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The role of dietitians in collaborative primary health care mental health programs
DDIIEETTIITTIIAANNSS
The role of dietitians in collaborative primary health care mental health programs
Foreword
TheCanadianCollaborativeMentalHealthInitiative(CCMHI)commendsDietitiansofCanadaforcreatingTheRoleofDietitiansinCollaborativePrimaryHealthCareMentalHealthPrograms.Thistoolkitisintendedtohelpdietitiansintheircareofclientswhohavementalillness,and,assuch,providesanexcellentintroductiontoboththecomplexrelationshipbetweennutritionandmentalhealthissuesandtotherolethatdietitiansplayinhelpingclientsmanagethatrelationship.Accordingly,thistoolkitisalsoasuperbresourceforothermembersofthecareteam,tohelpthemunderstandtheskillsandthevaluethatdietitiansbringtotheteam.
DietitiansofCanadahaveplayedakeyroleintheleadershipoftheCanadianCollaborativeMentalHealthInitiativeandareablyrepresentedontheinitiativesSteeringCommitteebyMarshaSharpandLindaDietrich.Throughouttheinitiative,MarshaandLindahavemadesurethattheinitiativepaysattentiontoboththebroaderdeterminantsofhealthandthebroaderimplicationsofthereconceptualizationofprimaryhealthcare.CCMHIisa2yearnationalprojectfundedbyHealthCanadasPrimaryHealthCareTransitionFund.ThegoalofCCMHIistoimprovethementalhealthandwellbeingofCanadiansbystrengtheningrelationshipsandimprovingcollaborationamonghealthcareproviders,consumers,familiesandcommunities.Thefocushasbeenonstrengtheningthedeliveryofmentalhealthservicesinthecontextofprimaryhealthcarethroughcollaborationandconsumercentredness.Wehavemetourgoalthroughfourmainareas: Strengthenedthecaseforcollaborativementalhealthcare Clarifiedthekeybarrierstocollaborativementalhealth
care Developedtoolsforgettingatthesebarriers Builtthefoundationforcontinuedstrengtheningof
collaborationtheCanadianCollaborativeMentalHealthCharter
TheDietitiansofCanadatoolkitisoneofthemanytoolkitsdevelopedthroughCCMHI.OtherCCMHIresourceswhich
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The role of dietitians in collaborative primary health care mental health programs
mightinterestdietitiansinterestedinmentalhealthissuesincludeanannotativebibliographywhichdescribesover300relevantjournalarticles,apaperdescribingtheexperimentalevidenceforbetterpracticesincollaborativementalhealthcareand,amongmanyotherresearchpapers,CollaborativeMentalHealthCareinPrimaryHealthCare:aReviewofCanadianInitiatives:VolumeII.Thisreviewdescribes89collaborativementalhealthinitiativesacrossCanada.Dietitiansornutritionistsplayanimportantrolein18%oftheinitiativesdescribedinthereviewandcanbefoundtobecontributingincollaborativeteamsinVancouver,NorthernSaskatchewan,St.Boniface,Niagara,SouthwesternOntario,Toronto,Hamilton,SouthwesternNewBrunswick,WhitehorseandYellowknife.ForaccesstoallofCCMHIstoolkits,researchpapersandotherresources,gotowww.ccmhi.ca.
OneoftheprinciplesenshrinedintheCanadianCollaborativeMentalHealthCharter,endorsedbyDietitiansofCanada,isAllCanadianshavetherighttohealthservicesthatpromoteahealthy,mind,bodyandspirit.DietitiansofCanadahasbeenfrontandcentre,keepingusmindfulofthisimportantunity.WelookforwardtodietitiansallacrossCanadaplayingakeyroleinmakingthisprincipleliveandbreathe.
Regards,
ScottDudgeonExecutiveDirectorCanadianCollaborativeMentalHealthInitiative(CCMHI)
Dr.NickKatesChair,CanadianCollaborativeMentalHealthInitiative(CCMHI)
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Executive summary
Thisdocumentisdesignedtoserveasamechanismtostimulateinterestanddiscussionabouttheincorporationofdietitianservicesintoprimaryhealthcarementalhealthprograms.ItstemsfromTheCanadianCollaborativeMentalHealthInitiative(CCMHI)thataddressestheimportantgoalofgreaterintegrationofspecializedservices,suchasnutritionandmentalhealthexpertise,inprimarycaresettings.TheCCMHIinvolvestwelvenationalorganizations,includingtheDietitiansofCanada,tohelpstrengthenthecapacityofprimaryhealthcareproviderstoworktogethertodeliverqualitymentalhealthservices.
Thispaperisacompilationoftheconsultationprocessthatexamineddietitianservicesinmentalhealth.ItbeganwiththereviewofdraftspecialpopulationandgeneraltoolkitsdevelopedbytheCCMHISteeringCommittee.Thisreviewwasconductedbyaworkinggroupcomprisedofnutritionprofessionalsinmentalhealthtoensurerepresentationofdietitiansroleincollaborativecare.Subsequently,thistoolkitoutliningtheimportantrolethattheregistereddietitianplaysincollaborativeprimaryhealthcarementalhealthprogramswasdeveloped.Processesusedintheevolvementofthisdocumentincludedareviewoftheliteratureprovidingevidenceofeffectivenessofnutritionservicesforindividualswithmentalhealthissues,aswellasdirectedinputfromworkinggroupmembers,independentreviewersindieteticsandhealthaswellasconsumersandtheircaregivers.
Individualswithmentalhealthissueshavebeenidentifiedasbeingatnutritionalriskduetoavarietyoffactors.Severalnutritionalconsequencesoccurasaresultofeatingdisorders,mooddisorders,schizophrenialikesyndromes,personalitydisorders,substanceusedisorders,dementia,attentiondeficithyperactivitydisorder,autismaswellasdevelopmentaldelaysanddisabilities.Specificconcernsincludesignificantweightfluctuations,potentialnutrientdeficiencies,feedingissuesandsignificantnutritionrelatedsideeffectsofpharmacologicaltreatments.Furthermore,issuessuchaspoverty,socialisolation,marginalization,comorbidmedical
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conditions,concurrentdisorders,andagingcompoundthenutritionrelatedproblemsthispopulationencounters.
Dietitiansareuniquelyqualifiedtoidentifythenutritionalneedsofindividualswithmentalhealthissuesandtoplanappropriateinterventionswithinprimarycarecontexts.Basedoneducationinthescienceandmanagementofnutrition,andpracticesbasedonevidencebaseddecisionmakingandnationalstandards,thedieteticsprofessionalcanassessclinical,biochemical,andanthropometricmeasures,dietaryconcerns,andfeedingskillsaswellasunderstandthevarieddeterminantsofhealthactingoninterventionplans.
Dietitiansworkinginmentalhealthcanbecatalystsforimprovedcareofmentalclientsandeffectivemembersofcollaborativementalhealthcareteams.However,toachievetheirfullpotential,severalissuesneedtobeconsidered,includingtheallocationoffinancialresourcestoincludedietitianservicesinprimaryhealthcarecontexts,andtheneedtoexpandthementalhealthcontentand/orfieldexperienceindieteticstraining.Inaddition,strategiestoenhanceaccessibilityofdietaryservicesthroughhomevisiting,nutritiontrainingofparaprofessionalsandpeerworkers,andincreaseduseoftelemedicineservicesareneeded.Finally,thereisaneedtoadvocateforofficialrecognitionofnutritionandmentalhealththroughnationalpolicy,incorporatenutritionissuesandinterventionstrategiesintoclinicalguidelinesforpsychiatriccare,anddirectresearchinthisarea.Byaddressingtheseconcerns,thehealthandqualityoflifeofindividualswithmentalhealthissuescanbeenhancedandhealthcareresourcescanbeusedmoreeffectivelyandefficiently.
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Summarization of the toolkit
Background
OneofthekeydeliverablesoftheCanadianCollaborativeMentalHealthInitiative(CCMHI)isthedevelopmentoftoolkitsthatprovidehandsonadvicefortheimplementationofcollaborativementalhealthcare.Thetoolkitsaredirectedtowardsconsumers,familiesandcaregivers,educatorsandcliniciansandareintendedtocapturethevisionsandgoalsofprimaryhealthcare.
Inordertofurthertheagendaofcollaborativementalhealthcare,theCCMHIinconjunctionwiththeDietitiansofCanadacommissionedthisdocumenttoexaminetheroleofthedietitianinprimaryhealthcarementalhealthprograms.Nutritionissuesareprevalentinthesecontextsandarecommonlytreatedbybothprimaryhealthcareandspecialistsystemsthatwouldbenefitfromgreaterintegration.Thisspeakstoaneedforinnovativeprogramsthatchangethedailyrelationshipbetweenmentalhealth,nutritionandprimarycareservices.Suchprogramscaneliminatesomeofthebarrierstowellcoordinatedandcontinuouscare.
The population
Forthepurposesofthetoolkit,referenceismadetoindividualsdiagnosedwithamentalillnessaccordingtotheDiagnosticandStatisticalManualofMentalDisordersortheInternationalClassificationofDiseases.Thesehealthconditionsarecharacterizedbyalterationsinthinking,mood,orbehavior(orsomecombinationthereof),whichareassociatedwithdistressand/orimpairedfunctioningandspawnahostofhumanproblemsthatmayincludedisability,pain,ordeath.Thepopulationswhowouldbenefitfromnutritionservicesinprimaryhealthcarementalhealthprogramsinclude: AnxietyrelateddisordersandPostTraumaticStress
Disorder BorderlinePersonalityDisorderandPsychoticDisorders AttentionDeficitHyperactivityDisorderandAutism Primarymentalillness,includingindividualswithmood
disorders(e.g.,unipolarorbipolardepression),eating
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disorders,andschizophreniasyndromes.Thiscanincludethoseinforensicsprograms.
Complexdementia,neurological,ormedicalconditionswithassociatedorcomorbidpsychiatricillness.Thesewouldincludedementia/neurologicalconditionswithbehavioural/mentalhealthissuesandmedicalillnesswithpsychiatricdisorder(e.g.,apersonwithParkinsonsthatalsohaspsychosis)
Individualswithsubstanceabusedisorders Individualswithconcurrentdisorders,comorbidities,
developmentaldelaysordisabilities
Thescopeinwhichdietitianserviceswouldbebeneficialisbroadandthereforecooperativeconsultationamongprimarycarepractitionerswillbeneededtohelptodefinethepopulationwhowillbeservedinanyspecifiedcollaboration.Inparticular,withintheprimaryhealthcontextclarificationisneededregardingthetypeofregistereddietitianprovidingservice.Forexample,theregistereddietitiancanbeaspecialistinmentalhealththatspecificallycollaborateswithafamilyphysicianonaparticularissue.Alternatively,thedietitiancanworkinprimaryhealthcareandcounselclientswhomayhappentohavementalhealthissues.Inbothoftheseinstances,theneedsandperspectiveswilldiffer.
The importance of the dietitians role in primary health care mental health programs
Individualswithmentalhealthissueshavebeenidentifiedasbeingatnutritionalriskduetoavarietyoffactors.Severalnutritionalconsequencesoccurasaresultofeatingdisorders,mooddisorders,schizophrenialikesyndromes,personalitydisorders,substanceusedisorders,dementia,attentiondeficithyperactivitydisorder,autismaswellasdevelopmentaldelaysanddisabilities.Specificconcernscanincludepotentialnutrientdeficiencies,feedingissuesandsignificantnutritionrelatedsideeffectsofpharmacologicaltreatments.Furthertothis,issuessuchaspoverty,socialisolation,marginalization,comorbidmedicalconditions,concurrentdisorders,andagingcompoundthenutritionrelatedproblemsthispopulationencounters.
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Dietitiansareuniquelyqualifiedtoidentifythenutritionalneedsofindividualswithmentalhealthissuesandtoplanappropriateinterventionswithinprimarycarecontexts.Basedoneducationinthescienceandmanagementofnutrition,andpracticesbasedonevidencebaseddecisionmakingandnationalstandards,thedieteticsprofessionalcanassessclinical,biochemical,andanthropometricmeasures,dietaryconcerns,andfeedingskillsaswellasunderstandthevarieddeterminantsofhealthactingoninterventionplans.
Key information from the consultation process
Thistoolkitevolvedfromaconsultationprocessthatexaminedtheroleofdietitianservicesinmentalhealth.ItbeganwiththereviewofthedraftsofspecialpopulationandgeneraltoolkitsdevelopedbytheCCMHISteeringCommittee.Thesedocumentswereexaminedbyaworkinggroupofnutritionprofessionalsemployedinpsychiatry,geriatrics,homecare,andprogramsformarginalizedpopulations.Atthisphaseoftheconsultationprocess,memberswereprovidedwithaquestionnairetohelpthemintegratetheirfeedbackfromadieteticsperspective.Thequestionnairecombinedwithcommunicationamongtheworkinggroupalsoattemptedtogatherinformationonrelevantresourcesandcollaborativecareinitiatives.Inadditiontothis,semistructuredinterviewswithconsumersandtheircaregiversselectedfromorganizationsthatprovidesupporttoindividualswithmentalhealthissueswereconducted.Theseinterviewswereintendedtogatherinformationconcerningexperienceswithdietitians.Atotalof10interviewswereconducted.Theseprocessesaswellasreviewoftheliteratureprovidingevidenceofeffectivenessofnutritionservicesforindividualswithmentalhealthissuesledtothedevelopmentofthistoolkit.
Inordertoevaluatethefinaltoolkit,inputfromtheworkinggroupmembers,independentreviewersincludingnutritionandotherhealthprofessionalsaswellasconsumersandtheircaregiversweresought.Feedbackwasdirectedbytheuseofaquestionnaireintendedtoelicitopinionsabouttheadequacyinwhichthetoolkitoutlinedcollaborativecare,the
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definedpopulation,issuesinmentalhealthandnutrition,thevisionsandgoalsofprimaryhealthcare,importantconsiderationssuchasrelevantpoliciesandlegislation,examplesofcollaborativemodelsanddefinitionoftheroleofthedietitian.
Thekeyfindingsoftheconsultationprocessincluded:
ThedirectandnondirecthealthcarecostsassociatedwithmentalillnessesinCanadaaresignificantandaccountforatleast$6.85billion,thusanyprogramstargetedatimprovingconsumersymptomsandfunctioning,suchasdietitianservices,havethepotentialtoreducethesignificantcostofmentalillnessinCanada.
Individualswithmentalillnessesareatheightenednutritionrisk.Inparticular,peoplewhosufferfromeatingdisorders,mooddisorders,schizophrenialikesyndromes,substanceusedisordersanddementiaareatriskofsignificantweightfluctuations,nutrientdeficiencies,developingcomorbiditiesthataffectnutritionalwellbeingandencounteringavarietyofdrugnutrientinteractions.Withinthispopulationarespecialsubgroupsthatincludemarginalizedindividuals,childrenandadolescents,individualswithconcurrentdisordersaswellasindividualswithdevelopmentaldelaysordisabilities.Someoftheimportantnutritionrelatedissuesfacingthisgroupincludefoodsecurity,failuretothrive,swallowinganddentalproblems.Asamultidisciplinaryteammember,theregistereddietitiancanoffertheseclientsnutritioncareplansthatconsidersthemedical,psychiatric,psychological,social,spiritual,andpharmacologicaspectsoftheirtreatment.
Individualswithmentalhealthissuesvaluetheroleofthedietitianandresearchsuggeststhatiftheirservicesareprovidedinamannerthatmeetstheirneedstheywillseeknutritionalcareinaprimaryhealthcarecontext.
RegistereddietitiansacrossCanadaidentifiedthataccessibility,lackofcoordinationofsystems,lackoffunding,lackofunderstandingofeachothersroleswithinaninterdisciplinaryteam,aneedtoimplementcontentand/orfieldexperiencethataddressesthe
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nutritionneedsofpersonswithmentalhealthissuesintrainingprogramsaswellasaneedforprotocolsthataddressestheuniquenutritionalneedsofthispopulationarecurrentbarrierstoprovidingnutritioncareforthispopulation.
Registereddietitiansvalueaclientcentered,collaborative,populationhealthapproachtocare.Theirspecializedtrainingandskillsprovidemeaningfulenhancementtothecareofindividualswithmentalhealthissues.
Recommendations and conclusions
Dietitiansworkinginmentalhealthcanbecatalystsforimprovedcareofclients.However,toachievetheirfullpotential,severalissuesneedtobeconsidered,includingtheallocationoffinancialresourcestoincludedietitianservicesinprimaryhealthcarecontexts,andtheneedtoexpandthementalhealthcontentand/orfieldexperienceindieteticstraining.Furthermore,strategiestoenhanceaccessibilityofdietaryservicesthroughhomevisiting,nutritiontrainingofparaprofessionalsandpeerworkers,andincreaseduseoftelemedicineservicesareneeded.Finally,thereisaneedtoadvocateforofficialrecognitionofnutritionandmentalhealththroughnationalpolicy,incorporatenutritionissuesandinterventionstrategiesintoclinicalguidelinesforpsychiatriccare,anddirectresearchinthisarea.Byaddressingtheseconcerns,thequalityoflifeofindividualswithmentalhealthissuescanbeenhancedandhealthcareresourcescanbeusedmoreeffectivelyandefficiently.
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Table of contents
Foreword....................................................................... i
Executive summary..................................................... iii
Summarization of the toolkit ....................................... v
Background .................................................................... v The population................................................................ v The importance of the dietitians role in primary health care mental health programs ................................................. vi Key information from the consultation process................ vii Recommendations and conclusions ................................. ix
Introduction................................................................. 1
Consultation process.................................................... 5
Defining primary health care and mental health populations .................................................................. 7
Definition of primary health care ......................................7 Benefits of primary health care ........................................7 Defining the population ...................................................7
Issues in mental health and nutrition .......................11
Key lessons from the literature ...................................... 11 Mental illness as a significant health issue ................... 11 Special populations of those who suffer from mental illness ....................................................................... 13 The role of nutrition in mental health.......................... 16
Key lessons from the review process .............................. 21
Vision and goals of primary health care ....................25
Accessibility .................................................................. 25 Collaborative structures ................................................. 28 Richness of collaboration ............................................... 32 Consumer and family centredness.................................. 33
Important considerations in development of initiatives...................................................................................35
Policies, legislation, and regulations ............................... 35 Current perspectives in mental health ............................ 36 Funding........................................................................ 36 Appropriate technologies ............................................... 38 Evidence-based research ............................................... 38 Community needs ......................................................... 39 Planning and implementation......................................... 39 Evaluation .................................................................... 40
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Selected Canadian examples .....................................43
The Hamilton Health Services Organization Mental Health Nutrition Program ......................................................... 43 The Cool Aid Community Health Centre, Victoria, BC ....... 46 Defining me: Developing a healthy body image and lifestyle, Mount Saint Vincent University, Halifax ............. 48 Other examples ............................................................ 49
Summary....................................................................51
Role of the registered dietitian in primary health care mental health programs ................................................ 51 Recommendations......................................................... 57
Appendix A .................................................................61
Appendix B .................................................................63
Appendix C .................................................................67
Appendix D.................................................................69
Appendix E .................................................................73
Reference list .............................................................79
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The role of dietitians in collaborative primary health care mental health programs
Introduction
Thefocusoftheprimaryhealthcareapproachisbothaphilosophyofhealthcareandamodelforprovidinghealthcareservices.Primarycarereformsharesseveralgeneralprinciples(111)thatmustbeimplementedsimultaneously,whichincludeahealthsystemthatisaccessible,haspublicparticipation,ismorecomprehensive,includesintersectoralcooperation,focusesonillnesspreventionandhealthpromotion,andplacesemphasisonappropriateskillsandtechnology.Toachievethis,networksofprimarycareprovidersmustbeestablished.Examplesoftheseincludegroupsofexistingfamilypractices(2),largergroupsofprimarycarepracticeslinkedwithotherprovidersofhealthsuchasregistereddietitiansandcommunityservices(9),orlinkagesofprimarycarepracticeswithlocalcommunityagenciesandsocialserviceprovidersinasingleorganization(4;8).
Oneimportantgoalidentifiedinprovincialplanningdocumentsisgreaterintegrationofspecializedservicesintoprimarycaresettings.Formanyhealthproviders,attemptstoaccomplishthisaredescribedasjourneysintounfamiliarterritory.Despitethis,manyexamplesofsuccessfulprogramsexistandinclude:
Thetimeisnowrightfornutritiontobecomeamainstream,everydaycomponentofmentalhealthcare,andaregularfactorinmentalhealthpromotionThepotentialrewards,ineconomicterms,andintermsofalleviatinghumansufferingareenormous.Dr.AndrewMcCulloch,
ChiefExecutive,TheMentalHealth
Foundation,2006,(12)
Thecentreslocalesdesservicescommunautaires(CLSCs)inQuebec
Communityhealthcentresinmanypartsofthecountry TheHealthServicesOrganization(HSO)Programin
Ontario Thestreethealthteams,whichareactiveinmostlarge
citiesacrossCanada
Mentalhealthandnutritionissuesareprevalentinthesecontextsandarecommonlytreatedbybothprimaryhealthcareandspecialistsystemsthatwouldbenefitfromgreaterintegration.Thisspeakstoaneedforinnovativeprogramsthatchangethedaytodayrelationshipbetweenmentalhealth,nutritionandprimarycareservices.Suchprogramscaneliminatesomeofthebarrierstowellcoordinatedandcontinuouscare.
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TheCanadianCollaborativeMentalHealthInitiative(CCMHI)isapartnershipoftwelvenationalprofessionalgroups,includingtheDietitiansofCanada.Itisintendedtostrengthenthecapacityofprimaryhealthcareproviderstoworktogethertodeliverqualitymentalhealthservices.Theprojectgoalsinclude: Analysisofthecurrentstateofcollaborativementalhealth
attheprimaryhealthcarelevel Developmentofacharterincludingasharedvisionof
collaborativecareinthedomainofmentalhealththatwasendorsedbytheDCBoardofDirectorsonOctober21,2005
Approachesandstrategiesforcollaborativecare Disseminationofinitialfindings,materials,educational
toolsandguidelinestosupporttheimplementationandevaluationofcollaborativecareapproaches.
TheCCMHIhasdevelopedanumberoftoolkitsexaminingmentalhealthissuesandtargetingspecialpopulations.Aspartofthedevelopmentofthesetoolkits,agroupofDCmembersthatworkinvariousareasofmentalhealthreviewedandprovidedfeedbackonthesedocumentsfromadieteticsperspective.ThesetoolkitsaswellasseveralothersarelocatedontheCCMHIwebsite(www.ccmhi.ca).AsfollowuptothedevelopmentoftheseCCMHIresources,DCwasprovidedtheopportunitytodevelopatoolkitabouttheroleofregistereddietitiansinprimaryhealthcarementalhealthprograms.
Registereddietitianscanaugmentandcomplementfamilyphysiciansactivitiesinpreventing,assessing,andtreatingnutritionrelatedproblems.Thismodelofsharedcarecanbeappliedtointegratingotherspecializedservicesintoprimarycarepractice.
CrustoloAM,KatesN,AckermanS,Schamehorn,
2005,(13)
Thisdocumentisthetoolkitintendedtooutlinetheroleforregistereddietitiansinmentalhealthandprimaryhealthcare.Itisdividedintosevensections,someofwhicharerelevanttospecificaudiences.Thesectionsinclude: Descriptionoftheconsultativeprocess. Definingprimaryhealthcareandthementalhealth
populationsthatarebestservedbydieteticsservices. Examiningissuespertainingtodieteticsandpsychiatry
thatarerelevanttoallprofessionalsworkinginmentalhealth.
Outliningthevisionandgoalsofprimaryhealthcareanddiscussingtheminthecontextofdieteticsandmental
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Aswellasitsimpactonshortandlongtermmentalhealth,theevidenceindicatesthatfoodplaysanimportantcontributingroleinthedevelopment,managementandpreventionofspecificmentalhealthproblemssuchasdepression,schizophrenia,attentiondeficienthyperactivitydisorder,andAlzheimersdisease.
Dr.DeborahCornah,Consultant,
MentalHealthFoundation,2006(12)
health.Thissectionalsospeakstoallprofessionalsworkingwithmentalhealthconsumers.
Importantconsiderationspertainingtothedevelopmentofprimarycareinitiativesencompassingmentalhealthanddieteticsservices.Thissectionidentifieskeyissuessuchasfundingandevidencebasedresearchthatwillbeofinteresttoplannersofprimaryhealthcareprograms.
Examplesofexistingprogramsintegratingmentalhealthandnutritionservices.Thisisalsoofinteresttothoseinvolvedinthedevelopmentofprimaryhealthcareprograms.
Summarizingthepotentialroleofthedietitianinprimaryhealthcarementalhealthprograms,whichspeakstoallhealthprofessionals,butparticularlyoutlinesstrategiesforfuturedirectionofthedieteticsprofessioninmentalhealth.
DietitiansinteracteverydaywithCanadiansthathavementalhealthissueswhoareseekingassistancetoimprovetheirhealth.Asaresult,theyencounterissuesrelatedtoaccessibilityofservices,identifytheneedtointegrateservices,andworkwithchangeintheformofemergingresearch,knowledgeandnewtechnology.Itisbasedonthecollectiveknowledgeandexpertiseofdietitiansworkinginmentalhealththatthisdocumentwasprepared.Itisanticipatedthistoolkitwillleadthereadertoaclear,indepthunderstandingoftherolethattheregistereddietitiancanhaveintheenhancementofprimaryhealthcarementalhealthprograms.
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Consultation process
Dietitiansareuniquelyqualifiedtoidentifynutritionalneedsandtoplanappropriateinterventionatallpointsofthecontinuumof(mentalhealth)care.DCMentalHealthNetwork,
1998,(14)
ThePrimaryHealthCareMentalHealthandNutritionWorkingGroupusedinthisprojectwerecomprisedofregistereddietitiansfromacrossCanadawhoworkinpsychiatry,homecare,geriatrics,andaddictionsaswellaswithprogramstargetedtomarginalizedindividuals.Inadditiontotheworkinggroup,anumberofreviewerswereutilizedthatincludeddietitiansworkinginmentalhealth,otherhealthprofessionals,aswellasconsumersandtheircaregivers.MembersoftheworkinggroupaswellasthereviewersareidentifiedinAppendixA.
Astrategywasdevelopedtoensuremultipleperspectivesinthedevelopmentofthistoolkit.Thisstrategyconsistedof:
1. Identificationofcurrentliteraturerelevanttothedevelopment,implementation,evaluationandsustainabilityofcollaborativecareinitiativesinmentalhealthandnutrition.
2. ReviewofthedraftsofCCMHIspecialpopulationandgeneraltoolkitswithaviewtoensuringdieteticswasrepresented.Membersoftheadvisorygroupandotherreviewerswereaskedtoreviewtoolkitsspecifictotheirpracticeareaandweregivenaquestionnairetohelpdirecttheirfeedback.ThequestionnaireislocatedinAppendixBandisadaptedfromtheSpecialtyGeriatric/GenericMentalHealthQuestionnaireoftheGeriatrictoolkit.
3. Completionofsemistructuredinterviewswithconsumersthatwereselectedmembersofmentalhealthorganizations(AppendixC).
4. Communicationwithintheworkinggroupincludingconferencecallstogatherinformationconcerningmentalhealthandnutritionand,inparticular,informationonrelevantresourcesandcollaborativecareinitiatives.
5. Development,reviewandfinalapprovalofthistoolkit.Aquestionnairecombinedwiththisdocumentwassenttoallworkinggroupmembersaswellasindependentreviewerstoprovidedirectedfeedback(AppendixD).
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Thistoolkitisasynthesisofthefiveaforementionedstagesandincludes:Iwasdiagnosedmanic
depressive21yearsago.SincethenIhavehadtogoonmanydifferentdietsbecauseofcholesterol,diabetesIrealizenowtheimportanceofnutrition.
Consumer,Toolkitparticipant
Adefinitionofthepopulationandprimaryhealthcare. Anexplorationoftheliteraturepertainingtomental
healthandnutritionanditsrelevancetoprimaryhealthcare.
Discussionoftheimportanceofdietitianservicesforthosewithmentalhealthneeds.
Currentchallengesandpotentialstrategiesforenhancingaccessibility,collaborativestructures,richnessofcollaborationandconsumercentredcare.
Theimpactoffundamentalstructuressuchaspolicies,legislationandregulations,funding,computertechnologies,evidencebasedresearchandcommunityneeds.
Recommendationsforstrategicallypositioningthedietitianintheplanning,developmentandevaluationofcollaborativecareinitiativesinmentalhealth.
Asthefundamentalbasistothistoolkit,primaryhealthcareandthementalhealthpopulationtowhichitaddressesisoutlinedinthefollowingsection.
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Defining primary health care and mental health populations PrimaryHealthCareis
essentialhealthcaremadeuniversallyaccessibletoindividualsandfamiliesinthecommunitybymeansacceptabletothem,throughtheirfullparticipationandatacostthatthecommunityandcountrycanafford.Itformsanintegralpart,bothofthecountryshealthcaresystem,ofwhichitisthenucleus,andoftheoverallsocialandeconomicdevelopmentofthecommunityItisthefirstlevelofcontactofindividuals,thefamilyandcommunitywiththenationalhealthcaresystem,bringinghealthcareascloseaspossibletowherepeopleliveandworkandconstitutesthefirstelementsofacontinuinghealthcareprocessPrimaryHealthCareaddressesthemainhealthproblemsinthecommunity,providingpromotive,preventive,curative,supportiveandrehabilitativeservicesaccordingly.
WHO,1978
Definition of primary health care
ThereareseveraldefinitionsofPrimaryHealthCare.Forthepurposesofthistoolkit,themostrecognizeddefinitionsetoutbytheWorldHealthOrganizationinthe1978AlmaAtaDeclarationwillbeused.
In1978,WHOadoptedtheprimaryhealthcareapproachasthebasisforeffectivedeliveryofhealthservices.Theprimaryhealthcareapproachisbothaphilosophyofcareandamodelforprovidinghealthservices.Thefocusoftheprimaryhealthcareapproachisonpreventingillnessandpromotinghealth.WHOidentifiedfiveprinciplesofprimaryhealthcare:accessibility,publicparticipation,healthpromotion,appropriateskillsandtechnology,andintersectoralcooperation.Allfiveprinciplesaredesignedtoworktogetherandmustbeimplementedsimultaneouslyinordertoachievethebenefitsoftheprimaryhealthcareapproach.
Benefits of primary health care
Primaryhealthcareinitiativesofferthefoundationuponwhichtobuildanationalframeworkforourhealthsystem(15).Theyseeklinkagesbeyondtraditionalhealthcaredeliverysuchasschoolandworkplaceenvironments.Theyfocusoneducatingthepublicthroughhealthpromotionanddiseaseprevention.TheyalsoencourageallCanadianstotakeanactiveroleintheirhealth.
Laterinthisdocument(Section7)thereaderwillseeanumberofexamplesofprimaryhealthcare.Theyillustratethedifferentmixesofprofessionalsandrangesofservicesratherthanacookiecutterresponse.Implementingtheprimaryhealthcareapproachhasshowntoincreasethequalityandaccessibilityofcareaswellascreateefficienciesandcostsavings(15).
Defining the population
Mentalhealthisastateofsuccessfulperformanceofmentalfunction,resultinginproductiveactivities,fulfilling
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relationshipswithotherpeople,andtheabilitytoadapttochangeandtocopewithadversity(16).Mentalhealthisindispensabletopersonalwellbeing,familyandinterpersonalrelationships,andcontributiontocommunityorsociety.
DC endorses reformed primary health care and principles for reform including the population health approach as well as addressing health determinants and their inter-relationships. The key determinants are (19):
Income and social status Social support networks Education and literacy Employment/working
conditions
Social environments ctices
enetic
rvices
Physical environments
Personal health praand coping skills
Healthy child development
Biology and gendowment
Health se Gender
Everyonehasmentalhealthneeds,whetherornottheyhaveadiagnosisofmentalillness.Whilementalhealthismorethananabsenceofmentalillness,forthepurposesofthistoolkit,itreferstoindividualsdiagnosedwithamentalillnessaccordingtotheDiagnosticandStatisticalManualofMentalDisorders(17)orInternationalClassificationofDiseases(18).Thesehealthconditionsarecharacterizedbyalterationsinthinking,mood,orbehavior(orsomecombinationthereof),whichareassociatedwithdistressand/orimpairedfunctioningandspawnahostofhumanproblemsthatmayincludedisability,pain,ordeath.Mentaldisordersincludethreemajorcategories:schizophrenia,affectivedisorders(majordepressionandbipolardisorder)andanxietydisorders(panicdisorder,obsessivecompulsivedisorder,posttraumaticstressdisorder,andphobia).
Forthepurposesofthistoolkit,thepopulationswhowouldmostbenefitfromnutritionservicesinmentalhealthwithintheprimaryhealthcarecontextinclude: AnxietyrelateddisordersandPostTraumaticStress
Disorder BorderlinePersonalityDisorderandPsychoticDisorders AttentionDeficitHyperactivityDisorderandAutism Primarymentalillness,includingindividualswithmood
disorders(e.g.,unipolarorbipolardepression),eatingdisorders,andschizophreniasyndromes.Thiscanincludethoseinforensicsprograms.
Complexdementia,neurological,ormedicalconditionswithassociatedorcomorbidpsychiatricillness.Thesewouldincludedementia/neurologicalconditionswithbehavioural/mentalhealthissuesandmedicalillnesswithpsychiatricdisorder(e.g.,apersonwithParkinsonsthatalsohaspsychosis)
Individualswithsubstanceabusedisorders Individualswithconcurrentdisorders,comorbidities,
developmentaldelaysordisabilities
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Giventhebroadscopeofprimaryhealthcareandthepopulationdefinedherethatwouldbenefitfromservicesofadietitian,itisevidentthattheroleofthenutritionprofessionalhaspotentiallyinfinitepossibilitiesintheprimarymentalhealthcarecontext.Cooperativeconsultationsamongprimarycarepractitionerswillhelptodefinethepopulationwhowillbeservedinanyspecifiedcollaboration.Inparticular,withintheprimaryhealthcontext,clarificationisneededregardingthetypeofregistereddietitianprovidingservice.Forexample,theregistereddietitiancanbeaspecialistinmentalhealththatspecificallycollaborateswithafamilyphysicianonaparticularissue.Alternatively,thedietitiancanworkinprimaryhealthcareandcounselclientswhomayhappentohavementalhealthissues.Inbothoftheseinstances,theneedsandperspectiveswilldiffer.
The role of the dietitian in mental health can include (20):
Identifying concerns such as poor intake, significant weight changes, drug interactions, and food accessibility
Acting as a resource to community support agencies as well as home operators for menu planning and food service standards
Facilitating psycho-educational groups for food and nutrition
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Issues in mental health and nutrition Canadianfamilyphysiciansreceiverelativelylittletraininginthefundamentalsofnutritionduringmedicalschool,havetimeconstraints,andarepresentedwithavastamountofnewinformationeveryyear;allthesefactorshinderthemfromprovidingeffectivedietarycounseling.Registereddietitianshavespecializedskills,knowledge,andtrainingintheareaoffoodandnutrition,yetonly16.6%ofCanadianfamilyphysicianswhosemainpracticesettingsareprivateoffices,privateclinics,communityclinics,orcommunityhealthcentersindicatetheyhavedietitiansornutritionistsonstaff.
CrustoloAM,KatesN,AckermanS,Schamehorn,
2005,(13)
Individualsdiagnosedwithmentalillnesstypicallyhaveconditionsthatplacethematnutritionalrisk.Dietitiansprovidetheexpertisetoaddresstheseissuesbasedontheireducationinthescienceandmanagementofnutrition,andtheircommitmenttoevidencebasedpracticesthatadheretonationallyestablishedstandardsandaremonitoredbyprovincialbodies(20).
Withreferencetotheresearchliteratureandinformationgatheredfromtheconsultationprocess,theimportanceoftheroleoftheregistereddietitianinmentalhealthisoutlined.
Key lessons from the literature
Whenreferringtotheresearchinthecontextsofmentalhealthandnutrition,therearethreespecificareastoconsider.First,isthelargebodyofevidencesuggestingthesignificantimpactofmentalillnessonthehealthcaresystem.Secondly,specifichighrisksubpopulationsofthosewhosufferfrommentalillnessneedtobehighlighted.Finally,andmostimportantly,theaccumulationofknowledgeregardingtheroleofnutritioninmentalhealthisdetailed.
Mental illness as a significant health issue Mentalillnessesareconditionsassociatedwithlonglastingdisabilityandsignificantmortalitythroughsuicide,medicalillness,andaccidentaldeath(2123).Thefollowingaresomekeypointsfromtheliteraturethathighlightthesignificanceofmentalhealthissues: TheWorldHealthOrganizationsGlobalBurdenof
Diseasestudyrevealedthatclinicaldepressionisanillnessoftremendouscostandwillrankasthesecondmostburdensomeillnessbytheyear2020(24).Globally,nearly3%ofthetotalburdenofhumandiseaseisattributedtoschizophrenia.
Mentaldisordersareamongthemostimpairingofchronicdiseases(25;26).
Hospitalizationratesforbipolardisorderingeneralhospitalsareincreasingamongwomenandmenbetween15and24yearsofage.
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Thedirectandnondirecthealthcarecostsassociatedwithschizophreniaareestimatedtobe$2.02billionorabout0.3%oftheCanadianDomesticProduct(27;28).Thiscombinedwiththehighunemploymentrateduetoschizophreniaresultsinanadditionalproductivitymorbidityandmortalitylossestimateof$4.83billion,foratotalcostestimateof$6.85billion.
IrememberthefirsttimeIevertalkedtoadietitian.Iwascompletelymanicandnoteating.Shetriedtokeepmefocusedbutitwasobviouswewerentgettinganywhere.LaterwhenIcamedownfrommyepisode,itwashelpfultotalktoher.
Consumer,Toolkitparticipant
Whilestillarelativelyrarecondition,Canadianautismdiagnostictrendsappeartobeincreasing(29).
InCanada,morbidityandmortalityrelatedtosubstanceabuseaccountfor21%ofdeaths,23%ofpotentiallifelost,and8%ofhospitalizations(30).Substanceusedisordersareassociatedwithahostofhealthandsocialproblems.
Peoplewithpersonalitytraitsthatimpactontheircareareestimatedtocomprise2030%oftheprimarycarepopulation.BasedonUSdata,about6%to9%ofthepopulationhaveapersonalitydisorder(31).
Anxietydisordersaffect12%ofthepopulation,causingmildtosevereimpairment(32).
Approximately3%ofwomenwillbeaffectedbyaneatingdisorderduringtheirlifetime.Since1987,hospitalizationsforeatingdisordersingeneralhospitalshaveincreasedby34%amongyoungwomenundertheageof15andby29%among1524yearolds(31).
AreportfromtheCanadianInstituteforHealthInformationrevealsthatpatientswithaprimarydiagnosisofmentalillnessaccountedfor6%ofthe2.8millionhospitalstaysin20022003.Another9%ofhospitalstaysinvolvedpatientswithanonpsychiatricprimarydiagnosisandanassociatedmentalillness.Combined,thesehospitalstaysaccountedforonethirdofthetotalnumberofdayspatientsspentinCanadianhospitals.Thesestaysweremorethantwiceaslong,onaverage,asstaysnotinvolvingmentalillness.
Peoplewithmentalillnessesaremorelikelytouseemergencyandurgentcare(33).Whiletherearetrendstowardsdeinstitutionalizationofthementallyill,thispresentsmanychallengestocommunitiesastheseindividualstendtohavesignificanthealthissues.
Past year prevalence rates of selected mental disorders in Canada (34)
Any disorder 10.9%
Depression 4.8%
Social phobia 3.0%
Alcohol dependency
2.6%
Mania 1.0%
Drug dependency
0.8%
Asaresultofthesealarmingfacts,mentalhealthissueshavebecomeatoppriorityonthehealthcareagenda.Programs
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targetedatimprovingconsumersymptomsandfunctioning,suchasindividualizednutritioninterventions,havethepotentialtomakesignificantcontributionsinreducingthecostofmentalillnessinCanada.Primaryhealthcareprovidesarelevantforumtoaddressmentalhealthissuesasthereisevidencetosuggestthatpeoplewithmentalillnessesarewillingtoengagewiththemedicalsystem(35).Thisinformationimplicatesthatifopportunitiesareprovidedinamannerthatmeetstheconsumersdieteticneeds,theywillseeknutritionalcareintheprimaryhealthcontext.
Special populations of those who suffer from mental illness Special populations of those
who suffer from mental illness may be at particular nutrition risk. These can include:
Marginalized individuals Children and adolescents Elderly Rural or isolated groups ith co-
morbidities
s
tal delays or
disabilities
Individuals w
Individuals with concurrent disorder
Individuals with developmen
Primarymentalhealthcarereformisalsoleadingtomanyopportunitiesfortheregistereddietitiantobeinvolvedincollaborativeapproachesinvolvingspecialpopulationswithmentalhealthissues.Theseincludemarginalizedindividuals,childrenandadolescents,theelderly,thoselivinginruralandisolatedregions,individualswithdevelopmentaldelaysordisabilities,aswellasindividualswithmentaldisordersthatsufferfromconcurrentdisordersandcomorbidities.Thefollowinghighlightssomeoftheimportantissuesfacingeachofthesegroups:
MarginalizedIndividuals:Thisgroupisdefinedasthosewhoarehomeless(absoluteorrelative),individualslivingwithaddiction,thoselivingwithdisabilities,streetyouth,solesupportparents,gay/lesbian/bisexual/transgendered,Aboriginals,andracialminorities(includingimmigrantsandrefugees).Affectivedisordersarefarmorecommoninthissubpopulation,rangingfrom20%to40%(36).TheRoyalCommissiononAboriginalpeoplesindicatesthatthisgroupismorelikelytofaceinadequatenutrition(37)andtheiroverallmentalhealthstatusismarkedlyworsethanthatofnonAboriginalpeoplebyalmostanymeasure(38).
Thelivesofmarginalizedpeoplesmaybecharacterizedashavingunstablelivingconditionsduetoalackoffinancial,social,spiritualandphysicalresourcesandinadequatesupport.Poorhealthalsocompoundstherisksfacedbyhomelesswomenwhobecomepregnant[Inonelarge,crosssectionalsurveyofhomelessyouthinToronto,onequarterofthewomensampledwerepregnant(39)].
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ChildrenandAdolescents:Theliteraturesuggeststhatcommonmentalhealthproblemsamongchildrenandyouthbetweentheagesof018yearsinclude:depression,anxiety,disruptivebehaviourdisorders,ADHD,eatingdisordersanddevelopmentaldisorders.Reportedprevalenceratesformentalhealthconcernsinchildrenandyouthrangefrom15%to20%(4043);5%ofthosebetweentheagesof417yearssufferextremeimpairment(44).Thereisevidencetosuggestthateatingdisorderissuesarebecominganincreasinglysignificanttothisgroup.Mentalhealthconcernsareamongthemostcommonreasonsthatchildrenseeafamilypractitioner(42).
Therecentandwidespreadappearanceoftransfatinthedietraisesgreatconcern,primarily,becausethesefatsassumethesamepositionasessentialfattyacidsinthebrain,meaningvitalnutrientsarenotabletoassumetheirrightfulpositionforthebraintofunctioneffectively.Transfatsareprevalentandpervasive
Dr.DeborahCornah,Consultant,
MentalHealthFoundation,2006(12)
TheElderly:Itisestimatedthat20%ofadultsoverage65haveamentaldisorder,includingdementia,depression,psychosis,bipolardisorder,schizophreniaandanxietydisorder(45).Olderadultswithmentalillnessfaceincreasedriskofmedicalillnessduetothelongtermeffectsofunhealthylifestyles,physiologicalchangesandcompoundingmedicalillnessesthatincreasethesusceptibilityforadditionalmedicalproblemsanddrugsideeffects.
RuralorIsolatedGroups:Thehealthofacommunityisinverselyproportionaltotheremotenessofitslocation.HealthindicatorsconsistentlyrevealthatsignificantdisparitiesexistinhealthoutcomesbetweenpeoplewholiveinnorthernversussouthernregionsofCanada,aswellasbetweenpeoplewholiveinAtlanticregionsversustherestofCanada(46).Inmostruralareas,thecostoftheNutritiousFoodBasketexceedsprovincialaverages.Manyruralcommunityagenciesalsohaveinsufficientfundstohireadietitian.
IndividualswithCoMorbidities:Individualswithchronicmentalillnesseshavebeenreportedtohavehigherthanexpectedlifetimeratesofhypertension(34.1%versus28.7%inthegeneralpopulation),diabetes(14.9%versus6.4%inthegeneralpopulation),andheartproblems(15.6%versus11.5%inthegeneralpopulation)(47;48).Thereisalsoconcernthatthesearenotbeingaddressedeitherintermsofpreventionortreatment(49).
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Thereareseveralothercomorbiditiesthatoccurinmentalillnessthathavesignificantnutritionalimplications.Thelifetimesmokingrateforthispopulationis59%,whichismuchhigherthanthe25%formenand21%forwomeninthegeneralpopulation.Smokersareatthehighestriskfordevelopingchronicobstructivepulmonarydisease(50).Individualswithmentalillnessaremorelikelytohaveachronicinfection,suchasHIV(about8timestherateinthegeneralpopulation),hepatitisB(about5timestherateofthegeneralpopulation)andC(about11timestherateofthegeneralpopulation)(51).LargerscalewellcontrolledstudiesindicatethatDSMIVeatingdisordersinadolescentfemaleswithtype1DMaretwiceascommonasthatfoundincontrolgroups(52).Thecooccurrenceofdiabetesandeatingdisorderspresentsmanyuniquechallengestohealthprofessionals.Thereisalsoevidencetosuggestthatdepressionisasignificanthealthissuerelatedtodiabetes(53).
Giventhattheprimaryhealthcaredefinitionincludesrehabilitativeservices,theRDsrolealsoneedstoberecognizedhere.Wecanplayakeyroleinforensicsandwithworkingrouphomesformentalhealthconsumers.Thiscanenhancetheconsumersqualityoflifeinareassuchashousing,vocationandrelationships.
RD,Toolkitparticipant
IndividualswithConcurrentDisorders:Inworkingwithpeoplewithmentalillness,particularattentionshouldbepaidtothehighratesofconcurrentmentalhealthandsubstanceabuseproblems.Canadianliteraturereportsratesofconcurrentdisorderof56%amongstpeoplewithbipolardisorderand47%ofpeoplewithschizophrenia(54).Theriskforsubstanceabuseproblemsare3timesthatofthegeneralpopulationforalcoholand5timesfordruguse.Peoplewithpersonalitydisorderswhoaccessprimarycarealsohavehigherratesofconcurrentdisorders(55).PeoplewithconcurrentdisordershavepooreroutcomesincludingdifficultywithdailylivingandincreasedriskforHIV/AIDS.
IndividualswithDevelopmentalDelaysorDisabilities:Developmentaldisabilitiesisagenerictermthatrefersprimarilytomentalretardationandsomeofthepervasivedevelopmentaldisorders.Mentalretardation(56)ischaracterizedbysignificantlybelowaverageintellectualfunctioningwhichhasitsonsetbeforetheageofeighteenyearsandisaccompaniedbysignificantimpairmentinadaptivefunctioning.Thepervasivedevelopmentaldisorders(17)arecharacterizedbysignificantimpairmentinmultipleareasofdevelopment,particularlysocialinteractionandcommunication,andaccompaniedbystereotypedbehaviour,
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interestsoractivity.FivedisordersareidentifiedunderthecategoryofPervasiveDevelopmentalDisorders:1.AutisticDisorder,2.RettsDisorder,3.ChildhoodDisintegrativeDisorder,4.AspergersDisorder,and5.PervasiveDevelopmentalDisorderNotOtherwiseSpecified.Somehealthproblemsforindividualsdiagnosedwiththeseconditionsincludeincreasedriskforobesity,cardiovasculardisease,swallowing,dental,andvisionproblems(57).
Psychologicalfactorsaredeterminantsofhealthwhichcanimpactthesuccessofpreventioneffortsandactivities.Stoppingsmoking,increasingexercise,improvingdietareallaboutbehaviourchangewhichisimpactedbypsychologicalandsocialfactors.Mood(depression,anxiety)hasgreatimpactonhowapersontakescareoftheirwellnessandtheirillnessandcangreatlyimpactthecourseofchronicdisease.AssociateExecutiveDirectorandRegistrar,Accreditation
Panel,CanadianPsychologicalAssociation
The role of nutrition in mental health Aspreviouslyidentifiedmanyindividualswithmentalhealthissuesareatheightenednutritionrisk.Someoftheresearchliteraturehighlightingtheseissuesaredetailedinthefollowing:
EatingDisorders:Alargebodyofevidenceexiststhathighlightstheroleofthedietitianinthepreventionandtreatmentofeatingdisorders.Amultidisciplinaryteamapproachtotreatmentisrequiredtoaddressthephysical,emotional,mental,andspiritualaspectsoftheindividual.Thegoalsofnutritiontherapyaretoprovideguidancethatfostersanourishingeatingstyleandpromotesnormalphysiologicfunctionandphysicalactivityaswellassupportingeatingbehavioursthatbringaboutapeaceful,satisfyingrelationshipwithfoodandeating(58).
MoodDisorders:Thereareoftennutritionalconsequencesofmaniaanddepressionthatincludeanorexiaandweightlossaswellastheconverse:increasedappetiteandweightgain(5862).Psychodieteticinvestigationshavealsoshownthatsomenutrientsaffectmood,moodstateaffectsfoodconsumption,manypsychiatricmedicationshavenutritionrelatedsideeffects(e.g.,thesideeffectsoftricyclicantidepressantsincludeincreasedappetite,nauseaandvomiting,constipationanddiarrhea),andmooddisordersinsomeclientsmaybearesultofinbornerrorsofmetabolism(6265).Studiesofnutritionsupplementshavedemonstratedvaryingefficaciesatamelioratingmoodsymptoms(6669).
Investigationsofthedietaryintakeofindividualswithbipolardisorderhavebeentypicallyneglected,butbasedondatafromasmallclinicaltrialattheUniversityofCalgary,itappearsthatthosewithbipolardisorderhaveahigher
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prevalenceofinadequatenutrientintakes(i.e.,75%oftheRDA)formanyessentialnutrients(70).
SomenotablefindingshavebeenfoundwithregardstonutritionanddepressionusingtheGovernmentofCanadasNationalPopulationHealthSurvey(71;72).ThissurveyallowedforthecomparisonofsampleswithandwithoutdepressionbasedonscoresoftheCompositeInternationalDiagnosticInterviewShortFormForMajorDepression(72).Comparisonsofthedepressedandnondepressedsamplesindicatedthatthosewhoweredepressedwere2.5timesmorelikelytohavefoodsecurityproblems,werealmost3timesmorelikelytoneedhelppreparingmeals,andabout2timesmorelikelytohaveselfreportedfoodallergies(70).
SchizophrenialikeSyndromes:Nutritionalconcernsforthisgroupincludethosementionedformooddisorders.Inaddition,otherissuesariseiftheindividualssymptomsincludefoodrelateddelusionsandhallucinations.Dieteticsresearchintheareaofmooddisordersandschizophrenialikesyndromeshaslargelybeendominatedbyinterventionstudiesusingavarietyofvitamins,minerals,dietaryneurotransmitterprecursors(e.g.,tryptophanasaprecursortoserotonin)andothernutrientfactorsastreatments.Ofthemicronutrientsexaminedtodate,theevidencesuggeststhatfolate,vitaminB12,theessentialfattyacids,andtryptophansupplementationmaybeeffectiveinthetreatmentofmooddisordersandschizophrenialikesyndromes(7377).
SomeoftheusualmedicationsusedtotreatSchizophrenialikesyndromesincludeantipsychotics,antiparkinsonianagents,antidepressants,andmoodstabilizers.Manyofthesehavesignificantnutritionrelatedsideeffectsthatincludeincreasedriskofobesityandobesityrelateddisorders,aswellasincreasedbloodglucoseandtriglycerides(78).
SubstanceUseDisorders:Vitaminandmineraldeficienciesandexcessesassociatedwithalcoholand/ordrugdependencyincludevitaminsA,B1,B3,folate,B6,C,D,Kaswellaszinc,magnesium,andiron(7981).Nutritioninterventionisusedinconjunctionwithmedical,behavioural,andpharmacologictreatmenttoimprovetheefficacyoftreatmentandrecoveryfromsubstanceabuse(79;82;83).
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AnxietyDisorders:Dietrelatedfactorsshouldbeconsideredaspossibleprecipitantsofanxiety.Forexample,caffeineintakeinsomeatriskindividualscanprecipitateorexaggerateanxiety(84).
Inordertointegratesuccessfulbehaviourchangestrategies,weneedtoaddressandunderstandwhatpromotesandlimitsbehaviourchange.Somefactorsaresocialandenvironmental(e.g.,whatkindoffoodissoldinschool,whetherschoolsofferphysicaleducationprograms,whatfoodsaremostaffordable)butsomearealsopsychological(e.g.,whydopeopleovereatandeatthewrongfoods;whatistheimpactofstressondietandexerciseandhowelsecanstressbemanaged;thekindsofexpectationsandbeliefschildrenhaveaboutbodyimageandphysicalactivity).AssociateExecutiveDirectorandRegistrar,Accreditation
Panel,CanadianPsychologicalAssociation
Dementia:ThetypesofdementiagenerallyseenincludeseniledementiaoftheAlzheimerstype(SDAT),andvasculardementia,suchasmultiinfarctdementia(MID).OthertypesofvasculardementiaincludethoseassociatedwithParkinsonsdisease,Huntingtonsdisease,substanceabuse,andmanyotherconditions(85).Commonnutritionalconcernsrelatedtodementiaincludedecreasedintake,weightloss,anorexia,andincreasedenergyneedsassociatedwithhighlevelsofphysicalmovement,unrecognizedinfections,dysphagiaorothercauses(8587).
AttentionDeficitHyperactivityDisorder(ADHD):TherelationshipbetweendietandADHDhasbeenwidelydebated.Presently,manyinconsistenciesexistinresearchfindingswhichmayinlargepartbeduetomethodologicalshortcomingsintheresearch.Whiletheefficacyofoneparticulartreatmenthasnotbeengenerallyaccepted,controlledanduncontrolledhumantrialssuggestcaffeineandsugarmayhavearoleinsomeinstances.Studiesalsoshowthatthemethylphenidate(Ritalin),apharmacologictreatmentforADHD,depressesappetiteinchildren,resultinginaslowerrateofweightgainandgrowth(57).
Autism:Todate,studiesinvestigatingtheroleoffolicacid,vitaminB6,magnesiumandvitaminB12havebeenconducted.EfficacyinthetreatmentofautismdemonstratedbycontrolledhumantrialshasbeenfoundforvitaminB6(8890).Nutritionalconcernsinautismincludelimitedfoodselection,strongfooddislikes,pica,aswellasmedicationandnutrientinteractions(57).
DevelopmentalDelaysandDisabilities:Developmentaldelayoccurswhenchildrenhavenotreachedspecifiedmilestonesbytheexpectedtimeperiod.Earlyinterventionservicesincludingnutritionresourcesandprogramsthatprovidesupporttofamiliescanenhanceachildsdevelopment.Nutritionisrelatedtosecondaryconditionsinpersonswithdevelopmentaldisabilitiesinmanysignificantways.
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Nutritionmaybeviewedasariskfactorforsecondaryconditions(e.g.,poornutritionalstatusmakethesecondaryconditionworse),nutritioncanbeaprotectivefactorandmanysecondaryconditionscanfurthermodifyonesdietandcreatesubsequentnutritionalproblems.
Sincenutritionisamajorlifestylefactorinhealthpromotionandinthepreventionandmanagementofsomecommonchronicconditionssuchasdiabetes,heartdisease,andobesity,itislogicalthatnutritionservicesbepositionedintheprimaryhealthcaresetting.Inthissetting,initialidentification,accessibleinterventionandlongtermrelationshipscanbeestablishedbetweentheclientandprovider.ThePrimaryHealthCareActionGroup,2005(91)
Personswithdevelopmentaldisabilitiesandspecialhealthcareneedsfrequentlyhavenutritionproblemsincludinggrowthalterations(e.g.,failuretothrive,obesity,andgrowthretardation),metabolicdisorders,poorfeedingskills,medicationnutrientinteractions,andpartialortotaldependenceonenteralorparenteralnutrition.Poorhealthhabits,limitedaccesstoservices,andlongtermuseofmultiplemedicationsareconsideredriskfactorsforadditionalhealthproblems(57).
Someadditionalkeyfactsdemonstratingtheimportanceofnutritionservicesforthosewithmentalillnessareoutlinedasfollows:
Physicalcomorbidconditionsinfluencethenutritionalwellbeingofindividualswithpsychiatricillness(59).Themostcommonoftheseareobesity,type2diabetesmellitus,dyslipidemia,liverandkidneydegeneration,infectiousdiseasesuchasHIV,AIDS,tuberculosis,aswellashepatitisA/B/C(36;57).Giventheseoverlappingandinteractingrisks,itisapparentthatindividualswithmentalillnessesfacesignificantthreatstotheirnutritionalwellbeing.
Thetransitionfrominstitutionaltocommunitybasedpsychiatriccarecarrieswithitsmanyhealthimplications,includingananticipatedincreaseintheactualnutritionalriskinthesevulnerablegroups(14).
Foodinaccessibilityisaprevalentissue.Foodsecuritymaybedefinedashavingaccessatalltimestonutritious,safe,personallyacceptableandculturallyappropriatefoods,producedinwaysthatareenvironmentallysoundandsociallyjust.Homelessindividualswithmentalillnessareparticularlysusceptibletofoodsecurityissues.Forexample,theyaremoresusceptibletofoodborneillnessesassomeobtaintheirfoodfromstrangersandgarbagereceptacles(92).
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Drugnutrientinteractions.TheimpactofantipsychoticagentsaswellasTCAsandpharmacologictreatmentsforADHDhasbeenpreviouslycited.AbnormalitiesinvitaminD,calciumandbonestatus,constipation,andgumhyperplasiahavebeenassociatedwiththeuseoftheanticonvulsantsphenytoinand/orphenobarbital(57).Manyolderadultstakemultiplemedicationsforextendedperiodsoftimeandareatriskforcomplicationscausedbymedicationinteractions.Inaddition,medicationmayhavealongerhalflifebecauseofdecreasedleanbodymass.Constipationisasideeffectoflongtermpsychotropicuse,whichresultsinincreaseduseoflaxativesandstoolsofteners.Nutritioninterventionsmaypreventordecreasetheseverityofadverseeffectsofmedications(e.g.,adequatefluidandfibrecanpreventconstipation).
Some examples of where the dietitian can work with mental health consumers include:
Treating many of the physical co-morbid conditions such as obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, chronic obstructive lung disease, metabolic syndrome, liver and kidney degeneration, as well as infectious diseases such as HIV, AIDS, TB, and Hepatitis A/B/C
Assisting the client to obtain nutritious, safe, personally acceptable and culturally appropriate foods
Helping to minimize the nutrition-related side effects of many psychiatric medications
Nutritionalknowledgeandattitudesofpsychiatrichealthprofessionalsimpactuponthecareoftheconsumerwithmentalhealthissues.Astudyinvestigatinginterrelationshipsamongnutritionknowledge,habits,andattitudesofpsychiatrichealthcareprovidersdemonstratedacomprehensivenutritioneducationprogramisessentialforhealthcareproviderstopromotesuccessfulnutritioneducationforthepatientstheyserve(93).
Alternativeandcomplementarytherapiesarehavinganincreasinglysignificantroleinthetreatmentofmentalillness.Thesecanincludeherbalremedies,botanicalorhomeopathicpreparations,useofvitamin/mineralsupplements,andsocalledOrthomolecularmedicine.Whiletheremaybebenefittosomeofthesetherapiesinsomeclients,correctunderstandingofdeficienciesandexcessesareimportanttoavoidthedevelopmentofserioushealthproblems.Clientsmaypurchasenutritionsupplementpackagesofherbs,vitamins,minerals,andaminoacidsfrominformationsuppliedontheInternet,ontherecommendationoffamilysupportgroupmembers,ontheadviceofhealthfoodstoreemployees,andbasedoninformationinprintedmaterials.Thepromiseofimprovedsymptomcontrolpromptsthesepurchases.
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Unfortunately,researchrelatedtotheuseoftheseproducts,includingsafetyandefficacy,isextremelylimited.(Intheprimaryhealth
caresetting)suchcomprehensiveserviceswouldincludearangeofhealthpromotionandtreatmentservices.Healthpromotionactivitiesmightincludesimpleinterventionssuchaspromotinghealthylifestyletospecializedservicesaimedatpreventingdiabetes,lowbirthweightorfailuretothriveamongchildrenortheelderly.TreatmentservicesmightrangefromadvicetoavoidhighdoesofaparticularvitaminsupplementtocomplexinterventionsformanagementofchronicconditionsThePrimaryHealthCareActionGroup,2005(91)
Atthepresenttime,currenttreatmentguidelinesformanyofthesementalillnessesfocusonbothpsychotherapyandpsychiatricmedications(94;95),butpossiblenutritionimplicationsarenotadequatelyaddressed.
Althoughthefieldofpsychiatricnutritionhasreceivedinadequateattention(93),interestinthisareaisgrowing.Aneedformultidisciplinary,practiceandoutcomebaseddieteticpracticeandstudiesinpsychiatricdisordersisclearlyevident.
Ascanbeevidencedbythisdiscussion,therearemultiplenutritionrelatedproblemsassociatedwithmentalillnesswhichhighlightstheneedforthespecializedservicestheregistereddietitiancanoffer.
Key lessons from the review process
Thereviewprocessinvolvedconsultationwithregistereddietitiansworkinginvariousfacetsofmentalhealth.Inaddition,inputandopinionsweregatheredfromgovernment,professionalbodies,theacademiccommunity,consumersandconsumer/advocacygroups,andhealthprofessionalsfromvariousdisciplines.
Whiletherehasbeennoformalreviewofdietitianservicesinpsychiatriccare,itislargelybelievedthatcurrentstaffinglevelsareinadequate.Whiledietitianservicesareavailableinpsychiatricinstitutions,manyofthosewithmentalhealthissuesaretreatedinthecommunity,includingprimaryhealthcaresettings.SinceaccesstodieteticsservicesinthecommunityiswidelyvariableacrossCanada,manyofthosewithmentalhealthproblemshavenoorlimitedaccesstodietitianservices.
Thereareapproximately800DCmembers(16%oftotalmembership)whoindicatetheyworkinsomeaspectofpsychiatriccare.Currently,theDCMentalHealthNetworkisconductingasurveytoobtainaclearprofileofdietitiansand
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theirworkinpsychiatriccare.Inoneinstance,thestafftoconsumerratioisreportedtobe1FTEofdietitianservicesinpsychiatriccarefor325inpatientsandnearly1000outpatients.Dietitianswhoworkincommunitypsychiatricfacilitiesreportaslittleas8hoursofworkpermonthfor25residents.Basedonanaverage(nothighneeds)familymedicinemodelofprimaryhealthcareinOntario,ithasbeenestimatedthataratioofMD:RDof10:1orlowerwouldenabletheRDtoprovideprimarilyclinicalservices,withfollowupofclientsstatus,completesomehealthpromotionactivitiesandkeepwaitinglistsmanageable(i.e.,
The role of dietitians in collaborative primary health care mental health programs
providethetailorednutritionteachingandreinforcementtheseindividualsneed.
Somefamiliesmayhavedifficultyacceptingthatamemberoftheirfamilyhasamentalillnessandmayrequireextrahelptoincorporatenutritionalinterventionsintotheirlifestyle.Povertycanhaveanegativeimpactonthepersonshealthanddevelopmentthroughalackoffoodsecurity.Ataminimum,foodsecurityincludestheavailabilityofsufficient,nutritionallyadequate,andsafefoodandtheassurancethatonecanobtainadequatefoodwithoutrelyingonemergencyfeedingprogramsorresortingtoscavenging,stealing,orotherdesperatemeasurestosecurefood.Whilemanyadultswithmentalhealthissuesarecapableofworkinginparttimeorfulltimejobs,opportunitiesarelimited.
Based on a national DC survey, some of the challenges identified in the implementation of the CCMHI Charter Principles included:
Lack of funding Lack of coordination
between social, education and health systems
Lack of understanding of each others roles within an interdisciplinary team
Thehealthissuesforindividualswithmentalillnessesaresimilartothehealthissuesforeveryone.Theseincludephysicalactivity,nutrition,accesstohealthcare,clinicalpreventiveservices,oralcare,andfamilycaregiving.Asresearchintheareaofhumangeneticsincreases,theincidenceofgeneticallyrelatedmentalillnessesmayeventuallydecrease.Asgenetictechniquesimprovetoidentifythetendencyofanindividualforchronicdiseasesuchasheartdiseaseordiabetes,neweducationalstrategiesmustbedevelopedtoworkwithindividualswithmentalhealthissuesinwellnessprogramstopreventsuchdisorders(98).
Finally,amajorneedidentifiedintheconsultationprocesswastoencourageeducationinmentalhealthfordietitiansintraining.Thedevelopmentandimplementationofcontentand/orfieldexperiencethataddressesthenutritionneedsofpersonswithmentalhealthissuesinundergraduateandgraduatenutritionprogramsaswellasdieteticsinternshipsisrequired.Inparticular,itisidentifiedthatskillsincounselingtechniquesincludingbehaviourmodificationneedtobedeveloped.Inaddition,continuingeducationopportunitiesregardingdieteticsandpsychiatryshouldbeestablished.ThiscouldincludeonlinecoursesthroughDCaswellassessionsattheannualDCconference.Inrelationshiptothis,theregistereddietitianalsohastheopportunityforincreasingthe
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The role of dietitians in collaborative primary health care mental health programs
levelofnutritionknowledgeamonghealthcareandhumanserviceproviders.
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The role of dietitians in collaborative primary health care mental health programs
Vision and goals of primary health care
Asdietitians,wearerecognizedforourspecializedrole.Inthisspecializedrole,oneproblemisphysicallybeingwheretheserviceisneeded.Inourcase,patientsoftenhavetotravelonbusrouteswhicharenoteasyforthemtonavigate.Thisleadstosomeconsumersnotbeingabletoaccesstheservice.Iliketheideaofprovidingtheserviceintheirareaonalessfrequentbasisinsteadofthemhavingtotravelthesedistances.
RD,Toolkitparticipant
Provincialplansforprimarycarereformshareseveralgeneralvisionsforasystemthatisaccessible,bettercoordinated,consumercentred,comprehensiveandcommunityfocused.Thesegeneralvisionsreflectedindieteticspracticeareasfollows.
Accessibility
AccessibilitymeansnutritionservicesareuniversallyavailabletoallCanadiansregardlessofgeographiclocation.Distributionofnutritionprofessionalsinrural,remoteandurbancommunitiesiskeytotheprincipleofaccessibility.Accessinvolvesboththeavailabilityofaregularsourceofnutritionalcareandinsomeinstancestheabilityoftheindividualorsomeoneelsetopayforit.OnestrategytoenhanceaccessibilitytodietitiansservicesistherecentmediacampaignthattheDCConsultingDietitiansNetworkconductedtoencourageworksitesacrossCanadatohavedietitianservicesaspartoftheiremployeeinsuranceplans.
Ingeneral,manyruralandisolatedcommunitieshavedifficultyrecruitingqualifiednutritionprofessionals.Nutritionrelatedissuesspecifictoruralpopulationsincludeincreasedfoodcosts.Manyruralcommunityagencieshaveinsufficientfundstohireadietitianforsufficienthours.Thereisalsodifficultlyinmaintaininglevelofexpertiseforclientswithveryspecialnutritionalneeds(i.e.,hometubefeeding,dysphagia).Effortstorecruitdietitianstotheseareasthroughinternshipprogramsmayhelpalleviatetheseissuesaswouldtheuseofonlinecoursesandvideoconferencing.
Theshortageofregistereddietitiansinruralareasisoftencompoundedbythelackoflessformalizedsourcesofsupport.Oftenmissing,forexample,isconsumerandfamilyadvocacyformentalhealth.AlsoabsentinmanyruralsettingsarecoordinatedeffortssuchasAssertiveCommunityTreatment(ACT)teamsthatrelyonnumbersofpatientsandnumerouslocalresourcesfortheirsuccess(99).Nutritionprogramsthattargetinformalcaregivers,naturalhelpers,peerhelpersandparaprofessionalsmaybeofparticular
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The role of dietitians in collaborative primary health care mental health programs
importanceinimprovingaccesstoappropriatedieteticsservicesrelatedtomentalhealthinmanyruralareas.Inaddition,strategiessuchastelemedicineandadditionaltrainingoptionsneedtobeconsidered.
Ruralresidentsoftendoexperienceuniquestressorsduetotheagriculturalnatureoftheirlivelihoodformanypeople;theFarmandRuralStressLineisanexampleofaservicethatcouldbebetterpromotedandutilized.Dietitians(andallparaprofessionals)needtoutilizesomeofthescreeningtoolsavailableandtobeabletorefertoappropriateservices.Forexample,withoverweightclients,lookingatstresslevelsandeatingresponsesisimperativetogoodpractice.Also,especiallyinruralareas,consumersneedtohavecompleteconfidenceintheconfidentialityfactor;wemustbeseenastrustworthyandprofessional.
RD,Toolkitparticipant
Transportationsupportmayaddressisolation,poverty,distancebarrierstoprofessionalresources,andlowerutilizationinruralareas.Transportationhaslongbeenaprobleminaccessingmentalhealthservices,especiallyamongtheruralandpoor(100).Simplyprovidingatransitpassthroughsocialservicesmaynotbesufficient,particularlyforphysicallyormentallychallengedindividuals.Thissuggeststhataneedforhomevisitingservicesbytheregistereddietitianorinvolvingfamilyorpaid/volunteerdriverstoensureclientscanattendtheirappointments.Presently,homecaredietitiansaremandatedtoseethehomebound,whichistypicallydefinedasphysicalincapabilities.Definitionsofhomeboundmayalsoneedtoincludementalhealthfactors.
InCanada,ithasbeenfoundthatastrongbarriertodieteticserviceisfinancialastherearelimitedpubliclyfundedprograms.Anothercircumstanceexistswhenconsumerslackproperidentificationtoprovecoverage,eitherthroughlossortheft.Obtainingreplacementidentificationpresentsanotherchallengeduetoexpense,lackofproofofresidencyandbureaucracy.Dietitiansatalllevelsneedtoadvocateforadequacyofservicesformentalhealthconsumersandexaminewaysthataclientinneedofnutritioncarethatlacksproperidentificationcanstillaccesstheseservices.
Dependingonplaceofresidence,theabilitytofollowprescribedregimenssuchasappropriaterest,exerciseandnutritionalrequirementscanbeimpossibletocontrol.Duetotheirrelianceondonations,scarceresourcesandalargeclientele,facilitiessuchassoupkitchens,andsheltersmustoperateonlimitedmenusthatdonotalwaysprovideadequateorappropriatenutritionforconsumersonrestrictedormodifieddietsforhealthconditions.Thisspeakstoaneedfordietitianstobeavailableforsuchcommunityprogramstoassistwithmenuandrecipedevelopment,helpingtoadvocateforappropriatefoodsanddevelopingprogramsbasedonskillsbuilding.
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The role of dietitians in collaborative primary health care mental health programs
Manymarginalizedconsumershaveextremedifficultyoperatinginanenvironmentthatisgenerallygearedtowardsconsumersofamuchhighersocioeconomicclass.Similartothisistheissuethatprofessionalprejudicescanalsoimpactondiagnosis,treatmentandassessmentofneed(101).Alienation,stigma,institutionalization,andalackoftrustinauthorityfigures,suchashealthcareproviders,hasdevelopedovertimewithmanymarginalizedconsumers.Thismayinclude,forexample,AboriginalPeoples,formercorrectionalservicesresidents,sexualminoritiesandimmigrantorrefugeepopulations.Thisspeakstotheneedtoinvestindevelopingstrongcollaborationincare,havingrespectforthementalhealthclient,andbuildingatrustingrelationshipwithreciprocalcommunication.
Adjustmentsneedtobemadetoreinforcetherolethatwecanplayinthisnewcollaborativeapproach.Moredietitiansneedtobetrainedinandawareofthespecialneedsofmentalhealthclientsandweneedtobemoreaccessibletoboththeclientandtheotherprofessionalteammembers.
RD,Toolkitparticipant
Individualconsumersuniquelifecircumstancesmustbeconsideredwhendevelopingacollaborativeapproachtocare.Forexample,hoursofoperationhavebeenshowntoplayaroleinconsumersuseofservices.Theseconsumershavemanycompetingprioritiessuchasfindingshelter,money,andclothing,duringthetypicalbusinessday.Therefore,nutritionconcernsmay,ofnecessity,becomealowerpriority.Manywithinthispopulationaretransientandthereforearelosttofollowup.Tofacilitatecompliancewithnutritioncounselingandeducation,nutritioncareprovidersmustworkwithconsumerstoidentifyallthefactorsinfluencingtheirabilitytoachieveormaintaingoodhealth.
Ithinkweneedtouse(Dietitiantoolkit)thisinHomeCaretopromotemorereferralsfromCCACmentalhealthclientsasIthinkthatthecasemanagersavoidthatbecausetheyareusuallylongandinvolvedclientsandtheyarenotsurethattheywanttofundforthat!
RD,Toolkitparticipant
Forsomeconsumers,theirabilitytobeeffectivepartnersintheirnutritioncaremaybeaffectedbyliteracy,orphysicalormentalincapacity.Properevaluationofcompetencyandleveloffunctioningshouldbecarriedouttonegotiateacomfortablelevelofinvolvementfortheconsumerintheirnutritioncaremanagement.However,theobjectiveshouldalwaysbetobuildarelationshipthataidsinthedevelopmentofgrowingempowermentoftheconsumerinregardstotheirhealth.
Barrierstocarecanbefoundatalllevelsfrompolicyandlegislativeconcernsatthesystemsleveltoindividualissuesthatimpedeaccesstoappropriatehealthcare.Acollaborativementalhealthcareinitiativethatincludesregistereddietitianservicesshouldexploredifferentapproachestoservice
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The role of dietitians in collaborative primary health care mental health programs
delivery,andsupportandempowerconsumerstoovercomeindividualchallengesuniquetotheirlifecircumstance.
Collaborative structures
Factorsrelatedtoaccessibilityandcollaborationinourprograminclude:1. Allteammembershaveanappreciationofeachothersothattheteamknowswhateachmemberroleis.
2. Havingteammembersinoneplacesoconsumersarenottraveling.
3. Eachconsumerwithmentalillnesshaveacaseworkertohelpcoordinateandensureincreasedcompliance.
RD,Toolkitparticipant
Collaborationmeanshealthprofessionalsfromvariousdisciplinesfunctioninterdependentlytomeettheneedsofconsumers.Italsorecognizesthathealthandwellbeingarelinkedtobotheconomicandsocialpolicy.Collaborationorintersectoralcooperationalsomeansexpertsinthementalhealthsectorareworkingwithexpertsineducation,financing,housing,employment,immigration,etc.Sharedvisionisthebasisofanysuccessfulcollaborativementalhealthcareinitiative.Thisinvolvesbringingallkeystakeholders,includingconsumers,tothetable.
Collaborativepracticeinvolvespatientcentredcarewithaminimumoftwocaregiversfromdifferentdisciplinesworkingtogetherwiththecarerecipienttomeettheassessedhealthcareneeds(102).Avarietyofstrategiesforprovidinginterdependentcareexists.Forexample,theycanbeadhoccollaborationsthataredevelopedtodealwithissuesofimmediateconcernandthendisbandedaftertheresolutionoftheacuteproblem.Theycanbebrokeredservicemodelswhereaprimarycareproviderhasdevelopedinformalrelationshipswithotherprovidersandthroughreferralorinteragencyserviceagreementsobtainaccessfortheconsumertoexternalserviceswithoutactualreciprocalcollaboration.Initiativesmightalsoprovidediverseservicesinonesettingwithcompleteintegrationofoperations.Withsuchacollaborativeeffort,servicestarestreamlinedandapermanencyofserviceintegrationoccurs.Thisalsoallowsforstrongcollaborationoutsidethecoreservicegroupwithsuchimportantservicesasshelters,dropincentresandotheradvocacygroupsorserviceproviders.Thistypeofarrangementtendstobemostsuccessfulwiththefullintegrationofservicesthathavetheflexibilitytotreatawidespectrumofillnessseverities.
Inconsideringthedifferenttypesofstrategiesavailable,itisimportanttonotethatnotallnutritionservicesneedtobeprovidedbythesamedietitianinthesamepracticesettingasotherprimarycareproviders.Aneffective
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The role of dietitians in collaborative primary health care mental health programs
networking/referralsystemthatlinksdietitiansandothercareproviders,workinginvarietyofcommunitybasedsettings,wouldsignificantlyimprovecontinuityofcareforthementalhealthconsumer.Dependingontheclientsneeds,appropriatelinkagewithdietitiansofdifferentmandatescanbemade.Table1outlineshowdietitiansfromavarietyofsettingscanprovidecomplimentaryservicesforthekeyelementsofprimaryhealthcare.Itisimportanttonote,however,thatsufficientstaffingineachsettingisessentialtoprovidetherequiredcareneededbymentalhealthconsumers.
Primaryhealthcareisdeliveredinmanysettingssuchastheworkplace,home,schools,healthcareinstitutions,theofficesofhealthproviders,homesfortheaged,nursinghomes,daycarecentersandcommunityclinics.Itisalsoavailablebytelephone,healthinformationservicesandtheInternet.Nationalconsultationsforthecollaborativemental
healthcareCharter:synthesisreport,2006(103)
Attitudinalbarriershavebeenidentifiedasanissueincollaborativementalhealthcare(103).Inanationalconsultationprocess,commentsacrossprovidersofvarioushealthdisciplinesindicatedthatlackofmutualrespect,territoriality,silomentality,turfwarsandprofessionalprotectionismimpededcollaborativepractice.Furthertothis,attitudinalbarrierswereseenasacriticalissuethatmustbeaddressedinordertoeffectivelydelivermentalhealthservices.
Keyelementsinestablishingcollaborativeserviceincludeinvolvingallpartnersasequal,buildingstronglinkagestohospitalprograms,developingclearmemorandumsofagreement,clarifyingtherolesandresponsibilitiesofallteammembers,anddevelopingclearprotocolsforsharingofinformation.Dietitianscancontributealottotheseelementsgiventheirskillsincommunitydevelopment.Inparticular,theservicesoutlinedinTable1offersignificantcontributionstothementalhealthconsumerintermsofhealthpromotionandillnessprevention.
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The role of dietitians in collaborative primary health care mental health programs
Table 1: A network of dietetics services relative to key elements of primary health care*
Key elements of primary health care (PHC)
Dietetic practice settings
% Dietitians in
practice setting**
Range of comprehensive PHC
nutrition services provided
Utilizes population health strategies
Applies collaborative
practice
Affordable and cost
effective***
Community health centre model with registered dietitians as a salaried member of the interdisciplinary team
6%
Public health/ community dietitians 26%
Mandate is typically to provide population health promotion and disease prevention services
Home Care 20%
Mandate is typically to provide services for homebound clients at risk or with existing medical conditions
Mandate is typically to provide services for homebound clients at risk or with existing medical conditions
* Adapted from Table 2 Dietetics practice A complementary network of services relative to key elements in primary health care (20)
** % of dietitians in each practice setting based on approximation derived from DCs Skills and Practice Registry relative to the number of DC members working in a primary health care setting (N=1390) in 2001
*** The potential for savings relative to decreased hospitalization and long-term disability as a result of nutrition intervention has been well documented (104)
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Table 1: A network of dietetics services relative to key elements of primary health care* continued
Key elements of primary health care (PHC)
Dietetic practice settings
% Dietitians in
practice setting**
Range of comprehensive PHC
nutrition services provided
Utilizes population health strategies
Applies collaborative
practice
Affordable and cost
effective***
Ambulatory/primary care practice 15%
Mandate is typically to provide services for clients at risk or with existing medical conditions
Mandate is typically to provide services for clients at risk or with existing medical conditions
Consulting/Private Practice 33%
Focus is on individuals and groups. Also provide services to community psychiatric facilities, non-profit organizations, etc.
Dietitians maintains client record and liaises with other care providers as needed
Fee for service is a barrier to some clients. Medical insurance coverage available in some instances
* Adapted from Table 2 Dietetics practice A complementary network of services relative to key elements in primary health care (20)
** % of dietitians in each practice setting based on approximation derived from DCs Skills and Practice Registry relative to the number of DC members working in a primary health care setting (N=1390) in 2001
*** The potential for savings relative to decreased hospitalization and long-term disability as a result of nutrition intervention has been well documented (104)
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The role of dietitians in collaborative primary health care mental health programs
Richness of collaboration
Thistoolkit(SeriousMentalIllness)hasaddressedanumberoftheissues,especiallythecomorbidconditionssuchasdiabetes,cardiacdisease,andsubstanceabuse.Withtruecollaboration,thesemedicalissuescouldbeaddressedinthemedicalsystem.Howevermanyofourpatientsdonotdowellindiabeticorcardiovascularclinicsastheiruniqueneedsarenotbeingmet.Professionalsatalllevelsneedtobeeducatedaboutthespecificrequirementsofthispopulation.
RD,Toolkitparticipant
Thementalhealthconsumerhasdiverseandinterrelatedsetsofdeterminantsofhealthandneedstherebysuggestingtherequirementofanumberofpotentialteamplayerstosupporttheindividual.Teammembersshouldincludetheregistereddietitianalongwithotherprofessionalswithmentalhealthexpertisesuchasthoseoutlinedinthefollowing: Nurse/nursepractitioner Outreachworker Recreationtherapists Socialworker Translator Counselor Housingworker Casemanager Familytherapist Mentalhealthworkers
Occupationaltherapist Physicaltherapist Pharmacist Psychologist Volunteers(including
drivers) Dentist Familyphysician Psychiatrist
Othercommunityagenciesorresourcescanhelpsupportconsumerswhenspecialneedsarise.Potentialcommunitypartnersinclude: Housingprograms Foodbanks Immigrant/refugee
services Police/corrections Hospitaldischarge
planners Publichealth VeteransAffairs Shelters/dropins Homecareservices Employment/vocational
services Publicguardianand
trusteesOffice Addictionprograms Socialservices Communitypsychiatric
facilities LegalAid
Childrensmentalhealthagencies
Transportation Rehabilitationprograms
(e.g.,respiratory) Volunteerorganizations/
advocacygroupsSchools
Religiousgroups Longtermcarefacilities MealsonWheel Community
Kitchens/GardensBuyingclubs/food cooperatives
Supportgroups Recreation Daycarecenters
Hospitaldiabetes anddyslipidemiaprograms
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The role of dietitians in collaborative primary health care mental health programs
Serviceagreementsorreferralthroughbrokeredservicescanbeenlistedwiththesecommunityresources.Insomeinstances,theregistereddietitiancanmakeavaluablecontributiontothedevelopmentandmaintenanceofsomeoftheabovementionedprograms(e.g.,communitykitchens,buyingclubsandschoolfoodprograms).
Weneedtotalkaboutmentalillnessmoreandthiswillhelptobreakdownthestigmaattached.
RD,ToolkitparticipantConsumer and family centredness
Consumerparticipationmeansclientsareencouragedtoparticipateinmakingdecisionsabouttheirownhealth,identifyingthehealthneedsoftheircommunityandconsideringthemeritsofalternativeapproachestoaddressingtheseneeds.Involvingmentalhealthserviceconsumersinthedesign,implementationandevaluationofservicesisimperativetotheirsuccess.However,somespecialchallengesmayexistthatcanlimittheirinput.Forexample,duetostigmatizingfactors,mentalhealthconsumersarenotusuallyseenaseffectiveselfadvocates.Inaddition,thoseinspecialpopulationsmayfindparticipationinsuchactivitiesespeciallydemandingandintimidating.Nonetheless,consumershaveavaluableperspectivetocontribute.Somestrategiestoenhanceconsumercentrednessinclude:
Iffamiliesarepresentforthenutritioncounselingorhaveseparateaccesstodietitian,thisimprovesthepotentialforbetteroutcomesinnutritionandotherareas,suchasmedicationcompliance.
RD,Toolkitparticipant
Inclusivemeetingsbetweenconsumersandproviders Consumerinvolvementinprogramplanningprocesses Consumerparticipationinprograms(e.g.,peerhelpers) Clientadvocate/complaintsofficerstoaddressconsumers
needs Consumerabilityforselfreferrals Transportationforclientswhocannotreadilyaccess
services
Inparticular,apreferenceforhomebasedcareexistsastheconsumermaybemorelikelytocommunicatemoreeffectivelyinfamiliarsurroundings.Furthermore,theirsurroundingscanprovidevaluableinformationfortheassessment.
Mostconsumersutilizingprimarycareservicesbringoneormorefamilymemberstotheirappointments,thuspresentinganopportunityforfamilyfocusedcare.Evidenceindicatesthatfamilysupport,inconjunctionwithtreatment,leadstobetterclientandfamilyoutcomes,reducesutilizationofacute
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The role of dietitians in collaborative primary health care mental health programs
services,increasesawarenessamongfamilymembers,improvesclientandfamilycopingskills,reducescaregiverburdenandimprovesfamilymembersabilitiestosupportandillrelative(105).Familycaregiversrequirefinancial,emotionalandpracticalsupporttohelpthemcopewiththevariousphasesofdebilitatingillnessaffectingtheirlovedone.
Thereneedstobefamilycentrednesswhenevertherearefamilymembersavailable.Itisverychallengingforsomeconsumerstogiveadiethistoryandtoimplementshopping,mealplanning,cookingandfoodportioningadvice.Whenconsumersareisolatedfromfamilyandsocialsupports,IthinktheRDneedstobefocusedonwhatthemostimportantoutcomeshouldbeandkeeptheinterventionadviceappropriatetotheindividualsabilitytoprocessinformationandfollowup.
RD,Toolkitparticipant
Dietitiansareparticularlyskilledintheareaofprovidingfamilyfocusedcare.Theirtrainingandexperienceenablesthemtoreviewfoodselectionswithfamiliestoaddressspecificneedsandrequestsandtodevelopnutritioncareplansthatareuniquetoanindividualsneeds.
MywifepropsmeupwhenIamdepressed.ShecooksthemealsandmakessureIameatingwell.ItonlymadesensetotalktoadietitianaboutproblemsIhavewitheatingwhenIamillandtohavemywifetherewithme.
Consumer,Toolkitparticipant
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The role of dietitians in collaborative primary health care mental health programs
Important considerations in development of initiatives
Theestablishmentofprimarymentalhealthcareinitiativesincorporatingnutritionservicesnotonlyneedstoconsiderthevisionsofprimaryhealthcare,butshouldalsoincorporatefactorssuchasfamiliaritywithpolicies,legislationandregulations,currentperspectivesonmentalhealth,fundingsources,evidencebasedresearch,appropriatetechnologyandtheneedsofthecommunityserved.Inaddition,considerationsforplanningandevaluationarekeycomponentsoftheprocessofdevelopingtheseinitiatives.
Ingeneral,Ithinkthereisverylittlenutritioncounselingadvicemadeavailabletoconsumerswithmentalhealthchallengesinthecommunity.
RD,Toolkitparticipant Policies, legislation, and regulations
Legislation,professionalregulatoryacts,andpracticestandardsusuallyvarybyprovincialjurisdiction.Registereddietitiansarewelladvisedtobeawareoftherelevantlegislationintheirrespectiveprovince.Someofthesemayinclude: Legislationaffectingageofmajority(abilitytogive
consent) Childwelfarelegislation(affectingdutytoreportcasesof
neglectorabuse)Havingnationallyrecognizedstandardsfornutritionandmentalhealthwouldbebeneficialtoourprofessionandtheconsumersweworkwith.
RD,Toolkitparticipant
Privacylegislation,includingbothfederalandprovincial(e.g.,HealthInformationActs)
Professionalregulatoryacts Environmentalprotection(e.g.,foodsafety) CanadaHealthAct Disabilitylegislation YouthCriminalJusticeAct ConventionRelatingtotheStatusofRefugees(United
Nations,1951) CanadianMulticulturalismAct ImmigrationAct Communitypsychiatricfacilitieslicensingstandards Hospital/medicalacts Publicguardianacts Mentalhealthacts Schoolanddaycareguidelinespertainingtotheprovision
offoodservices HumanRightsAct
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The role of dietitians in collaborative primary health care mental health programs
CanadianNaturalHealthProductsRegulations Thedevelopmentofrespectfulinterdisciplinaryrelationshipsisvitaltothesuccessofthecollaborativeinitiativesanditisthereforenece