From the Editor

We often speak of the challenges patients face in accessing mental health care. But, of course, such challenges may vary greatly, depending on demographics – think rural versus urban, young versus older, White versus non-White. How equitable is care? This week, we look at two new papers; one draws on Canadian data while the other on American. And though the studies are different, they point in a similar direction: unique populations face significant challenges accessing care.

In the first selection, Dr. Lucy C. Barker (of the University of Toronto) and her co-authors consider follow-up after an ED visit for patients in the post-partum period. In a new Lancet Psychiatry paper, they drew on Ontario databases, with more than 12 000 visits analyzed. They write: “Fewer than half of emergency department visits for a psychiatric reason in the post-partum period were followed by timely outpatient care, with social-determinants-of-health-based disparities in access to care.” We consider the paper and its implications.

In the second selection, Jocelyn E. Remmert (of the U.S. Department of Veterans Affairs) and her co-authors consider depression care and race. In a new Psychiatric Services paper, they look at antidepressant prescribing, finding big differences between White and Black veterans. “Among veterans, Black patients were almost two times less likely than White patients to have an antidepressant prescription, even after the analyses controlled for depression symptoms, demographic characteristics, psychosocial variables, and other clinical symptoms.”


Selection 1: “Follow-up after post-partum psychiatric emergency department visits: an equity-focused population-based study in Canada”

Lucy C. Barker, Hilary K. Brown, Susan E. Bronskill, et al.

The Lancet Psychiatry, May 2022

Approximately one in 100 post-partum individuals visit the emergency department for a psychiatric reason in the first year after obstetric delivery in Ontario, Canada. These visits are a marker of a substantial need for mental health care, and they are a crucial opportunity to coordinate outpatient health service supports when the visit does not result in hospital admission. Given the high-risk nature of mental illness in the post-partum period, both for the childbearing parents and their infants, rapid follow-up after post-partum psychiatric emergency department attendance is essential to facilitate treatment provision and prevent further destabilisation. Yet, little is known about the follow-up care individuals receive after post-partum psychiatric emergency department visits.

Social determinants of health, the conditions produced by structural, social, economic, and political mechanisms that affect health outcomes, are associated with access to and utilisation of post-partum mental health services in general. Adolescents, people who live rurally, people who have a low income, people who are immigrants, and people who are minoritised all face several barriers to receiving post-partum mental health care. In the perinatal period, those marginalised with respect to multiple social factors can experience particularly acute barriers to care. For example, among immigrants to Canada, socioeconomic barriers might intersect with immigration-related factors to create distinct barriers to post-partum mental health care. This has not been explored in the context of follow-up after emergency department attendance.

So begin a paper by Barker et al.

Here’s what they did:

  • “In this population-based cohort study, we used routinely collected health administrative data from Ontario, Canada from April 1, 2008 to March 10, 2020…”
  • They drew on Ontario data for hospital visits and physician billing.
  • The primary outcome: “the proportion of individuals with any outpatient physician (psychiatrist or family physician) visit for a mental health reason within 30 days of the index emergency department visit.”
  • Statistical analyses were done, including modified Poisson regression and conditional inference tree (CTREE).

Here’s what they found:

  • 12 158 people attended the emergency department for a psychiatric reason in the post-partum period.
  • Demographics. The patients were typically in their 20s (mean age 26.9 years); most lived in an urban area (81.0%); some were immigrants (15.5%). 
  • Diagnoses. “The most common emergency department presentations were for anxiety and anxiety-related disorders (32.3%), whereas bipolar disorder (1.2%) and schizophrenia presentations (1.2%) were the least common…”
  • Follow-ups. 5 442 (44.8%) of 12 158 individuals received 30-day follow-up. 
  • Statistical analyses. “In modified Poisson regression models, younger age, lower neighbourhood income, smaller community size, and being an immigrant were associated with a lower likelihood of follow-up.”
  • Psychiatric follow-ups. “When the outcome was restricted to psychiatrist visits for the secondary outcome, 17.6% individuals had 30-day follow-up.”
  • Pandemic follow-ups. “Of 1 264 individuals in the pandemic cohort, 49.5% had follow-up within 30 days. Although patterns related to social determinants of health were similar to the main cohort, small community size was the only social determinant of health associated with low follow-up in the adjusted model…”

A few thoughts:

1. This is a good paper.

2. Ouch.

3. A six-word summary: most didn’t get timely follow-up.

4. A longer summary: “In this population-based study of over 12 000 post-partum individuals who had attended the emergency department for a psychiatric reason in the 12 years before the COVID-19 pandemic, and over 1 200 individuals with such visits during the pandemic, fewer than half received physician follow-up within 30 days, which is a significant gap in health care for this high-risk population. In addition to low access to care overall, care was not distributed equitably.”

5. This summary doesn’t quite capture the detailed analyses done by the authors.

6. Like all studies, there are limitations. The authors note several including: “With respect to our outcome, although we captured mental health care from all family physicians and psychiatrists, we could not measure follow-up with non-physicians (eg, psychologists). Non-physician care in Ontario is typically paid out-of-pocket or through private insurance, which might introduce greater socioeconomic barriers.”

7. The policy implications? The authors see several: “Specialised approaches might be needed to address the needs of adolescents (eg, flexible integrated services), individuals with a low-income (eg, home visits), individuals who live in rural areas (eg, virtual care), and immigrants (eg, multi-lingual services), while advocating for upstream changes to the structural factors (eg, social and economic policies) that create health inequities. Any social group is not homogeneous, and heterogeneity within groups should be considered when designing services.” Thoughtful.

They add: “Meaningful collaboration with affected populations is important to identify and implement changes that are needed.” An excellent point.

The full The Lancet Psychiatry paper can be found here:

Selection 2: Racial Disparities in Prescription of Antidepressants Among U.S. Veterans Referred to Behavioral Health Care”

Jocelyn E. Remmert, Gabriella Guzman, Shahrzad Mavandadi, et al.

Psychiatric Services, 13 April 2022

Depression is a leading cause of disability worldwide, with an estimated 17.3 million (7.1%) U.S. adults ages ≥18 years reporting at least one depressive episode in the past year. Veterans are at high risk for developing depression, given the stressors associated with military service. According to a recent study, the prevalence of depression among U.S. veterans in 2005–2016 was roughly 9.6%.

Primary care serves as an initial point of contact for patients and a setting in which depression is often first recognized and treated. Antidepressant medications, a treatment recommended for patients with moderate to severe depression, are commonly prescribed in primary care. Prescription of antidepressants in the general U.S. population and in primary care has increased markedly in recent decades. Access to antidepressant treatment is essential, especially for individuals with severe depression and when such treatment is preferred by the patient. Many primary care providers cannot provide psychotherapy; therefore, antidepressant medications can be an important early intervention for patients who have limited access to mental health care.

Despite the recent increase in antidepressant prescription, rates of antidepressant treatment are not equal across racial-ethnic groups…

So begins a paper by Remmert et al.

Here’s what they did:

  • “Veterans in primary care who were referred from primary care to a collaborative care program completed an assessment of demographic characteristics and clinical symptoms, including of current antidepressant prescription before the referral, verified by chart review.” Patients were referred based on the results of annual screening measures (e.g., 2-item Patient Health Questionnaire) or the provider’s clinical judgment.
  • Data was collected from January 2015 to December 2020.
  • “The primary outcome was whether the patient had a current antidepressant prescription at the time of assessment.”
  • Different statistical analyses were done. “Logistic regression analyses were conducted to examine the relationships between patient race and both depression symptoms and antidepressant prescription.”

Here’s what they found:

  • In total, 8 419 patients were referred.
  • Demographics. Almost half were Black (48.5%); most were male (85.4%); the average age was 51.3 years; a majority were unemployed (57.4%).
  • Severity. About half were in the moderate depression range (47.6%).
  • Logical regression. “White patients were significantly more likely than Black patients to be prescribed an antidepressant (odds ratio [OR]=1.80…).” Also, “Race was again significantly associated with antidepressant prescription when we controlled for demographic characteristics and depression symptoms (OR=1.96…).” “Race remained a significant predictor when we controlled for depression symptoms, demographic and psychosocial variables, and comorbid mental health conditions, with White patients being significantly more likely than Black patients to be prescribed an antidepressant (OR=1.96…).”
  • Depression severity. “Among patients meeting criteria for moderate to severe depression (PHQ-9 score ≥10), 20% of Black patients were prescribed an antidepressant, compared with 30% of White patients…”

A few thoughts:

1. This is an interesting study.

2. Ouch.

3. A two-word summary: race mattered.

4. Looking for more bad news? While race bestowed an advantage for White patients, most patients – White and Black – were untreated at the time of the referral. That’s not meant to gloss over the race-based differences, of course. It is to suggest that patients in general were poorly served by the VA (but, yes, White patients were roughly twice as likely to be on antidepressants).

5. Like all papers, there are limitations. The authors note: “most patients were men; women are more frequently prescribed antidepressants than men, and the racial disparities in this sample may be different from those in samples with different gender compositions.”

6. We can circle back to the point in the opening comments: two different papers, drawing on different data, but with a similar finding.

The full Psychiatric Services paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.