Burden, Access, and Unmet Need: the mental
health service landscape in Ontario
Association of General Hospital Psychiatric Services
Paul Kurdyak MD PhD
Disclosures

Salary Support from:
• ICES
• CIHR
Overview
1.
2.
3.
4.
The burden of mental illness and
addictions
Medical Comorbidity
Access to psychiatrists
Increasing help-seeking behaviour – a
CAMH natural experiment
Opening Eyes, Opening Minds:
The Ontario Burden of Mental Illness and Addictions Report
3
Burden of Mental Illness and Addictions in Ontario



A collaboration between PHO and ICES
Involved CAMH scientists
Important because:
• Sets a baseline for evaluating future public health or
population-based interventions
• Has fostered relationships between mental health and
public health
Unit of Measurement: HALY




HALY: Health-Adjusted Life Years
HALY = YLL + YERF
YLL: Years of life lost due to premature mortality
YERF: Equivalent years of healthy life lost due to
disease/disability
Disease Categories

Mental Health Conditions
•
•
•
•
•
•

Agoraphobia
Bipolar disorder
Major depression
Panic disorder
Schizophrenia
Social phobia
Addictions
• Alcohol use disorders
• Cocaine use disorders
• Prescription opioid misuse
HALYs by Mental Health Condition/ Addiction
250,000
200,000
Female
HALYs
Male
150,000
Total
100,000
50,000
0
Depression
BPD
Alcohol
Social
Phobia
SCZ
PD
Agoraphobia Cocaine
Prescription
opioid
misuse
YLLs by Mental Health Condition/ Addiction
YLL by Mental Health Condition/ Addiction
20,000
Female
15,000
Male
YLL
Total
10,000
5,000
0
Alcohol
SCZ
Depression
Cocaine
BPD
Prescription
opioid
misuse
Social
Phobia
Agoraphobia
PD
YERFs by Mental Health Condition/ Addiction
YERF by Mental Health Condition/ Addiction
250,000
200,000
Female
Male
Total
YERF
150,000
100,000
50,000
0
Depression
BPD
Alcohol
Social
Phobia
SCZ
PD
Agoraphobia Cocaine Prescription
opioid
misuse
HALYs by Age Group
200,000
Health-adjusted life years (HALYs)
Schizophrenia
180,000
Bipolar disorder
160,000
Agoraphobia
140,000
Panic disorder
120,000
Social phobia
100,000
Depression
Alcohol use disorders
80,000
Prescription opioid misuse
60,000
Cocaine use disorders
40,000
20,000
0
18-24
25-34
35-44
45-54
55-64
65+
Age Groups
10
Comparison to Other BoD Studies
All MI&A examined
Major depression
Bipolar disorder
Alcohol use disorders
Social phobia
Schizophrenia
Panic disorder
Agoraphobia
Cocaine use disorders
Prescription opioid misuse
All cancers
Lung cancer
Colorectal cancer
Breast cancer
Prostate cancer
All infectious diseases
Hepatitis C
S. pneumoniae
Human papillomavirus
E. coli
Hepatitis B
MI&A
Cancers
YLL
Infectious Diseases
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Overview
1.
2.
3.
4.
The burden of mental illness and addictions
Medical Comorbidity
Access to psychiatrists
Increasing help-seeking behaviour – a CAMH
natural experiment
Mortality Burden Dramatically Under-estimated




Cause of death is disease-specific.
No one dies from schizophrenia
Premature mortality in schizophrenia mostly due to
cardiovascular disease and risk factors
Access to medical care is very poor
All Cause Mortality: SCZ and BPD (20062010)
Male
Female
Crude Rate
Ratio
Age Adjusted RR
(95% CI)
Crude Rate
Ratio
Age Adjusted RR
(95% CI)
SCZ
1.84
2.51 (2.43, 2.60)
2.64
2.34 (2.26, 2.42)
BPD
1.80
2.00 (1.95, 2.05)
1.64
1.89 (1.85, 1.94)
Schizophrenia Outcomes Following AMI
89,825 AMI Subjects
1087 Allocated to
Schizophrenia
88,738 Allocated to
No Schizophrenia
Excluded:
8 – Missing Data
81 – Not Incident AMI
156 – Death before Discharge
842 with
Schizophrenia
Mortality Outcome
Excluded:
33 – Death within 30
days of discharge
809 with
Schizophrenia
Process of Care
Outcome
Excluded:
394 – Missing Data
7628 – Not Incident AMI
9890 – Death before Discharge
70,826 without
Schizophrenia
Excluded:
1724 - Death within
30 days of discharge
69,102 without
Schizophrenia
15
Mortality
2.5
2
1.5
1
0.5
0
Unadjusted
Adjusted
AOR 1.56, 95% CI 1.08-2.23; p=0.02
16
Cardiac Procedures
1
0.75
0.5
0.25
0
Unadjusted
Adjusted
AOR 0.48, 95% CI 0.40-0.56; p<0.001
17
Cardiologist Visits
1
0.75
0.5
0.25
0
Unadjusted
Adjusted
AOR 0.53, 95% CI 0.43-0.65; p<0.001
18
Overview
1.
2.
3.
4.
The burden of mental illness and
addictions
Medical Comorbidity
Access to psychiatrists
Increasing help-seeking behaviour – a
CAMH natural experiment
Ability to Access Psychiatrists


Primary care physician surveys from multiple
jurisdictions - psychiatrists most difficult specialists to
access
NPS survey 2007 - from 2004 to 2007, ability to accept
urgent referral (< 1 week) increased from 44% to 49%

Other specialties increased from 60% (2004) to 80%
(2007)

2010 survey – 35% primary care physicans rated
access to psychiatrists as poor (vs. 4% of GIM and 2%
for pediatricians)
20
297 Psychiatrists
230 Contacted
160 Unavailable
(70%)
21
297 Psychiatrists
230 Contacted
160 Unavailable
(70%)
64 (27%) Need to review
referral information and
no wait-time estimate
22
297 Psychiatrists
230 Contacted
160 Unavailable
(70%)
64 (27%) Need to review
referral information and
no wait-time estimate
6 (3%) offered
immediate appointments
(wait times 4-55 days)
23
Ontario Psychiatrist Supply
Toronto
and Ottawa have
2-4 times more
psychiatrists per capita
than other regions in
Ontario.
24
What Are Psychiatrists Doing?




There are large differences between psychiatrist
supply across different regions
Toronto and Ottawa have large supplies per capita
The rest of the province hovers around 10
psychiatrists/100,000
If there are so many psychiatrists (and so
many more in Toronto and Ottawa), why
are they the most difficult to access?
25
Mean # Unique Patients and # New Patients per
Year

Low supply area
psychiatrists see twice
as many patients and
twice as many new
patients/year
26
Psychiatrists vs Patients in Toronto
25% of psychiatrists see 6% of outpatients
27
Patient Income Across Visit Categories Toronto

Almost half of patients
seen >16 times/year
are in the top income
quintile
28
Summary




Psychiatrists in high supply areas see fewer patients,
fewer new patients and see these fewer patients more
frequently and for longer per visit
In high supply areas, as visit frequency increases,
patient SES increases
The increased psychiatrist supply does not translate
into better follow-up post-hospitalization
Access to psychiatrists does not improve with
increased per capita supply
29
Follow-up 30 days Post-Hospitalization
50
Schizophrenia
Bipolar
Depression
45
40
35
30
25
20
15
10
5
0
No Visit
PC Visit Only
Psych Visit Only
Shared Care
30
Readmission 31-60 days Post-Hospitalization
10
Schizophrenia
9
Bipolar
8
Depression
7
6
5
4
3
2
1
0
No Visit
PC Visit Only
Psych Visit Only
Shared Care
31
Summary
1.
2.
3.
4.
The burden of mental illness and addictions
Medical Comorbidity
Access to psychiatrists
Increasing help-seeking behaviour – a
CAMH natural experiment
32
Mental Illness and Addiction Treatment Rates



Two thirds of people with depression do not seek
help
Up to 90% of people with addictions do not seek
treatment
Very little evidence on increasing treatment-seeking
behaviours to address burden of mental illness and
addiction
The CAMH Campaign
A Natural Experiment



The campaign is the only intervention that occurred in
March 2010 (nothing else changed that could explain
changes in visit volumes)
Permits an evaluation of the campaign using quasiexperimental methods
ED volumes AND Gen Psych. Assessment Clinic
volumes – direct-to-consumer marketing vs. service
provider marketing
Methods





All patients who presented to the ED (N=29,069) and
the Gen Psych. Assessment Clinic (N=8326) from
April 1, 2006 to December 31, 2011.
Grouped monthly
Pre-campaign – April 1, 2006 to March 31, 2010
Post-campaign – April 1, 2010 to December 31, 2011
Also used regional-level data for system-level
analyses (preliminary)
Statistical Analysis


Time series analysis methods used to model the data
series and test for an effect of the campaign.
Geographic Information Systems (GIS) using patient
postal code for mapping patient distance from ED.
ED Volumes
700
600
500
400
300
200
100
0
Apr/06 Oct/06 Apr/07 Oct/07 Apr/08 Oct/08 Apr/09 Oct/09 Apr/10 Oct/10 Apr/11 Oct/11
Time
Actual # visits
General Psychiatry Assessment Clinic Volumes
300
250
200
150
100
50
0
Apr/06
Oct/06
Apr/07
Oct/07
Apr/08
Oct/08
Apr/09
Oct/09
Apr/10
Time
Number of referrals
Oct/10
Apr/11
Oct/11
ED Volumes: % new to CAMH and Region
600
CAMH
Foundation
550
Monthly ED Visits, Proportion New (%)
500
450
400
350
CAMH Monthly Visits
New to CAMH (Actual)
New to CAMH (%)
New to TCLHIN (%)
New to TCLHIN (Actual)
300
250
200
150
100
50
0
Time
Pre-Campaign Map
Post-Campaign Map
Maps Side by Side
Limitations

Just starting system context
• Don’t know if we are duplicating services
• Preliminarily – campaign increased volume in all categories:
previous CAMH ED visit, new to CAMH, and new to region
Main Findings



Addressing stigma increases help-seeking and
referral behaviour
Can have a significant impact on volumes
Low treatment rates can be addressed using
marketing strategies addressing stigma AND
highlighting service availability
Summary




Huge burden of mental illness and addictions in
Ontario
High supply of psychiatrists in Toronto and
incentivization are perpetuating poor access in the
face of very high psychiatrist supply
Access to care at high times of need (posthospitalization) is poor
CAMH campaign suggests there is a large unmet
need “market” that is currently not being served