It's time to recognize mental illness as a chronic disease in our healthcare system

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In 2011 Dr. Richard Lewanczuk, an epidemiologist and chronic disease researcher in Alberta, posed an intriguing question to a collection of mental health experts during a lecture entitled “Principles of Chronic Disease Management” (Lewanczuk, 2011).  In his opening lines, Lewanczuk asked his audience, “Can we apply the principles of chronic disease management to addiction?” This question is intriguing to me because it suggests there is a need to transform chronic disease prevention and management (CDPM) to include chronic mental health disorders. For this blog post I decided to ask the question, does chronic mental illness fit within the current chronic disease model? I've learned that, for the province of Alberta, there is a definite gap between what is stated in guiding documents and what is practiced in healthcare services. 

There is no question that chronic disease is a significant healthcare issue in Alberta. According to the Canadian Chronic Disease Indicators (CCDI) tool , approximately 40% of Albertans aged 20 years or older have at least one major chronic disease (Public Health Agency of Canada, 2018).  The tool includes 10 major chronic diseases in the reported data: (a) heart disease, (b) stroke, (c) cancer (ever had), (d) asthma, (e) chronic obstructive pulmonary disease, (f) diabetes, (g) arthritis, (h) Alzheimer’s disease or other dementia, and (i) mood disorders and/or anxiety disorders. While mental health disorders are recognized as chronic diseases in the national data collection tool, the recognition of mental health disorders as chronic disease by Alberta service providers is not so clear.

Current CDPM services in Alberta do not specifically address chronic mental health disorders. Alberta Health Services (AHS) and The Alberta Policy Coalition for Chronic Disease Prevention (APCCP) represent some of the major players in current CDPM action in the province. The Alberta Health Services (AHS) Chronic Disease Management Team and Chronic Disease Prevention Team list the following chronic diseases as their focus: (a) cancer, (b) cardiovascular disease (heart disease, stroke, hypertension), (c) diabetes, (d) obesity, (e) lung diseases (chronic obstructive pulmonary disease), and (f) asthma (AHS, 2019). There is no mention of mental health disorders within these teams. The 2015-2018 AHS Chronic Disease Prevention Action Plan includes stress as a modifiable risk factor to major chronic diseases, but does include mental health disorders as chronic disease (AHS, 2016a). Currently, mental health conditions and disorders are addressed by a separate Addictions and Mental Health Team within AHS. APCCP includes healthy eating, active living, alcohol-related harm, tobacco reduction, and investment in prevention as their priority areas of action (APCCP, 2016). Once again, there is no specific mention of chronic mental health disorders within current APCCP guiding documents. Regardless of strategic discussions currently taking place, the public perception of AHS and APCCP is that addiction and mental illness are not considered to be chronic disease priorities.

However, there are clear indications that in the future CDPM services in Alberta will recognize chronic mental health conditions and disorders. In the 2014 Report on the Auditor General of Alberta, depression is listed as a major chronic disease (Office of the Auditor General, 2014).  In A Vision for Chronic Condition and Disease Prevention and Management, Alberta Health Services defines chronic health conditions as “persistent or otherwise long lasting… [that] can occur at any age, and span non-communicable and communicable disease, and are inclusive of neurological conditions and mental health” (AHS, 2016b, p. 17). The AHS Chronic Disease Prevention Team consulted the AHS Addictions and Mental Health Team in the creation of this vision document. These are some of the first signs of a large-scale shift in thinking about mental health disorders as a chronic condition requiring alignment with CDPM strategies in Alberta.

Ontario is one province with a similar CDPM climate. The Ontario government has committed to supporting Health Teams, which provides clients with a medical home from which they can receive access to primary care and specialized services (B. Ho, personal communication, July 29, 2019). This supports collaborative care, but does it recognize mental illness as a chronic disease? In a recent class discussion, another colleague shared this about CDPM in Ontario:

The Government of Ontario published a Chronic Disease Prevention Guideline which

includes mental illness as a chronic disease of public health importance.  Depression

is one of the top 10 chronic conditions in Ontario and is the most common metal

health problem faced by Ontarians.  However Public Health Ontario's scope of

chronic diseases is much more narrowly focused and does not include mental health. 

Until recently, Ontario have viewed mental illness as a separate condition but there is

a new policy framework being implemented entitled "Making it Happen" that will

develop a client centered system of services and supports to increase efficiency and

accountability. (K.A. Keenan, personal communication, June 27, 2019)

British Columbia appears to be a national leader in recognizing chronic mental health as a chronic disease in both vison and in practice. While conducting my own research for a blog post on mental wellness in pregnancy, I discovered British Columbia is the only province in Canada with a best practice guideline for the prevention and management of chronic mental health disorders during pregnancy. In another class discussion, a colleague from British Columbia shared this about CDPM in her province:

In BC, mental health is considered one of the five chronic diseases, along with

cardiovascular diseases, cancer, respiratory disease and diabetes (BC Healthy Living

Alliance, 2009, p. 6). In many BC papers and websites, depression is listed as one of

the major mental health illnesses that falls under chronic disease. (B. Denicola,

personal communication, June 27, 2019)

I believe Alberta service providers could learn much from British Columbia when it comes to recognizing chronic mental health disorders in the chronic disease model. Although the AHS chronic disease vision document was published in 2016, it is taking years for the knowledge in the vision to be demonstrated in practice. I will be keeping a close eye on how the Alberta CDPM vision is realized within our province’s healthcare system in the years to come. I believe the vision is an essential tool for recognizing mental illness as chronic disease in Alberta.

References

Alberta Health Services. (2016a). AHS Chronic Disease Prevention Action Plan 2015-2018. Retrieved from https://www.albertahealthservices.ca/assets/info/cdp/if-cdp-action-plan.pdf

Alberta Health Services. (2016b). A Vision for Chronic Condition and Disease Prevention and Management. Retrieved from https://www.albertahealthservices.ca/assets/info/hp/cdm/if-hp-cdm-ccdmp-strategy.pdf

Alberta Health Services. (2019). Chronic Disease Prevention. Retrieved from https://www.albertahealthservices.ca/info/Page15338.aspx

Alberta Policy Coalition for Chronic Disease Prevention. A wellness foundation for Alberta: It’s about health. It's about time. Retrieved from http://abpolicycoalitionforprevention.ca/healthy-communities/prevention/#1475449239784-9c199076-1624

BC Healthy Living Alliance (2009). Healthy futures for BC families: policy recommendations for improving the health of British Columbians. Retrieved from https://www.bchealthyliving.ca/wp-content/uploads/2014/07/BCHLA_Healthy_Futures_Final_Web.pdf

BC Reproductive Mental Health Program & Perinatal Services. (2014).  Best Practice Guidelines for Mental Health Disorders in the Perinatal Period. Retrieved from http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MentalHealthDisordersGuideline.pdf

Lewanczuk, R. (2011). Principles of Chronic Disease Management [Video file]. Retrieved from https://www.albertafamilywellness.org/resources/video/principles-of-chronic-disease-management

Office of the Auditor General. (2014). Report of the Auditor General of Alberta. Retrieved from https://www.oag.ab.ca/reports/health-report-chronic-disease-management-sept-2014

Public Health Agency of Canada. (2018).  Canadian Chronic Disease Indicators, Quick Stats, 2018 Edition. Retrieved from https://health-infobase.canada.ca/ccdi/