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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

4 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 11 Comparison to Other BoD Studies MI&A Cancers

Infectious Diseases 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: Excluded: 8 8 Missing Missing Data Data 81 81 Not Not Incident Incident AMI AMI 156 156 Death Death before

before Discharge Discharge 842 with Schizophrenia Mortality Outcome Excluded: Excluded: 33 33 Death Death within within 30 30

days days of of discharge discharge 809 with Schizophrenia Process of Care Outcome Excluded: Excluded: 394 394 Missing

Missing Data Data 7628 7628 Not Not Incident Incident AMI AMI 9890 9890 Death Death before before Discharge Discharge 70,826 without Schizophrenia

Excluded: Excluded: 1724 1724 -- Death Death within within 30 30 days days of of discharge discharge 69,102 without Schizophrenia

16 Mortality Unadjusted Adjusted AOR 1.56, 95% CI 1.08-2.23; p=0.02 17 Cardiac Procedures Unadjusted

Adjusted AOR 0.48, 95% CI 0.40-0.56; p<0.001 18 Cardiologist Visits Unadjusted Adjusted AOR 0.53, 95% CI 0.43-0.65; p<0.001 19 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) 21 297 Psychiatrists 230 Contacted 160 Unavailable (70%) 22 297 Psychiatrists 230 Contacted 160 Unavailable

(70%) 64 (27%) Need to review referral information and no wait-time estimate 23 297 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) 24 Ontario Psychiatrist Supply Toronto and Ottawa have 24 times more psychiatrists per capita than other regions in Ontario. 25 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? 26 Mean # Unique Patients and # New Patients per Year Low supply area psychiatrists see twice as many patients and twice as many new patients/year

27 Psychiatrists vs Patients in Toronto 25% of psychiatrists see 6% of outpatients 28 Patient Income Across Visit Categories Toronto Almost half of patients seen >16 times/year are in the top income quintile

29 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 30 Follow-up 30 days Post-Hospitalization 31 Readmission 31-60 days Post-Hospitalization

32 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

33 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 General Psychiatry Assessment Clinic Volumes ED Volumes: % new to CAMH and Region Pre-Campaign Map Post-Campaign Map

Maps Side by Side Limitations Just starting system context Dont 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

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