Economic Conditions and Children”s Mental Health
7 million deaths in children under five were attributable to the environment. These included 570 000 deaths from respiratory economic Conditions and Children’s Mental Health, 361 000 deaths from diarrhoea, 270,000 deaths from neonatal conditions, 200 000 deaths from malaria and 200 000 deaths from unintentional injuries.
Environmental risks that children are particularly vulnerable to include air pollution, inadequate water, sanitation and hygiene, hazardous chemicals and wastes, radiation, climate change as well as emerging threats like e-waste. Reducing environmental risks could prevent 1 in 4 child deaths. These documents highlight the importance of reducing environmentally related health outcomes, and cite strategies for reducing the environmental impact on children of all ages, through creating safe and healthy environments. Lifetime prevalence rates for any kind of psychological disorder are higher than previously thought, are increasing in recent cohorts and affect nearly half the population. Despite being common, mental illness is underdiagnosed by doctors. Less than half of those who meet diagnostic criteria for psychological disorders are identified by doctors.
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Patients, too, appear reluctant to seek professional help. Only 2 in every 5 people experiencing a mood, anxiety or substance use disorder seeking assistance in the year of the onset of the disorder. Overall rates of psychiatric disorder are almost identical for men and women but striking gender differences are found in the patterns of mental illness. Gender is a critical determinant of mental health and mental illness. The morbidity associated with mental illness has received substantially more attention than the gender specific determinants and mechanisms that promote and protect mental health and foster resilience to stress and adversity.
Gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. Gender differences occur particularly in the rates of common mental disorders – depression, anxiety and somatic complaints. These disorders, in which women predominate, affect approximately 1 in 3 people in the community and constitute a serious public health problem. Unipolar depression, predicted to be the second leading cause of global disability burden by 2020, is twice as common in women. Depression is not only the most common women’s mental health problem but may be more persistent in women than men. Reducing the overrepresentation of women who are depressed would contribute significantly to lessening the global burden of disability caused by psychological disorders.
The lifetime prevalence rate for alcohol dependence, another common disorder, is more than twice as high in men than women. In developed countries, approximately 1 in 5 men and 1 in 12 women develop alcohol dependence during their lives. Men are also more than three times more likely to be diagnosed with antisocial personality disorder than women. Gender differences have been reported in age of onset of symptoms, frequency of psychotic symptoms, course of these disorders, social adjustment and long term outcome. The disability associated with mental illness falls most heavily on those who experience three or more comorbid disorders. Gender specific risk factors for common mental disorders that disproportionately affect women include gender based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others.
The mental health impact of long term, cumulative psychosocial adversity has not been adequately investigated. Economic and social policies that cause sudden, disruptive and severe changes to income, employment and social capital that cannot be controlled or avoided, significantly increase gender inequality and the rate of common mental disorders. Doctors are more likely to diagnose depression in women compared with men, even when they have similar scores on standardized measures of depression or present with identical symptoms. Female gender is a significant predictor of being prescribed mood altering psychotropic drugs. Gender differences exist in patterns of help seeking for psychological disorder. Women are more likely to seek help from and disclose mental health problems to their primary health care physician while men are more likely to seek specialist mental health care and are the principal users of inpatient care.
Men are more likely than women to disclose problems with alcohol use to their health care provider. Gender stereotypes regarding proneness to emotional problems in women and alcohol problems in men, appear to reinforce social stigma and constrain help seeking along stereotypical lines. They are a barrier to the accurate identification and treatment of psychological disorder. Violence related mental health problems are also poorly identified. Women are reluctant to disclose a history of violent victimization unless physicians ask about it directly. The complexity of violence related health outcomes increases when victimization is undetected and results in high and costly rates of utilization of the health and mental health care system.
Leading mental health problems of the older adults are depression, organic brain syndromes and dementias. 50 million people affected by violent conflicts, civil wars, disasters, and displacement are women and children. At least one in five women suffer rape or attempted rape in their lifetime. Depression, anxiety, psychological distress, sexual violence, domestic violence and escalating rates of substance use affect women to a greater extent than men across different countries and different settings. Pressures created by their multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse, combine to account for women’s poor mental health.
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In most centres, these patients are not recognized and therefore not treated. Communication between health workers and women patients is extremely authoritarian in many countries, making a woman’s disclosure of psychological and emotional distress difficult, and often stigmatized. Research shows that there are 3 main factors which are highly protective against the development of mental problems especially depression. Promote the formulation and implementation of health policies that address women’s needs and concerns from childhood to old age. Enhance the competence of primary health care providers to recognize and treat mental health consequences of domestic violence, sexual abuse, and acute and chronic stress in women.
Call the Mental Health Helpline at 1-866-531-2600 or find your local CMHA branch. Mental health and physical health are fundamentally linked. People living with a serious mental illness are at higher risk of experiencing a wide range of chronic physical conditions. Conversely, people living with chronic physical health conditions experience depression and anxiety at twice the rate of the general population. Introduction Mental health and physical health are fundamentally linked. Co-existing mental and physical conditions can diminish quality of life and lead to longer illness duration and worse health outcomes. Understanding the links between mind and body is the first step in developing strategies to reduce the incidence of co-existing conditions and support those already living with mental illnesses and chronic physical conditions.
Why do mental illnesses and chronic physical conditions co-exist? Both mind and body are affected by changes to physiological and emotional processes, as well as by social factors such as income and housing. These three pathways of biology, illness experience, and the social determinants of health can increase the likelihood of someone living with a mental illness or chronic physical condition developing a co-existing condition. People living with mental illnesses experience a range of physical symptoms that result both from the illness itself and as a consequence of treatment. Mental illnesses can alter hormonal balances and sleep cycles, while many psychiatric medications have side-effects ranging from weight gain to irregular heart rhythms. 2,3 These symptoms create an increased vulnerability to a range of physical conditions. Furthermore, the way that people experience their mental illnesses can increase their susceptibility of developing poor physical health.
Mental illness can impact social and cognitive function and decrease energy levels, which can negatively impact the adoption of healthy behaviours. People may lack motivation to take care of their health. Canadians with chronic physical conditions have twice the likelihood of also experiencing a mood or anxiety disorder when compared to those without a chronic physical condition. One out of every two Canadians with major depression and a co-existing chronic physical condition report limitations in their day-to-day activities. People living with mental illnesses often face higher rates of poverty, unemployment, lack of stable housing, and social isolation.
These social factors increase the vulnerability of developing chronic physical conditions. For example, people who are unable to afford healthier food options often experience nutritional deficiencies. Poor nutrition is a significant risk factor for the development of heart disease and diabetes. Some chronic physical conditions can cause high blood sugar levels and disrupt the circulation of blood, which can impact brain function. 4 People living with chronic physical conditions often experience emotional stress and chronic pain, which are both associated with the development of depression and anxiety.
Experiences with disability can also cause distress and isolate people from social supports. Mental and physical illnesses also share many symptoms, such as food cravings and decreased energy levels, which can increase food consumption, decrease physical activity and contribute to weight gain. These factors increase the risk of developing chronic physical conditions and can also have a detrimental impact upon an individual’s mental well-being. The social determinants of health can also impact upon a person’s mental well-being. People living in poverty with chronic physical conditions are at risk of developing mental health problems and may face barriers to accessing mental health care, contributing to worsening mental health problems.
Housing insecurity can be particularly stressful and lead to poorer mental and physical health. Common co-existing mental illnesses and chronic physical conditions People living with the most common chronic physical conditions in Ontario also face worse mental health than the general population. Figure 1 illustrates the elevated rates of mood disorders in Ontarians with diabetes, heart disease, cancer, arthritis and asthma. People with serious mental illnesses face a greater risk of developing a range of chronic physical conditions compared to the general population, impacting almost every biological system in the body. 7 Table 1 summarizes the risk of people with a mental illness developing various chronic physical conditions. Diabetes Diabetes rates are significantly elevated among people with mental illnesses. 8 Both depression and schizophrenia are risk factors for the development of type 2 diabetes due to their impact on the body’s resistance to insulin.
9,10 People with mental illnesses also experience many of the other risk factors for diabetes, such as obesity and high cholesterol levels. Conversely, people with diabetes have nearly twice the rate of diagnosed mental illnesses as those without diabetes. Forty percent of people with diabetes12 also exhibit elevated symptoms of anxiety. 13 People living with diabetes often experience significant emotional stress which can negatively affect an individual’s mental health.
The biological impact of high blood sugar levels is also associated with the development of depression in people with diabetes. Heart Disease and Stroke People with serious mental illnesses often experience high blood pressure and elevated levels of stress hormones and adrenaline which increase the heart rate. Antipsychotic medication has also been linked with the development of an abnormal heart rhythm. These physical changes interfere with cardiovascular function and significantly elevate the risk of developing heart disease among people with mental illnesses. Conversely, there are significantly elevated rates of depression among people with heart disease. It is three times more likely that a person with heart disease will experience depression when compared to people who do not have heart problems. 17 Depression also often occurs following a stroke.
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Co-existing heart disease and mental illness contribute to worse health status and higher health care utilization rates. 19 Similarly, psychological distress has been shown to slow rehabilitation from stroke and increase the risk of stroke-related death. Chronic Diseases in Canada 28, no. American Journal of Preventive Medicine 23 no. Stroke: Journal of the American Heart Association 32, no. 21,22 Smoking is commonly identified as a risk factor for respiratory illnesses. People living with chronic respiratory diseases experience significantly elevated rates of anxiety and depression.
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23 A co-existing mental health problem can lead to poor self-care practices which can increase the symptoms of COPD and contribute to increased hospital admissions, health care costs, and reduced quality of life. Cancers The research linking mental illness and cancer has yielded mixed results. Recent research has found significantly higher rates of cancer among people with schizophrenia than expected. 25 People with schizophrenia have been found in some studies to have approximately twice the risk of developing gallbladder and bowel cancers, which may be linked to high-fat diets. 26,27 Findings are inconclusive for respiratory cancers.
People living with cancers face a higher risk of developing depression, due in part to high levels of stress, emotional upset, and changes in body image. 30 A co-existing mental health problem can interfere with cancer treatment and remission. For example, older women with breast cancer and a diagnosis of depression were significantly less likely to receive optimal treatment. Arthritis Research has consistently found a lower rate of arthritis in people with serious mental illnesses than the general population. It has been previously suggested that schizophrenia may reduce the risk of developing arthritis due to genetics, the anti-inflammatory side effects of antipsychotic medications, and more sedentary lifestyles linked to institutionalization and illness. By comparison, people with arthritis are at significantly elevated risk of developing mood and anxiety disorders. 34 These rates are strongest among younger age groups and are also linked to experiences with frequent or chronic pain.
Addressing Access to Health Care People with serious mental illnesses face many barriers to accessing primary health care. These barriers are complex and range from the impact of poverty on the ability to afford transportation for medical appointments to systemic barriers related to the way that primary health care is currently provided in Ontario. The stigma associated with mental illness also continues to be a barrier to the diagnosis and treatment of chronic physical conditions in people with mental illnesses. Stigma acts as a barrier in multiple ways. It can directly prevent people from accessing health care services, and negative past experiences can prevent people from seeking health care out of fear of discrimination. Furthermore, stigma can lead to a misdiagnosis of physical ailments as psychologically based.
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People with serious mental illnesses who have access to primary health care are less likely to receive preventive health checks. They also have decreased access to specialist care and lower rates of surgical treatments following diagnosis of a chronic physical condition. The mental health of people with chronic physical conditions is also frequently overlooked. Diagnostic overshadowing can mask psychiatric complaints, particularly for the development of mild to moderate mental illnesses. Short appointment times are often not sufficient to discuss mental or emotional health for people with complex chronic health needs.
There are several initiatives in Ontario that can help to reduce barriers to health care. The Chronic Disease Prevention and Management Framework being implemented in Ontario has the potential to address the importance of emotional and mental health care for people living with a chronic physical condition. Some community mental health agencies have established primary health care programs to ensure their clients with serious mental illnesses are receiving preventive health care and assistance in managing co-existing chronic physical conditions. However, these initiatives currently lack sufficient infrastructure, incentives and momentum. For example, only half of Ontario’s doctors reported that they coordinate, collaborate or integrate the health care they provide with psychiatrists, mental health nurses, counsellors, or social workers. 41 This rate may improve as Family Health Teams begin to provide collaborative care with non-physician mental health specialists as part of Ontario’s primary health care reform. Current Activities CMHA Ontario is active in supporting people to promote their mental and physical health.
We do this by advocating for increased access to primary health care, as well as for more affordable housing, income and employment supports, and for healthy public policies that address the broad determinants of health. What Is the Fit between Mental Health, Mental Illness and Ontario’s Approach to Chronic Disease Prevention and Management? We have also launched the Minding Our Bodies initiative in partnership with YMCA Ontario and York University’s Faculty of Health, with support from the Ontario Ministry of Health Promotion through the Communities in Action Fund, designed to increase capacity within the community mental health system in Ontario to promote active living and to create new opportunities for physical activity for people with serious mental illness. Canadian Journal of Psychiatry 44 no. Journal of General Internal Medicine 21 no. When the world of health policy and public health considers the health of women, one tendency is first and foremost to link the well-being of women to that of children and the family, and, legitimately, to the health of society overall. Such efforts to improve the health of women’s children through programs that affect women’s health are laudable.
Yet, in the past decade, as women have begun to exercise greater influence over health policy formation, questions about such trends have been raised. Initially, women asked “Where is the “M” in MCH programs? What about programs designed to address women’s needs as women as well as mothers? Epidemiologic and anthropological data point to different patterns and clusters of psychiatric disorders and psychological distress among women than among men. The origins of much of the pain and suffering particular to women can be traced to the social circumstances of many women’s lives. Depression, hopelessness, exhaustion, anger and fear grow out of hunger, overwork, domestic and civil violence, entrapment and economic dependence.
Comparative analysis of empirical studies of mental disorders reveals a consistency across diverse societies and social contexts: symptoms of depression and anxiety as well as unspecified psychiatric disorder and psychological distress are more prevalent among women, whereas substance disorders are more prevalent among men. The disability-adjusted life years data recently tabulated by the World Bank reflect these differences. Ethnographic research and case descriptions enrich the quantitative findings of these prevalence studies of psychiatric morbidity, elaborating on the social context of depression, dependency and hopelessness and on the gendered dimension of these epidemiological clusters of social and psychological distress. Anthropology also offers an alternative approach to understanding the experience and expression of emotional distress. In short, a considerable body of evidence points to the social origins of psychological distress for women. Many women work a “double day” maintaining households, raising children, carrying out economically productive activities in marketing and agriculture and in household-based industries.
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It took the United Nation’s “Decade for Women” to begin to make women’s productive, as well as reproductive, roles visible to the world. Many development policies, and most recently in Asia, monetary policies to ease the debts of the rich and the consequent monetary crises, have hit women in traditional marketing, agricultural, and even in governmental and commercial sectors hard. Such a description of the social origins underlying psychiatric disorders can be disheartening. However, the resilience of individuals and the ability of governments and community organizations to develop policies and programs to address both the needs of the psychiatrically ill and the social origins of psychological and psychosocial distress offer not only hope but examples as well.
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What has been accomplished thus far? Just as important as an understanding of the social origins of women’s ill health is a recognition of what can be done and is being done to improve women’s status and well-being. The development of policies and programs consistent with broader definitions of health require listening to the women whom such programs are designed to serve and giving voice to their concerns, at all stages of planning, implementation and management. Much local listening work — that is, going into communities and talking with women about how they live and what their health and in particular mental health needs are — remains to be done. Building on local movements and enhancing grass-roots strengths offer pathways through which the status of women and women’s health may be improved.
Numerous local initiatives abound, from adult literacy programs in India to grass roots movements throughout the world’s local communities of women, to resist oppression and to organize and reshape community health programs. Efforts at both the international and local levels are crucial, but to be maximally effective the two must connect. Health policies can be distinguished from “healthy” policies at the level of the state. Healthy policies are those government programs that, while not specifically aimed at fighting illness and disease, nonetheless have positive consequences for health. Healthy policies for women are supported by state gender ideologies that enhance the cultural, political and legal status of women by legitimizing equitable public investment in and protection of females as well as males.
Health policies that incorporate mental health into public health and address women’s needs and concerns from childhood to old age can be developed in numerous ways to further mainstreaming of gender perspectives. Ethical considerations and competence of practitioners are central to the formulation of integrated health programs capable of redressing the trauma of rape, the stigma of sexual or domestic violence, the depression of isolation or gender oppression, and the anxiety of scarcity. Although the social roots of many of these problems mean that they cannot be simply patched over with medical care, to ignore the potential role of the health care system to attend to needy women would imply that a society does not want to invest its resources in women’s health. Institutions of health education, such as medical schools and training programs for health workers, need to be evaluated and barriers to treating mental illness and the consequences of violence addressed. Such dilemmas can be partially resolved by offering support to local public health movements and grass-roots efforts. Health policies and accompanying programs of health research may become leverage to mobilize political will and participation, and to promote change in policies controlled by other sectors of government.