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.
So opens a new paper by Chiu et al.
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.
“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.
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.
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.
The paper has a clear limitation: non-physician services weren’t considered.
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.
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.
So begins an “analysis” piece from The Globe’s André Picard on the occasion of CAMH’s big donation.
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.
In a word, it is about hope – something we don’t see enough of in the mental health field.
Wow. What a big donation – done anonymously, and without strings.
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.