Depression in Canada - Panel Calls for Action

After two days of hearings at a consensus development conference on depression in adults, a panel of experts led by the Hon. Michael Kirby, Chair, Mental Health Commission of Canada is recommending wide and immediate changes to how depression is viewed, prevented, diagnosed, and treated in Canada.

The panel of health professionals, academics, and public representatives called on federal and provincial governments to develop and promote policies to significantly impact the systems set up to
help those with depression. "Governments at all levels need to demonstrate leadership in developing and promoting policies that will create positive changes in the treatment system. They need to champion respect for the person with depression in the home, the workplace, and in the community," the panel concluded. "Depression must be recognized as the health priority it is and resourced accordingly. An investment by an informed and caring population is an investment in Canada's future."

Key panel recommendations include:

Addressing stigma through a public awareness campaign about depression in language which will be understood by everyone.

Increasing mental health investments in the critical period of childhood and adolescence.

Developing a comprehensive framework for research in depression through a group of partners lead by the Mental Health Commission of Canada.

Including people with depression regardless of age in the decision-making regarding their own care.

Encouraging public and private employers to create mentally healthy work places and to improve support for employees with depression.

Changing the health system so that effective drug and psychotherapy are accessible to all people with depression and committing to training and funding health care
 providers.

The Consensus Development Conference on Depression in Adults: How to Improve Prevention, Diagnosis and Treatment was hosted by the Institute of Health Economics, Alberta Health Services-Alberta Mental Health Board, and the Mental Health Commission of Canada, with support from the Alberta Depression Initiative. For a copy of the panel's recommendations, go to www.ihe.ca and download consensus statement on depression from the homepage.

Panel Recommendations:

Improved anti-discrimination laws, and/or enforcement of such laws, may be required to ensure that persons living with mental health problems or illness have the same rights as other Canadians.

To allow caregivers to write off expenses incurred in supporting the depressed person, the Income Tax Act must be amended.

CPP disability and provincial income support programs must also be applied equitably so that a disability caused by mental illness is treated in the same way as a disability caused by physical illness.

Similarly, access to employment insurance, workers' compensation and short and long term disability benefits must ensure equitable access for persons living with a mental or physical illness.

Public and private employers must be encouraged to create a mentally healthy work place and to improve support for employees with depression.

Interventions for depression should be tailored for and made available to identified high risk groups (e.g. chronically ill people, trauma/abuse victims, those suffering from substance abuse disorders, families with a positive history for depression, post partum mothers, and the elderly).

Childhood and adolescence are critical periods with respect to depression. This age group must become a priority in mental health.

A population health approach to prevention, early identification and intervention should be implemented in schools.

The healthy management of stress and anxiety should be a particular focus for prevention efforts at home, school and in the workplace.

Individuals presenting for assessment of depression by health care providers should be asked about the presence or absence of trauma and adverse childhood experiences.

A better understanding by service providers of the relationship between substance use disorders, chronic diseases and depression is essential for the optimal prevention, early detection and effective intervention of these disorders.

Universal screening of Canadians for depression is not recommended. Targeted screening of at-risk and marginalized groups is recommended.

The use of assessment tools to support a stepped care approach for depression is recommended for the family physician.

The College of Family Physicians of Canada, the Canadian Psychiatric Association, the Canadian Psychological Association and people with direct experience with depression should develop a toolkit of recommended screening and assessment tools appropriate for Canadian settings.

Investigate and evaluate service innovations that could help to fill the gaps in mental health service delivery (e.g. telehealth, internet-based therapy, telephone therapy, family-practice located shared therapy, stepped care models, chronic disease management models, and alternative reimbursement models).

Treatment studies should be independently evaluated for long-term efficacy.

We need studies that will help us understand how to match patients with optimal treatment. Effectiveness trials of antidepressant medications, psychotherapy and combinations of them are required.

Health system modifications are required so that effective supported self management, psychotherapy and pharmacotherapy are accessible to all people with depression. This includes commitment to training and funding practitioners.

The effectiveness and safety of treatment approaches such as self management, lifestyle management and therapies that involve brain stimulation need to be subject to rigorous evaluation.

The Mental Health Commission of Canada should facilitate discussions about how to best incorporate traditional healing methods and spiritual practices from various cultures into routine treatment of depression.

 The Mental Health Commission of Canada should: -   Ensure that its knowledge exchange center has a focus on mental health literacy to meet the specific needs of people with depression.

Develop a program that addresses the stigma associated with depression in our society.

A substantial reorganization of the delivery of services for the management of depression is required. The assessment and treatment of depression must be integrated into Chronic Disease Management and Primary Care Reform initiatives. This is compatible with the patient-centered model developed by the Canadian Collaborative Mental Health Initiative. Health care and professional funding rules must be redesigned to encourage and support system change and innovation with respect to screening and a stepped care approach, within a Chronic Disease Management model.

Ongoing funding to facilitate the engagement of people with depression, their families and representative groups in the delivery of self-help and peer support groups and system reform is needed.

Involving employers and insurers as partners to build additional supports and services to meet the needs of people with depression in the workplace is required.

Methods need to be found to provide services and support to First Nations, Métis, Inuit and rural and remote communities. Targeted innovation is required in this area.

A group of partners led by the Mental Health Commission of Canada should develop a comprehensive framework for research in depression considering issues raised at the Consensus Development Conference on Depression in Adults. Other recommendations have relevance for future research. These recommendations refer to such things as: service delivery models, the role of primary care, better aligned funding methods to support more effective service delivery, identifying risks in critical periods during a person's lifetime, and the cumulative effects of stress.

The comprehensive research framework should include but not be limited to the following themes:

Biomedical Studies of Depression

Research on depression should capitalize on the advances in the neurosciences.

Multi-disciplinary research teams investigating symptoms, co-morbidities, neurochemistry, genetics or imaging that have relevance to treatment.

Pharmacotherapy research to develop more effective antidepressants. Current drugs have slow response, numerous side effects, but are safer, although more costly than older medications.

Prevention of Depression

Adequate prevention is dependent on the identification of risk factors.

A surveillance system to monitor risk factors for depression is needed to evaluate the effectiveness of prevention programs that may reduce depression including: -   prenatal programs, strategies to reduce childhood abuse and its impact, screening for postpartum depression. -   Organizational risk factors in workplaces and the programs to produce healthy workplaces.

Economics of Depression

Because resources are scarce and the need is great we must use our limited resources most effectively and efficiently. Therefore, continued investigation of the costs of depression is required including the human, workplace, social, and health systems costs.

The research agenda in this area might include:

Economic evaluation of different interventions and approaches.

Continued monitoring of health care expenditures to match the burden of depression.

Examination of financing and reimbursement structures for various models of care for depression that promote access and quality in a patient centered environment.

Examination of benefit structures to promote efficient use of services and recovery by patients.

Examination of the optimal balance of private (e.g. workers, citizens, patients, and employers) and public funding of increased access to psychotherapy according to the models developed in Australia and the United Kingdom.

Effectiveness of Services for Depression

Models of care for depression need to dovetail with primary care reforms. A possible research agenda might include:

Evaluation of new patient centered treatment pathways for depression integrated with other common mental disorders (e.g. anxiety disorders and substance use disorders) and common chronic diseases.

Development of minimum guideline treatment using simple protocols and standardized rating scales.

Evaluation of psychotherapies (including brief and group psychotherapy) and self directed treatments (e.g. web CBT).

Evaluation of consumer mutual aid/self-help/peer support.

Epidemiology of Depression

Emphasize longitudinal studies to examine:

The effects of critical developmental periods.

The effect of cumulative experiences of developmental stresses - 'chains of adversity' and 'chains of risk'.

Ensure the inclusion of depression relevant variables in emerging or proposed longitudinal studies in Canada.

Diagnostic assumptions regarding depression and its sub classifications need to be re-examined:

Investigate the use of a dimensional approach to diagnosis.

Boundaries between disorders are less clear than current diagnostic systems imply (e.g. anxiety and depression).

Consumers/Patients and Families/Caregivers

More support should be given to patient driven research. Their lived experiences are a valuable guide to the realities of mental illness.

Evidence

Mental health research needs to broaden its perspective on evidence beyond the randomized controlled trial. Qualitative methodology, narrative accounts, and others all
 need to be considered.

Knowledge Exchange

Any research agenda must invest in knowledge exchange activities and evaluate the outcomes and optimal approaches.

For further information: For interviews, please contact: Rhonda Lothammer, Institute of Health Economics, Cell: (780) 935-0382, rlothammer@ihe.ca