Thank you for inviting the coalition to take part in this consultation on mental health in Canada. I'm very pleased and honoured to represent the coalition.
As a brief introduction, the CCSMH, as we are known, is a national coalition sponsored by the Canadian Academy of Geriatric Psychiatry, with approximately 2,000 members across this country representing older adults, caregivers, and family members, as well as health professionals and decision-makers across multiple sectors and levels of government. Our mission is to promote mental health of seniors by connecting people, ideas, and resources. Our primary strategic goal is to ensure that seniors' mental health is recognized as a key Canadian health and wellness issue.
As you know, Canada is in the midst of a significant and permanent demographic shift to an aging population that will have profound impacts on our physical, mental, social, and economic well-being. From a public health perspective, we see older adults who are living well into retirement and more engaged in their health. On the flip side, more Canadians are living longer with chronic conditions, frailty, cognitive impairment, and mental illness.
This demographic shift will continue to have a significant impact on Canada's health care system, with mental health care systems particularly vulnerable. While there is a growing need for an appropriate range of physical and mental health services for seniors at home, in the community, and in long-term care settings, our current health care system is limited in its capacity to meet the needs of our aging population.
Mental health concerns in later life are a growing concern given the impact on older adults and their families, as well as society as a whole. We assert that mental illness in later life is not a normal part of aging, yet we know that the prevalence rate of mental illness increases as we age. The Mental Health Commission report, “Making the Case for Investing in Mental Health in Canada”, noted that 65% of men and 70% of women who reach 90 years of age or more have experienced or will experience a mental illness in their lifetime. Approximately 1.6 million older adults are living with mental illness today. By 2041, the number will jump to over 2.8 million of Canadians over the age of 60.
Based on these costly tolls on seniors' families and governments, it's the combination of seniors' physical and mental health that needs to be addressed. Interventions targeted and tailored to identify, connect, and support older adults and their families who are experiencing physical and mental health challenges can play a role in preventing depression, reducing anxiety, reducing substance use and harm, preventing suicide, and reducing stigma and the negative consequences associated with these mental health challenges.
We will be presenting a written brief, but for the purposes of this presentation, I'll be focusing on addictions and stigma in later life and will defer to Dr. Marnin Heisel in regard to suicide.
For older adults, alcohol and psychotropic prescription medication for anxiety, sleep, and pain are more of a concern. Findings from the “Canadian Addiction Survey” of 2004 indicated that 16% of adults aged 65 and older report heavy drinking: more than 14 drinks per week for men, and nine for women. Almost half of these heavy drinkers report consuming more than five drinks on one occasion at least once a month. Alcohol overuse in older adults is associated with poor mental health functioning and increased suicide risk. Other studies have found that seniors using alcohol and taking psychotropic drugs are at increased risk for hip fractures and injuries due to falls and motor vehicle collisions.
In preparing for this presentation, I consulted with board members of the Canadian Academy of Geriatric Psychiatry about what they see in their day-to-day practice. One board member and doctor noted the following:
Addictions, treatment, and housing are particularly poorly resourced for the elderly. Those with persistent addictions often lead to cognitive sequelae secondary to traumatic brain injury, nutritional deficiencies, and multiple medical illnesses. This triply damned group—old, addicted, and demented—is not a very sexy group to provide services for, yet merits a more focused intervention.
He noted that in his community this group of older adults often ended up homeless or in nursing homes without any service providers seeing the complexity of their situation.
Therefore, older adults often present with multiple medical conditions, exacerbated by alcohol, that may not fit the expected profile of the chronic drinker. Drinking can increase later in life as well, for a variety of reasons—loneliness, grief, or a way of self-medicating emotional pain. While substance use is known to decrease with aging, men report much higher rates of alcohol than women in all age categories. However, given the physical changes associated with aging, older adults may be more vulnerable to the negative effects of even low-use drinking on cognitive, emotional, and physical health. The economic and social costs of substance abuse in Canada is estimated at $39.8 billion. It's not clear what the costs are associated with older adults.
Despite this research, access to current data on the prevalence of alcohol and other drug use in later life is pretty slim. From the 2013 results of the Canadian tobacco, alcohol, and drugs survey, data is only provided for under 25 or over 25, missing an opportunity to inform decisions about alcohol use and misuse in later life. That said, we are encouraged by the Canadian longitudinal study on aging dataset that will likely provide us with some of this information moving forward.
As a growing demographic, older adults uniquely experience the phenomenon of a double-whammy stigma due to the combination of mental health and aging. We know that ageism and stigma can create barriers to accessing care, to proper detection and assessment, and to good public discourse. This phenomenon was recognized in “Out of the Shadows at Last”. The final report emphasized that symptoms of mental illness in later life are often attributed to growing older. In fact, recognition of ageism as a form of stigma was a pervasive theme throughout the standing committee report on aging.
I would also say that there is another level of stigma: sexism. Men are often diagnosed with alcohol and drug dependency and are at a higher risk of suicide. Depression and anxiety are also common comorbid diagnoses, yet, as noted by the Chief Public Health Officer's report, “Influencing Health—The Importance of Sex and Gender”, mental illness among men is often underdiagnosed and under-reported. This is thought to be associated with a multitude of hypothesis factors—social, cultural, and biological—as well as stigma associated with a perceived weakness in men with mental illness.
This intersection of age, mental illness, and gender creates an opportunity to explore how we can improve mental health for all older Canadians, especially older men, and those who support them. Delayed and untreated mental illness in older men can impact the health system. In a recent Australian study of older men with depressive symptoms, they were at a higher risk of hospital admissions unrelated to their mental health condition, and were more likely to have long hospital stays and worse outcomes, than non-depressed patients. In Canada, hospital stays for mental illness are much longer for this age group than any other. The average stay is 29 days for older adults over the age of 60, compared with 16 days for adults 45 to 60 years of age.
How does this stigma play out in real life? To give you a brief example, we would argue that in the strong focus on youth suicide, we talk about the lost potential of a young person who dies by suicide, but our response to older adult suicide is deafening in its silence. We don't talk about the lost legacy of older adults.
You asked for a focus on coordinating efforts of stakeholders at the national level. I'll focus on best practices. With the funding from the Public Health Agency of Canada, the coalition led the development of the first national interdisciplinary guidelines on depression, delirium, suicide risk and prevention, and mental health in long-term care. These guidelines were authored by a team of researchers and health providers from across disciplines, who reviewed international and national literature and synthesized the evidence.
Since the release in 2006, thousands of copies have been disseminated both electronically and in print across Canada and in over 60 countries. To support the knowledge translation and implementation of the guideline recommendations, again with the support of the Public Health Agency of Canada, we were able to create a variety of companion tools, including clinical pocket cards, resource guides for seniors and their families, and educational modules and tool kits for health care providers. We currently have updated the delirium and mental health and long-term care guidelines and are working on the update of the suicide and depression guideline.
We also co-authored with the Mental Health Commission of Canada the 2011 guidelines for comprehensive mental health services for older adults in Canada. The guidelines recommended a model—