CAPE Special Issue
Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access Helen-Maria Vasiliadis, PhD1, Alain Lesage, MD2, Carol Adair, PhD3, Richard Boyer, PhD4 Objectives: In 2002, Canada undertook its first national survey on mental health and well-being, including detailed questioning on service use. Mental disorders may affect more than 1 person in 5, according to past regional and less comprehensive mental health surveys in Canada, and most do not seek help. Individual determinants play a role in health resource use for mental health (MH) reasons. This study aimed to provide prevalence rates of health care service use for MH reasons by province and according to service type and to examine determinants of MH service use in Canada and across provinces. Methods: We assessed the prevalence rate (95% confidence interval [CI]) of past-year health service use for MH reasons, and we assessed potential determinants cross-sectionally, using data collected from the Statistics Canada Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). We estimated models of resource use with logistic regression (using odds ratios and 95%CIs). Results: The prevalence of health service use for MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%). The highest rates, on average, were observed in Nova Scotia (11.3%; 95%CI, 9.6% to 13.0%) and British Columbia (11.3%; 95%CI, 10.1% to 12.6%). The lowest rates were observed in Newfoundland and Labrador (6.7%; 95%CI, 5.3% to 8.0%) and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%). In Canada, the general medical system was the most used for MH reasons (5.4%; 95%CI, 5.1% to 5.8%) and the voluntary network sector was the least used (1.9%; 95%CI, 1.7% to 2.1%). No difference was observed in the rate of service use between specialty MH (3.5%; 95%CI, 3.2% to 3.8%) and other professional providers (4.0%; 95%CI, 3.7% to 4.3%). In multivariate analyses, after adjusting for age and sex, the presence of a mental disorder was a consistent predictor of health service use for MH across the provinces. Conclusions: There is up to a twofold difference in the type of service used for MH reasons across provinces. The primary care general medical system is the most widely used service for MH. Need remains the strongest predictor of use, especially when a mental disorder is present. Barriers to access, such as income, were not identified in all provinces. Different sociodemographic variables played a role in service seeking within each province. This suggests different attitudes toward common mental disorders and toward care seeking among the provinces. (Can J Psychiatry 2005;50:614–619) Information on funding and support and author affililations appears at the end of the article.
Clinical Implications · Need is the strongest predictor of help seeking for MH reasons. · Different sociodemographic determinants seem to play a role in health service use among the provinces. Limitations · The cross-sectional study design precludes examination of whether needs were met. · The lifetime trajectory of service use and the sequence of shared mental health care cannot be established. · We did not assess the perceived need for individual care in terms of preferred types of interventions or expert assessment of need for care and services in this large community survey.
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Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access
Key Words: mental health, service use any surveys in North America and Europe have indicated that mental disorders affect nearly 1 person in 5 each year (1–3) and that most (60% to 75%) do not seek help (1–5). In the absence of an expert assessment of the patient’s evaluated need for care, the presence of a disorder cannot automatically be equated with a need for care (6). It has been recommended that need should be defined by dimensions of distress and dysfunction, as well as by the perception of need (3). Service use however is not determined only by need. In addition to acceptability issues (for example, attitude toward illness or toward the health care system), the most frequent reason given by affected individuals for not consulting (72%) or for treatment dropout (58%) is the belief that the disorder will go away by itself or that they can manage on their own (2). Of those not seeking help, 45% reported that they thought consulting would not help (2). Predisposing variables such as age (7–12), sex (1,4,10,11,13–15), marital status (10,11,16–21), and education (22,23) but also enabling or barrier factors such as income (24), rural vs urban location (2,25,26), and social support (27–30) have also been shown to
M
Abbreviations used in this article AD
anxiety disorder
ADD
addictions
BAR
barriers to service use
CC
chronic condition
CIHR
Canadian Institutes of Health Research
CCHS 1.2
Canadian Community Health Survey: Mental Health and Well-Being
CI
confidence interval
COB
country of birth
DIS
distress
DSB
disability
ECA
Epidemiologic Catchment Area
EDU
education
GP
general practitioner
INT
interference
LNG
language spoken
MD
mood disorder
MH
mental health
MS
marital status
OR
odds ratio
REV
household income
SRH
self-rated health
SUI
suicidal ideation
SUPP
support
U
unmet mental health need
Can J Psychiatry, Vol 50, No 10, September 2005 W
play a role in help-seeking in many studies. In one Canadian regional study, need was the strongest predictor (18), with sex and perceived MH as significant, although less strong, predictors. One-year rates of service use for MH reasons have been reported worldwide (1,5,10,31–36). The only Canadian studies available to date have reported rates in the order of 12.7% in the 1980s in Edmonton (37), 8.6% in 1990 in Ontario (1), and up to 14.5% in the east end of Montreal (14). In the US, the 5-site ECA Study reported a 14.7% rate of service use (4). A more recent Montreal survey reported various 1-year prevalence rates of use for GPs (7%), psychologists (5%), and psychiatrists (2.7%) (38). Service use estimates are not entirely comparable across these previous Canadian studies because of differences in populations, time frames, questionnaire items, and data collection methods. The CCHS 1.2 provided, for the first time, an opportunity to examine variation in service use for MH concerns from data that were collected consistently across all provinces. The objectives of this brief report are, first, to provide the national and provincial prevalence rates of service use for MH reasons by type of service and, second, to examine individuallevel determinants of MH service use in Canada and across the provinces.
Methods Data We analyzed cross-sectional data on health care resource use for MH reasons and potential determinants of MH service use, as collected by Statistics Canada in the CCHS 1.2. The study population comprised people aged 15 years and over living in private occupied dwellings in the 10 provinces (n = 36 984 respondents). More details on content and survey methods are presented in the methods paper of this issue (39) and elsewhere (40). Dependent Outcome: Past-Year Health Care Service Use For MH Reasons The dependent variable of interest in our study was service use for MH reasons in the past 12 months in Canada and by province. We also collected information on the type of professional service used. Health service use in the past 12 months for MH reasons was grouped according to the following classifications, as previously reported (4,14): 1) specialty MH services (a psychiatrist or psychologist); 2) general medical system (GP or family doctor) or other medical specialist; 3) other professional (nurse, social worker, religious advisor, or other); and 4) voluntary support network (internet support group or chat room, self-help group, or telephone help-line). 615
The Canadian Journal of Psychiatry—CAPE Special Issue
Table 1 Past-year prevalence by type of service used for MH reasons Region
Any type of service use
Specialty MH
General medical
% (95%CI)
% (95%CI)
% (95%CI)
% (95%CI)
% (95%CI)
9.5 (9.1–10.0)
3.5 (3.2–3.8)
5.4 (5.1–5.8)
4.0 (3.7–4.3)
1.9 (1.7–2.1)
NL
6.7 (5.3–8.0)
1.8 (1.0–2.5)
4.8 (3.5–6.0)
2.8 (1.7–3.8)
0.8 (0.3–1.3)
PEl
7.5 (5.8–9.3)
1.7 (0.9–2.6)
3.1 (2.1–4.1)
3.3 (2.2–4.5)
3.2 (1.9–4.4)
NS
11.3 (9.6–13.0)
3.8 (2.8–4.9)
7.6 (6.4–8.9)
3.4 (2.7–4.2)
1.7 (1.1–2.4)
NB
9.5 (7.9–11.0)
3.9 (3.0–4.8)
5.2 (4.0–6.5)
2.8 (2.0–3.6)
1.3 (0.7–1.8)
Que
9.6 (8.4–10.7)
4.6 (3.9–5.3)
4.9 (4.2–5.7)
3.7 (2.8–4.5)
1.6 (1.2 –2.1)
Ont
8.7 (8.1–9.4)
3.1 (2.7–3.5)
5.4 (4.9–5.9)
3.7 (3.3–4.1)
1.6 (1.4 –1.9)
Man
10.5 (8.8–12.2)
3.4 (2.3–4.5)
5.3 (4.0–6.6)
4.7 (3.6–5.9)
2.3 (1.4–3.1)
Sask
9.8 (8.3–11.3)
2.5 (1.7–3.4)
4.5 (3.5–5.5)
5.0 (3.8–6.1)
2.9 (1.9 –3.9)
Alta
9.7 (8.4–11.1)
3.4 (2.6–4.3)
5.1 (4.1–6.1)
3.8 (3.1–4.5)
2.9 (2.1–3.6)
BC
11.3 (10.1–12.6)
3.3 (2.6–4.0)
6.6 (5.6–7.6)
5.7 (4.8–6.6)
2.5 (1.9–3.0
Canada
Other professional Voluntary network
Prevalence rates (95%CI) are weighted and bootstrapped
Independent Variables We examined individual determinants of resource use for MH reasons from all the variables collected in the CCHS 1.2 in Canada and in each province, using Andersen’s classic model of predisposing, enabling, and need factors (41). Predisposing variables included age, sex, marital status, education, language, country of birth, and cultural or ethnic origin. Enabling or impeding factors studied included urban or rural area of residence, tangible social support, affection, positive social interaction, emotional or informational support, perceived unmet MH need, and accessibility, acceptability, and availability barriers (summarized as barriers) to resource use. Need factors included standardized interview questions designed to detect, with high probability, the presence of a mental disorder (40), including depression, mania, panic disorder, panic attack, agoraphobia, and social phobia, or an eating disorder and included questions about the extent to which the mental disorder caused interference with life, as well as suicidal thoughts and chronic medical conditions. Other need factors studied were distress, self-perceived stress, ability to handle unexpected problems, and ability to handle day-to-day demands (summarized as distress). We studied psychological well-being, self-rated health, life satisfaction, and self-rated physical and mental health (summarized as self-rated health). We also examined the presence of a problem with gambling, alcohol, or illicit drug dependency (summarized as addiction) and whether addictions (alcohol or illicit drugs) caused interference with life. We considered variables reporting on the impact of health problems on participation and activity 616
limitation and whether the respondent needed help for a series of tasks or had difficulty with social situations (summarized as disability). Statistical Modelling We used logistic regression to model overall service use as a function of individual determinants in Canada and by province.We did not observe multicollinearity among the variables. We chose final predictive logistic regression models, using a stepwise selection approach with a 0.10 level of significance to enter the model and a 0.05 significance level to stay in the model. We also included age and sex in the final models. We obtained estimates (95%CI) from the BOOTVAR program developed by Statistics Canada (42).
Results Lifetime and Past-Year Prevalence of Mental Disorders The prevalence rates of ever having a specified mental disorder and of having the disorder in the past year were 7.3% (95%CI, 6.9% to 7.7%) and 4.8% (95%CI, 4.4% to 5.1%) for depression, 1.4% (95%CI, 1.2% to 1.6%) and 1.0% (95%CI, 0.8% to 1.1%) for mania, 2.1% (95%CI, 1.9% to 2.3%) and 1.5% (95%CI, 1.3% to 1.7%) for panic disorder, 12.0% (95%CI, 11.5% to 12.5%) and 7.8% (95%CI, 7.4% to 8.2%) for panic attacks, 4.7% (95%CI, 4.4% to 5.0%) and 3.0% (95%CI, 2.7% to 3.2%) for social phobia, and 0.7% (95%CI, 0.6% to 0.8%) and 0.7% (95%CI, 0.6% to 0.9%) for agoraphobia, respectively. W Can J Psychiatry, Vol 50, No 10, September 2005
Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access
Table 2 Summary determinants of type of health care services used for MH reasons across Canada Region
Important determinants of any type of services used Predisposing factors Age
Sex
MS
EDU
COB
Enabling factors Race LNG
Ö
SRH Ö
DIS
Ö
NL
Ö*
Ö*
PEI
Ö*
Ö*
NS
Ö*
Ö
Ö
NB
Ö
Ö
Ö
Ö
Que
Ö*
Ö
Ö
Ö
Ö
Ö
Ont
Ö
Ö
Ö
Ö
Man
Ö
Ö*
Sask
Ö
Ö*
Alta
Ö*
Ö
BC
Ö*
Ö
Ö
Ö
U
Ö
Ö
Ö
BAR
Canada
Ö
Ö
SUPP
Need factors
Ö
CC Ö
Ö
Ö
Ö
Ö Ö
Ö
Ö
AD
SUI
*
Ö
Ö
Ö
Ö
Ö
Ö
Ö
Ö*
Ö
ADD
INT
Ö
Ö
Ö
Ö
Ö
Ö
Ö
Ö Ö
Ö
Ö*
Ö
Ö
Ö
Ö*
Ö
Ö
Ö
Ö
Ö
Ö
DSB
Ö*
Ö Ö
MD
Ö
Ö
Ö*: Not significant after adjusting for all other variables in the model. MD includes depression and mania; AD includes agoraphobia, social phobia, panic attack, panic disorder, and eating disorder. Household income and urban or rural variables are not presented, since they were not significant.
Past-Year Prevalence of Service Use for MH Reasons The past-year prevalence rate of any type of resource use for MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%), and our data suggest differences among some of the provinces (Table 1). Differences were observed wherein Nova Scotia (11.3%; 95%CI, 9.6% to 13.0%) and British Columbia (11.3%; 95%CI, 10.1% to 12.6%) had the higher rates and Newfoundland and Labrador (6.7%; 95%CI, 5.3% to 8.0%) and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%) had the lower rates. In Canada, the general medical system was the most used for MH reasons, and the voluntary network sector was the least used (Table 1). No difference in use was observed between the specialty MH and other professional services (Table 1). Shared care in Canada, indicated by use of an MH specialist or other professional in addition to a general medical provider, represented 31% of those reporting the use of the general medical system. In turn, use of only the general medical system for MH reasons accounted for 27%, and any type of provider except the general medical system accounted for 42%. Determinants of Service Use for MH Reasons (Table 2) Among the variables examined in the multivariate analysis, the following were consistent predictors of health service use Can J Psychiatry, Vol 50, No 10, September 2005 W
in Canada after controlling for age, marital status, education, country of birth, language spoken, social support, barriers in accessing health services, distress, medical chronic conditions, and physical disability: female sex (OR 1.65; 95%CI, 1.46 to 1.87), self-rated MH (5 levels rated from poor to excellent, OR 0.63; 95%CI, 0.57 to 0.68), and the presence of a mental disorder such as depression (past OR 1.80; 95%CI, 1.50 to 2.16; present OR 4.23; 95%CI, 3.39 to 5.27), mania (past OR 1.81; 95%CI, 1.22 to 2.68; present OR 1.29; 95%CI, 0.82 to 2.032), panic attack (past OR 1.14; 95%CI, 0.96 to 1.35; present OR 2.02; 95%CI, 1.64 to 2.48), and panic disorder (past OR 2.21; 95%CI, 1.60 to 3.03; present OR 1.78; 95%CI, 1.22 to 2.60) compared with mental disorder never diagnosed as well as past-year suicidal ideation (OR 1.52; 95%CI, 1.14 to 2.02). Most people in Canada with a mental disorder or illicit drug dependence did not consult health resources for MH reasons in the past year. In our study, only 33.7% of respondents with presence of lifetime depression reported past-year use. The corresponding percentages were 42.3% for mania, 21.9% for panic attacks, 38.0% for panic disorder, 28.6% for social phobia, and 28.8% for agoraphobia. Of the people with suicidal ideation and drug dependency within the past year, only 44.1% and 37.3% consulted a 617
The Canadian Journal of Psychiatry—CAPE Special Issue
service, respectively. Further, of those for whom alcohol or illicit drug dependency caused interference with daily life, only 26.4% and 26.7%, respectively consulted a service.
Discussion In this study, the general medical system was the most widely consulted service for MH reasons in Canada, as reported in previous Canadian studies and in other countries (4,10,18,36,37). In Canada, 5.4% of respondents used the general medical system, and this did not differ significantly among the provinces, with the exception of Prince Edward Island having a lower rate, compared with Nova Scotia, Quebec, Ontario, and British Columbia. The next most frequently sought service in Canada was, on average, other professionals (4.0%), except for Nova Scotia, New Brunswick, and Quebec, where the specialty MH services (3.5%) were sought next. Finally, in Canada, the voluntary support network was the least used system, with 1.9% of respondents. Our multivariate models of service use showed that, among the variables studied, need was an important driver of resource use, as expected (41). Apart from the presence of a mental disorder, self-rated and perceived health was a significant predictor of service use in all provinces (41). Among the predisposing factors, sex, marital status, education, country of birth, and ethnicity (only for Quebec) were significant factors. Similar to previous reports, girls and women and single and divorced people were more likely to use a health service for MH reasons (18,43). People with lower educational levels (less than high school) were less likely to use a service, as were people born outside Canada. It has been reported elsewhere that differences in perceived acceptability of using health services for MH reasons by ethnic group may explain service use differences (18). In our study, however, ethnic status remained a significant predictor even after adjusting for acceptability (for example, people who prefer to manage on their own, who do not think MH services will help, or who have language problems). Our findings suggest that a more specific issue, such as the level of awareness of MH issues and available resources, may play a role in these groups. With respect to enabling factors, in Canada and among the provinces, household income did not appear to influence health service use. Our results underlie the need for further study of individual determinants that may explain differences in the type of resource preferred and used for MH reasons across provinces. Overall, however, at a time when Canadian planners are paying greater attention to moderate mental disorders and to increasing consultations for MH reasons (44), consistent with other countries, most people with an MH condition do not consult. Further, if they do consult, need is the most important predictor of use. This suggests that access to health care services for MH reasons by individuals is relatively equitable across provinces. Funding and Support This paper was supported by a CIHR grant to the authors and the following investigators: Rebecca Fuhrer, Paula Goering, Elliot 618
Goldner, Nick Kates, Elisabeth Lin, Anne Rhodes, Renee Robinson, and Raymond Tempier. Acknowledgements The research and analysis are based on data from Statistics Canada, and the opinions expressed do not represent the views of Statistics Canada. Dr Vasiliadis is a CIHR Strategic Training Fellow.
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Manuscript received and accepted May 2005. 1 Postdoctoral Fellow, Department of Psychiatry, Université de Montréal, Montreal, Quebec; Postdoctoral Fellow, Centre de Recherche Fernand-Seguin, Hôpital Louis-H Lafontaine, Montreal, Quebec. 2 Professor, Department of Psychiatry, Université de Montréal, Montreal, Quebec; Researcher, Centre de Recherche Fernand-Seguin, Hôpital Louis-H Lafontaine, Montreal, Quebec. 3 Associate Professor, Departments of Psychiatry and Community Health Sciences, University of Calgary, Calgary, Alberta. 4 Associate Professor, Department of Psychiatry, Université de Montréal, Montreal, Quebec; Head of Social Psychiatry Unit, Centre de Recherche Fernand-Seguin, Hôpital Louis-H Lafontaine, Montreal, Quebec. Address for correspondence: DR H-M Vasiliadis, Unité 218, Pav Bédard, Hôpital Louis-H Lafontaine, 7401 rue Hochelaga, Montreal QC H1N 3V2 e-mail:
[email protected] or
[email protected]
Résumé : L’utilisation des services pour des raisons de santé mentale : les différences interprovinciales de taux, de déterminants et d’équité d’accès Objectifs : En 2002, le Canada a entrepris sa première enquête nationale sur la santé mentale et le bien-être, qui comprenait des questions détaillées sur l’utilisation des services. Les troubles mentaux peuvent affecter plus d’une personne sur 5, selon de précédentes enquêtes régionales moins complètes sur la santé mentale au Canada, et la plupart ne recherchent pas d ’aide. Les déterminants individuels jouent un rôle dans l’utilisation des ressources de santé pour des raisons de santé mentale (SM). Trouver les taux de prévalence de l’utilisation des services de santé pour des raisons de SM par province et selon le type de service, et examiner les déterminants de l’utilisation des services de SM au Canada et dans les provinces. Méthodes : Nous avons évalué le taux de prévalence (intervalle de confiance [IC] de 95 %) de l ’utilisation des services pour des raisons de SM dans l’année écoulée, et nous avons évalué les déterminants potentiels de façon transversale, à l ’aide des données recueillies dans le volet Santé mentale et bien-être de l’Enquête sur la santé dans les collectivités canadiennes (ESCC, Cycle 1.2). Nous avons estimé les modèles d’utilisation des ressources au moyen de la régression logistique (à l’aide de risques relatifs et d’IC de 95 %). Résultats : La prévalence de l’utilisation des services pour des raisons de SM au Canada était de 9,5 % (IC 95 %, de 9,1 % à 10,0%). Les taux les plus élevés, en moyenne, ont été observés en Nouvelle-Écosse à 11,3 %, (IC 95 %, de 9,6 % à 13,0%) et en Colombie-Britannique, à 11,3 % (IC 95 %, de 10,1 % à 12,6 %), et les taux les plus faibles, à Terre-Neuve et au Labrador, à 6,7 % (IC 95 %, de 5,3 % à 8,0 %) et à l’Île-du-Prince-Édouard, à 7,5 % (IC 95 %, de 5,8 % à 9,3 %). Au Canada, le système médical général était le plus utilisé pour des raisons de SM, à 5,4 % (IC 95 %, de 5,1 % à 5,8 %), et le secteur des réseaux bénévoles était le moins utilisé, à 1,9 % (IC 95 %, de 1,7 % à 2,1 %). Aucune différence n ’a été observée dans le taux d’utilisation des services entre les spécialistes de la SM (3,5 %, IC 95 %, de 3,2 % à 3,8 %) et d’autres fournisseurs professionnels (4,0 %, IC 95 %, de 3,7 % à 4,3 %). Dans les analyses multivariées, après rajustement selon l’âge et le sexe, la présence d’un trouble mental était un prédicteur constant d’utilisation des services de santé pour des raisons de SM dans toutes les provinces. Conclusion : Il y a presque une double différence dans le type de service utilisé pour des raisons de SM dans les provinces. Le système médical général des soins primaires est le service le plus largement utilisé pour la SM. Le besoin demeure le prédicteur le plus fort de l’utilisation, en particulier la présence d’un trouble mental. Les obstacles à l’accès, comme le revenu, n’ont pas été identifiés dans toutes les provinces. Différentes variables sociodémographiques ont joué un rôle dans le recours aux services, dans chaque province, ce qui suggère différentes attitudes à l’endroit des troubles mentaux fréquents et du recours aux soins parmi les provinces.
Can J Psychiatry, Vol 50, No 10, September 2005 W
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