Making connections

A local researcher is working to find the links between child abuse and mental health

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Winnipeg Health Region
Wave, Summer 2014

Dr. Tracie Afifi's most recent research project certainly was a headline-grabber.

The study, published in April, reported that 32 per cent of Canadians (40 per cent in Manitoba) had experienced abuse as a child.

That finding - based on the first nationally representative investigation of child abuse in Canada - generated news coverage across the country.

And yet, these were not necessarily the most newsworthy numbers in the study.

"The numbers (on the prevalence of child abuse) weren't really a surprise because they're in keeping with data from the United States," says Afifi, an associate professor in the Departments of Community Health Sciences and Psychiatry, Faculty of Medicine, University of Manitoba.

The more significant finding, she says, is that many of those who suffer abuse as a child go on to experience mental health issues - such as depression, anxiety, substance abuse and suicide attempts - in later life.

"What was interesting to me is people were more interested in just the prevalence of child abuse, and they didn't really pay much attention to what the bulk of the paper was about, which was how abuse is associated with mental disorders," says Afifi, who is also principal investigator with the Manitoba Population Mental Health Research Group.

In fact, the study - produced along with co-investigators Drs. Harriet MacMillan, Michael Boyle, Jitender Sareen and researchers Tamara Taillieu and Kristene Cheung - suggests that those who are abused have a three times increased odds of experiencing a mental disorder and a six times increased odds of attempting suicide compared to individuals who did not experience abuse.

"From a public health standpoint, these findings highlight the urgent need to make prevention of child abuse a priority," says Afifi. "Also, success in preventing child abuse could lead to reductions in the prevalence of mental disorders, suicidal ideation, and suicide attempts," she says.

Canadian mental health researchers have long pondered the potential connections between child abuse and mental health issues in later life. But their research efforts have been hampered by the fact that there were no nationally representative Canadian data on the subject.

That changed with Statistics Canada's Canadian Community Health Survey: Mental Health 2012. It was the first time the agency had collected data on child abuse, and it opened the door for Afifi and her colleagues to take a closer look at the issue. 

As part of the data collection process, Statistics Canada interviewed thousands of Canadians, mostly in person, about their experiences with three categories of abuse: physical abuse, sexual abuse and exposure to intimate partner violence. The same respondents were also asked whether they had experienced any mental health issues. Once the surveys were completed, the information was placed in a database and made available to researchers.

Afifi and her colleagues then used a validated research tool to categorize the responses according to type and severity of abuse.

For physical abuse, the most severe classification involved being punched, kicked, choked, burned or physically attacked one or more times before age 18 by a guardian or parent. The moderate classification involved acts like being pushed, grabbed and shoved three or more times. The least severe classification was being slapped across the face, on the head or ears, or being spanked with something hard, such as spanked with an object, three or more times. Sexual abuse was defined as having been forced into unwanted sexual activity one or more times, and exposure to intimate violence was categorized as having seen parents or guardians hit each other three or more times. They also looked to see whether the respondents in question had experienced mental health disorders, such as depression, bipolar disorder, generalized anxiety disorder and alcohol and drug dependence.

Interestingly, one act not included in the Statistics Canada data or Afifi's study was the act of spanking a child by hitting him or her on the buttocks with a hand.

Although some experts, including Afifi, believe spanking should not be used on children of any age, the fact is that it is legal in Canada, and is considered an acceptable form of punishment by a number of Canadians. So, for the purposes of her current study, Afifi focused on acts that are deemed to be illegal. "You can't hit a child in the face or head, and you're not allowed to hit them with an object," she says. "These are not acceptable forms of violence, by law; therefore, we were very comfortable referring to them as physical abuse."

The importance of Afifi's research, funded by the Canadian Institutes of Health Research and Manitoba Research, cannot be underestimated. Statistics drive policy-making on how best to use limited resources for intervention and prevention programs for mental illness. In fact, informed, statistics-based mental health care is the raison d'être for the Manitoba Population Mental Health Research Group - the innovative coalition to which Afifi and many of the province's top mental health researchers belong.

Located at Health Sciences Centre Winnipeg's PsychHealth Centre at 771 Bannatyne Avenue, it is a nationally recognized leader in epidemiological mental health research. But it is the scope of the investigations being carried out by the group that sets it apart from other centres of mental health study in Canada, says Dr. Jitender Sareen, a professor of psychiatry in the Faculty of Medicine at the University of Manitoba and the research group's team leader.

Until the research group was formed six years ago, says Sareen, no one was doing in-depth epidemiological work - sifting through huge amounts of population health data - to reveal broad-sweeping, evidence-based insights about mental health in Canada. Now, says Sareen, the group's leading investigators - including Afifi and Drs. Laurence Katz, Sarvesh Logsetty, James Bolton and Murray Enns - are advancing our knowledge of mental health by providing empirical evidence at the population level that will improve prevention and treatment.

"People know now more than ever that mental health is an important health-care priority, but our group is really moving toward developing strategies about what we can do to improve care for people suffering from mental illness."

Afifi's work underscores the point. At the age of 37, she has already established herself as one of Canada's leading experts in mental health research. In addition to her groundbreaking research on child abuse, she has also conducted major studies into problem gambling, another area of interest. Over the last five years, she has published several research papers on the subject, and is involved in a study into the relationship between problem gambling and child abuse.

The main priority right now, though, is a follow-up study, also funded by the Canadian Institutes of Health Research and Manitoba Research, on the work published last spring. It could have far-reaching implications for how prevention and intervention strategies are developed for treating mental illness, including gambling addiction.

As Afifi explains, there is evidence to suggest that abuse can lead to mental health issues in a number of ways. "There is brain imaging research that shows that it (abuse) actually changes how your brain grows and develops. And so having your brain change can have an impact on physical and mental health outcomes," she says, noting this may be especially true for children under five years of age because they experience rapid brain development. In addition, repeated abuse can lead to chronic stress, anxiety, fear, shame, and reduced self-esteem, leading to mental health issues.  
Yet, while her last study suggests that some who suffered abuse in their youth also experienced mental health issues in later life, it also revealed that many adults who were mistreated as children didn't develop serious mental disorders. The question is, why?

"Preventing child abuse from occurring is a top priority, but so is preventing mental disorders after abuse is experienced," says Afifi. "Fortunately, not everyone who experiences child abuse will develop a mental disorder. We think of these individuals as being 'resilient.'"

And that's the focus of her current research - trying to learn from individuals deemed to be resilient.

"There's not a lot of research in the area of protective factors related to resilience following child maltreatment," she says. "So we want to take what we learn from what can be a protective factor and start thinking about intervention and prevention strategies for both child abuse and mental illness."

Many variables could be a factor in whether someone who suffers child abuse is resilient and goes on to have a relatively healthy life and sense of overall well-being. The challenge is finding them, says Afifi.

"Are there protective factors in their environment? Was it a relationship? Was it something to do with characteristics of their personality? Was there something in their school or community that is associated with having a better outcome even though they've experienced abuse?"

At this stage, Afifi is poring over the same Statistics Canada data that she used in her earlier study to find the answers.

When completed, Afifi hopes her research will be used to inform health professionals, and policy makers, and encourage parents to use positive parenting approaches that do not include physical acts, including spanking.

Sareen says Afifi's latest research project on resiliency will no doubt shed new light on the connections between child abuse and mental health. "Where we're at in the field now is similar to the 1960s and 1970s with smoking and lung cancer, when people were starting to get the idea that smoking has long-term negative impacts on physical health and mortality," he says.

Adds Afifi: "We know that child abuse is bad, so what we need to do now is focus on how we can prevent child abuse from happening, and how to help people who have been abused recover from it."

Afifi is reticent to make predictions about what makes some individuals more resilient to the trauma of child abuse than others. "At this point, we're looking at population-level data for people who would be categorized as abused, examining whether or not they have a mental disorder and whether they have a high quality of life."

She says they have yet to determine what portion of the 32 per cent of respondents in the Canadian Mental Health Survey who suffered child abuse could be considered resilient. "We're looking at different things like education, personality characteristics, family relationships and the influence of community to find correlations."

Afifi expects to conclude her study within the next year, and a number of research partner organizations - like Healthy Child Manitoba - are eager to learn the results. That's because if Afifi can identify consistent factors that promote resiliency, policy-makers in the health-care system, along with mental health-care providers, can develop strategies to help victims of abuse and lessen their chances of struggling with mental illness.

"The way I see it is that when a child is abused, there's a big potential for their development to be negatively affected," Afifi says. "My belief is if you can prevent the abuse from occurring, you can change the trajectory of the child's life."

Joel Schlesinger is a Winnipeg writer.

*   *   *

Probing the link between gambling and mental health

Although Dr. Tracie Afifi's recent work on the prevalence and impact of child abuse across Canada made a big splash earlier this year, much of her research into mental disorders has focused on problem gambling.

In the last decade, she has published four studies that examine the relationship between women and problem gambling, an area that had often been overlooked by other researchers, largely because gambling used to be a mainly male activity.

"Decades ago, very few women gambled," says Afifi. "Then gambling became legal and marketed as a socially acceptable form of entertainment, like going out for dinner, or to a movie."

Today, men and women gamble about the same amount, but Afifi says men are more likely to develop problems. What her work has uncovered, however, is that like men, women who are problem gamblers are more likely to suffer from other mental disorders.
"If you have a gambling problem, you're more likely to be depressed, have anxiety, have a substance abuse problem or attempt suicide."

Now Afifi wants to understand the nature of this relationship. "Are you more likely to start gambling and then develop these other disorders? Or are you more likely to have depression and become a problem gambler; or do they develop concurrently?" she asks.

"At the moment, how that relationship functions is really not well understood, so we're trying to figure out the temporal order of that relationship using Manitoba data."

Her work on problem gambling and child abuse intersected in a recently published study where she demonstrated that problem gamblers are more likely to have experienced childhood trauma. Going forward, she plans to explore this link further.

"There is definitely the potential to bring the issues together and examine the overlap between the two, but so far, I've only examined this relationship in one study."

*   *   *

Top experts tackle mental health issues through research

It's often said that everything is connected.

That's certainly true about mental health. Researchers and health-care providers are increasingly finding connections between upbringing, environment, genetics, physical health, economics and a number of other factors that can lead to better or worse mental health outcomes for individuals and families.

Yet this major insight - while known intuitively for years by those working in the field - has only recently been backed up by statistics revealing just how deep the roots of mental well-being and illness stretch into society's fabric.

And some of the best research in the epidemiology of mental health is being carried out by a team of top Canadian researchers here in Manitoba.

The Manitoba Population Mental Health Research Group brings together about a half-dozen leading medical doctors and other experts who study the effects and causes of mental illness at the population level, says group leader Dr. Jitender Sareen.

"It's a team of health-care investigators in Manitoba who work around mental health issues in First Nations, suicide, military mental health and even injuries," says Sareen, a professor in the Departments of Psychiatry, Psychology and Community Health Sciences at the University of Manitoba's Faculty of Medicine. "Our group has specific expertise in large epidemiological surveys that can look at trauma and its impact across a range of different groups."

While the researchers have access to vast amounts of health data that can be collated to find grains of statistical truth about the nature of mental illness, the group - headquartered at the Psychiatric Health Centre at 771 Bannatyne Avenue - also proves another adage: strength in numbers. And in more ways than one.

Not only are they using numbers to develop groundbreaking research on mental health, researchers can collaborate to push the boundaries of their work even further.

"The key is that we have expertise in mental health and epidemiology that is unique in Canada because of our skill sets and ability to work with different departments," Sareen says. "That builds synergy between different disciplines, allowing us to address broad questions using very large samples of the population."

The following feature brief overviews of the work of the Manitoba Population Mental Health Research Group's top investigators:

Dr. Jitender Sareen

Whether it's working with First Nations communities or veterans of the armed forces, Dr. Jitender Sareen's work, both as a clinician and a researcher, has largely focused on the causes of suicide and what can be done to prevent it.

He is a lead or co-investigator in several studies happening within the Manitoba Population Mental Health Research Group that ultimately will shed light on the causes of suicide to help shape policy and clinical practice.

One major area of study for Sareen is examining the impact of post-traumatic stress disorder on Canada's members and veterans of the armed forces, and how certain factors like community supports, or a lack thereof, can decrease or increase their risk of suicide.

"Soldiers often face a lot of trauma, so we're interested in what helps them recover quickly and what are the factors that cause them to have mental health problems," he says.

Sareen is also working on studies involving First Nations in remote communities where suicide rates among youth greatly exceed those for teens among other populations.
"It's a huge public health issue and it's important to understand community and cultural level factors as well as individual and family issues that cause suicide." 

In the last number of years, Sareen says increased research in this area has helped lead to the development of better prevention and intervention strategies. "We aim to develop evidence-based, culturally grounded interventions across vulnerable groups."

Dr. Murray Enns

With almost 25 years of studying depression, anxiety and suicide behind him, it's difficult to summarize the breadth of Dr. Murray Enns's work in just a few words.

As the head of the Department of Psychiatry at the University of Manitoba, Faculty of Medicine, and the Medical Director of the Winnipeg Regional Health Authority Adult Mental Health Program, much of his time is spent on the administrative side. Still, he remains active in several areas of study, much of it involving psycho-social risk factors for mental illness.

"I've had a special interest in personality and related characteristics - things like perfectionism, self-criticism, neuroticism and coping styles," he says.

For instance, he has studied how some people who are perfectionists are able to have a very high level of well-being, while others are more likely to suffer from depression as a result of this trait. "People who tend to be self-critical perfectionists, particularly when they encounter achievement-related life stress, are predisposed to become depressed."

But more recently, as part of the Manitoba Population Mental Health Research Group, he has been involved with studies examining mood and anxiety disorders at the population level. One recent study involved looking at prescription rates of benzodiazepines - like anti-anxiety medications Valium and Ativan - by physicians.

Enns says the study identified instances of over-prescription of the drugs that have led to less than desirable outcomes for patients. "Although very useful drugs, they also, when used at higher doses, or for older patients or in combination with other drugs, can create significant adverse effects, including putting people at risk for falls and putting others at risk of becoming addicted."

With the research, doctors are now better informed of how to properly prescribe the medications for optimal results, he adds.

Dr. Laurence Katz

As Medical Director of Child and Adolescent Mental Health at Health Sciences Centre Winnipeg, Dr. Laurence Katz has had a leading role in treating teens at risk of suicide in Manitoba. As a result, much of his research focuses on improving mental health outcomes for troubled youth.

Some of his research with the Manitoba Population Mental Health Research Group has involved investigating the relationship between suicide rates and the prevalence of prescribing antidepressants for teens.

"The main finding in that study was that the prescribing rates went down when Health Canada issued the warning, and for a year, suicide rates went up, which was sort of counter to the current thinking that the medications may be increasing the risk for suicide."

More recently, however, Katz's work has larger implications for the mental health of both youth and adults alike. As part of a large research team, spearheaded by the Mental Health Commission of Canada, he is one of several researchers investigating the impact of adequate housing in treating substance abuse and other mental illness.

"It used to be you had to treat people's mental disorders and substance abuse before you would get them housing," he says. "Housing First flipped that around, saying, 'No, in order to treat these people, you need to get them a home'."

Using administrative health data - Emergency Department visits, social assistance rates and use of social services - Katz has helped establish that there is a strong relationship between having a roof over one's head and mental health. "Indeed, the statistics tend to support that having a stable home is associated with more effective health service utilization."

Dr. James Bolton

As Medical Director of the Winnipeg Health Region's Crisis Response Centre, Dr. James Bolton sometimes works with patients who are at high risk of suicide.

Yet while he is acutely aware of many of the factors - such as depression and isolation - that can lead to someone attempting suicide, his work with the Manitoba Population Mental Health Research Group is looking beyond the individual and asking what the impact of suicide is on the family.

"One of the most important studies to date that I've been involved with looked at suicide bereavement among Manitoba parents," says Bolton, an associate professor in the Departments of Psychiatry, Psychology and Community Health Sciences at the University of Manitoba's Faculty of Medicine.

Using the databases at the Manitoba Centre for Health Policy, his team examined data on parents in Manitoba who had lost a child to suicide between 1996 and 2007.

"We looked at how they did physically and emotionally before the death and after, comparing them to parents who had not lost a child."

What his research team found was the impact on parents' mental and physical health was devastating.

"What we were able to show through this study - the first of its kind in the world - was that parents who lose a child to suicide experience significant negative consequences as a result," he says. "It leads them to be depressed and have higher rates of anxiety disorders in the two years after the death. They also have a higher likelihood of their marriages falling apart."

The study's findings provide solid empirical evidence to guide public health policy in the development of programs that don't just focus on the impact of suicide on individuals, but also on their families.

Dr. Sarvesh Logsetty

As a surgeon and Director of Health Sciences Centre Winnipeg's Burn Unit, Dr. Sarvesh Logsetty may not seem like a natural fit with the Manitoba Population Mental Health Research Group.

But the fact is few people understand the impact that severe injury can have on the mental health of patients better than the Winnipeg doctor.

"My research interest is the understanding of the effects of long-term traumatic injury on individuals, particularly its impact on their mental health," says the associate professor of surgery at the University of Manitoba's Faculty of Medicine.

Initially, Logsetty's work focused on post-traumatic stress disorder (PTSD) and expanded to depression and anxiety. Now his research includes examining the relationship between severe injury and the risk for suicide and even physical illness, such as Type 2 diabetes, cardiovascular disease and arthritis.

"We're starting to take a look at someone who breaks their leg and ask whether they're more prone to other problems - something nobody has examined yet at the population level," he says.

Like other researchers in the group, Logsetty is interested not just in the causes of mental illness related to severe injury. He's also investigating why some individuals are more resilient - experiencing better mental and physical health outcomes - than others.

"Our goal is to try to figure out why some people get better and others don't, and with that understanding, to develop treatments to help everyone get back to normal as much as possible."



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