En Dietitians Toolkit

The role of dietitians in collaborative primary health care mental health programs

DDIIEETTIITTIIAANNSS


Foreword

TheCanadianCollaborativeMentalHealthInitiative(CCMHI)commendsDietitiansofCanadaforcreatingTheRoleofDietitiansinCollaborativePrimaryHealthCareMentalHealthPrograms.Thistoolkitisintendedtohelpdietitiansintheircareofclientswhohavementalillness,and,assuch,providesanexcellentintroductiontoboththecomplexrelationshipbetweennutritionandmentalhealthissuesandtotherolethatdietitiansplayinhelpingclientsmanagethatrelationship.Accordingly,thistoolkitisalsoasuperbresourceforothermembersofthecareteam,tohelpthemunderstandtheskillsandthevaluethatdietitiansbringtotheteam.

DietitiansofCanadahaveplayedakeyroleintheleadershipoftheCanadianCollaborativeMentalHealthInitiativeandareablyrepresentedontheinitiativesSteeringCommitteebyMarshaSharpandLindaDietrich.Throughouttheinitiative,MarshaandLindahavemadesurethattheinitiativepaysattentiontoboththebroaderdeterminantsofhealthandthebroaderimplicationsofthereconceptualizationofprimaryhealthcare.CCMHIisa2yearnationalprojectfundedbyHealthCanadasPrimaryHealthCareTransitionFund.ThegoalofCCMHIistoimprovethementalhealthandwellbeingofCanadiansbystrengtheningrelationshipsandimprovingcollaborationamonghealthcareproviders,consumers,familiesandcommunities.Thefocushasbeenonstrengtheningthedeliveryofmentalhealthservicesinthecontextofprimaryhealthcarethroughcollaborationandconsumercentredness.Wehavemetourgoalthroughfourmainareas: Strengthenedthecaseforcollaborativementalhealthcare Clarifiedthekeybarrierstocollaborativementalhealth

care Developedtoolsforgettingatthesebarriers Builtthefoundationforcontinuedstrengtheningof

collaborationtheCanadianCollaborativeMentalHealthCharter

TheDietitiansofCanadatoolkitisoneofthemanytoolkitsdevelopedthroughCCMHI.OtherCCMHIresourceswhich

Dietitians of Canada

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mightinterestdietitiansinterestedinmentalhealthissuesincludeanannotativebibliographywhichdescribesover300relevantjournalarticles,apaperdescribingtheexperimentalevidenceforbetterpracticesincollaborativementalhealthcareand,amongmanyotherresearchpapers,CollaborativeMentalHealthCareinPrimaryHealthCare:aReviewofCanadianInitiatives:VolumeII.Thisreviewdescribes89collaborativementalhealthinitiativesacrossCanada.Dietitiansornutritionistsplayanimportantrolein18%oftheinitiativesdescribedinthereviewandcanbefoundtobecontributingincollaborativeteamsinVancouver,NorthernSaskatchewan,St.Boniface,Niagara,SouthwesternOntario,Toronto,Hamilton,SouthwesternNewBrunswick,WhitehorseandYellowknife.ForaccesstoallofCCMHIstoolkits,researchpapersandotherresources,gotowww.ccmhi.ca.

OneoftheprinciplesenshrinedintheCanadianCollaborativeMentalHealthCharter,endorsedbyDietitiansofCanada,isAllCanadianshavetherighttohealthservicesthatpromoteahealthy,mind,bodyandspirit.DietitiansofCanadahasbeenfrontandcentre,keepingusmindfulofthisimportantunity.WelookforwardtodietitiansallacrossCanadaplayingakeyroleinmakingthisprincipleliveandbreathe.

Regards,

ScottDudgeonExecutiveDirectorCanadianCollaborativeMentalHealthInitiative(CCMHI)

Dr.NickKatesChair,CanadianCollaborativeMentalHealthInitiative(CCMHI)


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Executive summary

Thisdocumentisdesignedtoserveasamechanismtostimulateinterestanddiscussionabouttheincorporationofdietitianservicesintoprimaryhealthcarementalhealthprograms.ItstemsfromTheCanadianCollaborativeMentalHealthInitiative(CCMHI)thataddressestheimportantgoalofgreaterintegrationofspecializedservices,suchasnutritionandmentalhealthexpertise,inprimarycaresettings.TheCCMHIinvolvestwelvenationalorganizations,includingtheDietitiansofCanada,tohelpstrengthenthecapacityofprimaryhealthcareproviderstoworktogethertodeliverqualitymentalhealthservices.

Thispaperisacompilationoftheconsultationprocessthatexamineddietitianservicesinmentalhealth.ItbeganwiththereviewofdraftspecialpopulationandgeneraltoolkitsdevelopedbytheCCMHISteeringCommittee.Thisreviewwasconductedbyaworkinggroupcomprisedofnutritionprofessionalsinmentalhealthtoensurerepresentationofdietitiansroleincollaborativecare.Subsequently,thistoolkitoutliningtheimportantrolethattheregistereddietitianplaysincollaborativeprimaryhealthcarementalhealthprogramswasdeveloped.Processesusedintheevolvementofthisdocumentincludedareviewoftheliteratureprovidingevidenceofeffectivenessofnutritionservicesforindividualswithmentalhealthissues,aswellasdirectedinputfromworkinggroupmembers,independentreviewersindieteticsandhealthaswellasconsumersandtheircaregivers.

Individualswithmentalhealthissueshavebeenidentifiedasbeingatnutritionalriskduetoavarietyoffactors.Severalnutritionalconsequencesoccurasaresultofeatingdisorders,mooddisorders,schizophrenialikesyndromes,personalitydisorders,substanceusedisorders,dementia,attentiondeficithyperactivitydisorder,autismaswellasdevelopmentaldelaysanddisabilities.Specificconcernsincludesignificantweightfluctuations,potentialnutrientdeficiencies,feedingissuesandsignificantnutritionrelatedsideeffectsofpharmacologicaltreatments.Furthermore,issuessuchaspoverty,socialisolation,marginalization,comorbidmedical


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conditions,concurrentdisorders,andagingcompoundthenutritionrelatedproblemsthispopulationencounters.

Dietitiansareuniquelyqualifiedtoidentifythenutritionalneedsofindividualswithmentalhealthissuesandtoplanappropriateinterventionswithinprimarycarecontexts.Basedoneducationinthescienceandmanagementofnutrition,andpracticesbasedonevidencebaseddecisionmakingandnationalstandards,thedieteticsprofessionalcanassessclinical,biochemical,andanthropometricmeasures,dietaryconcerns,andfeedingskillsaswellasunderstandthevarieddeterminantsofhealthactingoninterventionplans.

Dietitiansworkinginmentalhealthcanbecatalystsforimprovedcareofmentalclientsandeffectivemembersofcollaborativementalhealthcareteams.However,toachievetheirfullpotential,severalissuesneedtobeconsidered,includingtheallocationoffinancialresourcestoincludedietitianservicesinprimaryhealthcarecontexts,andtheneedtoexpandthementalhealthcontentand/orfieldexperienceindieteticstraining.Inaddition,strategiestoenhanceaccessibilityofdietaryservicesthroughhomevisiting,nutritiontrainingofparaprofessionalsandpeerworkers,andincreaseduseoftelemedicineservicesareneeded.Finally,thereisaneedtoadvocateforofficialrecognitionofnutritionandmentalhealththroughnationalpolicy,incorporatenutritionissuesandinterventionstrategiesintoclinicalguidelinesforpsychiatriccare,anddirectresearchinthisarea.Byaddressingtheseconcerns,thehealthandqualityoflifeofindividualswithmentalhealthissuescanbeenhancedandhealthcareresourcescanbeusedmoreeffectivelyandefficiently.


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Summarization of the toolkit

Background

OneofthekeydeliverablesoftheCanadianCollaborativeMentalHealthInitiative(CCMHI)isthedevelopmentoftoolkitsthatprovidehandsonadvicefortheimplementationofcollaborativementalhealthcare.Thetoolkitsaredirectedtowardsconsumers,familiesandcaregivers,educatorsandcliniciansandareintendedtocapturethevisionsandgoalsofprimaryhealthcare.

Inordertofurthertheagendaofcollaborativementalhealthcare,theCCMHIinconjunctionwiththeDietitiansofCanadacommissionedthisdocumenttoexaminetheroleofthedietitianinprimaryhealthcarementalhealthprograms.Nutritionissuesareprevalentinthesecontextsandarecommonlytreatedbybothprimaryhealthcareandspecialistsystemsthatwouldbenefitfromgreaterintegration.Thisspeakstoaneedforinnovativeprogramsthatchangethedailyrelationshipbetweenmentalhealth,nutritionandprimarycareservices.Suchprogramscaneliminatesomeofthebarrierstowellcoordinatedandcontinuouscare.

The population

Forthepurposesofthetoolkit,referenceismadetoindividualsdiagnosedwithamentalillnessaccordingtotheDiagnosticandStatisticalManualofMentalDisordersortheInternationalClassificationofDiseases.Thesehealthconditionsarecharacterizedbyalterationsinthinking,mood,orbehavior(orsomecombinationthereof),whichareassociatedwithdistressand/orimpairedfunctioningandspawnahostofhumanproblemsthatmayincludedisability,pain,ordeath.Thepopulationswhowouldbenefitfromnutritionservicesinprimaryhealthcarementalhealthprogramsinclude: AnxietyrelateddisordersandPostTraumaticStress

Disorder BorderlinePersonalityDisorderandPsychoticDisorders AttentionDeficitHyperactivityDisorderandAutism Primarymentalillness,includingindividualswithmood

disorders(e.g.,unipolarorbipolardepression),eating


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disorders,andschizophreniasyndromes.Thiscanincludethoseinforensicsprograms.

Complexdementia,neurological,ormedicalconditionswithassociatedorcomorbidpsychiatricillness.Thesewouldincludedementia/neurologicalconditionswithbehavioural/mentalhealthissuesandmedicalillnesswithpsychiatricdisorder(e.g.,apersonwithParkinsonsthatalsohaspsychosis)

Individualswithsubstanceabusedisorders Individualswithconcurrentdisorders,comorbidities,

developmentaldelaysordisabilities

Thescopeinwhichdietitianserviceswouldbebeneficialisbroadandthereforecooperativeconsultationamongprimarycarepractitionerswillbeneededtohelptodefinethepopulationwhowillbeservedinanyspecifiedcollaboration.Inparticular,withintheprimaryhealthcontextclarificationisneededregardingthetypeofregistereddietitianprovidingservice.Forexample,theregistereddietitiancanbeaspecialistinmentalhealththatspecificallycollaborateswithafamilyphysicianonaparticularissue.Alternatively,thedietitiancanworkinprimaryhealthcareandcounselclientswhomayhappentohavementalhealthissues.Inbothoftheseinstances,theneedsandperspectiveswilldiffer.

The importance of the dietitians role in primary health care mental health programs

Individualswithmentalhealthissueshavebeenidentifiedasbeingatnutritionalriskduetoavarietyoffactors.Severalnutritionalconsequencesoccurasaresultofeatingdisorders,mooddisorders,schizophrenialikesyndromes,personalitydisorders,substanceusedisorders,dementia,attentiondeficithyperactivitydisorder,autismaswellasdevelopmentaldelaysanddisabilities.Specificconcernscanincludepotentialnutrientdeficiencies,feedingissuesandsignificantnutritionrelatedsideeffectsofpharmacologicaltreatments.Furthertothis,issuessuchaspoverty,socialisolation,marginalization,comorbidmedicalconditions,concurrentdisorders,andagingcompoundthenutritionrelatedproblemsthispopulationencounters.


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Dietitiansareuniquelyqualifiedtoidentifythenutritionalneedsofindividualswithmentalhealthissuesandtoplanappropriateinterventionswithinprimarycarecontexts.Basedoneducationinthescienceandmanagementofnutrition,andpracticesbasedonevidencebaseddecisionmakingandnationalstandards,thedieteticsprofessionalcanassessclinical,biochemical,andanthropometricmeasures,dietaryconcerns,andfeedingskillsaswellasunderstandthevarieddeterminantsofhealthactingoninterventionplans.

Key information from the consultation process

Thistoolkitevolvedfromaconsultationprocessthatexaminedtheroleofdietitianservicesinmentalhealth.ItbeganwiththereviewofthedraftsofspecialpopulationandgeneraltoolkitsdevelopedbytheCCMHISteeringCommittee.Thesedocumentswereexaminedbyaworkinggroupofnutritionprofessionalsemployedinpsychiatry,geriatrics,homecare,andprogramsformarginalizedpopulations.Atthisphaseoftheconsultationprocess,memberswereprovidedwithaquestionnairetohelpthemintegratetheirfeedbackfromadieteticsperspective.Thequestionnairecombinedwithcommunicationamongtheworkinggroupalsoattemptedtogatherinformationonrelevantresourcesandcollaborativecareinitiatives.Inadditiontothis,semistructuredinterviewswithconsumersandtheircaregiversselectedfromorganizationsthatprovidesupporttoindividualswithmentalhealthissueswereconducted.Theseinterviewswereintendedtogatherinformationconcerningexperienceswithdietitians.Atotalof10interviewswereconducted.Theseprocessesaswellasreviewoftheliteratureprovidingevidenceofeffectivenessofnutritionservicesforindividualswithmentalhealthissuesledtothedevelopmentofthistoolkit.

Inordertoevaluatethefinaltoolkit,inputfromtheworkinggroupmembers,independentreviewersincludingnutritionandotherhealthprofessionalsaswellasconsumersandtheircaregiversweresought.Feedbackwasdirectedbytheuseofaquestionnaireintendedtoelicitopinionsabouttheadequacyinwhichthetoolkitoutlinedcollaborativecare,the


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definedpopulation,issuesinmentalhealthandnutrition,thevisionsandgoalsofprimaryhealthcare,importantconsiderationssuchasrelevantpoliciesandlegislation,examplesofcollaborativemodelsanddefinitionoftheroleofthedietitian.

Thekeyfindingsoftheconsultationprocessincluded:

ThedirectandnondirecthealthcarecostsassociatedwithmentalillnessesinCanadaaresignificantandaccountforatleast$6.85billion,thusanyprogramstargetedatimprovingconsumersymptomsandfunctioning,suchasdietitianservices,havethepotentialtoreducethesignificantcostofmentalillnessinCanada.

Individualswithmentalillnessesareatheightenednutritionrisk.Inparticular,peoplewhosufferfromeatingdisorders,mooddisorders,schizophrenialikesyndromes,substanceusedisordersanddementiaareatriskofsignificantweightfluctuations,nutrientdeficiencies,developingcomorbiditiesthataffectnutritionalwellbeingandencounteringavarietyofdrugnutrientinteractions.Withinthispopulationarespecialsubgroupsthatincludemarginalizedindividuals,childrenandadolescents,individualswithconcurrentdisordersaswellasindividualswithdevelopmentaldelaysordisabilities.Someoftheimportantnutritionrelatedissuesfacingthisgroupincludefoodsecurity,failuretothrive,swallowinganddentalproblems.Asamultidisciplinaryteammember,theregistereddietitiancanoffertheseclientsnutritioncareplansthatconsidersthemedical,psychiatric,psychological,social,spiritual,andpharmacologicaspectsoftheirtreatment.

Individualswithmentalhealthissuesvaluetheroleofthedietitianandresearchsuggeststhatiftheirservicesareprovidedinamannerthatmeetstheirneedstheywillseeknutritionalcareinaprimaryhealthcarecontext.

RegistereddietitiansacrossCanadaidentifiedthataccessibility,lackofcoordinationofsystems,lackoffunding,lackofunderstandingofeachothersroleswithinaninterdisciplinaryteam,aneedtoimplementcontentand/orfieldexperiencethataddressesthe


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nutritionneedsofpersonswithmentalhealthissuesintrainingprogramsaswellasaneedforprotocolsthataddressestheuniquenutritionalneedsofthispopulationarecurrentbarrierstoprovidingnutritioncareforthispopulation.

Registereddietitiansvalueaclientcentered,collaborative,populationhealthapproachtocare.Theirspecializedtrainingandskillsprovidemeaningfulenhancementtothecareofindividualswithmentalhealthissues.

Recommendations and conclusions

Dietitiansworkinginmentalhealthcanbecatalystsforimprovedcareofclients.However,toachievetheirfullpotential,severalissuesneedtobeconsidered,includingtheallocationoffinancialresourcestoincludedietitianservicesinprimaryhealthcarecontexts,andtheneedtoexpandthementalhealthcontentand/orfieldexperienceindieteticstraining.Furthermore,strategiestoenhanceaccessibilityofdietaryservicesthroughhomevisiting,nutritiontrainingofparaprofessionalsandpeerworkers,andincreaseduseoftelemedicineservicesareneeded.Finally,thereisaneedtoadvocateforofficialrecognitionofnutritionandmentalhealththroughnationalpolicy,incorporatenutritionissuesandinterventionstrategiesintoclinicalguidelinesforpsychiatriccare,anddirectresearchinthisarea.Byaddressingtheseconcerns,thequalityoflifeofindividualswithmentalhealthissuescanbeenhancedandhealthcareresourcescanbeusedmoreeffectivelyandefficiently.


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Table of contents

Foreword....................................................................... i

Executive summary..................................................... iii

Summarization of the toolkit ....................................... v

Background .................................................................... v The population................................................................ v The importance of the dietitians role in primary health care mental health programs ................................................. vi Key information from the consultation process................ vii Recommendations and conclusions ................................. ix

Introduction................................................................. 1

Consultation process.................................................... 5

Defining primary health care and mental health populations .................................................................. 7

Definition of primary health care ......................................7 Benefits of primary health care ........................................7 Defining the population ...................................................7

Issues in mental health and nutrition .......................11

Key lessons from the literature ...................................... 11 Mental illness as a significant health issue ................... 11 Special populations of those who suffer from mental illness ....................................................................... 13 The role of nutrition in mental health.......................... 16

Key lessons from the review process .............................. 21

Vision and goals of primary health care ....................25

Accessibility .................................................................. 25 Collaborative structures ................................................. 28 Richness of collaboration ............................................... 32 Consumer and family centredness.................................. 33

Important considerations in development of initiatives...................................................................................35

Policies, legislation, and regulations ............................... 35 Current perspectives in mental health ............................ 36 Funding........................................................................ 36 Appropriate technologies ............................................... 38 Evidence-based research ............................................... 38 Community needs ......................................................... 39 Planning and implementation......................................... 39 Evaluation .................................................................... 40



Selected Canadian examples .....................................43

The Hamilton Health Services Organization Mental Health Nutrition Program ......................................................... 43 The Cool Aid Community Health Centre, Victoria, BC ....... 46 Defining me: Developing a healthy body image and lifestyle, Mount Saint Vincent University, Halifax ............. 48 Other examples ............................................................ 49

Summary....................................................................51

Role of the registered dietitian in primary health care mental health programs ................................................ 51 Recommendations......................................................... 57

Appendix A .................................................................61

Appendix B .................................................................63

Appendix C .................................................................67

Appendix D.................................................................69

Appendix E .................................................................73

Reference list .............................................................79



Introduction

Thefocusoftheprimaryhealthcareapproachisbothaphilosophyofhealthcareandamodelforprovidinghealthcareservices.Primarycarereformsharesseveralgeneralprinciples(111)thatmustbeimplementedsimultaneously,whichincludeahealthsystemthatisaccessible,haspublicparticipation,ismorecomprehensive,includesintersectoralcooperation,focusesonillnesspreventionandhealthpromotion,andplacesemphasisonappropriateskillsandtechnology.Toachievethis,networksofprimarycareprovidersmustbeestablished.Examplesoftheseincludegroupsofexistingfamilypractices(2),largergroupsofprimarycarepracticeslinkedwithotherprovidersofhealthsuchasregistereddietitiansandcommunityservices(9),orlinkagesofprimarycarepracticeswithlocalcommunityagenciesandsocialserviceprovidersinasingleorganization(4;8).

Oneimportantgoalidentifiedinprovincialplanningdocumentsisgreaterintegrationofspecializedservicesintoprimarycaresettings.Formanyhealthproviders,attemptstoaccomplishthisaredescribedasjourneysintounfamiliarterritory.Despitethis,manyexamplesofsuccessfulprogramsexistandinclude:

Thetimeisnowrightfornutritiontobecomeamainstream,everydaycomponentofmentalhealthcare,andaregularfactorinmentalhealthpromotionThepotentialrewards,ineconomicterms,andintermsofalleviatinghumansufferingareenormous.Dr.AndrewMcCulloch,

ChiefExecutive,TheMentalHealth

Foundation,2006,(12)

Thecentreslocalesdesservicescommunautaires(CLSCs)inQuebec

Communityhealthcentresinmanypartsofthecountry TheHealthServicesOrganization(HSO)Programin

Ontario Thestreethealthteams,whichareactiveinmostlarge

citiesacrossCanada

Mentalhealthandnutritionissuesareprevalentinthesecontextsandarecommonlytreatedbybothprimaryhealthcareandspecialistsystemsthatwouldbenefitfromgreaterintegration.Thisspeakstoaneedforinnovativeprogramsthatchangethedaytodayrelationshipbetweenmentalhealth,nutritionandprimarycareservices.Suchprogramscaneliminatesomeofthebarrierstowellcoordinatedandcontinuouscare.


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TheCanadianCollaborativeMentalHealthInitiative(CCMHI)isapartnershipoftwelvenationalprofessionalgroups,includingtheDietitiansofCanada.Itisintendedtostrengthenthecapacityofprimaryhealthcareproviderstoworktogethertodeliverqualitymentalhealthservices.Theprojectgoalsinclude: Analysisofthecurrentstateofcollaborativementalhealth

attheprimaryhealthcarelevel Developmentofacharterincludingasharedvisionof

collaborativecareinthedomainofmentalhealththatwasendorsedbytheDCBoardofDirectorsonOctober21,2005

Approachesandstrategiesforcollaborativecare Disseminationofinitialfindings,materials,educational

toolsandguidelinestosupporttheimplementationandevaluationofcollaborativecareapproaches.

TheCCMHIhasdevelopedanumberoftoolkitsexaminingmentalhealthissuesandtargetingspecialpopulations.Aspartofthedevelopmentofthesetoolkits,agroupofDCmembersthatworkinvariousareasofmentalhealthreviewedandprovidedfeedbackonthesedocumentsfromadieteticsperspective.ThesetoolkitsaswellasseveralothersarelocatedontheCCMHIwebsite(www.ccmhi.ca).AsfollowuptothedevelopmentoftheseCCMHIresources,DCwasprovidedtheopportunitytodevelopatoolkitabouttheroleofregistereddietitiansinprimaryhealthcarementalhealthprograms.

Registereddietitianscanaugmentandcomplementfamilyphysiciansactivitiesinpreventing,assessing,andtreatingnutritionrelatedproblems.Thismodelofsharedcarecanbeappliedtointegratingotherspecializedservicesintoprimarycarepractice.

CrustoloAM,KatesN,AckermanS,Schamehorn,

2005,(13)

Thisdocumentisthetoolkitintendedtooutlinetheroleforregistereddietitiansinmentalhealthandprimaryhealthcare.Itisdividedintosevensections,someofwhicharerelevanttospecificaudiences.Thesectionsinclude: Descriptionoftheconsultativeprocess. Definingprimaryhealthcareandthementalhealth

populationsthatarebestservedbydieteticsservices. Examiningissuespertainingtodieteticsandpsychiatry

thatarerelevanttoallprofessionalsworkinginmentalhealth.

Outliningthevisionandgoalsofprimaryhealthcareanddiscussingtheminthecontextofdieteticsandmental


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Aswellasitsimpactonshortandlongtermmentalhealth,theevidenceindicatesthatfoodplaysanimportantcontributingroleinthedevelopment,managementandpreventionofspecificmentalhealthproblemssuchasdepression,schizophrenia,attentiondeficienthyperactivitydisorder,andAlzheimersdisease.

Dr.DeborahCornah,Consultant,

MentalHealthFoundation,2006(12)

health.Thissectionalsospeakstoallprofessionalsworkingwithmentalhealthconsumers.

Importantconsiderationspertainingtothedevelopmentofprimarycareinitiativesencompassingmentalhealthanddieteticsservices.Thissectionidentifieskeyissuessuchasfundingandevidencebasedresearchthatwillbeofinteresttoplannersofprimaryhealthcareprograms.

Examplesofexistingprogramsintegratingmentalhealthandnutritionservices.Thisisalsoofinteresttothoseinvolvedinthedevelopmentofprimaryhealthcareprograms.

Summarizingthepotentialroleofthedietitianinprimaryhealthcarementalhealthprograms,whichspeakstoallhealthprofessionals,butparticularlyoutlinesstrategiesforfuturedirectionofthedieteticsprofessioninmentalhealth.

DietitiansinteracteverydaywithCanadiansthathavementalhealthissueswhoareseekingassistancetoimprovetheirhealth.Asaresult,theyencounterissuesrelatedtoaccessibilityofservices,identifytheneedtointegrateservices,andworkwithchangeintheformofemergingresearch,knowledgeandnewtechnology.Itisbasedonthecollectiveknowledgeandexpertiseofdietitiansworkinginmentalhealththatthisdocumentwasprepared.Itisanticipatedthistoolkitwillleadthereadertoaclear,indepthunderstandingoftherolethattheregistereddietitiancanhaveintheenhancementofprimaryhealthcarementalhealthprograms.


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Consultation process

Dietitiansareuniquelyqualifiedtoidentifynutritionalneedsandtoplanappropriateinterventionatallpointsofthecontinuumof(mentalhealth)care.DCMentalHealthNetwork,

1998,(14)

ThePrimaryHealthCareMentalHealthandNutritionWorkingGroupusedinthisprojectwerecomprisedofregistereddietitiansfromacrossCanadawhoworkinpsychiatry,homecare,geriatrics,andaddictionsaswellaswithprogramstargetedtomarginalizedindividuals.Inadditiontotheworkinggroup,anumberofreviewerswereutilizedthatincludeddietitiansworkinginmentalhealth,otherhealthprofessionals,aswellasconsumersandtheircaregivers.MembersoftheworkinggroupaswellasthereviewersareidentifiedinAppendixA.

Astrategywasdevelopedtoensuremultipleperspectivesinthedevelopmentofthistoolkit.Thisstrategyconsistedof:

1. Identificationofcurrentliteraturerelevanttothedevelopment,implementation,evaluationandsustainabilityofcollaborativecareinitiativesinmentalhealthandnutrition.

2. ReviewofthedraftsofCCMHIspecialpopulationandgeneraltoolkitswithaviewtoensuringdieteticswasrepresented.Membersoftheadvisorygroupandotherreviewerswereaskedtoreviewtoolkitsspecifictotheirpracticeareaandweregivenaquestionnairetohelpdirecttheirfeedback.ThequestionnaireislocatedinAppendixBandisadaptedfromtheSpecialtyGeriatric/GenericMentalHealthQuestionnaireoftheGeriatrictoolkit.

3. Completionofsemistructuredinterviewswithconsumersthatwereselectedmembersofmentalhealthorganizations(AppendixC).

4. Communicationwithintheworkinggroupincludingconferencecallstogatherinformationconcerningmentalhealthandnutritionand,inparticular,informationonrelevantresourcesandcollaborativecareinitiatives.

5. Development,reviewandfinalapprovalofthistoolkit.Aquestionnairecombinedwiththisdocumentwassenttoallworkinggroupmembersaswellasindependentreviewerstoprovidedirectedfeedback(AppendixD).


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Thistoolkitisasynthesisofthefiveaforementionedstagesandincludes:Iwasdiagnosedmanic

depressive21yearsago.SincethenIhavehadtogoonmanydifferentdietsbecauseofcholesterol,diabetesIrealizenowtheimportanceofnutrition.

Consumer,Toolkitparticipant

Adefinitionofthepopulationandprimaryhealthcare. Anexplorationoftheliteraturepertainingtomental

healthandnutritionanditsrelevancetoprimaryhealthcare.

Discussionoftheimportanceofdietitianservicesforthosewithmentalhealthneeds.

Currentchallengesandpotentialstrategiesforenhancingaccessibility,collaborativestructures,richnessofcollaborationandconsumercentredcare.

Theimpactoffundamentalstructuressuchaspolicies,legislationandregulations,funding,computertechnologies,evidencebasedresearchandcommunityneeds.

Recommendationsforstrategicallypositioningthedietitianintheplanning,developmentandevaluationofcollaborativecareinitiativesinmentalhealth.

Asthefundamentalbasistothistoolkit,primaryhealthcareandthementalhealthpopulationtowhichitaddressesisoutlinedinthefollowingsection.


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Defining primary health care and mental health populations PrimaryHealthCareis

essentialhealthcaremadeuniversallyaccessibletoindividualsandfamiliesinthecommunitybymeansacceptabletothem,throughtheirfullparticipationandatacostthatthecommunityandcountrycanafford.Itformsanintegralpart,bothofthecountryshealthcaresystem,ofwhichitisthenucleus,andoftheoverallsocialandeconomicdevelopmentofthecommunityItisthefirstlevelofcontactofindividuals,thefamilyandcommunitywiththenationalhealthcaresystem,bringinghealthcareascloseaspossibletowherepeopleliveandworkandconstitutesthefirstelementsofacontinuinghealthcareprocessPrimaryHealthCareaddressesthemainhealthproblemsinthecommunity,providingpromotive,preventive,curative,supportiveandrehabilitativeservicesaccordingly.

WHO,1978

Definition of primary health care

ThereareseveraldefinitionsofPrimaryHealthCare.Forthepurposesofthistoolkit,themostrecognizeddefinitionsetoutbytheWorldHealthOrganizationinthe1978AlmaAtaDeclarationwillbeused.

In1978,WHOadoptedtheprimaryhealthcareapproachasthebasisforeffectivedeliveryofhealthservices.Theprimaryhealthcareapproachisbothaphilosophyofcareandamodelforprovidinghealthservices.Thefocusoftheprimaryhealthcareapproachisonpreventingillnessandpromotinghealth.WHOidentifiedfiveprinciplesofprimaryhealthcare:accessibility,publicparticipation,healthpromotion,appropriateskillsandtechnology,andintersectoralcooperation.Allfiveprinciplesaredesignedtoworktogetherandmustbeimplementedsimultaneouslyinordertoachievethebenefitsoftheprimaryhealthcareapproach.

Benefits of primary health care

Primaryhealthcareinitiativesofferthefoundationuponwhichtobuildanationalframeworkforourhealthsystem(15).Theyseeklinkagesbeyondtraditionalhealthcaredeliverysuchasschoolandworkplaceenvironments.Theyfocusoneducatingthepublicthroughhealthpromotionanddiseaseprevention.TheyalsoencourageallCanadianstotakeanactiveroleintheirhealth.

Laterinthisdocument(Section7)thereaderwillseeanumberofexamplesofprimaryhealthcare.Theyillustratethedifferentmixesofprofessionalsandrangesofservicesratherthanacookiecutterresponse.Implementingtheprimaryhealthcareapproachhasshowntoincreasethequalityandaccessibilityofcareaswellascreateefficienciesandcostsavings(15).

Defining the population

Mentalhealthisastateofsuccessfulperformanceofmentalfunction,resultinginproductiveactivities,fulfilling


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relationshipswithotherpeople,andtheabilitytoadapttochangeandtocopewithadversity(16).Mentalhealthisindispensabletopersonalwellbeing,familyandinterpersonalrelationships,andcontributiontocommunityorsociety.

DC endorses reformed primary health care and principles for reform including the population health approach as well as addressing health determinants and their inter-relationships. The key determinants are (19):

Income and social status Social support networks Education and literacy Employment/working

conditions

Social environments ctices

enetic

rvices

Physical environments

Personal health praand coping skills

Healthy child development

Biology and gendowment

Health se Gender

Everyonehasmentalhealthneeds,whetherornottheyhaveadiagnosisofmentalillness.Whilementalhealthismorethananabsenceofmentalillness,forthepurposesofthistoolkit,itreferstoindividualsdiagnosedwithamentalillnessaccordingtotheDiagnosticandStatisticalManualofMentalDisorders(17)orInternationalClassificationofDiseases(18).Thesehealthconditionsarecharacterizedbyalterationsinthinking,mood,orbehavior(orsomecombinationthereof),whichareassociatedwithdistressand/orimpairedfunctioningandspawnahostofhumanproblemsthatmayincludedisability,pain,ordeath.Mentaldisordersincludethreemajorcategories:schizophrenia,affectivedisorders(majordepressionandbipolardisorder)andanxietydisorders(panicdisorder,obsessivecompulsivedisorder,posttraumaticstressdisorder,andphobia).

Forthepurposesofthistoolkit,thepopulationswhowouldmostbenefitfromnutritionservicesinmentalhealthwithintheprimaryhealthcarecontextinclude: AnxietyrelateddisordersandPostTraumaticStress

Disorder BorderlinePersonalityDisorderandPsychoticDisorders AttentionDeficitHyperactivityDisorderandAutism Primarymentalillness,includingindividualswithmood

disorders(e.g.,unipolarorbipolardepression),eatingdisorders,andschizophreniasyndromes.Thiscanincludethoseinforensicsprograms.

Complexdementia,neurological,ormedicalconditionswithassociatedorcomorbidpsychiatricillness.Thesewouldincludedementia/neurologicalconditionswithbehavioural/mentalhealthissuesandmedicalillnesswithpsychiatricdisorder(e.g.,apersonwithParkinsonsthatalsohaspsychosis)

Individualswithsubstanceabusedisorders Individualswithconcurrentdisorders,comorbidities,

developmentaldelaysordisabilities


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Giventhebroadscopeofprimaryhealthcareandthepopulationdefinedherethatwouldbenefitfromservicesofadietitian,itisevidentthattheroleofthenutritionprofessionalhaspotentiallyinfinitepossibilitiesintheprimarymentalhealthcarecontext.Cooperativeconsultationsamongprimarycarepractitionerswillhelptodefinethepopulationwhowillbeservedinanyspecifiedcollaboration.Inparticular,withintheprimaryhealthcontext,clarificationisneededregardingthetypeofregistereddietitianprovidingservice.Forexample,theregistereddietitiancanbeaspecialistinmentalhealththatspecificallycollaborateswithafamilyphysicianonaparticularissue.Alternatively,thedietitiancanworkinprimaryhealthcareandcounselclientswhomayhappentohavementalhealthissues.Inbothoftheseinstances,theneedsandperspectiveswilldiffer.

The role of the dietitian in mental health can include (20):

Identifying concerns such as poor intake, significant weight changes, drug interactions, and food accessibility

Acting as a resource to community support agencies as well as home operators for menu planning and food service standards

Facilitating psycho-educational groups for food and nutrition


9



10


Issues in mental health and nutrition Canadianfamilyphysiciansreceiverelativelylittletraininginthefundamentalsofnutritionduringmedicalschool,havetimeconstraints,andarepresentedwithavastamountofnewinformationeveryyear;allthesefactorshinderthemfromprovidingeffectivedietarycounseling.Registereddietitianshavespecializedskills,knowledge,andtrainingintheareaoffoodandnutrition,yetonly16.6%ofCanadianfamilyphysicianswhosemainpracticesettingsareprivateoffices,privateclinics,communityclinics,orcommunityhealthcentersindicatetheyhavedietitiansornutritionistsonstaff.

CrustoloAM,KatesN,AckermanS,Schamehorn,

2005,(13)

Individualsdiagnosedwithmentalillnesstypicallyhaveconditionsthatplacethematnutritionalrisk.Dietitiansprovidetheexpertisetoaddresstheseissuesbasedontheireducationinthescienceandmanagementofnutrition,andtheircommitmenttoevidencebasedpracticesthatadheretonationallyestablishedstandardsandaremonitoredbyprovincialbodies(20).

Withreferencetotheresearchliteratureandinformationgatheredfromtheconsultationprocess,theimportanceoftheroleoftheregistereddietitianinmentalhealthisoutlined.

Key lessons from the literature

Whenreferringtotheresearchinthecontextsofmentalhealthandnutrition,therearethreespecificareastoconsider.First,isthelargebodyofevidencesuggestingthesignificantimpactofmentalillnessonthehealthcaresystem.Secondly,specifichighrisksubpopulationsofthosewhosufferfrommentalillnessneedtobehighlighted.Finally,andmostimportantly,theaccumulationofknowledgeregardingtheroleofnutritioninmentalhealthisdetailed.

Mental illness as a significant health issue Mentalillnessesareconditionsassociatedwithlonglastingdisabilityandsignificantmortalitythroughsuicide,medicalillness,andaccidentaldeath(2123).Thefollowingaresomekeypointsfromtheliteraturethathighlightthesignificanceofmentalhealthissues: TheWorldHealthOrganizationsGlobalBurdenof

Diseasestudyrevealedthatclinicaldepressionisanillnessoftremendouscostandwillrankasthesecondmostburdensomeillnessbytheyear2020(24).Globally,nearly3%ofthetotalburdenofhumandiseaseisattributedtoschizophrenia.

Mentaldisordersareamongthemostimpairingofchronicdiseases(25;26).

Hospitalizationratesforbipolardisorderingeneralhospitalsareincreasingamongwomenandmenbetween15and24yearsofage.


11


Thedirectandnondirecthealthcarecostsassociatedwithschizophreniaareestimatedtobe$2.02billionorabout0.3%oftheCanadianDomesticProduct(27;28).Thiscombinedwiththehighunemploymentrateduetoschizophreniaresultsinanadditionalproductivitymorbidityandmortalitylossestimateof$4.83billion,foratotalcostestimateof$6.85billion.

IrememberthefirsttimeIevertalkedtoadietitian.Iwascompletelymanicandnoteating.Shetriedtokeepmefocusedbutitwasobviouswewerentgettinganywhere.LaterwhenIcamedownfrommyepisode,itwashelpfultotalktoher.


Whilestillarelativelyrarecondition,Canadianautismdiagnostictrendsappeartobeincreasing(29).

InCanada,morbidityandmortalityrelatedtosubstanceabuseaccountfor21%ofdeaths,23%ofpotentiallifelost,and8%ofhospitalizations(30).Substanceusedisordersareassociatedwithahostofhealthandsocialproblems.

Peoplewithpersonalitytraitsthatimpactontheircareareestimatedtocomprise2030%oftheprimarycarepopulation.BasedonUSdata,about6%to9%ofthepopulationhaveapersonalitydisorder(31).

Anxietydisordersaffect12%ofthepopulation,causingmildtosevereimpairment(32).

Approximately3%ofwomenwillbeaffectedbyaneatingdisorderduringtheirlifetime.Since1987,hospitalizationsforeatingdisordersingeneralhospitalshaveincreasedby34%amongyoungwomenundertheageof15andby29%among1524yearolds(31).

AreportfromtheCanadianInstituteforHealthInformationrevealsthatpatientswithaprimarydiagnosisofmentalillnessaccountedfor6%ofthe2.8millionhospitalstaysin20022003.Another9%ofhospitalstaysinvolvedpatientswithanonpsychiatricprimarydiagnosisandanassociatedmentalillness.Combined,thesehospitalstaysaccountedforonethirdofthetotalnumberofdayspatientsspentinCanadianhospitals.Thesestaysweremorethantwiceaslong,onaverage,asstaysnotinvolvingmentalillness.

Peoplewithmentalillnessesaremorelikelytouseemergencyandurgentcare(33).Whiletherearetrendstowardsdeinstitutionalizationofthementallyill,thispresentsmanychallengestocommunitiesastheseindividualstendtohavesignificanthealthissues.

Past year prevalence rates of selected mental disorders in Canada (34)

Any disorder 10.9%

Depression 4.8%

Social phobia 3.0%

Alcohol dependency

2.6%

Mania 1.0%

Drug dependency

0.8%

Asaresultofthesealarmingfacts,mentalhealthissueshavebecomeatoppriorityonthehealthcareagenda.Programs


12


targetedatimprovingconsumersymptomsandfunctioning,suchasindividualizednutritioninterventions,havethepotentialtomakesignificantcontributionsinreducingthecostofmentalillnessinCanada.Primaryhealthcareprovidesarelevantforumtoaddressmentalhealthissuesasthereisevidencetosuggestthatpeoplewithmentalillnessesarewillingtoengagewiththemedicalsystem(35).Thisinformationimplicatesthatifopportunitiesareprovidedinamannerthatmeetstheconsumersdieteticneeds,theywillseeknutritionalcareintheprimaryhealthcontext.

Special populations of those who suffer from mental illness Special populations of those

who suffer from mental illness may be at particular nutrition risk. These can include:

Marginalized individuals Children and adolescents Elderly Rural or isolated groups ith co-

morbidities

s

tal delays or

disabilities

Individuals w

Individuals with concurrent disorder

Individuals with developmen

Primarymentalhealthcarereformisalsoleadingtomanyopportunitiesfortheregistereddietitiantobeinvolvedincollaborativeapproachesinvolvingspecialpopulationswithmentalhealthissues.Theseincludemarginalizedindividuals,childrenandadolescents,theelderly,thoselivinginruralandisolatedregions,individualswithdevelopmentaldelaysordisabilities,aswellasindividualswithmentaldisordersthatsufferfromconcurrentdisordersandcomorbidities.Thefollowinghighlightssomeoftheimportantissuesfacingeachofthesegroups:

MarginalizedIndividuals:Thisgroupisdefinedasthosewhoarehomeless(absoluteorrelative),individualslivingwithaddiction,thoselivingwithdisabilities,streetyouth,solesupportparents,gay/lesbian/bisexual/transgendered,Aboriginals,andracialminorities(includingimmigrantsandrefugees).Affectivedisordersarefarmorecommoninthissubpopulation,rangingfrom20%to40%(36).TheRoyalCommissiononAboriginalpeoplesindicatesthatthisgroupismorelikelytofaceinadequatenutrition(37)andtheiroverallmentalhealthstatusismarkedlyworsethanthatofnonAboriginalpeoplebyalmostanymeasure(38).

Thelivesofmarginalizedpeoplesmaybecharacterizedashavingunstablelivingconditionsduetoalackoffinancial,social,spiritualandphysicalresourcesandinadequatesupport.Poorhealthalsocompoundstherisksfacedbyhomelesswomenwhobecomepregnant[Inonelarge,crosssectionalsurveyofhomelessyouthinToronto,onequarterofthewomensampledwerepregnant(39)].


13


ChildrenandAdolescents:Theliteraturesuggeststhatcommonmentalhealthproblemsamongchildrenandyouthbetweentheagesof018yearsinclude:depression,anxiety,disruptivebehaviourdisorders,ADHD,eatingdisordersanddevelopmentaldisorders.Reportedprevalenceratesformentalhealthconcernsinchildrenandyouthrangefrom15%to20%(4043);5%ofthosebetweentheagesof417yearssufferextremeimpairment(44).Thereisevidencetosuggestthateatingdisorderissuesarebecominganincreasinglysignificanttothisgroup.Mentalhealthconcernsareamongthemostcommonreasonsthatchildrenseeafamilypractitioner(42).

Therecentandwidespreadappearanceoftransfatinthedietraisesgreatconcern,primarily,becausethesefatsassumethesamepositionasessentialfattyacidsinthebrain,meaningvitalnutrientsarenotabletoassumetheirrightfulpositionforthebraintofunctioneffectively.Transfatsareprevalentandpervasive

Dr.DeborahCornah,Consultant,

MentalHealthFoundation,2006(12)

TheElderly:Itisestimatedthat20%ofadultsoverage65haveamentaldisorder,includingdementia,depression,psychosis,bipolardisorder,schizophreniaandanxietydisorder(45).Olderadultswithmentalillnessfaceincreasedriskofmedicalillnessduetothelongtermeffectsofunhealthylifestyles,physiologicalchangesandcompoundingmedicalillnessesthatincreasethesusceptibilityforadditionalmedicalproblemsanddrugsideeffects.

RuralorIsolatedGroups:Thehealthofacommunityisinverselyproportionaltotheremotenessofitslocation.HealthindicatorsconsistentlyrevealthatsignificantdisparitiesexistinhealthoutcomesbetweenpeoplewholiveinnorthernversussouthernregionsofCanada,aswellasbetweenpeoplewholiveinAtlanticregionsversustherestofCanada(46).Inmostruralareas,thecostoftheNutritiousFoodBasketexceedsprovincialaverages.Manyruralcommunityagenciesalsohaveinsufficientfundstohireadietitian.

IndividualswithCoMorbidities:Individualswithchronicmentalillnesseshavebeenreportedtohavehigherthanexpectedlifetimeratesofhypertension(34.1%versus28.7%inthegeneralpopulation),diabetes(14.9%versus6.4%inthegeneralpopulation),andheartproblems(15.6%versus11.5%inthegeneralpopulation)(47;48).Thereisalsoconcernthatthesearenotbeingaddressedeitherintermsofpreventionortreatment(49).


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Thereareseveralothercomorbiditiesthatoccurinmentalillnessthathavesignificantnutritionalimplications.Thelifetimesmokingrateforthispopulationis59%,whichismuchhigherthanthe25%formenand21%forwomeninthegeneralpopulation.Smokersareatthehighestriskfordevelopingchronicobstructivepulmonarydisease(50).Individualswithmentalillnessaremorelikelytohaveachronicinfection,suchasHIV(about8timestherateinthegeneralpopulation),hepatitisB(about5timestherateofthegeneralpopulation)andC(about11timestherateofthegeneralpopulation)(51).LargerscalewellcontrolledstudiesindicatethatDSMIVeatingdisordersinadolescentfemaleswithtype1DMaretwiceascommonasthatfoundincontrolgroups(52).Thecooccurrenceofdiabetesandeatingdisorderspresentsmanyuniquechallengestohealthprofessionals.Thereisalsoevidencetosuggestthatdepressionisasignificanthealthissuerelatedtodiabetes(53).

Giventhattheprimaryhealthcaredefinitionincludesrehabilitativeservices,theRDsrolealsoneedstoberecognizedhere.Wecanplayakeyroleinforensicsandwithworkingrouphomesformentalhealthconsumers.Thiscanenhancetheconsumersqualityoflifeinareassuchashousing,vocationandrelationships.

RD,Toolkitparticipant

IndividualswithConcurrentDisorders:Inworkingwithpeoplewithmentalillness,particularattentionshouldbepaidtothehighratesofconcurrentmentalhealthandsubstanceabuseproblems.Canadianliteraturereportsratesofconcurrentdisorderof56%amongstpeoplewithbipolardisorderand47%ofpeoplewithschizophrenia(54).Theriskforsubstanceabuseproblemsare3timesthatofthegeneralpopulationforalcoholand5timesfordruguse.Peoplewithpersonalitydisorderswhoaccessprimarycarealsohavehigherratesofconcurrentdisorders(55).PeoplewithconcurrentdisordershavepooreroutcomesincludingdifficultywithdailylivingandincreasedriskforHIV/AIDS.

IndividualswithDevelopmentalDelaysorDisabilities:Developmentaldisabilitiesisagenerictermthatrefersprimarilytomentalretardationandsomeofthepervasivedevelopmentaldisorders.Mentalretardation(56)ischaracterizedbysignificantlybelowaverageintellectualfunctioningwhichhasitsonsetbeforetheageofeighteenyearsandisaccompaniedbysignificantimpairmentinadaptivefunctioning.Thepervasivedevelopmentaldisorders(17)arecharacterizedbysignificantimpairmentinmultipleareasofdevelopment,particularlysocialinteractionandcommunication,andaccompaniedbystereotypedbehaviour,


15


interestsoractivity.FivedisordersareidentifiedunderthecategoryofPervasiveDevelopmentalDisorders:1.AutisticDisorder,2.RettsDisorder,3.ChildhoodDisintegrativeDisorder,4.AspergersDisorder,and5.PervasiveDevelopmentalDisorderNotOtherwiseSpecified.Somehealthproblemsforindividualsdiagnosedwiththeseconditionsincludeincreasedriskforobesity,cardiovasculardisease,swallowing,dental,andvisionproblems(57).

Psychologicalfactorsaredeterminantsofhealthwhichcanimpactthesuccessofpreventioneffortsandactivities.Stoppingsmoking,increasingexercise,improvingdietareallaboutbehaviourchangewhichisimpactedbypsychologicalandsocialfactors.Mood(depression,anxiety)hasgreatimpactonhowapersontakescareoftheirwellnessandtheirillnessandcangreatlyimpactthecourseofchronicdisease.AssociateExecutiveDirectorandRegistrar,Accreditation

Panel,CanadianPsychologicalAssociation

The role of nutrition in mental health Aspreviouslyidentifiedmanyindividualswithmentalhealthissuesareatheightenednutritionrisk.Someoftheresearchliteraturehighlightingtheseissuesaredetailedinthefollowing:

EatingDisorders:Alargebodyofevidenceexiststhathighlightstheroleofthedietitianinthepreventionandtreatmentofeatingdisorders.Amultidisciplinaryteamapproachtotreatmentisrequiredtoaddressthephysical,emotional,mental,andspiritualaspectsoftheindividual.Thegoalsofnutritiontherapyaretoprovideguidancethatfostersanourishingeatingstyleandpromotesnormalphysiologicfunctionandphysicalactivityaswellassupportingeatingbehavioursthatbringaboutapeaceful,satisfyingrelationshipwithfoodandeating(58).

MoodDisorders:Thereareoftennutritionalconsequencesofmaniaanddepressionthatincludeanorexiaandweightlossaswellastheconverse:increasedappetiteandweightgain(5862).Psychodieteticinvestigationshavealsoshownthatsomenutrientsaffectmood,moodstateaffectsfoodconsumption,manypsychiatricmedicationshavenutritionrelatedsideeffects(e.g.,thesideeffectsoftricyclicantidepressantsincludeincreasedappetite,nauseaandvomiting,constipationanddiarrhea),andmooddisordersinsomeclientsmaybearesultofinbornerrorsofmetabolism(6265).Studiesofnutritionsupplementshavedemonstratedvaryingefficaciesatamelioratingmoodsymptoms(6669).

Investigationsofthedietaryintakeofindividualswithbipolardisorderhavebeentypicallyneglected,butbasedondatafromasmallclinicaltrialattheUniversityofCalgary,itappearsthatthosewithbipolardisorderhaveahigher


16


prevalenceofinadequatenutrientintakes(i.e.,75%oftheRDA)formanyessentialnutrients(70).

SomenotablefindingshavebeenfoundwithregardstonutritionanddepressionusingtheGovernmentofCanadasNationalPopulationHealthSurvey(71;72).ThissurveyallowedforthecomparisonofsampleswithandwithoutdepressionbasedonscoresoftheCompositeInternationalDiagnosticInterviewShortFormForMajorDepression(72).Comparisonsofthedepressedandnondepressedsamplesindicatedthatthosewhoweredepressedwere2.5timesmorelikelytohavefoodsecurityproblems,werealmost3timesmorelikelytoneedhelppreparingmeals,andabout2timesmorelikelytohaveselfreportedfoodallergies(70).

SchizophrenialikeSyndromes:Nutritionalconcernsforthisgroupincludethosementionedformooddisorders.Inaddition,otherissuesariseiftheindividualssymptomsincludefoodrelateddelusionsandhallucinations.Dieteticsresearchintheareaofmooddisordersandschizophrenialikesyndromeshaslargelybeendominatedbyinterventionstudiesusingavarietyofvitamins,minerals,dietaryneurotransmitterprecursors(e.g.,tryptophanasaprecursortoserotonin)andothernutrientfactorsastreatments.Ofthemicronutrientsexaminedtodate,theevidencesuggeststhatfolate,vitaminB12,theessentialfattyacids,andtryptophansupplementationmaybeeffectiveinthetreatmentofmooddisordersandschizophrenialikesyndromes(7377).

SomeoftheusualmedicationsusedtotreatSchizophrenialikesyndromesincludeantipsychotics,antiparkinsonianagents,antidepressants,andmoodstabilizers.Manyofthesehavesignificantnutritionrelatedsideeffectsthatincludeincreasedriskofobesityandobesityrelateddisorders,aswellasincreasedbloodglucoseandtriglycerides(78).

SubstanceUseDisorders:Vitaminandmineraldeficienciesandexcessesassociatedwithalcoholand/ordrugdependencyincludevitaminsA,B1,B3,folate,B6,C,D,Kaswellaszinc,magnesium,andiron(7981).Nutritioninterventionisusedinconjunctionwithmedical,behavioural,andpharmacologictreatmenttoimprovetheefficacyoftreatmentandrecoveryfromsubstanceabuse(79;82;83).


17


AnxietyDisorders:Dietrelatedfactorsshouldbeconsideredaspossibleprecipitantsofanxiety.Forexample,caffeineintakeinsomeatriskindividualscanprecipitateorexaggerateanxiety(84).

Inordertointegratesuccessfulbehaviourchangestrategies,weneedtoaddressandunderstandwhatpromotesandlimitsbehaviourchange.Somefactorsaresocialandenvironmental(e.g.,whatkindoffoodissoldinschool,whetherschoolsofferphysicaleducationprograms,whatfoodsaremostaffordable)butsomearealsopsychological(e.g.,whydopeopleovereatandeatthewrongfoods;whatistheimpactofstressondietandexerciseandhowelsecanstressbemanaged;thekindsofexpectationsandbeliefschildrenhaveaboutbodyimageandphysicalactivity).AssociateExecutiveDirectorandRegistrar,Accreditation

Panel,CanadianPsychologicalAssociation

Dementia:ThetypesofdementiagenerallyseenincludeseniledementiaoftheAlzheimerstype(SDAT),andvasculardementia,suchasmultiinfarctdementia(MID).OthertypesofvasculardementiaincludethoseassociatedwithParkinsonsdisease,Huntingtonsdisease,substanceabuse,andmanyotherconditions(85).Commonnutritionalconcernsrelatedtodementiaincludedecreasedintake,weightloss,anorexia,andincreasedenergyneedsassociatedwithhighlevelsofphysicalmovement,unrecognizedinfections,dysphagiaorothercauses(8587).

AttentionDeficitHyperactivityDisorder(ADHD):TherelationshipbetweendietandADHDhasbeenwidelydebated.Presently,manyinconsistenciesexistinresearchfindingswhichmayinlargepartbeduetomethodologicalshortcomingsintheresearch.Whiletheefficacyofoneparticulartreatmenthasnotbeengenerallyaccepted,controlledanduncontrolledhumantrialssuggestcaffeineandsugarmayhavearoleinsomeinstances.Studiesalsoshowthatthemethylphenidate(Ritalin),apharmacologictreatmentforADHD,depressesappetiteinchildren,resultinginaslowerrateofweightgainandgrowth(57).

Autism:Todate,studiesinvestigatingtheroleoffolicacid,vitaminB6,magnesiumandvitaminB12havebeenconducted.EfficacyinthetreatmentofautismdemonstratedbycontrolledhumantrialshasbeenfoundforvitaminB6(8890).Nutritionalconcernsinautismincludelimitedfoodselection,strongfooddislikes,pica,aswellasmedicationandnutrientinteractions(57).

DevelopmentalDelaysandDisabilities:Developmentaldelayoccurswhenchildrenhavenotreachedspecifiedmilestonesbytheexpectedtimeperiod.Earlyinterventionservicesincludingnutritionresourcesandprogramsthatprovidesupporttofamiliescanenhanceachildsdevelopment.Nutritionisrelatedtosecondaryconditionsinpersonswithdevelopmentaldisabilitiesinmanysignificantways.


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Nutritionmaybeviewedasariskfactorforsecondaryconditions(e.g.,poornutritionalstatusmakethesecondaryconditionworse),nutritioncanbeaprotectivefactorandmanysecondaryconditionscanfurthermodifyonesdietandcreatesubsequentnutritionalproblems.

Sincenutritionisamajorlifestylefactorinhealthpromotionandinthepreventionandmanagementofsomecommonchronicconditionssuchasdiabetes,heartdisease,andobesity,itislogicalthatnutritionservicesbepositionedintheprimaryhealthcaresetting.Inthissetting,initialidentification,accessibleinterventionandlongtermrelationshipscanbeestablishedbetweentheclientandprovider.ThePrimaryHealthCareActionGroup,2005(91)

Personswithdevelopmentaldisabilitiesandspecialhealthcareneedsfrequentlyhavenutritionproblemsincludinggrowthalterations(e.g.,failuretothrive,obesity,andgrowthretardation),metabolicdisorders,poorfeedingskills,medicationnutrientinteractions,andpartialortotaldependenceonenteralorparenteralnutrition.Poorhealthhabits,limitedaccesstoservices,andlongtermuseofmultiplemedicationsareconsideredriskfactorsforadditionalhealthproblems(57).

Someadditionalkeyfactsdemonstratingtheimportanceofnutritionservicesforthosewithmentalillnessareoutlinedasfollows:

Physicalcomorbidconditionsinfluencethenutritionalwellbeingofindividualswithpsychiatricillness(59).Themostcommonoftheseareobesity,type2diabetesmellitus,dyslipidemia,liverandkidneydegeneration,infectiousdiseasesuchasHIV,AIDS,tuberculosis,aswellashepatitisA/B/C(36;57).Giventheseoverlappingandinteractingrisks,itisapparentthatindividualswithmentalillnessesfacesignificantthreatstotheirnutritionalwellbeing.

Thetransitionfrominstitutionaltocommunitybasedpsychiatriccarecarrieswithitsmanyhealthimplications,includingananticipatedincreaseintheactualnutritionalriskinthesevulnerablegroups(14).

Foodinaccessibilityisaprevalentissue.Foodsecuritymaybedefinedashavingaccessatalltimestonutritious,safe,personallyacceptableandculturallyappropriatefoods,producedinwaysthatareenvironmentallysoundandsociallyjust.Homelessindividualswithmentalillnessareparticularlysusceptibletofoodsecurityissues.Forexample,theyaremoresusceptibletofoodborneillnessesassomeobtaintheirfoodfromstrangersandgarbagereceptacles(92).


19


Drugnutrientinteractions.TheimpactofantipsychoticagentsaswellasTCAsandpharmacologictreatmentsforADHDhasbeenpreviouslycited.AbnormalitiesinvitaminD,calciumandbonestatus,constipation,andgumhyperplasiahavebeenassociatedwiththeuseoftheanticonvulsantsphenytoinand/orphenobarbital(57).Manyolderadultstakemultiplemedicationsforextendedperiodsoftimeandareatriskforcomplicationscausedbymedicationinteractions.Inaddition,medicationmayhavealongerhalflifebecauseofdecreasedleanbodymass.Constipationisasideeffectoflongtermpsychotropicuse,whichresultsinincreaseduseoflaxativesandstoolsofteners.Nutritioninterventionsmaypreventordecreasetheseverityofadverseeffectsofmedications(e.g.,adequatefluidandfibrecanpreventconstipation).

Some examples of where the dietitian can work with mental health consumers include:

Treating many of the physical co-morbid conditions such as obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, chronic obstructive lung disease, metabolic syndrome, liver and kidney degeneration, as well as infectious diseases such as HIV, AIDS, TB, and Hepatitis A/B/C

Assisting the client to obtain nutritious, safe, personally acceptable and culturally appropriate foods

Helping to minimize the nutrition-related side effects of many psychiatric medications

Nutritionalknowledgeandattitudesofpsychiatrichealthprofessionalsimpactuponthecareoftheconsumerwithmentalhealthissues.Astudyinvestigatinginterrelationshipsamongnutritionknowledge,habits,andattitudesofpsychiatrichealthcareprovidersdemonstratedacomprehensivenutritioneducationprogramisessentialforhealthcareproviderstopromotesuccessfulnutritioneducationforthepatientstheyserve(93).

Alternativeandcomplementarytherapiesarehavinganincreasinglysignificantroleinthetreatmentofmentalillness.Thesecanincludeherbalremedies,botanicalorhomeopathicpreparations,useofvitamin/mineralsupplements,andsocalledOrthomolecularmedicine.Whiletheremaybebenefittosomeofthesetherapiesinsomeclients,correctunderstandingofdeficienciesandexcessesareimportanttoavoidthedevelopmentofserioushealthproblems.Clientsmaypurchasenutritionsupplementpackagesofherbs,vitamins,minerals,andaminoacidsfrominformationsuppliedontheInternet,ontherecommendationoffamilysupportgroupmembers,ontheadviceofhealthfoodstoreemployees,andbasedoninformationinprintedmaterials.Thepromiseofimprovedsymptomcontrolpromptsthesepurchases.


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Unfortunately,researchrelatedtotheuseoftheseproducts,includingsafetyandefficacy,isextremelylimited.(Intheprimaryhealth

caresetting)suchcomprehensiveserviceswouldincludearangeofhealthpromotionandtreatmentservices.Healthpromotionactivitiesmightincludesimpleinterventionssuchaspromotinghealthylifestyletospecializedservicesaimedatpreventingdiabetes,lowbirthweightorfailuretothriveamongchildrenortheelderly.TreatmentservicesmightrangefromadvicetoavoidhighdoesofaparticularvitaminsupplementtocomplexinterventionsformanagementofchronicconditionsThePrimaryHealthCareActionGroup,2005(91)

Atthepresenttime,currenttreatmentguidelinesformanyofthesementalillnessesfocusonbothpsychotherapyandpsychiatricmedications(94;95),butpossiblenutritionimplicationsarenotadequatelyaddressed.

Althoughthefieldofpsychiatricnutritionhasreceivedinadequateattention(93),interestinthisareaisgrowing.Aneedformultidisciplinary,practiceandoutcomebaseddieteticpracticeandstudiesinpsychiatricdisordersisclearlyevident.

Ascanbeevidencedbythisdiscussion,therearemultiplenutritionrelatedproblemsassociatedwithmentalillnesswhichhighlightstheneedforthespecializedservicestheregistereddietitiancanoffer.

Key lessons from the review process

Thereviewprocessinvolvedconsultationwithregistereddietitiansworkinginvariousfacetsofmentalhealth.Inaddition,inputandopinionsweregatheredfromgovernment,professionalbodies,theacademiccommunity,consumersandconsumer/advocacygroups,andhealthprofessionalsfromvariousdisciplines.

Whiletherehasbeennoformalreviewofdietitianservicesinpsychiatriccare,itislargelybelievedthatcurrentstaffinglevelsareinadequate.Whiledietitianservicesareavailableinpsychiatricinstitutions,manyofthosewithmentalhealthissuesaretreatedinthecommunity,includingprimaryhealthcaresettings.SinceaccesstodieteticsservicesinthecommunityiswidelyvariableacrossCanada,manyofthosewithmentalhealthproblemshavenoorlimitedaccesstodietitianservices.

Thereareapproximately800DCmembers(16%oftotalmembership)whoindicatetheyworkinsomeaspectofpsychiatriccare.Currently,theDCMentalHealthNetworkisconductingasurveytoobtainaclearprofileofdietitiansand


21


theirworkinpsychiatriccare.Inoneinstance,thestafftoconsumerratioisreportedtobe1FTEofdietitianservicesinpsychiatriccarefor325inpatientsandnearly1000outpatients.Dietitianswhoworkincommunitypsychiatricfacilitiesreportaslittleas8hoursofworkpermonthfor25residents.Basedonanaverage(nothighneeds)familymedicinemodelofprimaryhealthcareinOntario,ithasbeenestimatedthataratioofMD:RDof10:1orlowerwouldenabletheRDtoprovideprimarilyclinicalservices,withfollowupofclientsstatus,completesomehealthpromotionactivitiesandkeepwaitinglistsmanageable(i.e.,


providethetailorednutritionteachingandreinforcementtheseindividualsneed.

Somefamiliesmayhavedifficultyacceptingthatamemberoftheirfamilyhasamentalillnessandmayrequireextrahelptoincorporatenutritionalinterventionsintotheirlifestyle.Povertycanhaveanegativeimpactonthepersonshealthanddevelopmentthroughalackoffoodsecurity.Ataminimum,foodsecurityincludestheavailabilityofsufficient,nutritionallyadequate,andsafefoodandtheassurancethatonecanobtainadequatefoodwithoutrelyingonemergencyfeedingprogramsorresortingtoscavenging,stealing,orotherdesperatemeasurestosecurefood.Whilemanyadultswithmentalhealthissuesarecapableofworkinginparttimeorfulltimejobs,opportunitiesarelimited.

Based on a national DC survey, some of the challenges identified in the implementation of the CCMHI Charter Principles included:

Lack of funding Lack of coordination

between social, education and health systems

Lack of understanding of each others roles within an interdisciplinary team

Thehealthissuesforindividualswithmentalillnessesaresimilartothehealthissuesforeveryone.Theseincludephysicalactivity,nutrition,accesstohealthcare,clinicalpreventiveservices,oralcare,andfamilycaregiving.Asresearchintheareaofhumangeneticsincreases,theincidenceofgeneticallyrelatedmentalillnessesmayeventuallydecrease.Asgenetictechniquesimprovetoidentifythetendencyofanindividualforchronicdiseasesuchasheartdiseaseordiabetes,neweducationalstrategiesmustbedevelopedtoworkwithindividualswithmentalhealthissuesinwellnessprogramstopreventsuchdisorders(98).

Finally,amajorneedidentifiedintheconsultationprocesswastoencourageeducationinmentalhealthfordietitiansintraining.Thedevelopmentandimplementationofcontentand/orfieldexperiencethataddressesthenutritionneedsofpersonswithmentalhealthissuesinundergraduateandgraduatenutritionprogramsaswellasdieteticsinternshipsisrequired.Inparticular,itisidentifiedthatskillsincounselingtechniquesincludingbehaviourmodificationneedtobedeveloped.Inaddition,continuingeducationopportunitiesregardingdieteticsandpsychiatryshouldbeestablished.ThiscouldincludeonlinecoursesthroughDCaswellassessionsattheannualDCconference.Inrelationshiptothis,theregistereddietitianalsohastheopportunityforincreasingthe


23


levelofnutritionknowledgeamonghealthcareandhumanserviceproviders.


24


Vision and goals of primary health care

Asdietitians,wearerecognizedforourspecializedrole.Inthisspecializedrole,oneproblemisphysicallybeingwheretheserviceisneeded.Inourcase,patientsoftenhavetotravelonbusrouteswhicharenoteasyforthemtonavigate.Thisleadstosomeconsumersnotbeingabletoaccesstheservice.Iliketheideaofprovidingtheserviceintheirareaonalessfrequentbasisinsteadofthemhavingtotravelthesedistances.


Provincialplansforprimarycarereformshareseveralgeneralvisionsforasystemthatisaccessible,bettercoordinated,consumercentred,comprehensiveandcommunityfocused.Thesegeneralvisionsreflectedindieteticspracticeareasfollows.

Accessibility

AccessibilitymeansnutritionservicesareuniversallyavailabletoallCanadiansregardlessofgeographiclocation.Distributionofnutritionprofessionalsinrural,remoteandurbancommunitiesiskeytotheprincipleofaccessibility.Accessinvolvesboththeavailabilityofaregularsourceofnutritionalcareandinsomeinstancestheabilityoftheindividualorsomeoneelsetopayforit.OnestrategytoenhanceaccessibilitytodietitiansservicesistherecentmediacampaignthattheDCConsultingDietitiansNetworkconductedtoencourageworksitesacrossCanadatohavedietitianservicesaspartoftheiremployeeinsuranceplans.

Ingeneral,manyruralandisolatedcommunitieshavedifficultyrecruitingqualifiednutritionprofessionals.Nutritionrelatedissuesspecifictoruralpopulationsincludeincreasedfoodcosts.Manyruralcommunityagencieshaveinsufficientfundstohireadietitianforsufficienthours.Thereisalsodifficultlyinmaintaininglevelofexpertiseforclientswithveryspecialnutritionalneeds(i.e.,hometubefeeding,dysphagia).Effortstorecruitdietitianstotheseareasthroughinternshipprogramsmayhelpalleviatetheseissuesaswouldtheuseofonlinecoursesandvideoconferencing.

Theshortageofregistereddietitiansinruralareasisoftencompoundedbythelackoflessformalizedsourcesofsupport.Oftenmissing,forexample,isconsumerandfamilyadvocacyformentalhealth.AlsoabsentinmanyruralsettingsarecoordinatedeffortssuchasAssertiveCommunityTreatment(ACT)teamsthatrelyonnumbersofpatientsandnumerouslocalresourcesfortheirsuccess(99).Nutritionprogramsthattargetinformalcaregivers,naturalhelpers,peerhelpersandparaprofessionalsmaybeofparticular


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importanceinimprovingaccesstoappropriatedieteticsservicesrelatedtomentalhealthinmanyruralareas.Inaddition,strategiessuchastelemedicineandadditionaltrainingoptionsneedtobeconsidered.

Ruralresidentsoftendoexperienceuniquestressorsduetotheagriculturalnatureoftheirlivelihoodformanypeople;theFarmandRuralStressLineisanexampleofaservicethatcouldbebetterpromotedandutilized.Dietitians(andallparaprofessionals)needtoutilizesomeofthescreeningtoolsavailableandtobeabletorefertoappropriateservices.Forexample,withoverweightclients,lookingatstresslevelsandeatingresponsesisimperativetogoodpractice.Also,especiallyinruralareas,consumersneedtohavecompleteconfidenceintheconfidentialityfactor;wemustbeseenastrustworthyandprofessional.


Transportationsupportmayaddressisolation,poverty,distancebarrierstoprofessionalresources,andlowerutilizationinruralareas.Transportationhaslongbeenaprobleminaccessingmentalhealthservices,especiallyamongtheruralandpoor(100).Simplyprovidingatransitpassthroughsocialservicesmaynotbesufficient,particularlyforphysicallyormentallychallengedindividuals.Thissuggeststhataneedforhomevisitingservicesbytheregistereddietitianorinvolvingfamilyorpaid/volunteerdriverstoensureclientscanattendtheirappointments.Presently,homecaredietitiansaremandatedtoseethehomebound,whichistypicallydefinedasphysicalincapabilities.Definitionsofhomeboundmayalsoneedtoincludementalhealthfactors.

InCanada,ithasbeenfoundthatastrongbarriertodieteticserviceisfinancialastherearelimitedpubliclyfundedprograms.Anothercircumstanceexistswhenconsumerslackproperidentificationtoprovecoverage,eitherthroughlossortheft.Obtainingreplacementidentificationpresentsanotherchallengeduetoexpense,lackofproofofresidencyandbureaucracy.Dietitiansatalllevelsneedtoadvocateforadequacyofservicesformentalhealthconsumersandexaminewaysthataclientinneedofnutritioncarethatlacksproperidentificationcanstillaccesstheseservices.

Dependingonplaceofresidence,theabilitytofollowprescribedregimenssuchasappropriaterest,exerciseandnutritionalrequirementscanbeimpossibletocontrol.Duetotheirrelianceondonations,scarceresourcesandalargeclientele,facilitiessuchassoupkitchens,andsheltersmustoperateonlimitedmenusthatdonotalwaysprovideadequateorappropriatenutritionforconsumersonrestrictedormodifieddietsforhealthconditions.Thisspeakstoaneedfordietitianstobeavailableforsuchcommunityprogramstoassistwithmenuandrecipedevelopment,helpingtoadvocateforappropriatefoodsanddevelopingprogramsbasedonskillsbuilding.


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Manymarginalizedconsumershaveextremedifficultyoperatinginanenvironmentthatisgenerallygearedtowardsconsumersofamuchhighersocioeconomicclass.Similartothisistheissuethatprofessionalprejudicescanalsoimpactondiagnosis,treatmentandassessmentofneed(101).Alienation,stigma,institutionalization,andalackoftrustinauthorityfigures,suchashealthcareproviders,hasdevelopedovertimewithmanymarginalizedconsumers.Thismayinclude,forexample,AboriginalPeoples,formercorrectionalservicesresidents,sexualminoritiesandimmigrantorrefugeepopulations.Thisspeakstotheneedtoinvestindevelopingstrongcollaborationincare,havingrespectforthementalhealthclient,andbuildingatrustingrelationshipwithreciprocalcommunication.

Adjustmentsneedtobemadetoreinforcetherolethatwecanplayinthisnewcollaborativeapproach.Moredietitiansneedtobetrainedinandawareofthespecialneedsofmentalhealthclientsandweneedtobemoreaccessibletoboththeclientandtheotherprofessionalteammembers.


Individualconsumersuniquelifecircumstancesmustbeconsideredwhendevelopingacollaborativeapproachtocare.Forexample,hoursofoperationhavebeenshowntoplayaroleinconsumersuseofservices.Theseconsumershavemanycompetingprioritiessuchasfindingshelter,money,andclothing,duringthetypicalbusinessday.Therefore,nutritionconcernsmay,ofnecessity,becomealowerpriority.Manywithinthispopulationaretransientandthereforearelosttofollowup.Tofacilitatecompliancewithnutritioncounselingandeducation,nutritioncareprovidersmustworkwithconsumerstoidentifyallthefactorsinfluencingtheirabilitytoachieveormaintaingoodhealth.

Ithinkweneedtouse(Dietitiantoolkit)thisinHomeCaretopromotemorereferralsfromCCACmentalhealthclientsasIthinkthatthecasemanagersavoidthatbecausetheyareusuallylongandinvolvedclientsandtheyarenotsurethattheywanttofundforthat!


Forsomeconsumers,theirabilitytobeeffectivepartnersintheirnutritioncaremaybeaffectedbyliteracy,orphysicalormentalincapacity.Properevaluationofcompetencyandleveloffunctioningshouldbecarriedouttonegotiateacomfortablelevelofinvolvementfortheconsumerintheirnutritioncaremanagement.However,theobjectiveshouldalwaysbetobuildarelationshipthataidsinthedevelopmentofgrowingempowermentoftheconsumerinregardstotheirhealth.

Barrierstocarecanbefoundatalllevelsfrompolicyandlegislativeconcernsatthesystemsleveltoindividualissuesthatimpedeaccesstoappropriatehealthcare.Acollaborativementalhealthcareinitiativethatincludesregistereddietitianservicesshouldexploredifferentapproachestoservice


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delivery,andsupportandempowerconsumerstoovercomeindividualchallengesuniquetotheirlifecircumstance.

Collaborative structures

Factorsrelatedtoaccessibilityandcollaborationinourprograminclude:1. Allteammembershaveanappreciationofeachothersothattheteamknowswhateachmemberroleis.

2. Havingteammembersinoneplacesoconsumersarenottraveling.

3. Eachconsumerwithmentalillnesshaveacaseworkertohelpcoordinateandensureincreasedcompliance.


Collaborationmeanshealthprofessionalsfromvariousdisciplinesfunctioninterdependentlytomeettheneedsofconsumers.Italsorecognizesthathealthandwellbeingarelinkedtobotheconomicandsocialpolicy.Collaborationorintersectoralcooperationalsomeansexpertsinthementalhealthsectorareworkingwithexpertsineducation,financing,housing,employment,immigration,etc.Sharedvisionisthebasisofanysuccessfulcollaborativementalhealthcareinitiative.Thisinvolvesbringingallkeystakeholders,includingconsumers,tothetable.

Collaborativepracticeinvolvespatientcentredcarewithaminimumoftwocaregiversfromdifferentdisciplinesworkingtogetherwiththecarerecipienttomeettheassessedhealthcareneeds(102).Avarietyofstrategiesforprovidinginterdependentcareexists.Forexample,theycanbeadhoccollaborationsthataredevelopedtodealwithissuesofimmediateconcernandthendisbandedaftertheresolutionoftheacuteproblem.Theycanbebrokeredservicemodelswhereaprimarycareproviderhasdevelopedinformalrelationshipswithotherprovidersandthroughreferralorinteragencyserviceagreementsobtainaccessfortheconsumertoexternalserviceswithoutactualreciprocalcollaboration.Initiativesmightalsoprovidediverseservicesinonesettingwithcompleteintegrationofoperations.Withsuchacollaborativeeffort,servicestarestreamlinedandapermanencyofserviceintegrationoccurs.Thisalsoallowsforstrongcollaborationoutsidethecoreservicegroupwithsuchimportantservicesasshelters,dropincentresandotheradvocacygroupsorserviceproviders.Thistypeofarrangementtendstobemostsuccessfulwiththefullintegrationofservicesthathavetheflexibilitytotreatawidespectrumofillnessseverities.

Inconsideringthedifferenttypesofstrategiesavailable,itisimportanttonotethatnotallnutritionservicesneedtobeprovidedbythesamedietitianinthesamepracticesettingasotherprimarycareproviders.Aneffective


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networking/referralsystemthatlinksdietitiansandothercareproviders,workinginvarietyofcommunitybasedsettings,wouldsignificantlyimprovecontinuityofcareforthementalhealthconsumer.Dependingontheclientsneeds,appropriatelinkagewithdietitiansofdifferentmandatescanbemade.Table1outlineshowdietitiansfromavarietyofsettingscanprovidecomplimentaryservicesforthekeyelementsofprimaryhealthcare.Itisimportanttonote,however,thatsufficientstaffingineachsettingisessentialtoprovidetherequiredcareneededbymentalhealthconsumers.

Primaryhealthcareisdeliveredinmanysettingssuchastheworkplace,home,schools,healthcareinstitutions,theofficesofhealthproviders,homesfortheaged,nursinghomes,daycarecentersandcommunityclinics.Itisalsoavailablebytelephone,healthinformationservicesandtheInternet.Nationalconsultationsforthecollaborativemental

healthcareCharter:synthesisreport,2006(103)

Attitudinalbarriershavebeenidentifiedasanissueincollaborativementalhealthcare(103).Inanationalconsultationprocess,commentsacrossprovidersofvarioushealthdisciplinesindicatedthatlackofmutualrespect,territoriality,silomentality,turfwarsandprofessionalprotectionismimpededcollaborativepractice.Furthertothis,attitudinalbarrierswereseenasacriticalissuethatmustbeaddressedinordertoeffectivelydelivermentalhealthservices.

Keyelementsinestablishingcollaborativeserviceincludeinvolvingallpartnersasequal,buildingstronglinkagestohospitalprograms,developingclearmemorandumsofagreement,clarifyingtherolesandresponsibilitiesofallteammembers,anddevelopingclearprotocolsforsharingofinformation.Dietitianscancontributealottotheseelementsgiventheirskillsincommunitydevelopment.Inparticular,theservicesoutlinedinTable1offersignificantcontributionstothementalhealthconsumerintermsofhealthpromotionandillnessprevention.


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Table 1: A network of dietetics services relative to key elements of primary health care*

Key elements of primary health care (PHC)

Dietetic practice settings

% Dietitians in

practice setting**

Range of comprehensive PHC

nutrition services provided

Utilizes population health strategies

Applies collaborative

practice

Affordable and cost

effective***

Community health centre model with registered dietitians as a salaried member of the interdisciplinary team

6%

Public health/ community dietitians 26%

Mandate is typically to provide population health promotion and disease prevention services

Home Care 20%

Mandate is typically to provide services for homebound clients at risk or with existing medical conditions

Mandate is typically to provide services for homebound clients at risk or with existing medical conditions

* Adapted from Table 2 Dietetics practice A complementary network of services relative to key elements in primary health care (20)

** % of dietitians in each practice setting based on approximation derived from DCs Skills and Practice Registry relative to the number of DC members working in a primary health care setting (N=1390) in 2001

*** The potential for savings relative to decreased hospitalization and long-term disability as a result of nutrition intervention has been well documented (104)


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Table 1: A network of dietetics services relative to key elements of primary health care* continued

Key elements of primary health care (PHC)

Dietetic practice settings

% Dietitians in

practice setting**

Range of comprehensive PHC

nutrition services provided

Utilizes population health strategies

Applies collaborative

practice

Affordable and cost

effective***

Ambulatory/primary care practice 15%

Mandate is typically to provide services for clients at risk or with existing medical conditions

Mandate is typically to provide services for clients at risk or with existing medical conditions

Consulting/Private Practice 33%

Focus is on individuals and groups. Also provide services to community psychiatric facilities, non-profit organizations, etc.

Dietitians maintains client record and liaises with other care providers as needed

Fee for service is a barrier to some clients. Medical insurance coverage available in some instances

* Adapted from Table 2 Dietetics practice A complementary network of services relative to key elements in primary health care (20)

** % of dietitians in each practice setting based on approximation derived from DCs Skills and Practice Registry relative to the number of DC members working in a primary health care setting (N=1390) in 2001

*** The potential for savings relative to decreased hospitalization and long-term disability as a result of nutrition intervention has been well documented (104)


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Richness of collaboration

Thistoolkit(SeriousMentalIllness)hasaddressedanumberoftheissues,especiallythecomorbidconditionssuchasdiabetes,cardiacdisease,andsubstanceabuse.Withtruecollaboration,thesemedicalissuescouldbeaddressedinthemedicalsystem.Howevermanyofourpatientsdonotdowellindiabeticorcardiovascularclinicsastheiruniqueneedsarenotbeingmet.Professionalsatalllevelsneedtobeeducatedaboutthespecificrequirementsofthispopulation.


Thementalhealthconsumerhasdiverseandinterrelatedsetsofdeterminantsofhealthandneedstherebysuggestingtherequirementofanumberofpotentialteamplayerstosupporttheindividual.Teammembersshouldincludetheregistereddietitianalongwithotherprofessionalswithmentalhealthexpertisesuchasthoseoutlinedinthefollowing: Nurse/nursepractitioner Outreachworker Recreationtherapists Socialworker Translator Counselor Housingworker Casemanager Familytherapist Mentalhealthworkers

Occupationaltherapist Physicaltherapist Pharmacist Psychologist Volunteers(including

drivers) Dentist Familyphysician Psychiatrist

Othercommunityagenciesorresourcescanhelpsupportconsumerswhenspecialneedsarise.Potentialcommunitypartnersinclude: Housingprograms Foodbanks Immigrant/refugee

services Police/corrections Hospitaldischarge

planners Publichealth VeteransAffairs Shelters/dropins Homecareservices Employment/vocational

services Publicguardianand

trusteesOffice Addictionprograms Socialservices Communitypsychiatric

facilities LegalAid

Childrensmentalhealthagencies

Transportation Rehabilitationprograms

(e.g.,respiratory) Volunteerorganizations/

advocacygroupsSchools

Religiousgroups Longtermcarefacilities MealsonWheel Community

Kitchens/GardensBuyingclubs/food cooperatives

Supportgroups Recreation Daycarecenters

Hospitaldiabetes anddyslipidemiaprograms


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Serviceagreementsorreferralthroughbrokeredservicescanbeenlistedwiththesecommunityresources.Insomeinstances,theregistereddietitiancanmakeavaluablecontributiontothedevelopmentandmaintenanceofsomeoftheabovementionedprograms(e.g.,communitykitchens,buyingclubsandschoolfoodprograms).

Weneedtotalkaboutmentalillnessmoreandthiswillhelptobreakdownthestigmaattached.

RD,ToolkitparticipantConsumer and family centredness

Consumerparticipationmeansclientsareencouragedtoparticipateinmakingdecisionsabouttheirownhealth,identifyingthehealthneedsoftheircommunityandconsideringthemeritsofalternativeapproachestoaddressingtheseneeds.Involvingmentalhealthserviceconsumersinthedesign,implementationandevaluationofservicesisimperativetotheirsuccess.However,somespecialchallengesmayexistthatcanlimittheirinput.Forexample,duetostigmatizingfactors,mentalhealthconsumersarenotusuallyseenaseffectiveselfadvocates.Inaddition,thoseinspecialpopulationsmayfindparticipationinsuchactivitiesespeciallydemandingandintimidating.Nonetheless,consumershaveavaluableperspectivetocontribute.Somestrategiestoenhanceconsumercentrednessinclude:

Iffamiliesarepresentforthenutritioncounselingorhaveseparateaccesstodietitian,thisimprovesthepotentialforbetteroutcomesinnutritionandotherareas,suchasmedicationcompliance.


Inclusivemeetingsbetweenconsumersandproviders Consumerinvolvementinprogramplanningprocesses Consumerparticipationinprograms(e.g.,peerhelpers) Clientadvocate/complaintsofficerstoaddressconsumers

needs Consumerabilityforselfreferrals Transportationforclientswhocannotreadilyaccess

services

Inparticular,apreferenceforhomebasedcareexistsastheconsumermaybemorelikelytocommunicatemoreeffectivelyinfamiliarsurroundings.Furthermore,theirsurroundingscanprovidevaluableinformationfortheassessment.

Mostconsumersutilizingprimarycareservicesbringoneormorefamilymemberstotheirappointments,thuspresentinganopportunityforfamilyfocusedcare.Evidenceindicatesthatfamilysupport,inconjunctionwithtreatment,leadstobetterclientandfamilyoutcomes,reducesutilizationofacute


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services,increasesawarenessamongfamilymembers,improvesclientandfamilycopingskills,reducescaregiverburdenandimprovesfamilymembersabilitiestosupportandillrelative(105).Familycaregiversrequirefinancial,emotionalandpracticalsupporttohelpthemcopewiththevariousphasesofdebilitatingillnessaffectingtheirlovedone.

Thereneedstobefamilycentrednesswhenevertherearefamilymembersavailable.Itisverychallengingforsomeconsumerstogiveadiethistoryandtoimplementshopping,mealplanning,cookingandfoodportioningadvice.Whenconsumersareisolatedfromfamilyandsocialsupports,IthinktheRDneedstobefocusedonwhatthemostimportantoutcomeshouldbeandkeeptheinterventionadviceappropriatetotheindividualsabilitytoprocessinformationandfollowup.


Dietitiansareparticularlyskilledintheareaofprovidingfamilyfocusedcare.Theirtrainingandexperienceenablesthemtoreviewfoodselectionswithfamiliestoaddressspecificneedsandrequestsandtodevelopnutritioncareplansthatareuniquetoanindividualsneeds.

MywifepropsmeupwhenIamdepressed.ShecooksthemealsandmakessureIameatingwell.ItonlymadesensetotalktoadietitianaboutproblemsIhavewitheatingwhenIamillandtohavemywifetherewithme.



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Important considerations in development of initiatives

Theestablishmentofprimarymentalhealthcareinitiativesincorporatingnutritionservicesnotonlyneedstoconsiderthevisionsofprimaryhealthcare,butshouldalsoincorporatefactorssuchasfamiliaritywithpolicies,legislationandregulations,currentperspectivesonmentalhealth,fundingsources,evidencebasedresearch,appropriatetechnologyandtheneedsofthecommunityserved.Inaddition,considerationsforplanningandevaluationarekeycomponentsoftheprocessofdevelopingtheseinitiatives.

Ingeneral,Ithinkthereisverylittlenutritioncounselingadvicemadeavailabletoconsumerswithmentalhealthchallengesinthecommunity.

RD,Toolkitparticipant Policies, legislation, and regulations

Legislation,professionalregulatoryacts,andpracticestandardsusuallyvarybyprovincialjurisdiction.Registereddietitiansarewelladvisedtobeawareoftherelevantlegislationintheirrespectiveprovince.Someofthesemayinclude: Legislationaffectingageofmajority(abilitytogive

consent) Childwelfarelegislation(affectingdutytoreportcasesof

neglectorabuse)Havingnationallyrecognizedstandardsfornutritionandmentalhealthwouldbebeneficialtoourprofessionandtheconsumersweworkwith.


Privacylegislation,includingbothfederalandprovincial(e.g.,HealthInformationActs)

Professionalregulatoryacts Environmentalprotection(e.g.,foodsafety) CanadaHealthAct Disabilitylegislation YouthCriminalJusticeAct ConventionRelatingtotheStatusofRefugees(United

Nations,1951) CanadianMulticulturalismAct ImmigrationAct Communitypsychiatricfacilitieslicensingstandards Hospital/medicalacts Publicguardianacts Mentalhealthacts Schoolanddaycareguidelinespertainingtotheprovision

offoodservices HumanRightsAct


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CanadianNaturalHealthProductsRegulations Thedevelopmentofrespectfulinterdisciplinaryrelationshipsisvitaltothesuccessofthecollaborativeinitiativesanditisthereforenece

Documents

En Dietitians Toolkit