature. Ottawa: Health Canada, 1996.

Chapter 3 Schizophrenia

From: Public Health Agency of Canada

Highlights

• Schizophrenia affects 1% of the Canadian population.
• Onset is usually in early adulthood.
• Schizophrenia can be treated effectively with a combination of medication, education, primary care services, hospital-based services and community support, such as housing and employment.
• Fifty-two percent of hospitalizations for schizophrenia in general hospitals are among adults 25-44 years of age.
• Hospitalization rates for schizophrenia in general hospitals are increasing among young and middle-aged men.

What Is Schizophrenia?

Schizophrenia is a brain disease and one of the most serious mental illnesses in Canada. Common symptoms are mixed-up thoughts, delusions (false or irrational beliefs), hallucinations (seeing or hearing things that do not exist) and bizarre behaviour. People suffering from schizophrenia have difficulty performing tasks that require abstract memory and sustained attention.

All the signs and symptoms of schizophrenia vary greatly among individuals. There are no laboratory tests to diagnose schizophrenia. Diagnosis is based solely on clinical observation. For a diagnosis of schizophrenia to be made, symptoms must be present most of the time for a period of at least 1 month, with some signs of the disorder persisting for 6 months. These signs and symptoms are severe enough to cause marked social, educational or occupational dysfunction. The Canadian Psychiatric Association has developed guidelines for the assessment and diagnosis of schizophrenia.¹

Symptoms
Schizophrenia
Delusions and/or hallucinations Lack of motivation Social withdrawal Thought disorders

How Common Is Schizophrenia?

The prevalence of schizophrenia in the general population is estimated to vary between 0.2% and 2%, depending upon the measures used. However, a prevalence rate of 1% is generally accepted as the best estimate.²

Impact of Schizophrenia

Who Is Affected by Schizophrenia?

The onset of schizophrenia typically occurs between the late teens and mid-30s. Onset before adolescence is rare. Men and women are affected equally by schizophrenia, but men usually develop the illness earlier than women. If the illness develops after the age of 45, it tends to appear among women more than men, and they tend to display mood symptoms more prominently.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with schizophrenia. Statistics Canada's Canadian Community Health Survey (CCHS) will provide data on the prevalence of self-reported schizophrenia in the future. This will likely underestimate the true prevalence, however, since the survey team will not reach those individuals with schizophrenia who are homeless, in hospital or in supervised residential settings.

Although most individuals with schizophrenia are treated in the community, hospitalization is sometimes necessary to stabilize symptoms. At the present time, hospitalization data provide the best available, though limited, description of individuals with schizophrenia.

In 1999, rates of hospitalization for schizophrenia in general hospitals varied with age (Figure 3-1). Rates among men increased dramatically in the 20-24 year age group and remained high before beginning to decrease among 40-44 year olds. The pattern among women showed a gradual increase in hospitalizations to a peak between 35 and 49 years, after which it showed a steady decline. Men had much higher rates than women until the age of 50, after which rates among women were slightly higher.

Figure 3-1 Hospitalizations for schizophrenia* in general hospitals per 100,000 by age group, Canada, 1999/2000

How Does It Affect Them?

Schizophrenia has a profound effect on an individual's ability to function effectively in all aspects of life - self-care, family relationships, income, school, employment, housing, community and social life.³

The high rates of hospitalization among young and middle-aged men and women highlight the effect of schizophrenia on people who are in their most productive years - a time when most people are forming families, establishing careers, and generally "building equity" in their lives.

Early in the disease process, people with schizophrenia may lose their ability to relax, concentrate or sleep and they may withdraw from friends. Performance at work or school often suffers. With effective early treatment to control symptoms, individuals can prevent further symptoms and optimize their chance of leading full, productive lives.

The onset of schizophrenia in the early adulthood years usually leads to disruptions in an individual's education. Individuals with schizophrenia often find it difficult to maintain employment for a sustained period of time.

Although some individuals have healthy relationships, the majority with schizophrenia (60% to 70%) do not marry, and most have limited social contacts.⁴ The chronic course of the disorder contributes to ongoing social problems. As a result, individuals with schizophrenia are greatly over-represented in prison and homeless populations.⁴

Up to 80% of individuals with schizophrenia will abuse substances during their lifetime. Substance abuse is associated with poor functional recovery, suicidal behaviour and violence.¹

The responsibility for primary care of an individual with schizophrenia usually falls on the shoulders of the family. This has many implications. Not only are the family's normal activities disrupted, but family members must also cope with the unpredictability of the individual affected, the side effects of the medication, and the frustration and worry about the future of their loved one. In times of crisis, the decision whether to admit the individual to hospital involuntarily is one of the most difficult dilemmas that a family may face. The family often has to deal with the stigma attached to schizophrenia.

The mortality associated with schizophrenia is one of the most distressing consequences of the disorder. Approximately 40% to 60% of individuals with schizophrenia attempt suicide, and they are between 15 to 25 times more likely than the general population to die from a suicide attempt.⁵ Approximately 10% will die from suicide.

Economic Impact

Schizophrenia places a substantial financial burden on individuals with the illness, the members of their family and the health care system. In 1996, the total direct cost of schizophrenia in Canada was estimated to be $2.35 billion, or 0.3% of the Canadian Gross Domestic Product.⁶ This includes health care costs, administrative costs of income assistance plans, value of lost productivity, and incarceration costs attributable to schizophrenia. The indirect costs of schizophrenia are estimated to account for another $2 billion yearly. Globally, nearly 3% of the total burden of human disease is attributed to schizophrenia.⁷

Stigma Associated with Schizophrenia

Public misunderstanding and fear contribute to the serious stigma associated with schizophrenia. Contrary to popular opinion, most individuals with the disorder are withdrawn and not violent. Nonetheless, the stigma of violence interferes with an individual's ability to acquire housing, employment and treatment, and also compounds difficulties in social relationships. These stereotypes also increase the burden on families and care givers.

Causes of Schizophrenia

Historically, a number of psychological hypotheses were advanced to account for schizophrenia. Today medical science recognizes schizophrenia as a disease of the brain. Although the exact cause is unknown, it is likely that a functional abnormality in neurotransmitters produces the symptoms of the illness. This abnormality may be either the consequence or the cause of structural brain abnormalities.⁸

A combination of genetic and environmental factors is considered to be responsible for the development of this functional abnormality. These factors appear to affect the development of the brain at critical stages during gestation and after birth.

Genetic Influence

Immediate family members of individuals with schizophrenia are 10 times more likely than the general population to develop schizophrenia, and children of two parents with schizophrenia have a 40% chance of developing the disorder.³

Environmental Factors

Although the evidence to date is inconclusive, potential environmental contributions to the development of schizophrenia include prenatal or perinatal trauma, season and place of birth, and viral infections. While studies have established a link between severe social disadvantage and schizophrenia, the results suggest that social factors do not cause schizophrenia, but rather the reverse may be true: poor social circumstances are likely a result of the disorder.²

Treatment of Schizophrenia

Unfortunately, given our state of knowledge, methods for preventing schizophrenia remain unknown. Minimizing the impact of this serious illness depends mainly on early diagnosis, appropriate treatment and support.

Schizophrenia differs from other mental illnesses in the intensity of care that it requires. A comprehensive treatment program includes¹:

1. Antipsychotic medication, which forms the cornerstone of treatment for schizophrenia
2. Education of the individual about his / her illness and treatment
3. Family education and support
4. Support groups and social skills training
5. Rehabilitation to improve the activities of daily living
6. Vocational and recreational support
7. Cognitive therapy⁹
8. Integrated addictions program¹⁰

The course of schizophrenia varies, but in most cases it involves recurrent episodes of symptoms. Although available pharmacological treatments can relieve many of the symptoms, most people with schizophrenia continue to suffer some symptoms throughout their lives.

Appropriate treatment early in the course of the disease and adherence to continued and adequate treatment are essential to avoiding relapses and preventing hospitalization. During periods of remission, whether spontaneous or due to treatment, the individual may function well. Newer medications (and improved dosage guidelines for older medications) have substantially reduced the prevalence of severe neurological side effects that were once commonly associated with long-term pharmacological treatment of schizophrenia.

Optimizing the functional status and wellbeing of individuals with schizophrenia requires a supportive family and wide range of services, including institutional, community, social, employment and housing services. Ideally, multidisciplinary community treatment teams provide these services.

Social skills training strives to improve social functioning by working with individuals to resolve problems with employment, leisure, relationships and activities of daily life.

Occasionally, however, timely admission to hospital to control symptoms may prevent the development of more severe problems. Canadian hospitalization data provide insight into the use of hospital services as one of the treatment modalities.

In 1999, in the younger age groups with schizophrenia, the disorder was the diagnosis most responsible for determining their length of stay in hospital (Figure 3-2). In older age groups (65+ years), schizophrenia was more likely to be an associated condition.

Figure 3-2 Hospitalizations for schizophrenia in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000

Between 1987 and 1999, hospitalizations for schizophrenia increased slightly among women (3%), but they increased dramatically among men (28%) (Figure 3- 3).

Figure 3-3 Rates of hospitalization for schizophrenia* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

Hospitalization rates among women aged 45-64 and 65+ years demonstrated a slight increase between 1987 and 1999 (Figure 3-4). Rates among women aged between 25 and 44 years decreased during the same period.

Figure 3-4 Rates of hospitalization for schizophrenia* among women in general hospitals, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Hospitalization rates for schizophrenia rose among men in all age groups from 15 to 64 years between 1987 and 1999 (Figure 3- 5).

Figure 3-5 Rates of hospitalization for schizophrenia* among men in general hospitals, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

In 1999, the average length of stay in general hospitals due to schizophrenia was 26.9 days - a decrease of 26% since 1987 (Figure 3-6).

Figure 3-6 Average length of stay in general hospitals due to schizophrenia*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

The high hospitalization rates for schizophrenia among young adults support the clinical finding that the onset of schizophrenia typically occurs in adolescence and early adulthood. Higher rates among young men than young women agree with the observation that although schizophrenia affects both men and women, men develop it at an earlier age. Assessing whether the illness affects men differently than women in such a way that they require more hospitalization needs further research.

The increasing hospitalization rates for schizophrenia in general hospitals among young and middle-aged men may reflect, in part, the loss of psychiatric hospital beds that provided care for these men before deinstitutionalization. This care has now shifted to general hospitals. More research is needed to determine whether this also reflects shortcomings in the community treatment of the disease requiring hospitalization in order to control symptoms.

The length of stay in hospital associated with schizophrenia has decreased since 1995. This may reflect either improved treatment or the effect of decreases in hospital funding, which put pressure on the institutions to discharge people earlier than in previous years. Discharging people too early could be contributing to the increase in hospitalization rates through the need for re-admissions. Further research is needed to understand both the reason for this trend and its impact on individuals.

Future Surveillance Needs

Schizophrenia is a very serious mental illness with major ramifications for individuals and families, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Fortunately, schizophrenia can be treated effectively.

Existing data provide a very limited profile of schizophrenia in Canada. The available hospitalization data need to be complemented with additional data to fully monitor this illness in Canada. Priority data needs include:

• Incidence and prevalence of schizophrenia by age, sex and other key variables (for example, socioeconomic status, education and ethnicity).
• Impact of schizophrenia on the quality of life of the individual and family.
• Access to and use of health care services and community-based programs.
• Treatment outcomes.
• Access to community supports, such as housing, employment and education.
• Impact of schizophrenia on the workplace and the economy.
• Stigma associated with schizophrenia.
• Exposure to known or suspected risk and protective factors.

References

1. Canadian Psychiatric Association. Canadian clinical practice guidelines for the treatment of schizophrenia. Can J Psychiatry 1998;43:Supp2.
2. Hafner H, an der Heiden W. Epidemiology of schizophrenia. Can J Psychiatry 1997;42:139-51.
3. Keks N, Mazumdar P, Shields R. New developments in schizophrenia. Aust Fam Physician 2000;29:129-31,135-6.
4. http://www.nimh.nih.gov/publicat/schizoph.cfm.
5. Radomsky ED, Haas GI, Mann JJ, Sweeny JA. Suicidal behaviour in patients with schizophrenia and other psychotic disorders. Am J Psychiatry 1999;156:1590-5.
6. Goeree R, O'Brien BJ, Goering P, Blackhouse G, Agro K, Rhodes A, Watson J. The economic burden of schizophrenia in Canada. Can J Psychiatry 1999;44:464-72.
7. Murray CJL, Lopez AD (Eds.). The Global Burden of Disease. Cambridge, Mass: Harvard School of Public Health, 1996.
8. Cornblatt, BA, Green MF, Walker EF. Schizophrenia: etiology and neurocognition. Millon T, Blaneyu PH, Davis R, eds. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999: 292.
9. Norman RM, Townsend LA. Cognitive behaviour therapy for psychosis: a status report. Can J Psychiatry 1999;44:245-252.
10. Drake RE, Mueser KT. Managing comorbid schizophrenia and substance abuse. Current Psychiatry Reports 2001;3(5):418-422.

Chapter 2 Mood Disorders

From: Public Health Agency of Canada

Highlights

• Mood disorders include major depression, bipolar disorder (combining episodes of both mania and depression) and dysthymia.
• Approximately 8% of adults will experience major depression at some time in their lives. Approximately 1% will experience bipolar disorder.
• The onset of mood disorders usually occurs during adolescence.
• Worldwide, major depression is the leading cause of years lived with disability, and the fourth cause of disability-adjusted life years (DALYs).
• Mood disorders have a major economic impact through associated health care costs as well as lost work productivity.
• Most individuals with a mood disorder can be treated effectively in the community. Unfortunately, many individuals delay seeking treatment.
• Hospitalizations for mood disorders in general hospitals are approximately one and a half times higher among women than men.
• The wide disparity among age groups in hospitalization rates for depression in general hospitals has narrowed in recent years, because of a greater decrease in hospitalization rates in older age groups.
• Hospitalization rates for bipolar disorder in general hospitals are increasing among women and men between 15 and 24 years of age.
• Individuals with mood disorders are at high risk of suicide.

What Are Mood Disorders?

Mood disorders may involve depression only (also referred to as "unipolar depression") or they may include manic episodes (as in bipolar disorder, which is classically known as "manic depressive illness"). Individuals with mood disorders suffer significant distress or impairment in social, occupational, educational or other important areas of functioning.

Individuals with depression feel worthless, sad and empty to the extent that these feelings impair effective functioning. They may also lose interest in their usual activities, experience a change in appetite, suffer from disturbed sleep or have decreased energy.

Individuals with mania are overly energetic and may do things that are out of character, such as spending very freely and acquiring debt, breaking the law or showing lack of judgement in sexual behaviour. These symptoms are severe and last for several weeks, interfering with relationships, social life, education and work. Some individuals may appear to function normally, but this requires markedly increased effort as time with the illness progresses.

Both depressive and manic episodes can change the way an individual thinks and behaves, and how his/her body functions.

Major depressive disorder is characterized by one or more major depressive episodes (at least 2 weeks of depressed mood or loss of interest in usual activities accompanied by at least four additional symptoms of depression).¹

Bipolar disorder is characterized by at least one manic or mixed episode (mania and depression) with or without a history of major depression.²

Dysthymic disorder is essentially a chronically depressed mood that occurs for most of the day for more days than not over a period of at least two years,1 without long, symptomfree periods. Symptom-free periods last no longer than 2 months. Adults with the disorder complain of feeling sad or depressed, while children may feel irritable. The required minimum duration of symptoms for diagnosis in children is 1 year.

Symptoms
Depression	Mania
Feeling worthless, helpless or hopeless Loss of interest or pleasure (including hobbies or sexual desire) Change in appetite Sleep disturbances Decreased energy or fatigue (without significant physical exertion) Sense of worthlessness or guilt Poor concentration or difficulty making decisions	Excessively high or elated mood Unreasonable optimism or poor judgement Hyperactivity or racing thoughts Decreased sleep Extremely short attention span Rapid shifts to rage or sadness Irritability

How Common Are Mood Disorders?

As a group, mood disorders are one of the most common mental illnesses in the general population. Canadian studies looking at lifetime incidence of major depression found that 7.9% to 8.6% of adults over 18 years of age and living in the community met the criteria for a diagnosis of major depression at some time in their lives.¹ Other studies have reported that between 3% and 6% of adults will experience dysthymia during their lifetime, ³ and that between 0.6% and 1% of adults will have a manic episode during their lifetime.⁴

During any 12-month period, between 4% and 5% of the population will experience major depression.¹ According to the 1994/95 National Population Health Survey (NPHS), 6% of the Canadian population aged 12 years and over had symptoms consistent with depression at the time of the survey.⁵

Impact of Mood Disorders

Who Is Affected by Mood Disorders?

Mood disorders affect individuals of all ages, but usually appear in adolescence or young adulthood. However, late diagnosis is common: the average age of diagnosis of major depressive disorder is in the early twenties to early thirties.¹

Studies have consistently documented higher rates of depression among women than among men: the female-to-male ratio averages 2:1.³ Women are 2 to 3 times more likely than men to develop dysthymia.

Sex differences in the symptoms associated with depression may contribute to the differences in the prevalence of depression between men and women. For example, men are more likely to be irritable, angry and discouraged when depressed, whereas women express the more "classical" symptoms of feelings of worthlessness and helplessness, and persistent sad moods. As a result, depression may not be as easily recognized in a man. In addition, women are more likely than men to seek help from health professionals. Biological or social risk or protective factors may also differ between men and women.

For bipolar disorder, it is generally accepted that the ratio between men and women is approximately equal.⁶

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with mood disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide this for 2002.

Although most individuals with mood disorders are treated in the community, hospitalization is sometimes necessary. At the present time, hospitalization data provide the best available, though limited, description of individuals with mood disorders. The results must be viewed with caution, however, since this is only a subset of those with mood disorders: most individuals with mood disorders are treated in the community rather than in hospitals, and many do not receive treatment at all.

In 1999, more women than men were hospitalized for major depressive disorder in every age group except 90+ years (Figure 2-1). Young women aged 15-19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women between the ages of 40 and 44 years and men between the ages of 85 and 89 years had the highest rates of hospitalization for their sex.

Figure 2-1 Hospitalizations for major depressive disorder* in general hospitals per 100,000 by age group, Canada, 1999/2000

In 1999, in all except the 5-9 year age group, women were hospitalized for bipolar disorder at significantly higher rates than men (Figure 2-2). This contrasts with the generally accepted equal ratio of prevalence of the disorder among men and women. Further research is needed to explain this distribution. Women were most frequently hospitalized for bipolar disorder between the ages of 40 and 44 years.

Figure 2-2 Hospitalizations for bipolar disorder* in general hospitals per 100,000 by age group, Canada, 1999/2000

How Do Mood Disorders Affect People?

Because of their high prevalence, economic cost, risk of suicide and loss of quality of life, mood disorders present a serious public health concern in Canada. Depression and mania cause significant distress and impairment in social, occupational, educational or other important areas of functioning.⁷ According to the World Health Organization (WHO), major depression is the fourth leading cause of disability adjusted life years (DALYs) in the world.⁸ Major depression is the leading cause of years of life lived with disability (YLD) and bipolar is the sixth leading cause.⁸

Major depressive disorder is a recurrent illness with frequent episode relapses and recurrences. The more severe and longlasting the symptoms in the initial episode, due in some cases to a delay in receiving effective treatment, the less likely is a full recovery.

Unipolar major depressive disorder is identified as the fourth-ranked cause of disability and premature death worldwide.⁸ Depression also has a major impact on the mental health of family members and caregivers, often with an increased presence of depression and anxiety symptoms.

Dysthymia, as a result of its protracted nature, can be very debilitating.⁹ In spite of a high recovery rate, the risk of relapse is significant. Individuals with this disorder are also at high risk of experiencing an episode of major depression.¹⁰

Individuals with one episode of bipolar disorder tend to experience future episodes. Recovery rates vary among individuals. Those with purely manic episodes fare better than those with both mania and depression, who tend to take longer to recover and have more chronic course of illness.⁶

The mortality rate among individuals with bipolar disorder is 2 to 3 times greater than that of the general population, and includes higher rates of suicide.⁶

Child or spousal abuse or other violent behaviours may occur during severe manic episodes. Furthermore, individuals with bipolar disorder often show loss of insight, resulting in resistance to treatment, financial difficulties, illegal activities and substance abuse. Other associated problems include occupational or educational failure, financial difficulties, substance abuse, illegal activities and divorce.² Individuals with bipolar disorder may often have difficulty maintaining steady employment and, as a result, may suffer social and economic disadvantages.

Mood disorders frequently accompany other mental illnesses, such as anxiety disorders, personality disorders, and substance abuse and dependencies. The presence of another mental illness increases the severity of the illness and results in a poorer prognosis. Individuals with mood disorders are at high risk of suicide.

Economic Impact

Because of their high prevalence, mood disorders have a major effect on the Canadian economy. This effect is dual in nature - first, with the associated loss of productivity in the workplace due to absenteeism and diminished effectiveness; and second, with the high health care costs attributable to primary care visits, hospitalizations and medication.

At the individual and family level, the loss of income and cost of medication create a strain on the family financial resources.

Stigma Associated with Mood Disorders

The stigma against individuals with mood disorders has a major influence in determining whether an individual seeks treatment, takes prescribed medication or attends counselling. This effect is greater among men than women. The stigma also influences the successful re-integration of the individual into the family and community.

Employers may be concerned that the individual with a mood disorder will be unable to function at the level of other employees. When the illness goes untreated, this may be true. However, with treatment to reduce or manage symptoms, performance usually improves. Reducing the stigmatization of mental illness in the workplace will be helped by increased knowledge and an employer's willingness and ability to respond appropriately to an employee's needs.¹¹ Enforcement of human rights legislation can reinforce voluntary efforts.

Causes of Mood Disorders

Mood disorders have no single cause, but several factors, such as a biochemical imbalance in the brain, psychological factors and socio-economic factors, tend to make some individuals prone to such disorders.^9,12

Genetic Influence

Studies have established that individuals with depression and bipolar disorder often find a history of these disorders in immediate family members.^6,13 Evidence suggests that many different genes may act together and in combination with other factors to cause a mood disorder. Although some studies have suggested a few interesting genes or genomic regions, the exact genetic factors that are involved in mood disorders remain unknown.

Previous Episode of Depression

One episode of major depression is a strong predictor of future episodes. More than 50% of individuals who have an episode of major depression experience a recurrence.¹³

Stress

Stress has traditionally been viewed as a major risk factor for depression. Recent research efforts have indicated, however, that stress may predispose individuals only for an initial episode and not for recurring episodes.¹⁴ Responses to stress differ greatly among individuals: some are more susceptible than others to depression following life events, when they are in difficult relationships, or because of socio-economic factors such as inadequate income or housing, prejudice and workplace stress.

Physical Illness

A strong association exists between various chronic medical conditions and an elevated prevalence of major depression.^15,16 Several conditions, such as stroke and heart disease, Parkinson's disease, epilepsy, arthritis, cancer, AIDS and chronic obstructive pulmonary disease (COPD), may contribute to depression. Several factors associated with physical illness may contribute to the onset or worsening of depression. These include the psychological impact of disability, decline in quality of life, and the loss of valued social roles and relationships. Medication side effects may also be a contributing factor. Finally, it is possible that the physical disease itself may contribute directly to the onset of depression by affecting physiological mechanisms such as neurotransmitters, hormones and the immune system; for similar reasons, episodes of mania may occur following physical illness or use of medications.

Indirect factors also influence the relationship between physical conditions and depression. Such factors include disability and quality of life of individuals with chronic disease and the tendency for some medications used for treating physical illnesses to cause depression.Treating chronic physical illness effectively requires vigilance for the early detection and treatment of depression.

Treatment of Mood Disorders

Mood disorders are treatable. Many people with a mood disorder fail to seek treatment, however, and suffer needlessly. Of those who seek treatment, many remain undiagnosed or receive either incorrect medication or inadequate doses.¹⁷ The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, lack of knowledge, a lack of human resources and availability or accessibility of services. Current initiatives to relieve the burden of mood disorders include not only improved recognition and use of effective treatments, but also education for individuals and families and for the community. Primary care settings play a critical role in both recognizing and treating these illnesses. Innovative practice models have shown that effective interventions can decrease symptoms and increase work days.¹⁸ Effective early treatment of mood disorders can improve outcomes and decrease the risk of suicide.

Antidepressant medications and education in combination with various forms of psychotherapy, such as cognitive-behavioural therapy, have demonstrated their effectiveness in treating depression. A recent publication from the Canadian Psychiatric Association outlines the clinical guidelines for the treatment of depressive disorders.¹

Educating family and primary care providers is essential not only to ensure the recognition of early warning signs of depression, mania and suicide and to implement appropriate treatment, but also to ensure adherence to treatment in order to minimize future relapses. Sound support networks are crucial during both the acute phase of the illness and the post-illness adjustment to daily life.

Major depression results in poor productivity and sick leave from the workplace. The workplace, therefore, is an important area for addressing mental health issues. Supporting the development of healthy work environments, educating employers and employees in the area of mental health issues, and providing supportive reintegration into the work environment for those experiencing mental illness would go a long way toward minimizing the effect of major depression on the workplace.

Individuals with mood disorders may require hospitalization to adjust medication, to stabilize the disorder or to ensure protection against self-destructive behaviour.

Major Depressive Disorder

In 1999, among people under the age of 50 years with major depressive disorder who were hospitalized, the disorder was the main contributor to determining their length of stay (Figure 2-3). Among people with the disorder over the age of 50 years, depression was more likely to be an associated condition contributing to the length of stay. This is consistent with the association between physical illness and depression.

Figure 2-3 Hospitalizations for major depressive disorder in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000

Overall, between 1987 and 1999, hospitalization rates for major depressive disorder decreased by 33% among both men and women (Figure 2- 4).

Figure 2-4 Rates of hospitalization due to major depressive disorder* in general hospitals by sex, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population)

Among women 25 years of age and over, rates of hospitalization due to major depressive disorder decreased between 1987 to 1997 while remaining fairly stable among women under the age of 25 years (Figure 2-5). Women over the age of 65 years showed the greatest rate of reduction.

Figure 2-5 Rates of hospitalization due to major depressive disorder* in general hospitals among women, Canada, 1987/88- 1999/2000 (age standardized to 1991 Canadian population)

Among both men and women aged 15 years and over, the wide variations in hospitalization rates that were evident in 1987 had disappeared by 1999, mostly as a result of moderate decreases in the 25-64 year age groups and the large decrease among those aged 65 years and over.

Among men, hospitalization rates for major depressive disorder between 1987 and 1999 showed the greatest decrease in the 65+ age group (Figure 2- 6). During this same time period, rates among young men aged between 15 and 24 years increased to a level similar to that of all older age groups.

Figure 2-6 Rates of hospitalization due to major depressive disorder* in general hospitals among men, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population)

Between 1987 and 1999, the average length of stay in hospital in Canada due to major depressive disorder decreased by 20% (Figure 2-7).

Figure 2-7 Average length of stay in general hospitals due to major depressive disorder*, Canada, 1987/88-1999/2000

Bipolar Disorder

In 1999, bipolar disorder was the main contributor to the length of hospital stay among people with the disorder under the age of 50 years (Figure 2-8). Among older people, bipolar disorder was more likely to be an associated condition contributing to length of stay.

Figure 2-8 Hospitalizations for bipolar disorder in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000

Overall, hospitalization rates for bipolar disorders remained fairly stable among both men and women between 1987 and 1999 (Figure 2-9).

Figure 2-9 Rates of hospitalization due to bipolar disorder* in general hospitals by sex, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population)

Between 1987 and 1999, hospitalization rates for bipolar disorder among women under the age of 25 years more than doubled (Figure 2-10). During the same period, rates in the older age groups decreased.

Figure 2-10 Rates of hospitalization due to bipolar disorder* in general hospitals among women, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population)

Between 1987 and 1999, hospitalization rates for bipolar disorder among men aged 15-24 increased by 61%. Rates among men aged 25-44 years remained stable (Figure 2-11). Rates decreased by 14% among men aged 45- 64 years, and by 23% among men aged 65 years and over.

Figure 2-11 Rates of hospitalization due to bipolar disorder* in general hospitals among men, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population)

Between 1987 and 1999, the average length of stay in general hospital due to bipolar disorder decreased by 27% (Figure 2-12).

Figure 2-12 Average length of stay in general hospitals due to bipolar disorder*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

The higher hospitalization rates for depression among women than men support the clinical experience of higher rates of depression among women. Based on clinical research, rates of major depression among women are 2 times higher than among men. On the other hand, the hospitalization rates among women are only about 1.5 times higher than among men, suggesting that men may be hospitalized for major depression at higher rates than women. This requires further research for confirmation and explanation. Rates of bipolar disorder have been estimated to be equal among men and women. However, hospitalization rates for women with the disorder are much higher than men. Further research is required to assess if, in fact, rates of the disease are higher among women, or if women with the disorder are hospitalized at a higher rate than men, why this occurs.

Hospitalization rates for both depression and bipolar disorder among women peak between the ages of 35-49 years. Research is required to assess the factors in women's lives that contribute to this phenomenon.

Since 1987, hospitalization rates for depression among older Canadians have decreased much more than rates among younger age groups. Further research is required to determine the reasons for this trend. Has it been the result of better clinical treatment, and have outcomes for this age group also improved over this time period?

Hospitalization rates for bipolar disorder among young women and men have increased since the early 1990s. Does this signify an increase in bipolar disorder in these age groups, earlier recognition of the disorder, or a change in treatment?

Future Surveillance Needs

Mood disorders, including major depression, bipolar disorder and dysthymia are common and contribute to major personal and family distress. They also have a significant impact on workplace and health care costs.

Existing data provide a very limited profile of mood disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

• Incidence and prevalence of major depression, bipolar disorder and dysthymia by age, sex and other key variables (for example, socio-economic status, education, and ethnicity).
• Prevalence of depression in people with chronic physical illness.
• Impact of mood disorders on the quality of life of the individual and family.
• Access to and use of primary and specialist health care services.
• Treatment outcomes.
• Rates of suicide among individuals with mood disorders.
• Access to and use of public and private mental health services.
• Access and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs.
• Impact of mood disorders on the workplace and the economy.
• Stigma associated with mood disorders.
• Exposure to known or suspected risk and protective factors.

References

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