From the Editor

Canadians understand more about mental health and – with declining stigma – are more interested in services. So are they using more services and how have practice patterns changed with time?

In this week’s Reading, we consider a new paper from The Canadian Journal of Psychiatry. Chiu et al. try to answer these questions by looking at outpatient family doctor and psychiatrist visits from 2006 to 2014. They also look at ED visits and hospitalizations.

8b16181v-565x422Family docs and mental health: how much care do they deliver (and are all their patients this cute)?

They find that ED visits were up for mental health, as were hospitalizations, but physicians visits went down (all in terms of rates). They write: “The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.”

Also in this week’s Reading, we consider some good news: CAMH received a $100 million gift from an anonymous donor. Good news – but is it all good news for mental health charities?



Services and Utilization

“Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014”

Maria Chiu, Evgenia Gatov, Simone N. Vigod, Abigail Amartey, Natasha R. Saunders, Zhan Yao, Priscila Pequeno, and Paul Kurdyak

The Canadian Journal of Psychiatry, 1 January 2018 (Online First)

Mental illnesses and addiction are common and are associated with substantial disability and reduced quality of life, especially among those who do not receive timely and effective early intervention. The prevalence of these conditions has remained relatively stable throughout the past decade, but treatment seeking has increased. This may be attributed to active efforts to raise awareness and reduce stigma for mental illness. Unfortunately, many high-income countries are reporting unmet needs for care. Timely access is crucial, and there is some concern that emergency departments are becoming the only guaranteed entry point to mental health care. Little is known, however, about whether the health system is meeting the increasing demand for mental health services.

Evaluation of trends over time in how mental health services are used can help guide decisions about resource allocation and inform development of new models of care. Internationally, use of mental health services has increased over the past few decades. There has been an increase in the number of individuals receiving outpatient services, but there may be a decline in the number of visits per service user. In the acute care sector, the literature is mixed. Some studies have reported an increased use of emergency department and inpatient services, while others have reported a decreasing number of psychiatric beds and resultant decline in admission rates. Most previous studies have relied on self-report to ascertain service use, but these data are subject to recall and social desirability biases. Furthermore, published studies often did not differentiate between service sectors or types of professionals who were delivering mental health care, or focused on a single outcome in an isolated setting, such as emergency departments or hospitals only.

Population-based linked health administrative data provide a unique opportunity to examine trends in mental health service utilization in multiple sectors simultaneously without relying on patient recall. The province of Ontario, the most populous province in Canada, is an ideal setting for such an undertaking, owing to a universal health care system that insures almost 14 million residents. Our aim, therefore, was to generate a comprehensive picture of the extent and nature of mental health service utilization in the outpatient and acute care sectors by examining trends in outpatient physician visits, including primary care providers and psychiatrists, as well as visits to the emergency department and hospitalizations.

m_chiu-resizedMaria Chiu

So opens a new paper by Chiu et al.

Here’s what they did:

  • Drawing from several databases, they examined physician-based mental health service utilization. Databases included: the Registered Person’s Database, the National Ambulatory Care Reporting System, and the database of the Ontario Health Insurance Plan.
  • Ontario residents were included, between ages 16 and 105.
  • The study considered utilization between January 1, 2006, and December 31, 2014.
  • They looked at outpatient physician visits, acute care emergency department visits, and hospitalizations.
  • Visits to psychologists, social workers, and other community mental health supports were not considered.
  • Statistical analyses were done, including for outpatient and acute care service using 5 age categories.

Here’s what they found:

  • “Among the 11.4 million adults living in Ontario in 2014, there were 1.6 million individuals who accounted for 6.4 million outpatient physician visits for mental health care. Most of these visits were to primary care providers, with a substantial rate of visits to psychiatrists as well (378.4 visits and 180.6 visits per 1000 population, respectively, in 2014). Women had higher rates of outpatient visits to either physician specialty than men (619.5 and 495.0, per 1000 persons, respectively in 2014)…”
  • “In 2014, there were 217,512 emergency department visits and 67,446 psychiatric hospitalizations observed among 138,723 and 50,919 individuals, respectively. Men had higher rates than women with regards to emergency department visits (20.4 vs. 18.0 per 1000 population) and hospitalizations (6.2 vs. 5.7). The most common reasons for mental health–related emergency department visits and hospitalizations in 2014 were anxiety disorders (5.9 visits per 1000 population) and mood disorders (1.8 visits per 1000 population)…”
  • “Age- and sex-standardized rates of outpatient physician visits decreased over time, with a 6.5% relative decline between 2006 and 2014 and a significant declining linear trend throughout the study period…”
  • “Psychiatrists saw 75,912 more unique patients in 2014 than in 2006, a significant increase from 2.9% to 3.3% of the population served by these specialists, but the average number of psychiatrist visits per patient decreased from 6.7 to 5.4. Conversely, primary care physicians saw 88,439 fewer patients in 2014 than in 2006, a decrease from 14.8% to 12.7% of the population served, while the average number of visits per patient increased from 2.8 to 3.0.” See figure below.
  • “Mental health–related service use in acute care settings increased between 2006 and 2014. Age- and sex-standardized rates of emergency department visits significantly increased by 22%, from 16.1 to 19.7 per 1000 persons. Similarly, during the same period, the standardized rate of psychiatric hospitalizations increased by 8% from 5.6 to 6.0 per 1000.”


They summarize:

In this population-based study conducted in a publicly funded health care system, we observed an overall decline over time in outpatient physician visit rates for mental illness and addiction, along with an increased rate of acute care service use.

A few thoughts:

  1. This is a good study.
  1. No surprise here – there has been a rise in acute care use, with many more ED visits (up 22% over the study period) and more hospitalizations (up 8%). And in terms of physician care: “Primary care doctors provided the majority of physician-based outpatient mental health care in Ontario…” (A gentle reminder to us specialists about the importance of collaboration and capacity building.)
  1. The physician practice patterns are interesting. Overall, there was a decline in physician visits per 1,000 people over the study period. But the picture is complicated. The rate of visits to family docs remained the same, but they saw fewer patients with mental illness, but saw those patients more. In contrast, the rate of visits to psychiatrists increased, but psychiatrists saw more patients but less often.
  1. The paper has a clear limitation: non-physician services weren’t considered.
  1. Again, while acknowledging the complexity of these numbers, this much is clear: this study suggests that issues around access aren’t resolving on their own.


Donations and Mental Health

“Record $100-million donation to CAMH underscores cultural shift on mental health”

André Picard

The Globe and Mail, 11 January 2018

The Centre for Addiction and Mental Health announced Thursday that its foundation has received a record $100-million donation from an anonymous donor, monies that will be dedicated to research on everything from the causes of mental illness to how to improve access to care.

A gift of this magnitude is impressive in itself. We tend to forget the important role philanthropy plays in funding health research and, increasingly, health services.

But it is doubly noteworthy because it dramatically underscores a significant cultural shift, where it is as legitimate – and socially acceptable – for a philanthropist to embrace mental health as a cause as it is cancer or heart disease.

After all, the ultra-modern hospital and research labs of CAMH started out as the Provincial Lunatic Asylum, a place to be avoided and not even talked about. That sort of stigma is hard to shake off.

André Picard

So begins an “analysis” piece from The Globe’s André Picard on the occasion of CAMH’s big donation.

Picard makes several points:

  • “At a time when public investment in health research is stagnant, it’s the kind of bold, innovative gesture we should be seeing from the federal government, not just from private donors.”
  • “About 15 per cent of charitable donations in Canada go to health-related charities. Only a fraction of those go to mental health, but those donors tend to be particularly passionate, and often desperate to see a family member helped.”
  • “Mental health has always been the orphan of medicare. Starved of funds because of stigma and hopelessness, donations have tended to go to where there is the most crying need: community groups trying to plug the gaps in care. That use of funds is in stark contrast to conditions such as cancer, where billions get pumped into research into new treatments and the search for cures.”

Picard notes that this is beginning to change, and points to the success of Bell Let’s Talk which has given $86.5 million to date.

He closes:

In a word, it is about hope – something we don’t see enough of in the mental health field.

A few thoughts:

  1. Wow. What a big donation – done anonymously, and without strings.
  1. Picard makes good points.
  1. It should be pointed out, though, how large the charity gap is between mental and physical health giving. In a CMAJ editorial, deputy editor Kirsten Patrick wrote in 2015: “If the amount of money donated to various charities is a way of gauging the relative importance attributed to medical causes… in Canada, when ranked by donation amount, not one mental-health charity cracks the top-10 list.” Her observation is a couple of years old, but as of November, the statement remains true. Charity Intelligence Canada’s list of the top 10 charities still doesn’t include a single mental health charity. For the record, three of the charities are hospitals.


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