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Mental Illness in Canada is Vastly Underestimated: Does Anyone Care?

You’ve probably seen the ads – those Bell Canada commercials with Clara Hughes promoting mental health awareness with the "Let's Talk Day." It's a great idea that not only raised awareness of mental illness in Canada, but also saw Bell contribute 5 cents from every text and long distance call to support mental health programs. Personally, I loved Clara Hughes' involvement in the project - an act that is both courageous and generous.

Unfortunately, the statistic associated with this campaign – that 1 in 5 Canadians will experience mental illness in their lifetime – is seriously flawed.

Initially, when those commercials began airing, I thought little about the statistic itself. With time, that number eventually leapt into my consciousness with a red flag attached to it – ‘Wait a second, that can’t be right.’

Although a full-fledged clinical psychologist in private practice these days, I used to be more involved in research, publishing and teaching. As such, I’ve had the opportunity to become familiar with prevalence rates and epidemiology in general as it pertains to mental illness. In particular, I knew that large, national studies in the United States have revealed that approximately 1 in 2 people will develop a diagnosable mental illness in their lifetime.

That’s right – 1 in 2. Could it be that Americans’ mental health is that much worse than Canadians’?

Not likely.

So, I decided to follow-up on this “1 in 5” figure that was now not only appearing in Bell commercials, but was also making its way onto numerous newspaper articles on mental illness.

What I quickly learned was that Bell Canada and Clara Hughes were citing well-respected health agencies and organizations. A quick search revealed that the Canadian Institute of Health Research (CIHR), the Public Health Agency of Canada and the Canadian Mental Health Association (CMHA) all assert that statistic.

Therefore, I had to dig a little deeper. Where were these organizations getting these numbers?

On the CMHA website (the Fast Facts section), they cite the “1 in 5” (or 20%) figure and offer as a reference The Report on Mental Illness in Canada. This report is from 2002 (available on the internet) and does not state that 1 in 5 Canadians will be affected by mental illness in their lifetime. The actual statistic given is 1-year prevalence, not lifetime prevalence.

So, CMHA made a mistake. They misquoted a study – no problem. I contacted CMHA, Bell and Health Canada in February to inform them of the error.

A CMHA representative contacted me and expressed concern, but otherwise the organization has done nothing to rectify the error (this is somewhat embarrassing because anyone can download and read The Report on Mental Illness and see that CMHA clearly misread or misunderstood the report – but they are for some reason not changing the mistake).

Bell Canada acknowledged receipt of my email and said they would look into the matter, and I have not heard from them since.

The Public Health Agency of Canada (PHAC) has been the most responsive. A representative was kind enough to send a fairly detailed response. This person wrote that their “1 in 5” statistic comes from Statistics Canada’s 2002 Canadian Community Health Survey on Mental Health and Wellbeing (CCHS 1.2).

This national survey estimated the 12 month and lifetime prevalence of the following disorders:

- Major Depression
- Bipolar Disorder (only Bipolar I - not Bipolar II)
- Panic Disorder
- Agoraphobia
- Social Phobia
- Substance Dependence

Results from the study found the 1 in 10 Canadians had at least one of these disorders over a 1-year period, and 1 in 5 experienced one of these disorders in their lifetime.

This is where PHAC was getting their “1 in 5” statistic. However, anyone familiar with mental health and psychopathology should immediately recognize the problem with this estimate based on the list of disorders above. These represent only a portion of the mental health disorders that exist. Indeed, here are some of the major disorders missing from the list (I include in brackets the lifetime prevalence of each disorder based on U.S. estimates):

- Specific Phobia (12.5%)
- Generalized Anxiety Disorder (5.7%)
- PTSD (6.8%)
- OCD (1.6%)
- Dysthymia (2.5%)
- ADHD (8.1%)
- Oppositional Defiant Disorder (8.5%)
- Conduct Disorder (9.5%)
- Intermittent Explosive Disorder (5.2%)
- Schizophrenia (1%)
- Personality Disorders (14.8%)

As you can see, there were a large number of disorders not included in the Canadian survey, which explains the discrepancy between the Canadian and US prevalence estimates. The PHAC agent who emailed me recognized the cause of the discrepancy and acknowledged that "it is an incomplete list of conditions."

Furthermore, the PHAC representative wrote that because of the limitations in the Canadian survey "we use the wording that 'more than one in five Canadians will experience a mental illness in their lifetime.'(italics added)"

There are two problems with this approach. First, saying "more than 1 in 5" gives absolutely no clear way of knowing just how many more Canadians are affected by mental illness. It could 20.1% or 50%. This approach obscures just how serious and widespread mental illness is in Canada.

The second problem with this approach is that there is a risk that the "more than 1 in 5" phrase will morph into just "1 in 5" by health organizations and government officials. Indeed, this has already happened in several instances.

Although the report acknowledges that the true estimate of prevalence is more than 20%, it quickly shifts to the simpler 20% figure. In fact, seven paragraphs into the first page of the PHAC report on mental illness in Canada (entitled “The Human Face of Mental Health and Mental Illness in Canada” it states that "[m]ental illness affects approximately 20% of Canadians during their lifetime."

Health Canada also notes the 20% figure several times on its website (having dropped the "more than" specifier). Also, as previously mentioned, both CMHA and Bell Canada (the "Let's Talk" initiative) both cite the 20% figure.

Unfair and Biased

How unfair is this approach to estimating? Imagine if the true prevalence of cancer in Canada was somewhere around 50%, but the government of Canada estimated the prevalence to be approximately 20% because they only included in their estimate only a portion of all possible cancers. The medical community would be in an uproar because there are important implications drawn from such data.

Health awareness in the community and funding for research and treatment are all affected by the estimated severity of a problem. And if you vastly underestimated cancer rates, the realistic danger is that cancer research and treatment would not receive the necessary attention and money it deserves, and the community at large would suffer. Thus, it is important to always have an accurate understanding of the severity of a particular health problem.

Unfortunately, the lack of a representative list of mental health disorders was not the only problem with the Canadian survey. The survey excluded the following groups of people:- those living in the three Canadian territories and resident of remote areas,

- those living on Indian Reserves and Crown lands,
- residents of institutions, and
- full-time members of the Canadian Armed Forces

This list of excluded groups only highlights just how low and biased the 20% figure appears to be. Native Canadians are known to suffer from problems with substance abuse, depression and high suicide rates, and the Canadian Armed Forces tend to have higher rates of PTSD and depression than the general population.

I responded to PHAC with these concerns, and they again took the time to acknowledge my concerns.

They wrote:

You raise a valid point and concern around the statement that (more than) 1 in 5 or 20% of Canadians will experience a mental illness in their lifetime. The Public Health Agency of Canada will be precise on the seven mental illnesses (i.e., major depression, bipolar disorder, panic disorder, agoraphobia, social phobia, alcohol dependence or illicit drug dependence) on which this estimate is based to ensure accurate interpretation of this statistic. We will also continue to explore options for adding other mental illnesses to our surveillance system. Our website content is currently under review and we will use consistent language in communicating this measure.

This was a much appreciated response. However, many serious problems remain - most notably, the lack of action and concern regarding this problem. In addition to the aforementioned health agencies and Bell Canada, I also contacted the health editor of the Globe and Mail and wrote a brief editorial for the Montreal Gazette – with no response whatsoever.

It is often said that mental health is the orphan of the Canadian health care system. Sadly, the lack of awareness in just how prevalent mental illness is in Canada only serves to further validate this conclusion.

What is the Actual Prevalence of Mental Illness in Canada?

Due to the aforementioned limitations of existing epidemiological studies in Canada, there exists no robust statistic informing Canadians of the true prevalence.

However, we can look to U.S. estimates of prevalence to get a sense of what the numbers in Canada would look like. Arguably the best research study on prevalence in the U.S. comes from the National Comorbidity Survey – Replication. In this study, 12 month prevalence of mental illness was estimated at approximately 26%, which is greater than the Canadian figure that is incorrectly used as lifetime prevalence.

The lifetime prevalence of mental illness in the U.S. is 46%, which gives a rough Canadian estimate Thus, it is not the case that 1 in 5 Canadians will be affected by mental illness - the real number is likely much higher - closer to at least 2 in 5 Canadians.