ARCHIVED: Chapter 3: A Report on Mental Illnesses in Canada – Schizophrenia


Chapter 3 Schizophrenia

Highlights

  • Schizophrenia affects 1% of the Canadian population.
  • Onset is usually in early adulthood.
  • Schizophrenia can be treated effectively with a combination of medication, education, primary care services, hospital-based services and community support, such as housing and employment.
  • Fifty-two percent of hospitalizations for schizophrenia in general hospitals are among adults 25-44 years of age.
  • Hospitalization rates for schizophrenia in general hospitals are increasing among young and middle-aged men.

What Is Schizophrenia?

Schizophrenia is a brain disease and one of the most serious mental illnesses in Canada. Common symptoms are mixed-up thoughts, delusions (false or irrational beliefs), hallucinations (seeing or hearing things that do not exist) and bizarre behaviour. People suffering from schizophrenia have difficulty performing tasks that require abstract memory and sustained attention.

All the signs and symptoms of schizophrenia vary greatly among individuals. There are no laboratory tests to diagnose schizophrenia. Diagnosis is based solely on clinical observation. For a diagnosis of schizophrenia to be made, symptoms must be present most of the time for a period of at least 1 month, with some signs of the disorder persisting for 6 months. These signs and symptoms are severe enough to cause marked social, educational or occupational dysfunction. The Canadian Psychiatric Association has developed guidelines for the assessment and diagnosis of schizophrenia.Footnote 1

Symptoms

Schizophrenia

  • Delusions and/or hallucinations
  • Lack of motivation
  • Social withdrawal
  • Thought disorders

How Common Is Schizophrenia?

The prevalence of schizophrenia in the general population is estimated to vary between 0.2% and 2%, depending upon the measures used. However, a prevalence rate of 1% is generally accepted as the best estimate.Footnote 2

Impact of Schizophrenia

Who Is Affected by Schizophrenia?

The onset of schizophrenia typically occurs between the late teens and mid-30s. Onset before adolescence is rare. Men and women are affected equally by schizophrenia, but men usually develop the illness earlier than women. If the illness develops after the age of 45, it tends to appear among women more than men, and they tend to display mood symptoms more prominently.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with schizophrenia. Statistics Canada's Canadian Community Health Survey (CCHS) will provide data on the prevalence of self-reported schizophrenia in the future. This will likely underestimate the true prevalence, however, since the survey team will not reach those individuals with schizophrenia who are homeless, in hospital or in supervised residential settings.

Although most individuals with schizophrenia are treated in the community, hospitalization is sometimes necessary to stabilize symptoms. At the present time, hospitalization data provide the best available, though limited, description of individuals with schizophrenia.

In 1999, rates of hospitalization for schizophrenia in general hospitals varied with age (Figure 3-1). Rates among men increased dramatically in the 20-24 year age group and remained high before beginning to decrease among 40-44 year olds. The pattern among women showed a gradual increase in hospitalizations to a peak between 35 and 49 years, after which it showed a steady decline. Men had much higher rates than women until the age of 50, after which rates among women were slightly higher.

Figure 3-1 Hospitalizations for schizophrenia, using the most responsible diagnosis only, in general hospitals per 100,000 by age group, Canada, 1999/2000

 

Figure 3-1 Hospitalizations for schizophrenia* in general hospitals per 100,000 by age group, Canada, 1999/2000
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Figure 3-1 Hospitalizations for schizophrenia, using the most responsible diagnosis only, per 100,000, by age group, Canada, 1999/2000.
Age Group Females Males
1 to 4 years 0 0
5 to 9 years 0 0.1
10 to 14 years 2.5 2.5
15 to 19 years 32.2 73.3
20 to 24 years 63.8 177.1
25 to 29 years 80.8 175.3
30 to 34 years 97.6 173.0
35 to 39 years 122.5 184.8
40 to 44 years 121.1 146.4
45 to 49 years 125.3 130.3
50 to 54 years 108.5 93.8
55 to 59 years 93.2 71.8
60 to 64 years 86.0 61.4
65 to 69 years 70.7 40.8
70 to 74 years 57.1 28.9
75 to 79 years 40.9 18.6
80 to 84 years 28.4 12.1
85 to 89 years 16.8 13.0
90 years and older 11.5 17.9

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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How Does It Affect Them?

Schizophrenia has a profound effect on an individual's ability to function effectively in all aspects of life - self-care, family relationships, income, school, employment, housing, community and social life.Footnote 3

The high rates of hospitalization among young and middle-aged men and women highlight the effect of schizophrenia on people who are in their most productive years - a time when most people are forming families, establishing careers, and generally "building equity" in their lives.

Early in the disease process, people with schizophrenia may lose their ability to relax, concentrate or sleep and they may withdraw from friends. Performance at work or school often suffers. With effective early treatment to control symptoms, individuals can prevent further symptoms and optimize their chance of leading full, productive lives.

The onset of schizophrenia in the early adulthood years usually leads to disruptions in an individual's education. Individuals with schizophrenia often find it difficult to maintain employment for a sustained period of time.

Although some individuals have healthy relationships, the majority with schizophrenia (60% to 70%) do not marry, and most have limited social contacts.Footnote 4 The chronic course of the disorder contributes to ongoing social problems. As a result, individuals with schizophrenia are greatly over-represented in prison and homeless populations.Footnote 4

Up to 80% of individuals with schizophrenia will abuse substances during their lifetime. Substance abuse is associated with poor functional recovery, suicidal behaviour and violence.Footnote 1

The responsibility for primary care of an individual with schizophrenia usually falls on the shoulders of the family. This has many implications. Not only are the family's normal activities disrupted, but family members must also cope with the unpredictability of the individual affected, the side effects of the medication, and the frustration and worry about the future of their loved one. In times of crisis, the decision whether to admit the individual to hospital involuntarily is one of the most difficult dilemmas that a family may face. The family often has to deal with the stigma attached to schizophrenia.

The mortality associated with schizophrenia is one of the most distressing consequences of the disorder. Approximately 40% to 60% of individuals with schizophrenia attempt suicide, and they are between 15 to 25 times more likely than the general population to die from a suicide attempt.Footnote 5 Approximately 10% will die from suicide.

Economic Impact

Schizophrenia places a substantial financial burden on individuals with the illness, the members of their family and the health care system. In 1996, the total direct cost of schizophrenia in Canada was estimated to be $2.35 billion, or 0.3% of the Canadian Gross Domestic Product.Footnote 6 This includes health care costs, administrative costs of income assistance plans, value of lost productivity, and incarceration costs attributable to schizophrenia. The indirect costs of schizophrenia are estimated to account for another $2 billion yearly. Globally, nearly 3% of the total burden of human disease is attributed to schizophrenia.Footnote 7

Stigma Associated with Schizophrenia

Public misunderstanding and fear contribute to the serious stigma associated with schizophrenia. Contrary to popular opinion, most individuals with the disorder are withdrawn and not violent. Nonetheless, the stigma of violence interferes with an individual's ability to acquire housing, employment and treatment, and also compounds difficulties in social relationships. These stereotypes also increase the burden on families and care givers.

Causes of Schizophrenia

Historically, a number of psychological hypotheses were advanced to account for schizophrenia. Today medical science recognizes schizophrenia as a disease of the brain. Although the exact cause is unknown, it is likely that a functional abnormality in neurotransmitters produces the symptoms of the illness. This abnormality may be either the consequence or the cause of structural brain abnormalities.Footnote 8

A combination of genetic and environmental factors is considered to be responsible for the development of this functional abnormality. These factors appear to affect the development of the brain at critical stages during gestation and after birth.

Genetic Influence

Immediate family members of individuals with schizophrenia are 10 times more likely than the general population to develop schizophrenia, and children of two parents with schizophrenia have a 40% chance of developing the disorder.Footnote 3

Environmental Factors

Although the evidence to date is inconclusive, potential environmental contributions to the development of schizophrenia include prenatal or perinatal trauma, season and place of birth, and viral infections. While studies have established a link between severe social disadvantage and schizophrenia, the results suggest that social factors do not cause schizophrenia, but rather the reverse may be true: poor social circumstances are likely a result of the disorder.Footnote 2

Treatment of Schizophrenia

Unfortunately, given our state of knowledge, methods for preventing schizophrenia remain unknown. Minimizing the impact of this serious illness depends mainly on early diagnosis, appropriate treatment and support.

Schizophrenia differs from other mental illnesses in the intensity of care that it requires. A comprehensive treatment program includesFootnote 1:

  1. Antipsychotic medication, which forms the cornerstone of treatment for schizophrenia
  2. Education of the individual about his / her illness and treatment
  3. Family education and support
  4. Support groups and social skills training
  5. Rehabilitation to improve the activities of daily living
  6. Vocational and recreational support
  7. Cognitive therapyFootnote 9
  8. Integrated addictions programFootnote 10

The course of schizophrenia varies, but in most cases it involves recurrent episodes of symptoms. Although available pharmacological treatments can relieve many of the symptoms, most people with schizophrenia continue to suffer some symptoms throughout their lives.

Appropriate treatment early in the course of the disease and adherence to continued and adequate treatment are essential to avoiding relapses and preventing hospitalization. During periods of remission, whether spontaneous or due to treatment, the individual may function well. Newer medications (and improved dosage guidelines for older medications) have substantially reduced the prevalence of severe neurological side effects that were once commonly associated with long-term pharmacological treatment of schizophrenia.

Optimizing the functional status and wellbeing of individuals with schizophrenia requires a supportive family and wide range of services, including institutional, community, social, employment and housing services. Ideally, multidisciplinary community treatment teams provide these services.

Social skills training strives to improve social functioning by working with individuals to resolve problems with employment, leisure, relationships and activities of daily life.

Occasionally, however, timely admission to hospital to control symptoms may prevent the development of more severe problems. Canadian hospitalization data provide insight into the use of hospital services as one of the treatment modalities.

In 1999, in the younger age groups with schizophrenia, the disorder was the diagnosis most responsible for determining their length of stay in hospital (Figure 3-2). In older age groups (65+ years), schizophrenia was more likely to be an associated condition.

Figure 3-2 Hospitalizations for schizophrenia in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000

 

Figure 3-2 Hospitalizations for schizophrenia in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000
Text equivalent for figure 3-2
Figure 3-2 Hospitalizations for schizophrenia per 100,000 by contribution to length of stay and age group, Canada, 1999/2000.
Age Group Schizophrenia as the most responsible diagnosis for length of stay Schizophrenia as an associated condition
1 to 4 years 0 0.1
5 to 9 years 0.1 0.1
10 to 14 years 2.5 1.0
15 to 19 years 53.3 14.5
20 to 24 years 121.7 24.6
25 to 29 years 128.6 27.5
30 to 34 years 135.7 31.7
35 to 39 years 153.9 38.0
40 to 44 years 133.8 39.3
45 to 49 years 127.8 43.5
50 to 54 years 101.2 49.5
55 to 59 years 82.7 54.1
60 to 64 years 74.0 66.8
65 to 69 years 56.3 83.7
70 to 74 years 44.4 94.1
75 to 79 years 31.7 93.9
80 to 84 years 22.4 98.3
85 to 89 years 15.6 92.7
90 years and older 13.2 54.3

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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Between 1987 and 1999, hospitalizations for schizophrenia increased slightly among women (3%), but they increased dramatically among men (28%) (Figure 3- 3).

Figure 3-3 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

 

Figure 3-3 Rates of hospitalization for schizophrenia* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)
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Figure 3-3 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, in general hospitals, by sex, Canada, 1987/88 to 1999/2000 (standardized to 1991 Canadian population).
Year
Sex 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Women 67.1 67.6 65.8 66.4 66.7 66.6 68.7 70.9 68.2 69.4 71.0 68.6 69.1
Men 76.5 78.0 77.7 82.0 82.5 84.2 87.0 90.5 88.1 89.9 95 95 97.8
Women & Men 72.1 73.1 72.0 74.5 74.9 75.7 78.1 81.0 78.5 80.1 83.4 82.2 83.9

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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Hospitalization rates among women aged 45-64 and 65+ years demonstrated a slight increase between 1987 and 1999 (Figure 3-4). Rates among women aged between 25 and 44 years decreased during the same period.

Figure 3-4 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, among women in general hospitals, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Figure 3-4 Rates of hospitalization for schizophrenia* among women in general hospitals, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)
Text equivalent for figure 3-4
Figure 3-4 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, among women in general hospitals, Canada, 1987/88 to 1999/2000 (standardized to 1991 Canadian population).
Year
Age Group 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Women less than 15 years 0.6 0.7 0.4 1.1 0.7 0.8 0.5 0.8 0.8 1.2 1.3 0.8 0.8
Women 15 to 24 years 45.3 41.9 40.9 40.4 40.5 39.0 41.7 43.4 41.4 40.8 44.5 47.1 48.6
Women 25 to 44 years 108.1 109.8 107.3 108.3 109.2 107.1 110.4 113.9 106.8 107.9 108.9 104.7 104.5
Women 45 to 64 years 94.8 97.6 94.5 95.3 93.4 96.6 100.6 102.8 103.1 108.7 108.8 103.0 105.5
Women 65 years and older 45.0 44.1 42.5 43.3 46.4 48.4 47.1 49.5 49.4 47.4 53.3 51.9 51.2

 

Enhanced Surveillance/Population- Specific Surveillance Data

Overall description of "Tracks"

As part of the Federal Initiative to Address HIV/AIDS in Canada , PHAC monitors trends in HIV prevalence and associated risk behaviors in key populations identified in Canada through second-generation HIV surveillance systems. The overall objectives of these systems (known as the "Track" systems) are to describe the changing patterns in the prevalence and incidence of HIV infections, risk behaviour practices and testing patterns for HIV, hepatitis C and other sexually transmitted and blood borne infections (STBBIs) in each respective population. For a more detailed description of the Track systems, please refer to Chapter 3.

I-Track

I-Track is the national, second-generation HIV surveillance system of people who inject drugs (IDU). This system builds on previous research studies conducted in Canada and was developed in response to the need for a consistent approach in the collection of risk behaviour information across Canada. People who have injected drugs in the previous 6 months and who meet the age limit of consent for the given province/territory (age varies by site according to provincial/territorial ethical considerations) are eligible to participate in I-Track.

Summary of descriptive data from I-Track Phase 2 (2005-2008):Footnote 2

  • The proportion of youth (participants less than 29 years old) who reported borrowing used needles in the previous 6 months was 26%, compared with 21% among participants aged 30-49 and 17% among participants aged 50 and older.
  • Youth I-Track participants reported the lowest rate of consistent condom use during anal (42%) and vaginal (55%) sex.
  • Over 90% ( n = 2,972) of I-Track participants reported ever having been tested for HIV; of youth participants (n = 690), 88.7% had ever been tested for HIV. Among youth who reported that their most recent HIV test was negative, 69% reported having been tested for HIV in the previous 2 years.
  • Among participants who provided a biological sample of sufficient quantity for testing and who completed a questionnaire, the prevalence of HIV among youth was 6%, compared with 16% and 15% among participants aged 30-49 and 50 and older respectively. Of youth participants whose biological sample tested positive for HIV, 33% were unaware of their HIV positive status, compared with 19% of unaware respondents over 30 years of age.

M-Track

M-Track is the national, second-generation HIV surveillance system built on earlier local efforts and focused on gay, bisexual and other MSM in Canada. Men who have ever had sex with another man and who meet the age limit of consent for the given province/territory (age varies by site according to provincial/territorial ethical considerations) are eligible to participate in M-Track.

Summary of descriptive data from M-Track Phase 1 (2005-2007):Footnote 3

  • Across five sentinel sites 4,838 men participated in Phase 1 of M-Track, of whom 26% were 29 years of age or less.
  • The majority of all men who participated in M-Track reported multiple male sex partners (i.e. more than one male partner), including oral and/or anal sex, in the 6 months preceding survey administration (64%). Similarly, among youth MSM who participated in M-Track, 66% reported multiple male partners.
  • Among youth MSM who reported having anal sex with a casual male partnerFootnote* in the previous 6 months, nearly half (48%) reported consistent ("Always") condom use during anal sex (insertive and/or receptive) compared with 45% among M-Track participants over the age of 30.
  • Most men (86%) who participated in M-Track reported ever having been tested for HIV; among youth MSM this proportion was 75%. Further, among youth MSM who reported that their most recent HIV test was negative, 80% had been tested for HIV in the 2 years preceding survey participation.
  • Among youth participants who provided a biological sample of sufficient quantity for testing and who completed a questionnaire, the prevalence of HIV was 4%. The overall prevalence of HIV in M-Track Phase 1 was 15%.
  • Of all M-Track participants whose biological sample tested positive for HIV, 19% were unaware of their HIV-positive status.Footnote Of youth participants, the proportion unaware of their HIV-positive status was 34%.

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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Hospitalization rates for schizophrenia rose among men in all age groups from 15 to 64 years between 1987 and 1999 (Figure 3- 5).

Figure 3-5 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, among men in general hospitals, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

Figure 3-5 Rates of hospitalization for schizophrenia* among men in general hospitals, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)
Text equivalent for figure 3-5
Figure 3-5 Rates of hospitalization for schizophrenia, using the most responsible diagnosis only, among men in general hospitals, Canada, 1987/88 to 1999/2000 (standardized to 1991 Canadian population).
Year
Age Group 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Men less than 15 years 0.9 0.8 0.8 0.7 0.8 1.2 1.0 1.0 0.8 0.6 1.0 0.8 0.8
Men 15 to 24 years 97.5 93.9 89.4 94.7 89.2 88.8 94.3 97.4 100.5 106.4 122.3 121.3 126.5
Men 25 to 44 years 142.9 148.4 149.1 156.5 157.8 161.9 167.5 172.8 166 167.3 171.8 170.5 170.7
Men 45 to 64 years 53.7 55.2 56.3 61.1 66.0 66.1 67.0 74.2 73.1 76.6 82.0 83.6 92.8
Men 65 years and older 26.6 26.1 24.6 25.6 24.9 26.9 26.3 25.4 23.2 22.1 23.4 26.2 27.4

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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In 1999, the average length of stay in general hospitals due to schizophrenia was 26.9 days - a decrease of 26% since 1987 (Figure 3-6).

Figure 3-6 Average length of stay in general hospitals due to schizophrenia, using the most responsible diagnosis only, Canada, 1987/88-1999/2000

Figure 3-6 Average length of stay in general hospitals due to schizophrenia*, Canada, 1987/88-1999/2000
Text equivalent for figure 3-6
Figure 3-6 Average length of stay in general hospitals due to schizophrenia, using the most responsible diagnosis only, Canada, 1987/88 to 1999/2000.
Year 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Days 36.2 35.7 35.2 37.4 43.3 38.8 39.4 37.8 38.2 31.8 28 26.6 26.9

Source: Centre for Chronic Disease Prevention and Control, Health Canada using data from the Hospital Morbidity File, Canadian Institute for Health Information

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Discussion of Hospitalization Data

The high hospitalization rates for schizophrenia among young adults support the clinical finding that the onset of schizophrenia typically occurs in adolescence and early adulthood. Higher rates among young men than young women agree with the observation that although schizophrenia affects both men and women, men develop it at an earlier age. Assessing whether the illness affects men differently than women in such a way that they require more hospitalization needs further research.

The increasing hospitalization rates for schizophrenia in general hospitals among young and middle-aged men may reflect, in part, the loss of psychiatric hospital beds that provided care for these men before deinstitutionalization. This care has now shifted to general hospitals. More research is needed to determine whether this also reflects shortcomings in the community treatment of the disease requiring hospitalization in order to control symptoms.

The length of stay in hospital associated with schizophrenia has decreased since 1995. This may reflect either improved treatment or the effect of decreases in hospital funding, which put pressure on the institutions to discharge people earlier than in previous years. Discharging people too early could be contributing to the increase in hospitalization rates through the need for re-admissions. Further research is needed to understand both the reason for this trend and its impact on individuals.

Future Surveillance Needs

Schizophrenia is a very serious mental illness with major ramifications for individuals and families, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Fortunately, schizophrenia can be treated effectively.

Existing data provide a very limited profile of schizophrenia in Canada. The available hospitalization data need to be complemented with additional data to fully monitor this illness in Canada. Priority data needs include:

  • Incidence and prevalence of schizophrenia by age, sex and other key variables (for example, socioeconomic status, education and ethnicity).
  • Impact of schizophrenia on the quality of life of the individual and family.
  • Access to and use of health care services and community-based programs.
  • Treatment outcomes.
  • Access to community supports, such as housing, employment and education.
  • Impact of schizophrenia on the workplace and the economy.
  • Stigma associated with schizophrenia.
  • Exposure to known or suspected risk and protective factors.
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