From the Editor
“If your son or daughter had cancer or diabetes, do you think it would be reasonable for them to wait? I don’t think it’s any different for mental illness.”
Access. It’s one of the biggest problems with mental health services.
This week, we consider a new paper looking at access and first episode psychosis. Dr. Paul Kurdyak, a CAMH psychiatrist and a program lead with the Institute for Clinical Evaluative Sciences, made the above comment to the CBC when discussing this new paper. In it, Kelly Anderson and Dr. Kurdyak find that 40% of patients didn’t receive physician follow-up in the month after diagnosis. Imagine – tying back to Dr. Kurdyak’s comment – if 40% of young patients with leukemia didn’t have physician follow-up in a month after their cancer diagnosis.
We also look at the discussion around a new federal-provincial accord with an op ed written by Michael Wilson, the chair of the Mental Health Commission of Canada – particularly timely as the ministers of health met this week with an eye on a new accord.
Access and Psychosis
“Factors Associated with Timely Physician Follow-up after a First Diagnosis of Psychotic Disorder”
Kelly K. Anderson and Paul Kurdyak
The Canadian Journal of Psychiatry, 13 October 2016 Online First
Timely and adequate management of the early stages of psychosis is critical to the well-being of young people with psychotic disorders. There is strong evidence to suggest that long delays between the onset of psychotic symptoms and the initiation of treatment result in poor clinical and functional outcomes. These outcome trajectories are defined in the 2-year period following the first psychotic episode, making the early stages of psychotic disorder a critical period for detection and intervention.
Recognition of the importance of rapid access to care following the onset of psychosis has not prevented persistent access difficulties and lengthy delays. Many patients in the early stages of psychosis make multiple help-seeking attempts and cycle within and between different services, with poorly integrated care across providers. Physician follow-up, in particular, is critical for facilitating linkages with specialized services, reinforcing treatment plans, and providing continuity of care. Prior literature has focused on physician follow-up after hospitalisation or emergency department (ED) visits. To our knowledge, there are no prior studies investigating the follow-up care received after the first diagnosis of psychosis, despite evidence of the need for early and continuous physician involvement in this population.
So begins a paper by Anderson and Kurdyak, just published by The Canadian Journal of Psychiatry. The authors analyze data for follow-up care after first diagnosis of psychosis – whether there was physician follow-up within a month, if it involved a family doctor or a psychiatrist, and the demographics of patients who received follow-up.
Here’s what they did:
· The authors drew from several Ontario databases (linked through the Institute for Clinical Evaluative Sciences), containing extensive data on: hospital and physician services, demographics and mortality, and outpatient visits.
· The study included “Ontario residents aged 14 to 35 years who received a first diagnosis of schizophrenia or schizoaffective disorder between 1999 and 2008, inclusive.”
· Exclusion criteria: not having OHIP and a history of schizophrenia, schizophreniform, or schizoaffective disorder (as indicated by past treatment).
· The author looked at physician follow-up. “Using physician billing records, we evaluated the short-term (30-day) outpatient physician follow-up subsequent to the index diagnosis of psychosis, categorized as 1) no follow-up by a general practitioner (GP) or psychiatrist, 2) GP follow-up, 3) psychiatrist follow-up, or 4) both GP and psychiatrist follow-up.”
· The authors also considered sociodemographic data including age, sex, and migrant status, and also drawing on the Ontario Marginalization Index.
· Different statistical analyses were done.
Here’s what they found:
· There were 20,096 incident cases of psychotic disorder in Ontario, for people aged 14 to 35 years over the 10-year study period. 62% were identified through physician and ED visits; 38% through hospitalization.
· Basic demographics: the patients were young (mean age: 24.8), male (68%) and urban (90%).
· In terms of physician follow-up: “Approximately 40% of patients did not receive any physician follow-up within 30 days of the index diagnosis of psychotic disorder, and the proportion of patients receiving physician follow-up did not differ by hospitalisation status at the index diagnosis.” If follow-up did occur, it tended to be with psychiatrists.
· Using multilevel logistic regression models: males were less likely to receive any follow-up compared to females. Among those not hospitalized, “those living in the least deprived areas of the province were 24% more likely to receive physician follow-up than those living in the most deprived areas of the province…” Follow-up grew worse with time – “a 3% to 4% decrease in the likelihood of physician follow-up per year…” (!!)
· In terms of psychiatrist follow-up: “Nearly 60% of patients did not receive any follow-up by a psychiatrist in the 30-day period following the index diagnosis of psychotic disorder, and the proportion of patients who received psychiatrist follow-up was significantly higher among those who were hospitalised at the index episode (44.8%) compared to those who were not hospitalised (39.6%).”
· Using multilevel logistic regression models: gender wasn’t associated with the likelihood of psychiatrist follow-up, but age was (older less than younger). Rural people and those in deprived areas of the province were less likely to receive follow-up. And, again, things grew worse with time: “We again found that the likelihood of psychiatrist follow-up decreased with time, with a 5% to 6% decrease in the likelihood of psychiatrist follow-up per year…” (!!)
The authors note:
Our findings suggest that approximately 2 of 5 people with first-episode psychosis in Ontario are not receiving follow-up from any physician within 30 days of the first diagnosis of schizophrenia, even among patients whose illness severity warranted inpatient treatment at the index diagnosis. Patients without prior engagement with services are at highest risk of not receiving physician follow-up, particularly from a psychiatrist. When the incident presentation is less acute, such that inpatient hospitalisation is not required, disadvantaged populations are at risk of not receiving follow-up care from a physician. We also observed a decrease in the odds of physician follow-up over time, which coincided with the implementation of EPI services across the province.
A few thoughts…
1. This is a good study.
2. This paper adds to a growing literature showing that Canadian patients have difficulty with basic access to psychiatric services. For those of us in mental health, the results aren’t surprising – but they are important, pushing us past anecdote and speculation (it seems that…) to data-driven evidence (we know…). In the past year, The Canadian Journal of Psychiatry has published particularly strong papers on access – Patten et al., Puyat et al., Kurdyak et al, to name a few. (Perhaps we can now rename this journal The Canadian Journal of Inaccessible Psychiatry.)
3. As much as we aspire to equal access to health care in our public system, the results suggested otherwise: people in rural and less affluent areas didn’t get the same opportunities as those in urban and more affluent areas.
4. One interesting aspect of the study period in this paper: it covered the time when first-episode programs were rolled out in several major urban centres. Why didn’t this seem to matter? The authors forward a few explanations, including the possibility of previously unmet need. There isn’t an obvious answer, but perhaps a cautionary tale: new programs don’t necessarily improve access, at least not immediately.
Access and the Accord
“Health Accord must address growing mental health crisis in Canada”
The Globe and Mail, 13 October 2016
As the federal, provincial and territorial governments work toward a new Health Accord, one thing is apparent – there must be a significant infusion of new money earmarked to address the pressing social and economic imperative of mental health problems and illnesses in this country.
Throwing money at a problem rarely yields the desired results. So, part of the answer lies in making thoughtful, measurable investments centred on promoting innovation and sharing best practices.
So opens an op ed by Michael Wilson. In this Globe piece, Wilson sees the importance of recent work in mental health (and work spearheaded by the Mental Health Commission of Canada, which he now chairs), in particular with Housing First and in addressing psychological health at the workplace, but he sees much work to be done.
Further to this unfinished work, he writes:
· “We need to address a dire lack in access to services.”
· He sees the 15-24 age group as needing to be the focus of more services – since youth are in “the key stage of cognitive development.”
· He urges us to “close a gap around the aspiring workforce, people who want to be gainfully employed, but who are living with a serious mental illness…”
He closes with a call for action:
For the first time, mental health is poised to take a place of prominence in the new Health Accord. Of course, there needs to be significant funding earmarked for ramping up access to services, community care and suicide prevention. But there must also be latitude for proving the sound economics of creative approaches.
A final thought: Since a new federal-provincial accord is now being seriously discussed, we have an amazing opportunity. But more federal cash will not necessarily “buy” much – witness the big health transfers of the Martin-Harper era, and the puny results. Increasing spending on mental health would be well intentioned, but we need more than just good intentions. We need to be smart. Otherwise, this amazing opportunity could pass us by.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.