A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in - PDF document

A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 31313131 CCCHAPTER HAPTER HAPTER 222MMMMOOD OOD OOD DDDISORDERSISORDERSISORDERS Mood disorders include major depression, bipolardisorder (combining episodes of both mania anddepression) and dysthymia.Approximately 8% of adults will experience majordepression at some time in their lives. Approximately 1%will experience bipolar disorder.The onset of mood disorders usually occurs duringWorldwide, major depression is the leading cause of yearslived with disability, and the fourth cause of disability-adjusted life years (DALYs).Mood disorders have a major economic impact throughassociated health care costs as well as lost workMost individuals with a mood disorder can be treatedeffectively in the community. Unfortunately, manyindividuals delay seeking treatment.Hospitalizations for mood disorders in general hospitalsare approximately one and a half times higher amongwomen than men.The wide disparity among age groups in hospitalizationrates for depression in general hospitals has narrowed inhospitalization rates in older age groups.hospitals are increasing among women and men between15 and 24 years of age.Individuals with mood disorders are at high risk of suicide. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 32323232 What Are Mood Disorders?What Are Mood Disorders?What Are Mood Disorders?What Are Mood Disorders? Mood disorders may involve depression only(also referred to as “unipolar depression”) orthey may include manic episodes (as inbipolar disorder, which is classically known as“manic depressive illness”). Individuals withmood disorders suffer significant distress orimpairment in social, occupational,educational or other important areas offunctioning.Individuals with depression feel worth

less, sadand empty to the extent that these feelingsimpair effective functioning. They may alsolose interest in their usual activities,experience a change in appetite, suffer fromdisturbed sleep or have decreased energy.Individuals with mania are overly energeticsuch as spending very freely and acquiringdebt, breaking the law or showing lack ofjudgement in sexual behaviour. Thesesymptoms are severe and last for severalweeks, interfering with relationships, sociallife, education and work. Some individualsmay appear to function normally, but thisrequires markedly increased effort as timewith the illness progresses.Both depressive and manic episodes canchange the way an individual thinks andbehaves, and how his/her body functions.Major depressive disorderMajor depressive disorderMajor depressive disorderMajor depressive disorder is characterized byone or more major depressive episodes (atleast 2 weeks of depressed mood or loss ofinterest in usual activities accompanied by atleast four additional symptoms ofdepression).Bipolar disorder Bipolar disorder Bipolar disorder Bipolar disorder is characterized by at leastone manic or mixed episode (mania anddepression) with or without a history of majordepression.Dysthymic disorder Dysthymic disorder Dysthymic disorder Dysthymic disorder is essentially a chronicallydepressed mood that occurs for most of theday for more days than not over a period ofat least two years, without long, symptom-free periods. Symptom-free periods last nolonger than 2 months. Adults with thedisorder complain of feeling sad ordepressed, while children may feel irritable.The required minimum duration of symptomsfor diagnosis in children is 1 year. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 33333333 How Common Are Mood Disorders?How Common Are Mood Disorders?How Common Are Mood Disorders?How Common Are Mood Disorders? As

a group, mood disorders are one of themost common mental illnesses in the generalpopulation. Canadian studies looking atlifetime incidence of major depression foundthat 7.9% to 8.6% of adults over 18 years ofage and living in the community met thecriteria for a diagnosis of major depression atsome time in their lives. Other studies havereported that between 3% and 6% of adultswill experience dysthymia during theirlifetime, and that between 0.6% and 1% ofadults will have a manic episode during theirlifetime.During any 12-month period, between 4%and 5% of the population will experiencemajor depression. According to the 1994/95National Population Health Survey (NPHS), 6%of the Canadian population aged 12 years andover had symptoms consistent withdepression at the time of the survey. Symptoms Mania Feeling worthless, helpless or hopelessLoss of interest or pleasure (includinghobbies or sexual desire)Change in appetiteSleep disturbancesDecreased energy or fatigue (withoutsignificant physical exertion)Sense of worthlessness or guiltPoor concentration or difficulty makingdecisionsExcessively high or elated moodUnreasonable optimism or poorjudgementDecreased sleepExtremely short attention spanRapid shifts to rage or sadnessIrritability A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 34343434 Impact of Mood DisordersImpact of Mood DisordersImpact of Mood DisordersImpact of Mood Disorders Who Is Affected by MoodWho Is Affected by MoodWho Is Affected by MoodWho Is Affected by MoodDisorders?Disorders?Disorders?Disorders?Mood disorders affect individuals of all ages,but usually appear in adolescence or youngadulthood. However, late diagnosis iscommon: the average age of diagnosis ofmajor depressive disorder is in the earlytwenties to early thirties.1Studies have consistently documented higherrates of depression among women thanamong men: the fema

le-to-male ratioaverages 2:1. Women are 2 to 3 times morelikely than men to develop dysthymia.Sex differences in the symptoms associatedwith depression may contribute to thedifferences in the prevalence of depressionbetween men and women. For example,men are more likely to be irritable, angry anddiscouraged when depressed, whereaswomen express the more "classical" symptomsof feelings of worthlessness and helplessness,and persistent sad moods. As a result,depression may not be as easily recognized ina man. In addition, women are more likelythan men to seek help from healthprofessionals. Biological or social risk orprotective factors may also differ betweenmen and women.For bipolar disorder, it is generally acceptedthat the ratio between men and women isapproximately equal.Ideally, data from a population survey wouldprovide information on the age/sexdistribution of individuals with mooddisorders. Statistics Canada’s CanadianCommunity Health Survey (CCHS) will providethis for 2002.Although most individuals with mooddisorders are treated in the community,hospitalization is sometimes necessary. At thepresent time, hospitalization data provide thebest available, though limited, description ofindividuals with mood disorders. The resultsmust be viewed with caution, however, sincethis is only a subset of those with mooddisorders: most individuals with mooddisorders are treated in the community ratherthan in hospitals, and many do not receivetreatment at all. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 35353535 In 1999, more womenthan men werehospitalized for majordepressive disorder inevery age groupexcept 90+ years(Figure 2-1). Youngwomen aged 15-19years had much higherrates of hospitalizationthan the immediatelyadjacent age groups.Women between theages of 40 and 44between the ages of85 and 89 years hadthe highest rates ofhospitalization

for their sex. Figure 2-1Hospitalizations for major depressive disorder* in generalhospitals per 100,000 by age group, Canada, 1999/2000 1001201401601802001-45-910-Age Group (Years)Hospitalizations per 100,000 Females Males* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information In 1999, in all exceptthe 5-9 year agegroup, women werehospitalized forbipolar disorder atsignificantly higherrates than men(Figure 2-2). Thiscontrasts with thegenerally acceptedequal ratio ofprevalence of thedisorder among menand women. Furtherresearch is neededto explain thisdistribution. Womenfrequentlyhospitalized forbipolar disorderbetween the ages of40 and 44 years. Figure 2-2Hospitalizations for bipolar disorder* in generalhospitals per 100,000 by age group, Canada, 1999/2000 1-45-910-Age Group (Years)Hospitalizations per 100,000 Females Males* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 36363636 Because of their high prevalence, economiccost, risk of suicide and loss of quality of life,mood disorders present a serious publichealth concern in Canada. Depression andmania cause significant distress andimpairment in social, occupational,educational or other important areas offunctioning. According to the World HealthOrganization (WHO), major depression is thefourth leading cause of disability adjusted lifeyears (DALYs) in the world. Major depressionis the leading cause of years of life lived withdisability (YLD) and bipolar is the sixth leadingcause.Major depressive disorderMajor depressive disorderMajor depressive disorderMajor depre

ssive disorder is a recurrent illnesswith frequent episode relapses andrecurrences. The more severe and long-lasting the symptoms in the initial episode,due in some cases to a delay in receivingeffective treatment, the less likely is a fullrecovery.Unipolar major depressive disorder isidentified as the fourth-ranked cause ofdisability and premature death worldwide.Depression also has a major impact on themental health of family members andcaregivers, often with an increased presenceof depression and anxiety symptoms.DysthymiaDysthymiaDysthymiaDysthymia, as a result of its protractednature, can be very debilitating. In spite of ahigh recovery rate, the risk of relapse issignificant. Individuals with this disorder arealso at high risk of experiencing an episode ofmajor depression.Individuals with one episode of bipolarbipolarbipolarbipolardisorder disorder disorder disorder tend to experience future episodes.Recovery rates vary among individuals. Thosewith purely manic episodes fare better thanthose with both mania and depression, whotend to take longer to recover and have morechronic course of illness.The mortality rate among individuals withbipolar disorder is 2 to 3 times greater thanthat of the general population, and includeshigher rates of suicide.Child or spousal abuse or other violentbehaviours may occur during severe manicepisodes. Furthermore, individuals withbipolar disorder often show loss of insight,resulting in resistance to treatment, financialdifficulties, illegal activities and substanceabuse. Other associated problems includeoccupational or educational failure, financialdifficulties, substance abuse, illegal activitiesand divorce. Individuals with bipolar disordermay often have difficulty maintaining steadysocial and economic disadvantages.Mood disorders frequently accompany othermental illnesses, such as anxiety disorders,personality disorders, and substance abuseand dependencies. The presence of anothermental illness inc

reases the severity of theillness and results in a poorer prognosis.Individuals with mood disorders are at highrisk of suicide. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 37373737 Stigma Associated with Mood DisordersStigma Associated with Mood DisordersStigma Associated with Mood DisordersStigma Associated with Mood Disorders The stigma against individuals with mooddisorders has a major influence indetermining whether an individual seekstreatment, takes prescribed medication orinfluences the successful re-integration of theindividual into the family and community.Employers may be concerned that theindividual with a mood disorder will be unableto function at the level of other employees.When the illness goes untreated, this may betrue. However, with treatment to reduce ormanage symptoms, performance usuallyimproves. Reducing the stigmatization ofmental illness in the workplace will be helpedby increased knowledge and an employer'swillingness and ability to respondappropriately to an employee's needs.Enforcement of human rights legislation canreinforce voluntary efforts. Economic ImpactEconomic ImpactEconomic ImpactEconomic ImpactBecause of their high prevalence, mooddisorders have a major effect on the Canadianeconomy. This effect is dual in nature - first,with the associated loss of productivity in theworkplace due to absenteeism anddiminished effectiveness; and second, withthe high health care costs attributable toprimary care visits, hospitalizations andmedication.At the individual and family level, the loss ofincome and cost of medication create a strainon the family financial resources. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 38383838 Causes of Mood DisordersCauses of Mood DisordersCauses of Mood DisordersCauses of Moo

d Disorders Mood disorders have no single cause, butseveral factors, such as a biochemicalimbalance in the brain, psychological factorsand socio-economic factors, tend to makesome individuals prone to such disorders.9,12Studies have established that individuals withdepression and bipolar disorder often find ahistory of these disorders in immediate family6,13 Evidence suggests that manydifferent genes may act together and incombination with other factors to cause amood disorder. Although some studies havesuggested a few interesting genes orgenomic regions, the exact genetic factorsthat are involved in mood disorders remainPrevious Episode of DepressionPrevious Episode of DepressionPrevious Episode of DepressionPrevious Episode of DepressionOne episode of major depression is a strongpredictor of future episodes. More than 50%of individuals who have an episode of majorStressStressStressStressStress has traditionally been viewed as a majorrisk factor for depression. Recent researchefforts have indicated, however, that stressmay predispose individuals only for an initialepisode and not for recurring episodes.Responses to stress differ greatly amongindividuals: some are more susceptible thanothers to depression following life events,when they are in difficult relationships, orbecause of socio-economic factors such asinadequate income or housing, prejudice andworkplace stress.A strong association exists between variouschronic medical conditions and an elevatedprevalence of major depression.15,16 Severalconditions, such as stroke and heart disease,Parkinson’s disease, epilepsy, arthritis, cancer,AIDS and chronic obstructive pulmonarydisease (COPD), may contribute to depression.Several factors associated with physical illnessmay contribute to the onset or worsening ofdepression. These include the psychologicalimpact of disability, decline in quality of life,and the loss of valued social roles andrelationships. Medication side effects mayalso be a c

ontributing factor. Finally, it ispossible that the physical disease itself maycontribute directly to the onset of depressionby affecting physiological mechanisms suchas neurotransmitters, hormones and theimmune system; for similar reasons, episodesof mania may occur following physical illnessor use of medications.Indirect factors also influence the relationshipbetween physical conditions and depression.Such factors include disability and quality oflife of individuals with chronic disease and thetendency for some medications used fortreating physical illnesses to causedepression.Treating chronic physical illnesseffectively requires vigilance for the earlydetection and treatment of depression. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 39393939 Treatment of Mood DisordersTreatment of Mood DisordersTreatment of Mood DisordersTreatment of Mood Disorders Mood disorders are treatable. Many peoplewith a mood disorder fail to seek treatment,however, and suffer needlessly. Of those whoseek treatment, many remain undiagnosed orreceive either incorrect medication orinadequate doses. The delay in seeking andreceiving a diagnosis and treatment may bedue to a number of factors, such as stigma,lack of knowledge, a lack of human resourcesand availability or accessibility of services.Current initiatives to relieve the burden ofmood disorders include not only improvedrecognition and use of effective treatments,but also education for individuals and familiesand for the community. Primary care settingsplay a critical role in both recognizing andtreating these illnesses. Innovative practicemodels have shown that effectiveinterventions can decrease symptoms andincrease work days. Effective earlytreatment of mood disorders can improveoutcomes and decrease the risk of suicide.Antidepressant medications and education incombination with various forms ofpsy

chotherapy, such as cognitive-behaviouraltherapy, have demonstrated theireffectiveness in treating depression. A recentpublication from the Canadian PsychiatricAssociation outlines the clinical guidelines forthe treatment of depressive disorders.Educating family and primary care providers isessential not only to ensure the recognitionof early warning signs of depression, maniaand suicide and to implement appropriatetreatment, but also to ensure adherence totreatment in order to minimize futurerelapses. Sound support networks are crucialduring both the acute phase of the illness andthe post-illness adjustment to daily life.Major depression results in poor productivityand sick leave from the workplace. Theworkplace, therefore, is an important area foraddressing mental health issues. Supportingthe development of healthy workenvironments, educating employers andemployees in the area of mental healthissues, and providing supportive reintegrationinto the work environment for thoseexperiencing mental illness would go a longway toward minimizing the effect of majordepression on the workplace.Individuals with mood disorders may requirehospitalization to adjust medication, tostabilize the disorder or to ensure protectionagainst self-destructive behaviour. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 40404040 In 1999, amongpeople under the ageof 50 years with majordepressive disorderwho were hospitalized,the disorder was themain contributor todetermining theirlength of stay (Figure2-3). Among peoplewith the disorder overthe age of 50 years,depression was morelikely to be anassociated conditioncontributing to thelength of stay. This isconsistent with theassociation betweenphysical illness and depression. Figure 2-3Hospitalizations for major depressive disorder ingeneral hospitals per 100,000 by contribution tolength of stay and age group, Canada,

1999/2000 1,0001,2501,50011-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-8990+Age Group (Years)Hospitalizations per 100,000 Depression as an associated condition Depression as the most responsible diagnosisfor len g th of sta y Source:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information Major Depressive DisorderMajor Depressive DisorderMajor Depressive DisorderMajor Depressive Disorder Overall, between1987 and 1999,hospitalization ratesfor major depressivedisorder decreased by33% among both menand women (Figure 2- Figure 2-4Rates of hospitalization due to major depressive disorder*in general hospitals by sex, Canada, 1987/88-1999/2000(age standardized to 1991 Canadian population) 1001502002503001987198819891990199119921993199419951996199719981999YearRate per 100,000 Women Men Women & Men* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 41414141 Among women 25over, rates ofhospitalization dueto major depressivedisorder decreasedbetween 1987 to1997 whileremaining fairlystable amongwomen under the(Figure 2-5). Womenover the age of 65years showed thegreatest rate ofreduction. Among men,hospitalization ratesfor major depressivedisorder between1987 and 1999showed the greatestdecrease in the 65+age group (Figure 2-6). During this sameamong young menaged between 15 and24 years increased toa level similar to thatof all older agegroups. Among both men and women aged 15 years and over, the wide variations in hospitalization ratesthat were evident in 1987 had disappeared by 1999, mostly as a result of moderate decreases in the25-64 year

age groups and the large decrease among those aged 65 years and over. Figure 2-5Rates of hospitalization due to major depressive disorder*in general hospitals among women, Canada, 1987/88-1999/2000 (age standardized to 1991 Canadian population) 1001502002503001987198819891990199119921993199419951996199719981999YearRate per 100,000 years 15-24 years 25-44 years 45-64 years 65+ years* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information Figure 2-6Rates of hospitalization due to major depressive disorder*in general hospitals among men, Canada, 1987/88-1999/2000(age standardized to 1991 Canadian population) 1001502002503001987198819891990199119921993199419951996199719981999YearRate per 100,000 5 years 15-24 years 25-44 years 45-64 years 65+ years* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 42424242 Bipolar DisorderBipolar DisorderBipolar DisorderBipolar Disorder In 1999, bipolardisorder was themain contributor tothe length ofhospital stay amongpeople with thedisorder under the(Figure 2-8).Among olderpeople, bipolardisorder was morelikely to be anassociated conditioncontributing tolength of stay. Figure 2-7Average length of stay in general hospitals due to majordepressive disorder*, Canada, 1987/88-1999/2000 YearAverage Number of Days Days19.018.518.819.217.717.216.616.316.015.515.015.415.21987198819891990199119921993199419951996199719981999* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health I

nformation Figure 2-8Hospitalizations for bipolar disorder in generalhospitals per 100,000 by contribution to length ofstay and age group, Canada, 1999/2000 1001201-45-910-Age Group (Years)Hospitalizations per 100,000 Bipolar disorder as an associated condition Bipolar disorder as the most responsible diagnosisfor length of staySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information Between 1987 and1999, the averagelength of stay inhospital in Canadadue to majordepressive disorderdecreased by 20%(Figure 2-7). A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 43434343 hospitalization ratesfor bipolar disordersremained fairlystable among bothmen and womenbetween 1987 and1999 (Figure 2-9). Between 1987 and1999, hospitalizationrates for bipolardisorder amongwomen under themore than doubled(Figure 2-10).During the sameperiod, rates in theolder age groups Figure 2-9Rates of hospitalization due to bipolar disorder* ingeneral hospitals by sex, Canada, 1987/88-1999/2000(age standardized to 1991 Canadian population) 1987198819891990199119921993199419951996199719981999YearRate per 100,000 Women Men Women & Men* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information Figure 2-10Rates of hospitalization due to bipolar disorder* in generalhospitals among women, Canada, 1987/88-1999/2000 (agestandardized to 1991 Canadian population) 1987198819891990199119921993199419951996199719981999YearRate per 100,000 5 years 15-24 years 25-44 years 45-64 years 65+ years* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Heal

th Information A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 44444444 Between 1987 and1999, hospitalizationrates for bipolardisorder among menaged 15-24 increasedby 61%. Rates amongmen aged 25-44 yearsremained stable(Figure 2-11). Ratesdecreased by 14%among men aged 45-64 years, and by 23%among men aged 65years and over. Between 1987 and1999, the averagelength of stay ingeneral hospital dueto bipolar disorderdecreased by 27%(Figure 2-12). Figure 2-12Average length of stay in general hospitals due to bipolardisorder*, Canada, 1987/88-1999/2000 YearAverage Number of Days Days28.028.728.128.428.728.826.626.424.422.322.820.620.41987198819891990199119921993199419951996199719981999* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information Figure 2-11Rates of hospitalization due to bipolar disorder* in generalhospitals among men, Canada, 1987/88-1999/2000 (agestandardized to 1991 Canadian population) 1987198819891990199119921993199419951996199719981999YearRate per 100,000 5 years 15-24 years 25-44 years 45-64 years 65+ years* Using most responsible diagnosis onlySource:Centre for Chronic Disease Prevention and Control, Health Canada using datafrom Hospital Morbidity File, Canadian Institute for Health Information A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 45454545 Discussion of Hospitalization DataDiscussion of Hospitalization DataDiscussion of Hospitalization DataDiscussion of Hospitalization Data The higher hospitalization rates for depressionamong women than men support the clinicalexperience of higher rates of depressionamong women. Based on clinical research,rates of major depression among women are2

times higher than among men. On theother hand, the hospitalization rates amongwomen are only about 1.5 times higher thanamong men, suggesting that men may behospitalized for major depression at higherrates than women. This requires furtherresearch for confirmation and explanation.Rates of bipolar disorder have been estimatedto be equal among men and women.However, hospitalization rates for womenwith the disorder are much higher than men.Further research is required to assess if, infact, rates of the disease are higher amongwomen, or if women with the disorder arehospitalized at a higher rate than men, whythis occurs.Hospitalization rates for both depression andbipolar disorder among women peak betweenthe ages of 35-49 years. Research is requiredto assess the factors in women’s lives thatcontribute to this phenomenon.Since 1987, hospitalization rates fordepression among older Canadians havedecreased much more than rates amongyounger age groups. Further research isrequired to determine the reasons for thistrend. Has it been the result of better clinicaltreatment, and have outcomes for this agegroup also improved over this time period?Hospitalization rates for bipolar disorderamong young women and men haveincreased since the early 1990s. Does thissignify an increase in bipolar disorder in theseage groups, earlier recognition of thedisorder, or a change in treatment? A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 46464646 Future Surveillance NeedsFuture Surveillance NeedsFuture Surveillance NeedsFuture Surveillance Needs Mood disorders, including major depression,bipolar disorder and dysthymia are commonand contribute to major personal and familydistress. They also have a significant impacton workplace and health care costs.Existing data provide a very limited profile ofmood disorders in Canada. The availablehospitalization data needs t

o becomplemented with additional data to fullymonitor these disorders in Canada. Prioritydata needs include:Incidence and prevalence ofmajor depression, bipolardisorder and dysthymia by age,sex and other key variables (forexample, socio-economicstatus, education, andethnicity).Prevalence of depression in peoplewith chronic physical illness.Impact of mood disorders on thequality of life of the individual andfamily.Access to and use of primary andspecialist health care services.Treatment outcomes.Rates of suicide among individualswith mood disorders.Access to and use of public andprivate mental health services.Access and use of mental healthservices in other systems, such asschools, criminal justice programs andfacilities, and employee assistanceprograms.Impact of mood disorders on theworkplace and the economy.Stigma associated with mooddisorders.Exposure to known or suspected riskand protective factors. A Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in CanadaA Report on Mental Illnesses in Canada 47474747 ReferencesReferencesReferencesReferences Canadian Psychiatric Association. Canadian clinical practice guidelines for the treatment ofdepressive disorders. Can J Psychiatry 2001;46:Supp1.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4thedition. Washington, DC: American Psychiatric Association, 1994.Bland RC. Epidemiology of affective disorders: a review. Can J Psychiatry 1997;42:367-377.Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S et al. Lifetime and 12-monthprevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry 1994;51:8-Stephens T, Joubert N. Mental health of the Canadian population: a comprehensive analysis.Chronic Diseases in Canada 1999:20:3 (www.hc-sc.ca/hpb/lcdc/publicat/cdic203/cd203c_e.html).Fogarty F, Russell JM, Newman SC, Bland RC. Mania. Acta Psychiatr Scand 1994;Suppl 376

:16-23.Judd LL, Paulus MP, Wells KB, Rapaport MH. Socioeconomic burden of subsyndromal depressivesymptoms and major depression in a sample of the general population. Am J Psychiatry1996;153:1411-7.Murray CJL, Lopez AD, eds. Summary: The Global Burden of Disease: A Comprehensive Assessmentof Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020.Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World HealthOrganization and the World Bank, Harvard University Press, 1996. http://www.who.int/msa/mnh/ems/dalys/into.htmHorwath E, Weissman MM. Epidemiology of depression and anxiety disorders. In: Tsuang MT,Tohen M, Zahner GEP, eds. Textbook in Psychiatric Epidemiology. New York: Wiley-Liss,1995:317-44.Klein DN, Schwartz JE, Rose S, Leader JB. Five-year course and outcome of dysthymic disorder: aprospective, naturalistic follow-up study. Am J Psychiatry 2000;157:931-9.Mintz J, Mintz LI, Arruda MJ, Hwang, SS. Treatments of depression and the functional capacity towork. Arch Gen Psychiatry 1992;49:761-8. Griffiths J, Ravindran AV, Merali, Anisman H. Dysthymia: a review of pharmacological andbehavioral factors. Mol Psychiatry 2000;5:242-61. Spaner D, Bland RC, Newman SC. Major depressive disorder. Acta Psychiatr Scand 1994;Suppl376:7-15. De Marco RR. The epidemiology of major depression: implications of occurrence, recurrence, andstress in a Canadian community sample. Can J Psychiatry 2000;45:67-74. Patten SB. Long-term medical conditions and major depression in the Canadian population. Can JPsychiatry 1999;44:151-7. Beaudet MP. Depression. Health Reports 1996;7(4):11-24.Bland RC. Psychiatry and the burden of mental illness. Can J Psychiatry 1998;43:801-10.Schoenbaum M, Untzer J, Sherbourne C, Duan N, Rubenstein LV, Mirand J et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomizedcontrolled trial. JAMA 2001;286