By Paul Kurdyak
“I had very little care for a lot of difficult symptoms (only a few walk-in clinic visits) until I was in crisis. My family took me to the ER, where I waited for many hours to see someone. After that wait I saw the ER doctor, but not a mental health professional. I was discharged in the early morning with no follow-up of any kind. My parents were told that I was just behaving badly. I later learned that there was a mental health team working at that ER, but was not referred to them. I had two more similar experiences in the ER over a couple of years, before I was referred to the appropriate type of care.” (Person with lived experience)
Stories of difficulty accessing services and fragmented care once services are accessed like the one above are all too common. There are repeated calls to address the shortcomings of the mental health system. However, as tragic as the stories are, it is hard to respond meaningfully to them because there is not enough information to guide and monitor investments in the mental health system.
In a recently released report entitled “Toward Quality Mental Health Services in Canada: A Comparison of Performance Indicators across 5 Provinces” a team of researchers from five provinces (BC, Alberta, Manitoba, Ontario and Quebec) developed, analyzed and produced mental health system performance indicators. This is the first time that mental health system performance has been compared across provinces. There were 6 indicators in total, measuring access to primary care for individuals with mental illnesses and addictions, the use of the Emergency Department as a first point of contact for mental illnesses and addictions, suicide attempts and completions, and overall mortality rates.
A key finding was poor access to mental health and addictions care for children and youth. Individuals between the ages of 20 and 24 had the lowest rates of regular access to a family physician, and males had worse access than women. This is problematic given that this age group is experiencing their first onset of mental illnesses and addictions. We also measured the proportion of individuals who had mental health or addiction-related Emergency Department visits with no outpatient (primary care or psychiatrist visits) in the preceding 2 years (see figure 4).
This indicator is a measure of system access, with the Emergency Department as a place where people go because there is nowhere else. Here again, between the ages of 15 and 19 had the highest rates of no prior contact – between 35 and 46 per cent, suggesting that this age group has the greatest struggles with access to care.
Youth between the ages of 15 and 19 had the highest rates of hospitalizations for suicide attempts. In Ontario, the rate was 3 per 1000 in this age category, and the rate was approximately 10 per 1000 in British Columbia and Alberta, and as high as 18 per 1000 in Manitoba. Timely access can help reduce the impact of mental illness and addiction across the lifespan, including reducing the likelihood that children and youth will attempt suicide as a result of distress and mental illness.
As important as results such as poor access for children and youth are, the ability to generate comparable performance indicators across multiple provinces is a milestone achievement. Measurement within the mental health system lags behind other areas of the health care system. Consider, for example, the sophistication of cancer care in most provinces. Organized and regionalized cancer care is a result of systematic feedback from ongoing performance measurement. Across Canada, mental health system performance has been largely invisible, with the result being a persistence of anecdote and an absence of evidence to inform policy. If Canadians are to get the mental health care they deserve, we need to have a much better understanding of the status quo so that quality improvement is targeted and equitable. Measurement is the first step to a broader quality improvement agenda. It is time to make the invisible visible so that we map a way forward to addressing the barriers to care Canadians are describing as they try to access services for mental illnesses and addictions.
What can we take from the results of our report? First, there is a lot of unmet need among individuals suffering from mental illnesses, particular in youth and young adults. Clinicians should have a high index of suspicion and inquire about mental health issues. And once detected, we clearly need to ensure that services are accessible, especially for children and young adults. This is particularly challenging since many young adults are mobile and have not had much connection to regular health care providers, as our report has shown.
We need to continue to measure mental health system performance. You cannot change what you cannot measure. Moving forward, we need to develop more relevant performance indicators, particularly those that are co-developed with individuals who struggle with mental illnesses. We also need to standardize data and measurement across provinces so that the effort we put into our report becomes routine. Finally, we need to include all provinces and territories so that, nationally, we develop the capacity to learn from one another as we bridge the gap between the current status quo and the future state of better access and quality.
Paul Kurdyak is a psychiatrist and Medical Director, Performance Improvement at the Centre for Addiction and Mental Health. He also is a Core Senior Scientist and Lead of the Mental Health and Addictions Research Program at the Institute for Clinical Evaluative Sciences (ICES).