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Community mental health services benefit from measuring clinical outcomes relevant to a community-based context in contrast to medically modeled outcomes. The Multnomah Community Ability Scale (MCAS) addresses broad dimensions of community functioning and was developed for clinical and evaluation purposes. We assessed the structural consistency and fit of the scale as a measure of community functioning through confirmatory factor analysis using a longitudinal sample of individuals (n=408) with severe and persistent mental illness receiving services from community mental health programs. None of the previously hypothesised factor solutions achieved a good fit and a high degree of invariance over time was observed. Through exploratory factor analysis, the possibility of alternative solutions was explored. After exclusion of two of the 17 items, four models--including four-, three-, two- and one-factor solutions--were tested for fit and invariance with no improvement. We discuss our findings of poor fit under the assumption that the MCAS should psychometrically behave as a scale. Alternative interpretations for the tool and suggestions for the use of its items as an index that measures aspects of disability are proposed.

The most recent review of the workplace prevention literature was published two decades ago. Since then, interest has been growing in the business and research communities in preventive workplace interventions. At the same time, there has been an increasing recognition of the complexity of developing workplace interventions. This study's purpose is to assess the literature from 2001 to 2006 using Cottrell's conceptualization to: 1) conduct a systematic review of the most recent literature, 2) describe the preventive psychological interventions for workers, 3) summarize the significant work- and health-related outcomes associated with these interventions, and 4) identify where the significant gaps still exist. Twenty-four studies on primary and secondary interventions regarding mental health issues in organizations were included and analyzed in this systematic review. Eight studies were identified as primary interventions, 14 were identified as secondary interventions, and 2 included both. There was a predominance of studies utilizing skills training. One-third of studies used a combination of individual, group and organization level interventions, most often supported by psychosocial intervention or participatory research. These components brought positive and significant results with regard to work and mental health outcomes to workers.

The rise in globalization, new technologies and changes in workforce demographics have created new work environments. As a result, countries around the world are seeking to restructure their educational systems to better prepare future generations for the challenges that they will face in this new labour market. These trends have also introduced new and increased demands on the educational sector and especially school principals who are responsible for the quality of education in schools. This study examines the association between mental health status and self-reported working conditions of principals. Our findings highlight potential mental health problems among principals. The results provide evidence that their satisifaction with their work characteristics are associated with their mental health status. They also indicate areas in which school boards may be well positioned to address some of the potential organizational difficulties encountered by this group.

Compared to the rest of the working population, individuals with a mental disorder have greater numbers of days during which they are either unproductive or unable to function at full capacity (Dewa and Lin 2000; Lim et al. 2000). About one-third of society's depression-related productivity losses can be attributed to these work disruptions (Greenberg et al. 2003). This study builds on previous work in which we observed that timely antidepressant use was associated with significant decreases in disability for workers on depression-related, short-term disability leave (SDIS) (Dewa et al. 2003). In this analysis, we examine the association between prior out-of-pocket drug expenditures and timely antidepressant use. We look at three outcomes in relation to previous annual out-of-pocket expenditures: (a) the likelihood of filling an antidepressant prescription during SDIS, (b) the likelihood of starting an antidepressant after SDIS begins and (c) the length of time before starting an antidepressant after SDIS begins.

Recruitment and retention of research participants is often the most labor-intensive and difficult component of clinical trials. Poor recruitment and retention frequently pose as a major barrier in the successful completion of clinical trials. In fact, many studies are prematurely terminated, or their findings questioned due to low recruitment and retention rates. The conduct of clinical trials involving youth with a first episode of mental illness comes with additional challenges in recruitment and retention including barriers associated with engagement and family involvement. To develop effective early interventions for first episode mental illness, it is necessary to develop strategies to enhance recruitment and retention in this patient population. This article presents the recruitment and retention challenges experienced in two clinical trials: one involving participants experiencing a first episode of depression and one involving participants experiencing a first episode psychosis. Challenges with recruitment and retention are identified and reviewed at both the patient level and clinician level. Strategies that were implemented to enhance recruitment and retention in these two studies are also discussed. Finally, ethical issues to consider when implementing these strategies are also highlighted.

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care.The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year.The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%).Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

The cost of health care services and supports for mental health and addictions is important to know. In order to calculate it, one must know who is receiving what is being provided by whom at what price. Without tracking these types of data, it is difficult to know the cost of the activities being provided. The systematic collection and analysis of such data allows decision makers to become more aware of how money is being spent. Without this information, it is difficult to evaluate different models of care or determine relative responsibilities of different government players. As a case study, we describe the analysis and findings of a project to assess the costs of mental health and addiction services within homeless shelters in Toronto, Ontario, Canada.

Objective: To measure total public and private expenditures on mental health in each province. Method: Data for expenditures on mental health services were collected in the following categories: physician expenditures (general and psychiatrist fees for service and alternative funding), inpatient hospital (psychiatric and general), outpatient hospital, community mental health, pharmaceuticals, and substance abuse. Data for 2 years, 2003 and 2004, were collected from the Canadian Institute for Health Information (hospital inpatient and fees for service physicians), the individual provinces (pharmaceuticals, alternative physician payments, hospital outpatient, and community), and the Canadian Centre on Substance Abuse. Totals were expressed in terms of per capita and as a percentage of total provincial health spending. Results: Total spending on mental health was $6.6 billion, of which $5.5 billion was from public sources. Nationally, the largest portion of expenditures was for hospitals, followed by community mental health expenses and pharmaceuticals. This varied by province. Public mental health spending was 6% of total public spending on health, while total mental health spending was 5% of total health spending. Conclusions: Canadian public mental health spending is lower than most developed countries, and a little below the minimum acceptable amount (5%) stated by the European Mental Health Economics Network.

Nous présentons ici une mesure globale du fardeau économique excédentaire associé à la maladie mentale au Canada, qui tient compte de l'utilisation des ressources médicales et des pertes de productivité imputables aux incapacités de courte et de longue durée, ainsi que de la diminution de la qualité de vie liée à l'état de santé (QVLES), dans la population de personnes souffrant de problèmes de santé mentale, diagnostiqués ou non. L'analyse était fondée sur le cycle 2.1 de l'Enquête sur la santé dans les collectivités canadiennes (2003), réalisée auprès de la population. Nous avons mesuré, à l'égard de tous les sujets, tous les services de santé utilisés, la perte de productivité attribuable à une incapacité de courte ou de longue durée et la qualité de vie liée à l'état de santé, et déterminé la valeur de ces facteurs en dollars; le fardeau économique est la différence, représentée par la valeur en dollars de ces facteurs, entre les populations souffrant ou non de maladies mentales. Le fardeau économique total s'est chiffré à 51 milliards $ en 2003. Plus de la moitié de ce fardeau était associé à une diminution de la QVLES. La pratique courante est d'inclure dans les évaluations économiques les changements liés à l'utilisation des ressources médicales, la perte de productivité et la diminution de la QVLES.

Investigations of socio-economic gradients in mental health services use in Canada have used different measures of socio-economic status and have shown conflicting results. We explored the relationships between education level, income level and mental health services use among people with a mental illness using data from the Canadian Community Health Survey: Cycle 1.2.We included adults who met the criteria for an anxiety or depressive disorder in the past 12 months (n=3,101). We calculated the likelihood of seeking mental healthcare from a psychiatrist, psychologist, family physician or social worker over a period of 12 months by education level.For each additional level of education, individuals were 15% more likely to see a psychiatrist, 12% more likely to see a family doctor, 16% more likely to see a psychologist and 16% more likely to see a social worker.We found marked inequity in mental health services use by education level that was consistent across service types. Programs aiming to deliver targeted services to consumers who have not completed high school should be developed and evaluated.

There appear to be links between psychiatric disorders and work-related stress as well as between psychiatric disorders and physical conditions. This study explores the relationships between chronic work stress, psychiatric disorders, and chronic physical conditions and disability among workers. By doing so, this study sought to understand how these factors are associated with worker disability when they are experienced alone versus in combination with one another.The study population was drawn from the Canadian Community Health Survey 1.2, a national population-based survey that gathered cross-sectional data on health status from 22,118 working respondents. The relationship between chronic work stress, chronic physical conditions, and psychiatric disorders and disability in the past 14 days was examined for working respondents by using logistic regressions controlling for sociodemographic characteristics, region, and occupation.Thirty-one percent of respondents experienced chronic work stress either alone or in combination with a chronic physical condition, a psychiatric disorder, or both. Forty-six percent reported at least one chronic physical condition either alone or in combination. Finally, 11% had a psychiatric disorder. Compared with the group with none of the factors, those with an increasing number of combined conditions had increasing odds of disability after the analysis controlled for sociodemographic characteristics, occupation, and region.The presence of chronic work stress seems to amplify effects of psychiatric disorders and chronic physical conditions on disability. In addition, psychiatric disorders co-occurring with physical illness seem to be associated with significantly higher odds of disability.

Objectives: Despite being recognized as a serious public health concern, suicidality among adolescents and young adults is frequently missed, and completed suicide remains the second leading cause of death for young Canadians. With such close links between depression, suicidality, and completed suicide, any intervention must address all 3 of these issues. However, to develop effective interventions, we must understand the types and rates of mental health service use among adolescents and young adults. This study examines service use rates in young Canadians with depression and suicidality and the influence of sex on the types of service provider chosen. Methods: We used data from the Canadian Community Health Survey: Mental Health and Well-Being. Our sample included 619 individuals, aged 15 to 24 years, who screened positive for depression and suicidality in the past 12 months. We examined mental health service use rates in general and by provider type. Results: Among adolescents aged 15 to 18 years with depression, 40% had not used any mental health services. This rate was higher for adolescents with suicidality at 50%. In young adults aged 19 to 24 with depression, 42% had not used any mental health services. Among young adults with suicidality, 48% had not accessed services. Female adolescents and young adults were more likely to receive services from nonspecialty mental health providers. Conclusions: In Canada, many adolescents and young adults with depression and suicidality do not receive mental health services. Further, there may be a preferential treatment of young men by mental health specialists. Further research is needed to understand the quality of care received by these young Canadians and the factors influencing service use.

Objective: Socially disadvantaged individuals are at high risk for having their mental health service needs unmet. We explored the relations among education level, income level, and self-reported barriers to mental health service use for individuals with a mental illness, using data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Methods: Our sample group comprised the 8.3% of adult respondents who met the CCHS 1.2 criteria for an anxiety or affective disorder in the past 12 months ( n = 3101). We examined the association between education and income levels and self-reported accessibility, availability, or acceptability barriers to mental health care. Results: Accessibility, availability, and acceptability barriers were reported by 3%, 5%, and 16% of our sample, respectively. Individuals with a high school diploma were less likely than individuals without a high school diploma to report acceptability barriers to care (odds ratio 0.65; 95% confidence interval, 0.45 to 0.93). Higher-income individuals were less likely than lower-income individuals to report acceptability barriers to care (odds ratio 0.69; 95% confidence interval, 0.50 to 0.96). Employment, distress level, age, and family structure were also associated with acceptability barriers. Conclusion: Issues related to acceptability explain most of the unmet need for mental health services. Program planners should consider the development of targeted approaches to service delivery and outreach for low-income, working individuals who have not completed high school.

The principal aim of this article is to share lessons learned by the authors while conducting economic evaluations, using clinical trial data, of mental health interventions. These lessons are quite general and have clear relevance for pharmacoeconomic studies. In addition, we explore how net benefit regression can be used to enhance consideration of key issues when conducting an economic evaluation based on clinical trial data. The first study we discuss found that cost-effectiveness results varied markedly based on the choice of both the patient outcome and the willingness to pay for more of that outcome. The importance of willingness to pay was also highlighted in the results from the second study. Even with a set willingness-to-pay value, most of the time the probability that the new treatment was cost effective was not 100%. In the third study, the cost effectiveness of the new treatment varied by patient characteristics. These observations have important implications for pharmacoeconomic studies. Namely, analysts must carefully consider choice of patient outcome, willingness to pay, patient heterogeneity and the statistical uncertainty inherent in the data. Net benefit regression is a useful technique for exploring these crucial issues when undertaking an economic evaluation using patient-level data on both costs and effects.

Background Although a growing number of collaborative mental health care models have been developed, targeting specific populations, few studies have utilized such interventions among homeless populations. This quasi-experimental study compared the outcomes of two shelter-based collaborative mental health care models for men experiencing homelessness and mental illness: (1) an integrated multidisciplinary collaborative care (IMCC) model and (2) a less resource intensive shifted outpatient collaborative care (SOCC) model. Methods In total 142 participants, 70 from IMCC and 72 from SOCC were enrolled and followed for 12 months. Outcome measures included community functioning, residential stability, and health service use. Multivariate regression models were used to compare study arms with respect to change in community functioning, residential stability, and health service use outcomes over time and to identify baseline demographic, clinical or homelessness variables associated with observed changes in these domains. Results We observed improvements in both programs over time on measures of community functioning, residential stability, hospitalizations, emergency department visits and community physician visits, with no significant differences between groups over time on these outcome measures. Conclusions Our findings suggest that shelter-based collaborative mental health care models may be effective for individuals experiencing homelessness and mental illness. Future studies should seek to confirm these findings and examine the cost effectiveness of collaborative care models for this population.

Objectives This paper reviews the current state of the published peer-reviewed literature related to return-to-work (RTW) interventions that incorporate work-related problem-solving skills for workers with sickness absences related to mental disorders. It addresses the question: What is the evidence for the effectiveness of these RTW interventions?Design Using a multiphase screening process, this systematic literature review was based on publically available peer-reviewed studies. Five electronic databases were searched: (1) Medline Current, (2) Medline In-process, (3) PsycINFO, (4) Econlit and (5) Web of Science.Setting The focus was on RTW interventions for workers with medically certified sickness absences related to mental disorders.Participants Workers with medically certified sickness absences related to mental disorders.Interventions RTW intervention included work-focused problem-solving skills.Primary and secondary outcome measures RTW rates and length of sickness absences.Results There were 4709 unique citations identified. Of these, eight articles representing a total of six studies were included in the review. In terms of bias avoidance, two of the six studies were rated as excellent, two as good and two as weak. Five studies were from the Netherlands; one was from Norway. There was variability among the studies with regard to RTW findings. Two of three studies reported significant differences in RTW rates between the intervention and control groups. One of six studies observed a significant difference in sickness absence duration between intervention and control groups.Conclusions There is limited evidence that combinations of interventions that include work-related problem-solving skills are effective in RTW outcomes. The evidence could be strengthened if future studies included more detailed examinations of intervention adherence and changes in problem-solving skills. Future studies should also examine the long-term effects of problem-solving skills on sickness absence recurrence and work productivity.

Functional recovery is increasingly recognized as a priority in the treatment of major depressive disorder (MDD), by both clinicians and patients. However, symptom improvement remains the focus of traditional clinical trials for MDD and of the regulatory approval process for new medications and other interventions. Many studies have shown that functional outcomes do not always correspond to symptom-based outcomes.Representatives from clinical practice, professional societies, academia, industry, and government were invited by the Canadian Network for Mood and Anxiety Treatments to develop recommendations for the conceptualization and measurement of functional outcomes in clinical trials of MDD.Definitions and conceptual frameworks to guide assessment of functioning are described, as well as research methodology applicable to the broad spectrum of treatments for MDD. Examples are given for validated instruments, including patient-reported outcome measures. Strategies for knowledge translation and dissemination are suggested and consensus recommendations summarized.As the societal burden and financial costs of MDD continue to escalate, so does the need for evidence-based and cost-effective interventions that demonstrate improvement in functioning. Routine assessment of functional outcomes will benefit not only individuals with MDD but also diverse stakeholders concerned about the efficacy and cost-effectiveness of interventions.

Revisions to the posttraumatic stress disorder (PTSD) diagnostic criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) clarify that secondary exposure can lead to the development of impairing symptoms requiring treatment. Historically known as secondary traumatic stress (STS), this reaction occurs through repeatedly hearing the details of traumatic events experienced by others. Professionals who work therapeutically with trauma victims may be at particular risk for this exposure. This meta-analysis of 38 published studies examines 17 risk factors for STS among professionals indirectly exposed to trauma through their therapeutic work with trauma victims. Small significant effect sizes were found for trauma caseload volume (r = .16), caseload frequency (r = .12), caseload ratio (r = .19), and having a personal trauma history (r = .19). Small negative effect sizes were found for work support (r = -.17) and social support (r = -.26). Demographic variables appear to be less implicated although more work is needed that examines the role of gender in the context of particular personal traumas. Caseload frequency and personal trauma effect sizes were moderated by year of publication. Future work should examine the measurement of STS and associated impairment, understudied risk factors, and effective interventions.

Canadian employers increasingly have become aware of the economic costs of mental disorders. Between oneto two-thirds of the economic burden has been attributed to work productivity losses.1–3 These losses have been measured as work absences or unproductive work days.4,5 From an employer’s perspective, there are at least 3 forms of work absences: sick days, SDIS claims, and long-term disability claims.6 They are differentiated by days covered and medical certification requirements. Over the past decade, SDIS claims related to mental disorders have garnered the most attention among employers because of their steady growth.7 In addition, the length of an SDIS claim for a mental disorder can be double that for a physical disorder, resulting in twice the cost.8 As organizations seek solutions to stem the rise in SDIS claims related to mental disorders, they have also been confronted with the fact that treatment alone is not the answer. The most difficult aspects of addressing mental disorders in the workplace are the negative attitudes and discrimination associated with mental disorders.9 This stigma can result in discouraging workers from seeking help and treatment.10 Nevertheless, evidence suggests that early treatment helps to decrease the burden of SDIS and that treatment may be able to increase work productivity.11,12 Thus addressing the stigma of mental disorders is one way employers may decrease the burden of mental disorders in the workplace. However, on identifying a potential solution, an employer must decide whether it is worth the investment. How much should an employer pay for a stigma intervention? Using an economic model, our paper explores basic requirements for a stigma program to produce sufficient savings to pay for itself. That is, when would an organization break even? Our analysis uses a simple model designed to highlight overall themes regarding costs. Future work could produce models more specific to particular organizational circumstances and intervention design. Clinical Implications An organization faced with a choice of programs in which to invest should examine whether it is getting value from its investment. Identifying the break-even point where the costs of implementing a stigma program are equivalent to the reductions in costs resulting from its implementation is a helpful way to understand whether there is value from an investment. Limitations A simple model was used for this analysis. Future work could produce models more specific to particular organizational circumstances and intervention design. Once a stigma program is piloted and evaluated in a real-world setting, the data emerging from the evaluation could be used to populate the model.

Contains fulltext : 154785.PDF (Publisher’s version ) (Open Access) OBJECTIVE: Medical certification is one of the basic administrative mechanisms used by social policies aimed at income protection. The assessment of work disability is central to the income protection application. Yet, there is evidence suggesting that determining work disability related to mental disorders is challenging. Although essential to the disability application process, few studies have looked at physician and other clinician experiences with the process. However, this type of information is critical to developing processes to support providers who participate in the assessments. This purpose of this paper is to explore the experiences of physicians and other clinicians assessing public long-term work disability related to mental disorders. METHODS: This is an exploratory and descriptive study using qualitative methods. Clinician input was gathered through focus groups and individual in-depth interviews. Verbatim transcripts were analyzed to identify recurrent and significant themes that arose during the focus groups and individual interviews. RESULTS: Many of the experiences that the clinicians in this sample discussed related to the difficulty of trying to fill the roles of advocate and medical expert as well as the challenge of determining the impact of functional capacity and work ability. The findings also highlight the current gap in knowledge about the factors that affect successful functioning in general and at work in particular. CONCLUSIONS: Given the challenges created by the current state of knowledge, it may be useful to consider a category of "partial disability". In addition, the fact that work disability depends on the interaction between the experience of the mental disorder and specific job requirements and the fact that people applying for public long-term disability are not working, it might be helpful to offer a clear description and guidelines of the meaning of work ability.

Background: Contrary to other developed countries where adolescent suicide rates have declined in the last decade, the rate in Canada has remained unchanged. Suicide is the second leading cause of death in Canadian adolescents and poses a serious public health concern. However, there is little epidemiological data examining the rates of suicidality or depression – two factors most closely associated with completed suicides. This study therefore examines the rates of depression and suicidality in adolescents aged 15–18.

Objective: This paper describes the main types of economic evaluation techniques. Method: To examine the strengths and limitations of different types of economic evaluations, we used a hypothetical example to review the reasoning underlying each method and to illustrate when it is appropriate to use each method. Results: The choice of economic evaluation method reflects a decision about what should represent “success” and how success should be valued. Measures of benefit and cost must be considered systematically and simultaneously. Claiming that a new treatment is cost-effective requires making a value judgment based on the personal beliefs of the claimant. Even when cost and effect data are objective, a verdict of cost-effective is subjective. The conclusions of an economic study can change significantly, depending on which patient outcome is used to measure success. Conclusions: Clinicians must be sure that important patient outcomes are not excluded from economic evaluations. Economic evaluation is a process designed to produce an estimate rather than a decision. New treatment can be more costly and still be cost-effective (if the extra benefit is valued more than the extra cost to produce it). However, since economic evaluation does not explicitly consider a decision maker's available budget, a new treatment can be deemed cost-effective but too expensive to approve.

BACKGROUND: Despite numerous prevention initiatives, suicide remains the second leading cause of death in youth aged 10–19. One of the major prevention strategies is the introduction of restrictive firearms regulations. For example, Bill C-17 was enacted in 1991 to promote safer handling and storage of firearms through mandatory safety courses for all new gun owners. Examining the suicide rates subsequent to Bill C-17 may shed light on the possible benefit of these regulations as a solution to this major public health issue. Therefore, this paper examines the trends in youth suicide from 1979–1999 and the association with changes in the firearms act in 1991. METHODS: Age-specific suicide rates for youth between 15–19 years and rates by methods of suicide were calculated based on data from Statistics Canada for the years 1979–1999. Time series analyses were conducted. RESULTS: Although the overall rates did not change from 1979–1999 in youth aged 15–19, there was a substantial change in the methods used. In particular, the rates of suicide by firearms dropped from 60% to 22% while suicide due to hanging/suffocation increased from 20% to 60% in this age group over this period of time. CONCLUSION: These results suggest a possible association between changes in the firearms act in 1991 and the methods used by youth to complete suicide. However, the overall rates of suicides did not change over this same period. These trends underscore the need for broader prevention interventions that do not solely focus on methods of suicide but rather, their underlying causes.

Research is changing. Recent years have seen a shift away from studies performed at single academic centers to larger, multisite projects involving numerous institutions in disparate geographic locations. The number of citations on PubMed for multicenter studies increased by 1.6–3 fold for each 5-year interval between 1985 and 1999 (McWilliams et al. 2003). While the shift is especially true in medicine, where clinical trials are often conducted as multicenter studies, the multisite design is of increasing importance in other fields, including health services research. A multisite study provides investigators with the opportunity to research different programs using a shared study design and methodology. Different sites investigate different services or programs, but have a common protocol. As a result, it becomes possible to measure “the same outcomes with the same instruments using the same timeframe across differing programs at multiple sites” (Dewa et al. 2002). Multisite studies are valuable, because the involvement of different centers means that the results obtained may be more generalizable than those of a single-center study. The existence of the common research protocol renders the outcomes of the various sites comparable. Multisite protocols, like all research, must be approved by local institutional review boards (IRBs) before investigators can proceed. This means that ethics approval must be sought separately from research ethics boards at each site in a multisite study. As well, studies affiliated with both hospitals and universities must seek ethics approval at both institutions. Some have questioned the effectiveness of this system. Christian et al. (2002) state that the effectiveness of IRBs has been undermined because of the IRB system's failure to adapt to the changing research environment. Indeed, the current procedure for research ethics review, which involves seeking out ethics approval from each individual local committee, is not very conducive to collaborative, multisite research. The process of obtaining ethics review at multiple sites can be a daunting task, consuming time, money, and energy. One study in the U.K. indicated that extra funding had to be sought to cover the cost of applying to 125 local ethics review boards (Tully et al. 2000) The time, effort, and valuable research dollars spent on obtaining ethics review for a multisite project can be a source of irritation and resentment for many investigators (Personal communication 2003). They do not feel the extra administrative hurdles contribute toward the protection of research subjects, as requests from individual boards may differ considerably. Some even go so far as to accuse the process of slowing the improvement and advancement of health care services by impeding project implementation. The inconsistency in ethics review, then, while a potential problem in all research, is especially problematic for multisite research. Inconsistency can result in subjects at different sites being afforded varying levels of protection. Without a standardized process for the interpretation of research ethics guidelines by IRBs, it is possible that subjects at Site A are better protected than their counterparts at Site B. Further, the money spent on securing multisite ethics approval does not represent the best use of research funds. There is concern, then, that large amounts of research funds—and therefore taxpayer dollars—are being squandered on repetitive, inconsistent, and unnecessary multiple ethics review processes. Money diverted to potentially unnecessary IRB review translates into less money spent on an actual study objective of improving health care services, raising questions regarding the ethics of such an opportunity cost. With the misdirected focus arising from the amount of money, manpower, and time required to seek multisite ethics review, some authors have pondered the question as to whether the system may even present an “unethical barrier” to potentially beneficial research activities (Tully et al. 2000). The problems associated with multisite IRB review are of particular relevance to health services research, as multisite studies are of increasing importance in this field. Weinberger et al. (2001), for example, write that multisite randomized controlled trials in health services research offer “numerous advantages” over single-site studies. First, multisite studies enhance external validity, increasing the generalizability of research results. Second, when the subject of the research is a condition with a “low incidence or prevalence, small event rate in the outcome … and/or large variation in the distribution of cost,” a multisite study may be the only way to assure the requisite statistical power (Weinberger et al. 2001, p. 628). Finally, in a multisite study, the necessary sample size can be gathered faster. Weinberger et al. explain that this faster recruitment has a further advantage—since the study can be completed more rapidly, the “timeliness of the findings is enhanced.” They emphasize that this is of special importance in health services research, where investigators are frequently asked by health care organizations and policymakers to provide them with results as quickly as possible. This last point, moreover, underscores why slow and inefficient ethics review for multisite research is of particular concern to health services researchers. The need for rapid dissemination of results to private and public entities for purposes of health care policy making makes speed a pressing factor for investigators on health services research projects. Unnecessary delays caused by a potentially ineffective multisite ethics review system can therefore affect the timeliness of health services research, with effects on subsequent health care policy and decision making. The following paper examines this issue of whether the current system for ethics review of multisite research is adequate, or whether there exist alternative methods that should be considered. First, the available literature on this matter will be examined, including empirical studies describing the variability of, and problems with, multisite research ethics review. Second, reasons for variability in research ethics board review will be explored. Finally, potential solutions to the problem of multisite ethics review will be considered, including the implementation of special multisite review boards, mechanisms to facilitate communication and cooperation between ethics boards, and the notion of education or training and certification for ethics board members.

Abstract: This article is a brief report that draws on the literature and interviews with CMHEI investigators to explore the challenges of obtaining research ethics board approval for multi-site studies. It goes on to suggest how the complexity of multi-site approval could be addressed in terms of study budget, staff time, and study timelines.

Abstract: In an earlier article, we described the mindset and process for implementing and conducting a multi-site study. In this article, we take the perspective of the multi-site study’s coordinating centre. Using the Community Mental Health Evaluation Initiative as a case study, we focus on four major aspects of the initiative — data collection and management, the evaluated programs, partnerships, and knowledge transfer. We discuss a variety of challenges that we faced in relation to these activities during the course of our longitudinal multi-site study and how we met them — both those actions that were met with success and those that were not.

Abstract: The Multnomah Community Ability Scale (MCAS) is a standardized measure of functioning of people with mental illness living in the community. This study assessed feasibility and utility of the MCAS for routine outcome monitoring of clients enrolled in intensive community support programs. Burden related to training and administration was assessed and scale properties were evaluated, using data collected from a multisite community mental health evaluation initiative. Minimum effort was required to achieve good inter-rater reliability and administer the measure. The validity of the MCAS for measuring change in community functioning in new program clients was supported. However, MCAS ratings for ongoing clients were stable. Future studies can assess the relevance of the MCAS for measuring improvement in this client group.

Individuals with severely disabling mental illness receive more benefit from supported employment initiatives than from other vocational services, but these initiatives show variable job tenure and low implementation by governments. For those with less severely disabling mental illnesses, such as depression, evidence-based treatment results in substantial restoration of job function, and restored work function occurs in synchrony with reduced symptomatology. However, there is a substantial degree of residual impairment despite receiving standard treatment. Major research trends include an increasing focus on occupational recovery in less severe forms of mental illness and potential application of integrated disability management models to occupational recovery from disabling mental disorders. Promising research directions include effectiveness of standard mental healthcare in restoring work function; effectiveness of actively managing co-morbid mental health problems for disabling physical disorders; population factors affecting return to work in those with disabling mental disorders; identification of policies fostering occupational recovery for disabling mental disorders; effectiveness of innovative mental healthcare focused on occupational recovery; and organizational interventions to foster occupational recovery in employees with disabling mental disorders.

This discussion paper explores the state of knowledge about the prevalence of mental illness and its effect on the working population. Major trends in the literature are also commented on, and significant gaps in knowledge are identified. Annually, 12% of Canadians from 15 to 64 years suffer from a mental disorder or substance dependence. Few studies have examined the prevalence of mental disorders among Canadian workers. Results from Ontario estimate that monthly, about 8% of the working population has a diagnosable mental disorder. Preliminary findings also indicate differences in the prevalence of mental disorders among workers with regard to occupation, age, sex, physical disorders, work environment and work-related stress. Studies indicate that mental and emotional health problems are associated with staggering social and economic costs, which create a heavy burden on the workplace. About one-third of society's depression-related productivity losses can be attributed to work disruptions. The impact of mental illness on the workplace has been examined in terms of its effect on presenteeism, absenteeism and disability days. The presence of any of these has been used to indicate decreased productivity, the largest burden arising from presenteeism. In total, Canada annually loses about $4.5 billion from this decreased productivity. Mental illness is also associated with short-term and long-term disability, which in turn is often related to insurance coverage. Mental illness related disability claims have doubled and mental illness accounts for 30% of disability claims, at a cost of $15 to $33 billion annually. The needs of the working population and employers must be addressed. We must be aware of patterns of mental disorder among occupational groups and industry sectors. In addition, we must understand how the disability benefit structure impacts the prevalence as well as patterns of disability related to mental illness. Effective policies and programs must be based on solid evidence.

The purpose of this review is to consider the prevalent types of fixed and flexible formularies, the general economic principles on which they are based and the evidence for their effectiveness in controlling rising drug expenditures. The principal-agent relationship and economic model underlying the various types of formularies are described. The principal-agent model describes a relationship where there is an asymmetry of information between two parties involved in a particular task. As a result of this asymmetry of information, the party with less information (the principal) allows the party with more information (the agent) to make decisions about that task or activity for them. In the case of formularies and cost-control, the principal is the payer. Depending on the incentives offered by the formulary, the agent can alternately be the prescriber, dispenser or patient. The success of a formulary type to control costs is dependent on two main factors. First, the payer (the principal) must identify the agent for whom it is reasonable to create incentives that incorporate the financial risks associated with use of the drugs. Second, the payer must develop a structure that best aligns the principal and agent objectives. The principal-agent framework serves as the vehicle through which the authors examine five major types of formularies (i.e., closed, best available price, reference-based pricing, tiered and open formularies) and their inherent incentives and limitations. The evidence for their effectiveness as cost-control mechanisms is reviewed and the system factors that can affect formulary success will be discussed. Finally, the authors' observations are summarized and interpreted, and suggested implications for future use of formularies in controlling the costs of pharmaceutical use are offered.

Little is known about how antidepressants are being used, but rising antidepressant expenditures and the accompanying impulse to control costs make this a critical issue to be addressed. The authors studied patterns of antidepressant use in a population of workers receiving depression-related short-term disability benefits to determine whether populations likely to benefit from antidepressants are using them and, if so, whether they are using them in a way that the benefits from their use are maximized.The analyses were based on 1996-1998 administrative data from short-term disability and prescription drug benefit claims and occupational health department records for employees of three Canadian companies.Approximately 58 percent of employees who were receiving depression-related short-term disability benefits had made at least one antidepressant claim. Employees who did not use antidepressants typically reported significantly fewer symptoms at baseline on average than those who did. About 91 percent of the employees who used antidepressants filled at least one prescription for a guideline-recommended first-line agent. Approximately 79 percent of antidepressant dosages reflected those suggested by the Canadian Network for Mood and Anxiety Treatment, and three timeframe indicators suggested that most patients used antidepressants within the recommended timeframes.The results of this study represent an important first step in exploring the question of how antidepressants are used among workers with depression-related disability. For the most part, these workers and those whose depression was more severe were more likely to obtain antidepressants.

Finding measures that can assess areas of expected program impact, provide valid results, and be easily integrated into routine program practices is a significant challenge. This paper is intended to assist program staff by providing an accessible inventory of measures appropriate for routine monitoring of the status and outcome of individuals using mental health outpatient and community programs. The inventory is not exhaustive, but rather includes examples of solid measures for assessing outcomes in four key domains--symptoms, functioning, quality of life, and satisfaction. These can provide a core of information, to which measurement of more in-depth issues can be added to address specific concerns.

Assertive Community Treatment (ACT) is an appealing community program model because it proposes to provide individuals with coping skills that allow them to maintain independent lives in their communities and it offers the potential to decrease inpatient stays and increase community tenure. But, it is not without its limitations. Critics point out that ACT's unique elements also make it a potentially very resource intensive program—an important consideration in times of fiscal constraints. Though the charge may be justified, there is little in the literature that actually quantifies the intensity of resources used. The process through which it achieves outcomes is not frequently described. Using ACT team workload information, we examine the time trade-offs—direct for indirect time—involved with implementing this model. In addition, we describe the specific activities that make up the direct and indirect time inputs that go into supporting clients in the community through assertive team oriented case management.

The introduction of new antipsychotic agents in the past decade has helped alter the treatments available to 2 vulnerable populations-those with schizophrenia and related psychotic conditions and elderly individuals with dementia.After examining overall trends in antipsychotic use, this analysis reviews patterns of atypical antipsychotic use in the elderly and financially disadvantaged populations of Ontario. It identifies affected subpopulations and offers several interpretations of how observed patterns of use reflect outpatient prescribing practices.This study used drug claims data from the Ontario Drug Benefit (ODB) program for the years 1992 to 1998. The use of antipsychotic agents was followed for 2 years in a subpopulation of ODB participants identified as consistent users of these agents (ie, those with evidence of1-time use).During the study period, the total number of ODB claimants grew by 1%, the number of claimants using antipsychotic agents increased by approximately 25%, and the expenditure per claimant in this group increased by nearly 250%. Much of this growth in expenditures was associated with use of the newer atypical antipsychotic agents olanzapine, risperidone, and quetiapine. Compared with patients agedor = 65 years, those aged65 years were more likely to receive an initial prescription for an atypical antipsychotic or be switched to an atypical antipsychotic. However, the proportion of patients aged85 years consistently using antipsychotic agents was greater than predicted based on the proportion of the ODB population they represent. These patients were more likely to use conventional antipsychotic agents exclusively.The introduction of the atypical antipsychotic agents was paralleled by a striking increase in ODB expenditures for antipsychotic drugs, although use of these agents was not consistent across age groups. There was more switching to atypical antipsychotics, as well as greater use in general, among younger compared with older patients, despite evidence that the atypical antipsychotics may be safer in the elderly than conventional antipsychotics. Guideline dissemination may be an important way of familiarizing clinicians with the atypical agents. Health care systems should be aware of the potential for a substantial increase in health care costs with more widespread adoption of these medications.

There has been a growing realization that the number of workplace disability claims for mental and nervous disorders is increasing. Yet, little is known about the working population disabled by these disorders. Absence of basic information describing this population makes it virtually impossible to plan effective workplace programs. Using administrative data collected from three major Canadian financial/insurance sector employers, we focus on one group of disorders--depression. In this study, we report the prevalence of short-term disability due to depression and describe the characteristics of workers affected and their disability outcomes. We observed that compared with other nervous and mental disorders, depression-related short-term disability generally affected more employees, lasted longer, and had a higher rate of recurrence. In addition, at the end of their episodes more than three quarters of workers returned to work. These estimates suggest that the potential magnitude of the impact of short-term disability should be a concern for employers. This study helps identify the main characteristics of workers who develop depression-related disability. It also helps clarify what happens to those on short-term disability.

Although most policymakers agree that a fundamental goal of the mental health system is to provide integrated community-based services, there is little empirical evidence with which to plan such a system. Studies in the community mental health literature have not used a standard set of evaluation methods. One way of addressing this gap is through a multisite program evaluation in which multiple sites and programs evaluate the same outcomes using the same instruments and time frame. The proposition of introducing the same study design in different settings and programs is deceptively straightforward. The difficulty is not in the conceptualization but in the implementation. This article examines the factors that act as implementation barriers, how are they magnified in a multisite study design, and how they can be successfully addressed. In discussing the issue of study design, this article considers processes used to address six major types of barriers to conducting collaborative studies identified by Lancaster or Lancaster's six Cs—contribution, communication, compatibility, consensus, credit, and commitment. A case study approach is used to examine implementation of a multisite community mental health evaluation of services and supports (case management, self-help initiatives, crisis interventions) represented by six independent evaluations of 15 community health programs. A principal finding was that one of the main vehicles to a successful multisite project is participation. It is only through participation that Lancaster's six Cs can be addressed. Key factors in large, geographically dispersed, and diverse groups include the use of advisory committees, explicit criteria and opportunities for participation, reliance on all modes of communication, and valuing informal interactions. The article concludes that whereas modern technology has assisted in making complicated research designs feasible, the operationalization of timeless virtues such as mutual respect and trust, flexibility, and commitment make them successful. © 2002 John Wiley & Sons, Inc.

Objectives The purpose of this systematic literature review is to examine the current state of knowledge regarding the return-to-work outcomes of sickness absences related to mental disorders that increase costs borne by employers. We address two questions: (1) Based on the existing literature, from the employer9s perspective, what are the relevant economic return-to-work outcomes for sickness absences related to mental disorders? and (2) From the employer9s economic perspective, are there gaps in knowledge about the relevant return-to-work outcomes for sickness absences related to mental disorders? Setting The included studies used administrative data from either an employer, insurer or occupational healthcare provider. Participants Studies included working adults between 18 and 65 years old who had a sickness absence related to a mental disorder. Primary and secondary outcome measures The studies considered two general return-to-work outcome categories: (1) outcomes focusing on return-to-work and (2) outcomes focusing on sickness absence recurrence. Results A total of 3820 unique citations were identified. Of these, 10 studies were identified whose quality ranged from good to excellent. Half of the identified studies came from one country. The studies considered two characteristics of sickness absence: (1) whether and how long it took for a worker to return-to-work and (2) sickness absence recurrence. None of the studies examined return-to-work outcomes related to work reintegration. Conclusions The existing literature suggests that along with the incidence of sickness absence related to mental disorders, the length of sickness absence episodes and sickness absence recurrence (ie, number and time between) should be areas of concern. However, there also seems to be gaps in the literature regarding the work reintegration process and its associated costs.

Background Interest in the well-being of physicians has increased because of their contributions to the healthcare system quality. There is growing recognition that physicians are exposed to workplace factors that increase the risk of work stress. Long-term exposure to high work stress can result in burnout. Reports from around the world suggest that about one-third to one-half of physicians experience burnout. Understanding the outcomes associated with burnout is critical to understanding its affects on the healthcare system. Productivity outcomes are among those that could have the most immediate effects on the healthcare system. This systematic literature review is one of the first to explore the evidence for the types of physician productivity outcomes associated with physician burnout. It answers the question, “How does burnout affect physician productivity?” Methods A systematic search was performed of: Medline Current, Medline in process, PsycInfo, Embase and Web of Science. The search period covered 2002 to 2012. The searches identified articles about practicing physicians working in civilian settings. Articles that primarily looked only at residents or medical students were excluded. Productivity was captured by hours worked, patients seen, sick leave, leaving the profession, retirement, workload and presenteeism. Studies also were excluded if: (1) the study sample was not comprised of at least 50% physicians, (2) the study did not examine the relationship between burnout and productivity or (3) a validated measure of burnout was not used. Results The search identified 870 unique citations; 5 met the inclusion/exclusion criteria. This review indicates that globally there is recognition of the potential impact of physician burnout on productivity. Productivity was examined using: number of sick leave days, work ability, intent to either continue practicing or change jobs. The majority of the studies indicate there is a negative relationship between burnout and productivity. However, there is variation depending on the type of productivity outcome examined. Conclusions There is evidence that burnout is associated with decreased productivity. However, this line of inquiry is still developing. A number of gaps are yet to be filled including understanding how to quantify the changes in productivity related to burnout.

Background Interest in the impact of burnout on physicians has been growing because of the possible burden this may have on health care systems. The objective of this study is to estimate the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. Methods Using an economic model, the costs related to early retirement and reduction in clinical hours of physicians were compared for those who were experiencing burnout against a scenario in which they did not experience burnout. The January 2012 Canadian Medical Association Masterfile was used to determine the number of practicing physicians. Transition probabilities were estimated using 2007–2008 Canadian Physician Health Survey and 2007 National Physician Survey data. Adjustments were also applied to outcome estimates based on ratio of actual to planned retirement and reduction in clinical hours. Results The total cost of burnout for all physicians practicing in Canada is estimated to be $213.1 million ($185.2 million due to early retirement and $27.9 million due to reduced clinical hours). Family physicians accounted for 58.8% of the burnout costs, followed by surgeons for 24.6% and other specialists for 16.6%. Conclusion The cost of burnout associated with early retirement and reduction in clinical hours is substantial and a significant proportion of practicing physicians experience symptoms of burnout. As health systems struggle with human resource shortages and expanding waiting times, this estimate sheds light on the extent to which the burden could be potentially decreased through prevention and promotion activities to address burnout among physicians.

Purpose Fear of stigma may lead employees to choose not to disclose a mental disorder in the workplace, thereby limiting help-seeking through workplace accommodation. Research suggests that various factors are considered in making decisions related to disclosure of concealable stigmatizing attributes, yet limited literature explores such decision-making in the context of mental disorder and work. The purpose of this grounded theory study was to develop a model of disclosure specific to mental health issues in a work context. Methods In-depth interviews were conducted with 13 employees of a post-secondary educational institution in Canada. Data were analyzed according to grounded theory methods through processes of open, selective, and theoretical coding. Results Findings indicated that employees begin from a default position of nondisclosure that is attributable to fear of being stigmatized in the workplace as a result of the mental disorder. In order to move from the default position, employees need a reason to disclose. The decision-making process itself is a risk–benefit analysis, during which employees weigh risks and benefits within the existing context as they assess it. The model identifies that fear of stigmatization is one of the problems with disclosure at work and describes the disclosure decision-making process. Conclusions Understanding of how employees make decisions about disclosure in the workplace may inform organizational policies, practices, and programs to improve the experiences of individuals diagnosed with a mental disorder at work. The findings suggest possible intervention strategies in education, policy, and culture for reducing stigma of mental disorders in the workplace.

Although Assertive Community Treatment (ACT) is one of the most widely studied of all community mental health treatment models, the process through which it produces outcomes is often treated as a ‘black box’. There is limited understanding of the model's essential elements and studies seldom describe program implementation. As a result, though localities may be interested in developing an ACT team, information necessary for implementation of the model (e.g. costing, cost-effectiveness, ACT service utilization) is inadequate to help plan services. Part of this gap in the literature can be attributed to the fact that the vital pieces of information needed to produce the much needed estimates are generally the most arduous to gather; they require daily recording of activities and hence, the participation of already overburdened program staff. The purpose of this paper is to describe our experiences in developing a multi-program economic evaluation and costing study of ACT. In discussing the process that we followed, we hope to pass on useful information that will help produce effective and efficient mental health evaluations in the future. Our project offers an example of how the worlds of research and service delivery can collaborate to come to symbiotic resolutions. Together, we have been able to collect data that is not only valuable for program evaluation but beneficial for administrative purposes to define priority areas, staffing and service planning.

Objectives: To consider the most common primary care reimbursement structures, to identify incentives inherent in each, and to discuss how each could be used to encourage a shared-care approach to treating mental disorders at the primary care level. Method: Three major financial reimbursement models—fee-for-service, capitation, and blended payment mechanisms—are examined. Each is considered in terms of its risk-sharing elements and the consequent incentives. We offer several scenarios to illustrate how the shared-care practice model might be encouraged under each financing mechanism. Results: The current fee-for-service system does not encourage shared care. For wide adoption of the shared-care practice model, there must be a change in the reimbursement system's incentives. While none of the financing mechanisms offers a perfect solution, each has potential. Each, however, must be carefully tailored to its environment. Conclusions: Financial considerations are just one aspect to achieving shared care. Nevertheless, in designing a system to encourage collaborative, coordinated care for those suffering from mental illness, decision makers should be wary of creating or maintaining obstacles (financial or otherwise) to provision of accessible, high-quality care. Objectifs: Examiner les structures de remboursement les plus répandues dans les soins primaires, trouver les incitatifs inhérents à chacune et présenter comment chacune pourrait servir à stimuler une approche de soins partagés pour le traitement des troubles mentaux dans les soins primaires. Méthode: Trois principaux modèles — rémunération à l'acte, capitation et mécanismes de versements confondus — sont examinés, chacun en fonction des éléments de partage des risques et des incitatifs qui s'ensuivent. Nous présentons plusieurs scénarios pour illustrer comment le modèle de la pratique des soins partagés peut être favorisé par chaque mécanisme de financement. Résultats: Le système actuel de rémunération à l'acte n'incite pas aux soins partagés. Pour que le modèle de la pratique des soins partagés soit largement adopté, il faut modifier les incitatifs du système de remboursement. Bien qu'aucun mécanisme de financement n'offre de solution parfaite, chacun offre des possibilités, mais doit être soigneusement adapté à son milieu. Conclusions: Les considérations financières ne sont qu'un aspect de la réalisation des soins partagés. Néanmoins, en concevant un système qui incite à des soins coopératifs et coordonnés dispensés aux personnes souffrant de maladie mentale, les décideurs doivent prendre garde de créer ou de maintenir des obstacles (financiers ou autres) à la prestation de soins accessibles de grande qualité.

Background: The use of selective serotonin reuptake inhibitors (SSRIs) as antidepressant therapy has increased considerably since the introduction of fluoxetine in 1989. By 1999, 3 of the 4 available SSRIs were among the top 10 most frequently used drugs in the United States. In addition, SSRIs were one of the major contributors to the growth in psychotropic medication expenditures during the past 5 years. Objective: The purpose of this article was to examine the utilization patterns of the 4 most commonly used SSRIs and their contribution to rising antidepressant medication expenditures among claimants in a publicly funded drug program. Using the results of forecasting models, we explored possible ways to control these growing expenditures. Methods: Cross-sectional antidepressant claims and expenditure data from the Ontario Drug Benefits program for 1992 to 1998 were examined. Five scenarios were modeled in which future SSRI expenditures and claims were predicted using exponential smoothing models. Results: If the historical patterns of use continued, a 20% increase in the 1998 level of expenditures was expected to occur by the year 2000. Predicted expenditures are sensitive to the composition of the SSRI claims. Exclusive use of 1 of the 4 major SSRIs (fluvoxamine, fluoxetine, paroxetine, and sertraline) could decrease projected expenditures by 30% or increase them by 11%. An "equal shares" approach, in which each of the 4 SSRIs are used in equal proportions in the population, may reduce expenditures by ∼8%. Conclusions: The current trends in the utilization data suggest that sertraline and paroxetine are being used as first-line treatments. The results of the forecasting models suggest that growing expenditures could be curbed if these 2 antidepressants were not used in that manner. Short of limiting the drugs available on benefit formularies, there may be a way to control costs through the use of a prescribing algorithm. Although our results support the use of fluoxetine for first-line SSRI treatment as a cost-control measure, we do not definitively recommend its adoption. These findings contribute to the discussion about using fixed versus flexible formularies as a potential cost-control mechanism.

1032 Objective: In Canada charitable or nonprofit organizations provide government-contracted mental health and addictions services, and they augment government funding by raising charitable revenues. This study estimated by source the revenues of nonprofit mental health and addictions organizations in Canada. Methods: A list of nonprofit, service-providing organizations in Canada was developed, financial returns to the Canada Revenue Agency (CRA) in 2007 were obtained, and data were analyzed in aggregate. Results: Information was obtained from 369 Canadian organizations, which had $915.4 million (Canadian dollars [CAD]) in total revenues: 85% were from the government, 4% were from charitable giving, and 11% were from other sources. Conclusions: The ratio of charitable giving to government funding of mental health care was about .55% ($35 million to $6.3 billion CAD). This charitable giving level cannot compensate for the relatively low levels of total government mental health spending identified in government reports. (Psychiatric Services 61:1032–1034, 2010) tion of the nonprofit sector in mental health.

While agreement is growing that mental illness burdens the North American economy, how it impacts productivity — particularly compared to physical illness — is unclear. Hypothesizing that lost work days are only the tip of the iceberg, we also examined the association of mental and chronic physical illness with partial work days and days requiring extra effort to function. Data from 4225 employed individuals, aged 18–54, were analyzed. These were a subset of respondents to the Ontario Health Survey's Mental Health Supplement, a 1990/91 epidemiologic survey of households across Ontario, Canada. Psychiatric disorder was assessed using the University of Michigan' modification of WHO's Composite International Diagnostic Interview (UM-CIDI). Similar to US reports, professional/managerial groups had lower rates of affective and anxiety disorders and fewer disability days compared to the rest of the workforce. However, no single occupational group was consistently at greater risk for either physical or psychiatric problems. Even after accounting for sociodemographic characteristics and work conditions, mental and physical status had clear, but different, impacts on productivity. Physical conditions alone had a fairly constant effect across all types of disability days and were the largest contributor to total work day loss. They also significantly impacted partial and extra effort days but were far less important than conditions involving a mental disorder. Respondents with mental health problems, either alone or in combination with physical illnesses, appeared more likely to go to work but to require greater effort to function. WHO projects that mental illness will become the second most important cause of global disease burden in the next century. Our findings suggest that among working individuals, it affects productivity more subtly than does physical illness. However, with an estimated eight percent of Ontario's workforce experiencing more than two months annually of decreased productivity, it still incurs significant social and economic costs.

Objective: The authors measured the total expenditures for two key sources of social support in Alberta in 2005 for persons with severe and persistent mental illness and compared these expenditures with the total mental health expenditures. Methods: Social services and assistance benefit data were from the federal government’s Canada Pension Plan–Disability Benefits and from Alberta Services’ Assured Income for the Severely Handicapped for beneficiaries with psychiatric diagnoses. These benefits were compared with the total public mental health expenditures in Alberta for budget year 2005–2006. Results: A total of 7,456 adults with certified mental illness conditions received federal disability benefits, and 17,138 received provincial disability and medical benefits. The total for social support (income) benefits was $207 million Canadian compared with $405 million Canadian spent by the provincial government for mental health services for adults under age 65. Conclusions: Social assistance forms a substantial portion of Canadian federal and provincial government support for persons with mental illness. Whenever a government-payer perspective is taken, these costs should be factored into the analysis. (Psychiatric Services 60:686– 688, 2009)

Since the FDA Black box warning in 2004, there has been a 58% drop in antidepressant use among children and adolescents with depression. Paralleling this decrease is an associated increase in completed suicides in youth. To date, no study has examined, on a clinician level, the changes in practice that have occurred subsequent to the FDA warning.To examine changes in pediatrician clinical practice resulting from the FDA warning on antidepressants.Subjects were recruited through a national program sponsored by the Canadian Pediatric Society that regularly surveys practicing pediatricians. The mail survey inquired about knowledge of the Black-box warning, whether their practice changed and reasons for changes in prescribing practices with antidepressants after the warning. We surveyed a total of 2395 pediatricians in Canada.Of the 1748 eligible pediatricians, 670 (38%) responded.Seventy-two percent (n = 484) of respondents were aware of the FDA warning. Of the 484 respondents who were aware of the warning, 80% (n = 386) changed their prescribing practices including 32% (n = 154) who followed their patients more closely. Seven percent (n = 35) stopped treatment with SSRIs in at least one patient. Physicians who had observed worsening depression/suicidality were more likely to discontinue treatment with SSRI's compared to those who had not observed these side effects previously (25% versus 6%, p0.001).This is the first national study to examine individual pediatrician practice changes in antidepressant use subsequent to the FDA warning. Further research is needed to better understand the reasons for these changes to aid in the development of strategies that could help clinicians to optimally integrate these warnings into clinical practice.

The aim of this study was to fill a gap in the literature by examining agreement on need as rated by clients and their key workers from first-episode psychosis early intervention programmes. Compared with adult populations and more chronic courses of illness, these clients may have unique needs given the onset of their illness in adolescence or early adulthood.Needs agreement between clients and key workers was assessed using the Camberwell Assessment of Need in a sample of 188 client-key worker pairs recruited from six early intervention programmes in Ontario, Canada. Ratings were assessed with percentage agreement and prevalence-adjusted Cohen's kappa.At the aggregate level, both clients and key workers rated a mean of 2.6 unmet needs. Compared with other diagnoses, key workers rated significantly more unmet need in clients with primary psychotic disorders. Agreement between individual client and key worker ratings was highest (adjusted κ 0.85) in the domains of telephone, risk to others, child care and accommodation. Lowest agreement (adjusted κ 0.4) was found in the domains of psychological distress, sexual expression, company, daytime activities and intimate relationships.While congruence is present in concrete domains, there is substantial variability in how clients and their key workers perceive need in more personal areas. The initial focus of care may necessarily be on needs such as shelter, food and treatment; however, subsequent care should incorporate a shared assessment of need to support strong relationships with providers and ongoing engagement in treatment.

Background Over the past decade, growing attention has been given to the mental health of workers. One way to examine the mental health of workers is to look at the incidence rates of mental illness-related sickness absence. There is a scarcity of literature in which the incidence rates of mental illness-related sickness absence among different countries have been considered together. The purpose of this systematic literature review is to address the question: Are there similarities and differences in the incidence rates of mental disorder-related sickness absence among and within OECD identified Social Democratic, Liberal and Latin American country categories? In this paper, we seek to identify differences and similarities in the literature rather than to explain them. With this review, we lay the groundwork for and point to areas for future research as well as to raise questions regarding reasons for the differences and similarities. Methods A systematic literature search of the following databases were performed: Medline Current, Medline In-process, PsycINFO, Econlit and Web of Science. The search period covered 2002–2013. The systematic literature search focused on working adults between 18–65 years old who had not retired and who had mental and/or substance abuse disorders. Intervention studies were excluded. The search focused on medically certified sickness absences. Results A total of 3,818 unique citations were identified. Of these, 10 studies met the inclusion/exclusion criteria; six were from Social Democratic countries. Their quality ranged from good to excellent. There was variation in the incidence rates reported by the studies from the Social Democratic, Liberal and Latin American countries in this review. Conclusions The results of this systematic review suggest that this is an emerging area of inquiry that needs to continue to grow. Priority areas to support growth include cross jurisdictional collaboration and development of a typology characterizing the benefit generosity and work integration policies of sickness absence schemes. Finally, the literature should be updated to reflect changes in sickness absence benefit schemes over time.

Using administrative data from the public long-term disability support program in Ontario, Canada, this paper examines the factors related to receipt of a paid employment benefit. These analyses include only ODSP beneficiaries who were primary beneficiaries, who had active files in March 2011 and who were