Mental and substance use disorders in Canada · Mental and substance use disorders in Canada. by Caryn Pearson, ... at some point in their life (Table 1). Since the measurement of

Ar ticle

Mental and substance use disorders in Canada

by Caryn Pearson, Teresa Janz and Jennifer AliHealth Statistics Division

September 2013

Catalogue no.82-624-XISSN 1925-6493

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Mental and substance use disorders in Canadaby Caryn Pearson, Teresa Janz and Jennifer Ali

Highlights

• In2012,atotalof2.8millionCanadiansaged15andolder,or10.1%,reportedsymptomsconsistentwithatleastoneofthefollowingmentalorsubstanceusedisorders:majordepressiveepisode,bipolardisorder,generalizedanxietydisorder,andabuseofordependenceonalcohol,cannabisorotherdrugs.

• Overthecourseofthelifetime,ratesofsubstanceusedisorderswerehigherthantheratesformooddisorders.About6millionCanadiansmetthecriteriaforsubstanceusedisorder,while3.5millionmetthecriteriaformooddisorder.

• Femaleshadhigherratesofmooddisordersandgeneralizedanxietydisorderthanmales,whilemaleshadhigherratesofsubstanceusedisorders.

Mentaldisordersareconditionsthatsignifyconsiderabledistress or disability, behavioural or psychologicaldysfunction,orriskofaharmfulorpooroutcome,suchassuffering,pain,disabilityordeath.1Whilementalhealthdisordersarecommonlyknownfortheirimpactonhealthand well-being, they also have an economic impact intermsofabsenteeism,lossofproductivity,unemploymentandmedical expenses.2A study of the global burden ofdiseasefoundthatmentaldisorderssuchasdepressionandgeneralized anxiety, as well as drug and alcohol use areamongthemaincausesofdisabilityworldwide.3

This article provides results from the 2012 CanadianCommunity Health Survey – Mental Health (CCHS

Statistics Canada, Catalogue no.82-624-X • Health at a Glance, September 2013

Statistics Canada, Catalogue no.82-624-X

Mental and substance use disorders in Canada

Healthat a Glance

– MH). The survey collected information on selecteddisorders fromCanadians aged 15 and older. The dataincludeboth lifetimeand12-monthratesofmentalandsubstance use disorders.This article also highlights dataon generalized anxiety disorder and cannabis abuse ordependencethatwerecollectedatthenationallevelforthefirsttimebyapopulationhealthsurvey.

Lifetimeratesreflectthosewhohavemetthecriteriaforamentalorsubstanceusedisorderatsomepointintheirpast.The12-monthratesprovideinformationregardingcurrentcasesofaconditioninthepopulation.The12-monthratesareusefulforinformingpolicyandprogramsaswellasforcomparingratesovertime.


Mental and substance use disorders in Canada2

Mental or substance use disorders over the lifetime In 2012, 1 in 3 Canadians4 (about 9.1 million people),metthecriteriaforatleastoneofthesixselectedmentalor substance use disorders5 at some point in their life(Table 1).Sincethemeasurementofcertaindisordershaschangedsincethelastsurveyin2002,andthedisordersin2012aredifferent,therateofanymentalorsubstanceusedisorder,aswellasmanyotherratesarenotcomparableovertime(seesection:‘Comparingthecontentofthe2002and2012CanadianCommunityHealthSurvey—MentalHealth’below).

Approximately 21.6% of Canadians (about 6 millionpeople)metthecriteriaforasubstanceusedisorderduringtheir lifetime (Table 1).Alcoholwas themost commonsubstance forwhichpeoplemet the criteria for abuseordependence at 18.1%. More Canadians had symptomsofcannabisabuseordependenceintheir lifetime(6.8%)comparedwithotherdrugs (4.0%).This is thefirst timeanationalrateofcannabisabuseordependencehasbeenassessed.

About3.5millionCanadians,or12.6%,metthecriteriaforamooddisorderduringtheirlifetime.Majordepressiveepisode(depression)accountedforthemajorityofcasesofmooddisorder; about3.2millionpeople, or 11.3%,had

symptomsconsistentwithdepression.About2.6%ofthepopulationhadaprofileconsistentwithbipolardisorder,whichaccountedforaminorityofmooddisordercases.

A total of 2.4 million Canadians reported symptomsconsistentwithgeneralizedanxietydisorderduring theirlifetime. A higher percentage of Canadians met thecriteriaforgeneralizedanxietydisorder(8.7%)thanabuseofordependenceoncannabisorotherdrugs,andbipolardisorder(Table1).

Comparing the content of the 2002 and 2012 Canadian Community Health Survey – Mental Health Mostdisordersmeasured intheCCHS–MH2012arenotcomparable to thedisordersmeasuredbythis surveyin2002.Thisisbecausetheselectionofdisordersusedtodefine certain composite measures of disorders, and thesurveyquestions,differonthetwosurveys.

Additionally,thesurveysmeasuredthedisordersaccordingtocriteriafromtheWorldHealthOrganizationCompositeInternationalDiagnosticInterview3.0(WHO–CIDI),whichwasrevisedafter2002.Specifically,thecriteriausedin 2002 to classify people with bipolar I disorder werefoundtooverestimatetherates.6Asaresultofthischange,the2012rateforbipolarIdisorderisnotcomparablewiththeratecalculatedin2002.

Table 1: Rates of selected mental or substance use disorders, lifetime and 12 month, Canada, household population 15 and older, 2012

Lifetime 12-month

percentMental or substance use disorders1 33.1 10.1

Substance use disorder2 21.6 4.4Alcohol abuse or dependence 18.1 3.2Cannabis abuse or dependence 6.8 1.3Other drug abuse or dependence (excluding Cannabis) 4.0 0.7

Mood disorder3 12.6 5.4Major Depressive Episode 11.3 4.7Bipolar Disorder 2.6 1.5

Generalized Anxiety Disorder 8.7 2.6

1. Mental or substance use disorders is comprised of: substance use disorders, mood disorders and general anxiety disorder. However, these three disorders cannot be added to create this rate because these three categories are not mutually exclusive, meaning that people may have a profile consistent with one or more of these disorders.

2. Substance use disorder includes alcohol abuse or dependence, cannabis abuse or dependence and other drug abuse or dependence.3. Mood disorder includes depression (major depressive episode) and bipolar disorder.Source: Statistics Canada, Canadian Community Health Survey – Mental Health, 2012.


Mental and substance use disorders in Canada 3

Other specific examplesof changes in2012are that theoverallmeasureofmentalorsubstanceusedisorder,bipolardisorder, and drug abuse or dependence are assesseddifferently.Newdisordersaremeasuredforthefirsttime,suchasgeneralizedanxietydisorderandcannabisabuseordependence;whilecertaindisordersarenolongermeasured—socialphobia,agoraphobiaandpanicdisorder.7

Because of these changes the only disorders that canbedirectlycomparedfrom2002to2012aredepressionandan older version of bipolar I disorder (also calledmanicepisode)definedaccordingtothe2002definition.WhenbipolarIdisorderisdefinedusingthe2002definition,the12-month rate remained steadybetween2002and2012ataround1%.In2012,the12-monthratefordepression,approximately5%,alsoremainedstablesince2002.Thisisconsistentwithotherstudieswhichhavealsofoundthatthe prevalence of depression and distress has remainedgenerallystableamongCanadiansoverthepast15years.8

Snapshot of mental health in 2012 In the 12 months prior to the survey, about 1 in 10Canadians, or 2.8 million people, met the criteria for

at least one of the six selected mental or substance usedisorders measured by the CCHS – MH (see textbox:‘Whatyouneedtoknowaboutthisstudy’).

Looking at 12-month rates for the broad categories ofdisorders (Table1), the largest percentageofCanadiansmet the criteria formooddisorders at5.4%.Depressionwas the most common type of mood disorder at 4.7%,while1.5%ofthepopulationmetthecriteriaforbipolardisorder.

Alcoholabuseordependencewasthemostcommontypeofsubstanceusedisorderinthepastyear,with3.2%ofthepopulationhavingaprofileconsistentwithalcoholabuseordependence.TheproportionofCanadianswhometthecriteriaforcannabisabuseordependenceinthepastyear(1.3%)wasalmostdoubletherateofotherdrugabuseordependence(0.7%).

Atotalof2.6%ofCanadiansmetthecriteriaforgeneralizedanxiety disorder in 2012.This is almost half the rate ofsubstanceusedisorder(4.4%),andmooddisorder(5.4%).

Chart 1 Rates of depression, 12-month,1 by age and sex, Canada, household population 15 and older, 2012

Eusewithcaution(thesedatahaveacoefficientofvariationfrom16.6%to33.3%)

1.Respondentswereclassifiedwithdepressioniftheymetthecriteriaforthisconditioninthe12monthspriortothesurvey.Seetextbox:‘Whatyouneedtoknowaboutthisstudy’formoreinformation.

Source: StatisticsCanada,CanadianCommunityHealthSurvey–MentalHealth,2012.

5.3

4.13.4

1.4

9.0

6.8

5.6

1.8

0

2

4

6

8

10

15 to 24 25 to 44 45 to 64 65 or over

percent

Males FemalesAge group

E



Chart 2 Rates of substance use disorders, 12-month,1 by sex, Canada, household population 15 and older, 2012

1.Respondentswereclassifiedwithsubstanceusedisorderiftheymetthecriteriaforthisconditioninthe12monthspriortothesurvey.Seetextbox:‘Whatyouneedtoknowaboutthisstudy’formoreinformation.


4.7

1.9

0.9

1.7

0.70.5

0

1

2

3

4

5

Alcohol abuse or dependence Cannabis abuse or dependence Other drug abuse or dependence

Males Females

percent

Type of abuse or dependence

Rates by age groups and sex, 12-monthIn2012,ratesofmooddisordersandsubstanceusedisordersforthe12monthspriortothesurveytendedtobelowerinolderagegroups.Mooddisorders,forbothmalesandfemales,werehighestamongyouthaged15to24(8.2%),andlowestforthoseaged65andolder(1.7%).Substanceusedisordersfollowedasimilarpattern—highestamongyouth (11.9%) and lowest among adults aged 45 andover (1.9%).Youthhavebeencommonly found inotherstudieshavehigher12-monthratesofmooddisordersandsubstanceusedisordersthanolderagegroups.9Similarly,lowratesofdisordersamongthoseaged65andolderisacommonpatternfoundinotherresearch.10,11

In2012,femaleshadahigherrateofdepressionwithintheprevious12months (5.8%), thanmales (3.6%).Femalesalsohadhigher ratesofdepressionthanmales inallagegroups—exceptamongthoseaged65andolder,wheretheratesweresimilar(Chart1).

For both males and females, rates of depression withinthe past yearwere highest among youth aged 15 to 24,and lowest among those aged 65 and older.The largest

differencebetweenmalesandfemaleswasintheyoungestage group, where among those aged 15 to 24, 9.0% offemales met the criteria for depression, compared with5.3%ofmales.

Generalized anxiety disorderGeneralized anxiety disorder was measured for the firsttime inaCanadiannationalpopulationhealth survey in2012.Similartowhatwasobservedfordepression,femalestendedtohaveahigherrateofgeneralizedanxietydisorder(3.2%) thanmales (2.0%).Unlikedepression,where theratesvariedbyage,theratesofgeneralizedanxietydisorderremained fairly steady across most age groups, rangingfrom 2.4% to 3.0%, until age 65 and olderwhere therewererelativelyfewcases.

Depression(4.7%)wasmorecommonamongCanadiansthan generalized anxiety disorder (2.6%) (Table 1). Ofthosewithgeneralizedanxietydisorder,52.6%alsometthecriteria for depression.This co-occurrence of depressionand generalized anxiety disorder is a commonly foundpatterninotherresearch.12,13



Chart 3 Excellent or very good self-rated mental health among Canadians without and with selected mental or substance disorders, 12-month,1 household population 15 and over, 2012

1.Respondentswereclassifiedwithamentalorsubstanceusedisorderiftheymetthecriteriaforthisconditioninthe12monthspriortothesurvey.Seetextbox:‘Whatyouneedtoknowaboutthisstudy’formoreinformation.


0

10

20

30

40

50

60

70

80

No mental or substance disorder

Mental or substanceuse disorder

Substance use disorder

Mood disorder Generalized anxiety disorder

percent

Very good or excellent self rated mental health

69.5

29.6

42.6

19.513.9

Perceptions of mental healthCanadianswithamentalorsubstanceusedisorderwithinthepast yearwere less likely to rate theirmental healthas positive during the same time frame, compared withthosewhodidnothaveamentalorsubstanceusedisorder(Chart 3).Approximately29.6%of thosewith amentalor substance use disorder perceived their mental healthasverygoodorexcellent.Thisfindingmaypartly reflecttheepisodicnatureofthesedisorders,sincetheycanoccurbetweenperiodsofgoodhealth.

People with a profile consistent with substance usedisorderratedtheirmentalhealthmuchhigherthanthosewith mood disorder or generalized anxiety disorder. Ahigher proportionof peoplewith substanceusedisorderrated their mental health as excellent or very good(42.6%),comparedtothosewithmooddisorder(19.5%)or generalized anxiety disorder (13.9%) — whose self-evaluationsofmentalhealthwereroughlythesame.

Substance use disordersSimilartowhatwasfoundfordepression,youthhadhigherratesofsubstanceusedisordersthanallotheragegroups.Youthaged15to24hadthehighestrateofsubstanceusedisorder(11.9%),whilethelowestrate,1.9%,wasamongthoseaged45andolder.14Youthhavealsobeenfoundinotherstudiestohavethehighestratesofsubstanceabuseordependence.15

Unlikedepressionandgeneralizedanxietydisorderwherefemaleswerefoundtohavehigherrates,maleshadhigherrates of substance use disorders in the past 12 months.Approximately6.4%ofmalesand2.5%offemalesreportedsymptomsconsistentwithsubstanceusedisorder.

Whilemalesandfemaleshadsimilarratesofother(non-cannabis) drug abuse or dependence over the past year,maleshadhigherratesofabuseofordependenceonalcoholandcannabisthandidfemales.Thatis,approximately4.7%ofmalesand1.7%offemalesmetthecriteriaforalcoholabuseordependenceinthepastyear;and1.9%ofmalesand0.7%offemalesmetthecriteriaforcannabisabuseordependence.



SummaryIn2012,1in10Canadiansmetthecriteriaforatleastoneofthesixselectedmentalorsubstancedisorders.

Due to changes inmeasurement, aswell as the suite ofdisordersassessed,veryfewcomparisonscanbemadewithdisordersmeasured in the 2002 survey.Only depressionandanolderversionofbipolarIdisorderdefinedaccordingtothecriteriain2002(manicepisode),canbecomparedwith2002.Forbothdisorders,theratesremainedrelativelystablebetween2002and2012.

In 2012, females had higher rates of depressionand anxiety disorders than males, and males hadhigher rates of substance use disorders. Rates of mood

disordersandsubstanceusedisorderstendedtobehighamongyouthandlowamongtheoldestagegroups.

Caryn Pearson, Teresa Janz and Jennifer Ali are analysts with the Health Statistics Division

The authors wish to thank Brenda Wannell, Cathy Trainor, Leanne Findlay, Adam Sunderland and Melanie Hoover for their contributions. Thank you also to Dr. Scott Patten from the University of Calgary for his expertise.



The rates given for mental and substance use disorders may bean underestimate of the extent of these issues in the Canadianpopulation.ThisisbecausetheCCHS–MHmeasuredselectmentaland substance use disorders,meaning not all disorders have beencoveredbythesurvey.ExcludedfromthesurveyarepersonslivingonreservesandotherAboriginalsettlements,full-timemembersoftheCanadianForces,andtheinstitutionalizedpopulation.

Mental or substance use disordersTheCCHS–MHusedtheWorldHealthOrganization-CompositeInternational Diagnostic Interview 3.0 (WHO-CIDI) to classifypeoplewithselectmentalorsubstanceusedisorders.Althoughthisisnotaclinicaldiagnosis,thisisastandardizedinstrumentthatistypically used to assessmental disorders in population surveys16,17according to the Diagnostic and Statistical Manual of MentalDisordersversionIV(DSM-IV)criteria.18

Thispaperanalyzes thesixCIDIdisordersassessed in thesurvey.The survey also asks respondents other questions about chronicconditions diagnosed by a health professional, such as: eatingdisorders,post-traumaticstressdisorder,attentiondeficitdisorder,obsessivecompulsivedisorder,Alzheimer’sorotherdementia,andschizophreniaandotherpsychosis(toseetheratesforsomeofthesedisorders,seeCANSIMtable105-1101).However,notethat themeasurementofchronicconditions(whichisdiagnosedbyahealthprofessional)isnotcomparabletotheCIDImeasurement(whichisbasedonsymptoms).

FollowingthemeasuresfromtheCIDI,thefollowingsixdisorderswereincludedintheCCHS–MH(lifetimeand12-month):

1. Depression (major depressive episode):isidentifiedasaperiodof2weeksormorewithpersistentdepressedmoodorlossofinterestinnormalactivities,aswellasothersymptomsincluding:decreasedenergy,changesinsleepandappetite,impairedconcentration,feelingsofhopelessness,orsuicidalthoughts.

2. Bipolar disorder:includesrespondentswhomeetthecriteriaforbipolarIdisorderorhypomanicepisode,whichincludesbipolarIIdisorder.Itischaracterizedbyatleast7days(orfewerifhospitalized)ofexaggeratedfeelingsofelevated

orirritablemoodplusacertainnumberandcombinationofothermanicsymptomssuchasracingthoughts,talkingmorethanusual,excessivespending,decreasedneedforsleep,increasedpleasureseekingactivity,orexaggeratedself-confidence.Manypeoplealsoexperienceatleastonedepressiveepisode.

3. Generalized anxiety disorder: isidentifiedbyapatternoffrequent,persistentworryandexcessiveanxietyaboutseveraleventsoractivitieslastingatleast6monthsalongwithothersymptoms.19

4. Alcohol abuse or dependence:includesthosewhometthecriteriaforabuseordependence(seedefinitionsofabuseordependencebelow)ofalcohol.

5. Cannabis abuse or dependence:includesthosewhometthecriteriaforabuseordependence(seedefinitionsbelow)ofcannabis.Wherepossible,cannabisabuseordependenceisanalyzedseparatelyfromotherdrugabuseordependence.

6. Other drug abuse or dependence (excluding cannabis):includesthosewhometthecriteriaforabuseordependence(seedefinitionsbelow)ofsubstancessuchasclubdrugs,cocaine,heroin,solvents,prescriptiondrugsusedfornonmedicalreasons,andanyotherillicitdrugs.

Abuse is characterizedby a pattern of recurrentuse where at least one of the following occurs:failure to fulfill major roles at work, school orhome, use in physically hazardous situations,recurrent alcohol or drug related problems, andcontinued use despite social or interpersonalproblemscausedorintensifiedbyalcoholordrugs.

Dependenceiswhenatleastthreeofthefollowingoccur in the same 12 month period: increasedtolerance, withdrawal, increased consumption,unsuccessful efforts to quit, a lot of time lostrecoveringorusing,reducedactivity,andcontinueduse despite persistent physical or psychologicalproblemscausedorintensifiedbyalcoholordrugs.

What you need to know about this study:



Notes1. SeeAmericanPsychiatricAssociation2000.

2. SeeLimetal.2008.

3. SeeInstituteforHealthMetricsandEvaluation.

4. MentalorsubstanceusedisordersweredeterminedbyanalgorithmbasedonresponsesusingtheCIDIandnotaclinicaldiagnosis.TheCCHS–MHmeasured select disorders ofCanadians aged 15 andolder.Theinstitutionalizedpopulationwerealsoexcludedfromthesamplewhichmayhaveledtoanunderestimationoftheprevalenceofmentalorsubstanceusedisorders.

5. The six selecteddisorders includemajordepressive episode,bipolardisorder, generalized anxiety disorder, alcohol abuse or dependence,cannabisabuseordependence,andotherdrugabuseordependence.These disorders cannot be added to create an overall total as thesedisordersarenotmutually exclusive,meaning thatpeoplemayhavehadaprofileconsistentwithoneormoreofthesedisorders.

6. PleaseseetheCCHSuserguideforadetailedoverviewofthechangestothemeasure.

7. SeeCCHS–MHUserGuideforfulldetailofthedifferences.

8. SeeSimpsonetal.2012.

9. SeeKessleretal.2010.



12. SeeBelzeretal.2004.

13. SeeNguyenetal.2005.

14. Theagegroupsof45to64and65andolderwerecombinedintooneagegroupof45andolderfortheanalysisofsubstanceusedisordersduetothesmallsampleofthose65andolderwithsubstanceusedisorders.



17. SeeAustralianBureauofStatistics,2009.

18. SeeCCHS–MHUserGuide.

19. Other symptoms of generalized anxiety disorder include difficultyconcentrating, irritability, sleep disturbance, shortness of breath,gastrointestinal symptoms, or restlessness. This anxiety is difficultto control and causes significant impairment when attempting toparticipateinnormaldailyactivities

ReferencesAustralianBureauofStatistics.2007 National Survey of Mental Health

and Welling: User’s guide (cat. No. 4327.0). Canberra: AustralianBureau of Statistics. http://www.abs.gov.au/AUSSTATS/[email protected]/Latestproducts/4327.0Main%20Features42007?opendocument&tabname=Summary&prodno=4327.0&issue=2007&num=&view=(accessedApril29,2013).

AmericanPsychiatricAssociation.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.Washington,DC:AmericanPsychiatricAssociation,2000.

Belzer,KennethandFranklinSchneier.2004.“Comorbidityofanxietyanddepressivedisorders:issuesinconceptualization,assessmentandtreatment.”Journal of Psychiatric Practice.Vol.10,no.5.

InstituteforHealthMetricsandEvaluation.The Global Burden of Disease: Generating Evidence, Guiding Policy.Seattle:UniversityofWashington,2013.

Kessler,Ronald,KatherineMcGonagle,ShanyangZhao,ChristopherNelson,MichaelHughes,SuzannEshleman,Hans-UlrichWittchenandKennethKendler. 1994.“Lifetimeand12-MonthPrevalenceofDSM-III-RPsychiatricDisorders in theUnitedStates.”Results from the National Comorbidity Survey.Vol.51.P8-19.

Kessler,Ronald,PatriciaBerglund,WaiTatChiu,OlgaDemler,StevenHeeringa,EvaHiripi,RobertJin,Beth-EllenPennell,EllenWalters,AlanZaslavskyandHuiZheng.2004.“TheUSNationalComorbiditySurveyReplication(NCS-R):Designandfieldprocedures.”International Journal of Methods in Psychiatric Research.Vol.13,no.2.P1369-92.http://ek5mt5zz7v.scholar.serialssolutions.com/?sid=google&auinit=RC&aulast=Kessler&atitle=The+US+National+Comorbidity+Survey+Replication+(NCS%E2%80%90R):+design+and+field+procedures&id=doi:10.1002/mpr.167&title=International+journal+of+methods+in+psychiatric+research&volume=13&issue=2&date=2004&spage=69&issn=1049-8931(accessedMay14,2013).

Kessler,Ronald,HowardBirnbaum,VictoriaShahly,EvelynBromet,IrvingHwang,KatieMcLaughlin,NancySampson,LauraHelenaAndrade,GiovannideGirolamo,KoenDemyttenaere,JosepMariaHaro,AimeeKaram,StanislavKostyuchenko,VivianeKovess,CarmenLara,DaphnaLevinson,HerbertMatschinger,YoshibumiNakane,MarkOakleyBrowne,JohanOrmel,JosePosada-Villa,RajeshSagarandDanStein.2010.“AgedifferencesintheprevalenceandcomorbidityofDSM-IVmajordepressiveepisodes:ResultsfromtheWHOWorldMentalHealthSurveyInitiative.”Depress Anxiety.Vol.27,no.4.P351-364.

LimK-L,JacobsP,OhinmaaA,SchopflocherD,andCSDewa.2008.“AnewPopulation-basedmeasureoftheeconomicburdenofmentalillnessinCanada.”Chronic Diseases in Canada.Vol.28,no.3.p92-98. http://publications.gc.ca/collections/collection_2009/aspc-phac/H12-27-28-3E.pdf (accessedMarch28,2013).

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Mental and substance use disorders in Canada · Mental and substance use disorders in Canada. by Caryn Pearson, ... at some point in their life (Table 1). Since the measurement of