Trends in mental health service utilisation in immigrant youth in Ontario, Canada, 1996-2012: a population-based longitudinal cohort study

Sociodemographic Differences in Physician-Based Mental Health and Virtual Care Utilization and Uptake of Virtual Care Among Children and Adolescents During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study

OBJECTIVE

We sought to evaluate the relationship between social determinants of health and physician-based mental healthcare utilization and virtual care use among children and adolescents in Ontario, Canada, during the COVID-19 pandemic.

METHODS

This population-based repeated cross-sectional study of children and adolescents (3-17 years; N = 2.5 million) used linked health and demographic administrative data in Ontario, Canada (2017-2021). Multivariable Poisson regressions with generalized estimating equations compared rates of outpatient physician-based mental healthcare use during the first year of the COVID-19 pandemic with expected rates based on pre-COVID patterns. Analyses were conducted by socioeconomic status (material deprivation quintiles of the Ontario Marginalization index), urban/rural region of residence, and immigration status.

RESULTS

Overall, pediatric physician-based mental healthcare visits were 5% lower than expected (rate ratio [RR] = 0.95, 95% confidence interval [CI], 0.92 to 0.98) among those living in the most deprived areas in the first year of the pandemic, compared with the least deprived with 4% higher than expected rates (RR = 1.04, 95% CI, 1.02 to 1.06). There were no differences in overall observed and expected visit rates by region of residence. Immigrants had 14% to 26% higher visit rates compared with expected from July 2020 to February 2021, whereas refugees had similarly observed and expected rates. Virtual care use was approximately 65% among refugees, compared with 70% for all strata.

CONCLUSION

During the first year of the pandemic, pediatric physician-based mental healthcare utilization was higher among immigrants and lower than expected among those with lower socioeconomic status. Refugees had the lowest use of virtual care. Further work is needed to understand whether these differences reflect issues in access to care or the need to help inform ongoing pandemic recovery planning.

Experiences of racial microaggression among immigrant and Canadian-born young adults: Effects of double stigma on mental health and service use

BACKGROUND

Significant disparities in utilization of mental health services exist among immigrant and Canadian-born populations. These gaps may be associated with a 'double stigma' - stigma related to being from a racialized background exacerbated by mental health stigma. Immigrant young adults may be particularly susceptible to this phenomenon, given developmental and social transitions from adolescence to adulthood.

AIMS

To investigate the joint effects of racial microaggression and mental health stigma on mental health and service use among first-generation immigrant and Canadian-born university students.

METHOD

We conducted an online cross-sectional study among first-generation immigrant and Canadian-born university students (N = 1,280, Mage = 19.10, SD = 1.50).

RESULTS

Despite no differences in anxiety or depression symptoms, first-generation (foreign-born) immigrants were less likely to have received therapy and to have taken medication for mental health issues compared to Canadian-born participants. First-generation immigrants also reported experiencing higher levels of racial microaggression and stigma toward service use. Results suggest the presence of a double stigma, mental health stigma and racial microaggression, each explained significant additional variance in symptoms of anxiety and depression and medication use. No effects of double stigma for therapy use were found - while higher mental health stigma predicted lower use of therapy, racial microaggression did not predict unique variance in therapy use.

CONCLUSIONS

Our findings highlight the joint effects of racial microaggression and stigma toward mental health and service as barriers to help-seeking among immigrant young adults. Mental health intervention and outreach programmes should target overt and covert forms of racial discrimination while incorporating culturally sensitive anti-stigma approaches to help reduce disparities in mental health service use among immigrants in Canada.

Correlates of child mental health and substance use related emergency department visits in Ontario: A linked population survey and administrative health data study

Introduction

Knowledge of the sociodemographic, behavioural, and clinical characteristics of children visiting emergency departments (EDs) for mental health or substance use concerns in Ontario, Canada is lacking.

Objectives

Using data from a population-based survey linked at the individual level to administrative health data, this study leverages a provincially representative sample and quasi-experimental design to strengthen inferences regarding the extent to which children's sociodemographic, behavioural, and clinical characteristics are associated with the risk of a mental health or substance use related ED visit.

Methods

9,301 children aged 4-17 years participating in the 2014 Ontario Child Health Study were linked retrospectively (6 months) and prospectively (12 months) with administrative health data on ED visits from the National Ambulatory Care Reporting System. Modified Poisson regression was used to examine correlates of mental health and substance use related ED visits among children aged 4-17 years over a 12-month period following their survey completion date, adjusting for ED visits in the 6 months prior to their survey completion date. Subgroup analyses of youths aged 14-17 years who independently completed survey content related to peer victimisation, substance use, and suicidality were also conducted.

Results

Among children aged 4-17 years, older age, parental immigrant status, internalising problems, and perceived need for professional help were statistically significant correlates that increased the risk of a mental health or substance use related ED visit; low-income and suicidal ideation with attempt were statistically significant only among youths aged 14-17 years.

Conclusions

Knowledge of the sociodemographic, behavioural, and clinical characteristics of children visiting EDs for mental health and substance use related concerns is required to better understand patient needs to coordinate effective emergency mental health care that optimises child outcomes, and to inform the development and targeting of upstream interventions that have the potential to prevent avoidable ED visits.

Highlights

Growing rates of child mental health and substance use related ED visits have been observed internationally.A population-based survey linked at the individual level to administrative health data was used to examine the extent to which children's sociodemographic, behavioural, and clinical characteristics are associated with the risk of a mental health or substance use related ED visit in Ontario, Canada.Older age, low-income, parental immigrant status, perceived need for professional help, internalising problems, and suicidality increase the risk of an ED visit.Knowledge of the characteristics of children visiting EDs can be used to coordinate effective emergency mental health care that optimises child outcomes, and to inform the development and targeting of upstream interventions that have the potential to prevent avoidable ED visits.

Social Disparities in Mental Health Service Use Among Children and Youth in Ontario: Evidence From a General, Population-Based Survey

OBJECTIVES

To examine differences in mental health-related service contacts between immigrant, refugee, racial and ethnic minoritized children and youth, and the extent to which social, and economic characteristics account for group differences.

METHODS

The sample for analyses includes 10,441 children and youth aged 4-17 years participating in the 2014 Ontario Child Health Study. The primary caregiver completed assessments of their child's mental health symptoms, perceptions of need for professional help, mental health-related service contacts, experiences of discrimination and sociodemographic and economic characteristics.

RESULTS

Adjusting for mental health symptoms and perceptions of need for professional help, children and youth from immigrant, refugee and racial and ethnic minoritized backgrounds were less likely to have mental health-related service contacts (adjusted odds ratios ranged from 0.54 to 0.79), compared to their non-immigrant peers and those who identified as White. Group differences generally remained the same or widened after adjusting for social and economic characteristics. Large differences in levels of perceived need were evident across non-migrant and migrant children and youth.

CONCLUSION

Lower estimates of mental health-related service contacts among immigrant, refugee and racial and ethnic minoritized children and youth underscore the importance and urgency of addressing barriers to recognition and treatment of mental ill-health among children and youth from minoritized backgrounds.

Mental Illness Following Physical Assault Among Children

Importance

Physical assault during childhood is common and can lead to lasting mental health problems. Yet, there are few studies on the patterns of mental illness (ie, timing of onset, type, and acuity) in survivors of physical assault.

Objective

To determine the risk of incident health record diagnoses of mental illness among children who experienced assault compared with children who did not.

Design, Setting, and Participants

This population-based matched cohort study used linked health administrative data sets in Ontario, Canada. Children aged 0 to 13 years who experienced an incident physical assault between 2006 and 2014 were age-matched (1:4) to children who had not experienced assault and followed up for a minimum of 5 years. Data were analyzed from January 2020 to March 2022.

Exposure

Physical assault resulting in hospitalization or an emergency department (ED) visit between the ages of 0 and 13 years.

Main Outcomes and Measures

The primary outcome was incident health record diagnosis of mental illness measured as any physician or hospital mental health care use or completed suicide. Secondary outcome measures included the acuity of incident mental illness and mental illness diagnostic category. Cox proportional hazards regression analysis generated hazard ratios (HR) for incident mental illness.

Results

A total of 21 948 children unexposed to assault and 5487 exposed to assault were included in the study with a mean (SD) age of 7.0 (4.6) years. There were more boys in the group that experienced assault (3006 individuals [54.8%]) compared with the group who did not (9909 individuals [45.1%]). Compared with children unexposed to assault, those exposed were more likely to be in the highest deprivation index quintile (standardized difference, 0.21) and live in rural areas (standardized difference, 0.48). Their mothers more often had active mental illness (standardized difference, 0.35). More than one-third of the exposed children had a health record diagnosis of mental illness (2219 children [38.6%]; incidence rate (IR), 53.3 per 1000 person-years) compared with 23.4% (5130 children; IR, 32.2 per 1000 person-years) of unexposed children, with an overall adjusted hazard ratio (aHR) of 1.96 (95% CI, 1.85-2.08). The greatest risk was observed in the first year following the assault (aHR, 3.08; 95% CI, 2.68-3.54). In both groups, nonpsychotic disorders were the most common type of mental illness. Initial mental illness diagnoses occurred in an acute care setting for 14.0% of exposed children (769 children) vs 2.8% of unexposed children (609 children).

Conclusions and Relevance

In this population-based matched cohort study, children who experienced assault had, on average, a 2 times higher risk of receiving a mental illness diagnosis and were more likely than children who had not experienced assault to present to acute care for mental illness. Early intervention to support mental health of assaulted children is warranted, particularly in the first year following assault.

Mental health and neurocognitive disorder-related hospitalization rates in immigrants and Canadian-born population: a linkage study

OBJECTIVES

Mental health and neurocognitive conditions are important causes of hospitalization among immigrants, though patterns may vary by immigrant category, world region of origin, and time since arrival in Canada. This study uses linked administrative data to explore differences in mental health hospitalization rates between immigrants and individuals born in Canada.

METHODS

Hospital records from the Discharge Abstract Database and the Ontario Mental Health Reporting System for 2011 to 2017 were linked to the 2016 Longitudinal Immigrant Database and to Statistics Canada's 2011 Canadian Census Health and Environment Cohort. Age-standardized hospitalization rates for mental health-related conditions (ASHR-MHs) were derived for immigrants and the Canadian-born population. ASHR-MHs overall and for leading mental health conditions were compared between immigrants and the Canadian-born population, stratified by sex and selected immigration characteristics. Quebec hospitalization data were not available.

RESULTS

Overall, immigrants had lower ASHR-MHs compared to the Canadian-born population. Mood disorders were leading causes of mental health hospitalization for both cohorts. Psychotic, substance-related, and neurocognitive disorders were also leading causes of mental health hospitalization, although there was variation in their relative importance between subgroups. Among immigrants, ASHR-MHs were higher among refugees and lower among economic immigrants, those from East Asia, and those who arrived in Canada most recently.

CONCLUSION

Differences in hospitalization rates among immigrants from various immigration streams and world regions, particularly for specific types of mental health conditions, highlight the importance of future research that incorporates both inpatient and outpatient mental health services to further understand these relationships.

Mental Health and its Influencing Factors Among Immigrants with Chronic Diseases in China

Immigrants are a special group in society, and their health is of great concern. Few studies have targeted this population in China. A cross-sectional descriptive correlational study was conducted from July to August 2018 in Hubei Province, China. Chi-square tests, Z-tests and multivariable linear regression analysis were performed to analyze the data using SPSS 24.0. A total of 1068 questionnaires were distributed. The results showed that the variables that affected the mental health of the immigrants with chronic diseases included gender, annual income, life events (L), negative emotion (NE), negative coping styles (NC) and objective support (OS) (p ≤ 0.05). Future research should focus on the physical and mental health of different immigrant groups and design effective, individualized interventions to improve the health status of immigrants, especially those with chronic diseases.

Culturally-Appropriate Orientation Increases the Effectiveness of Mental Health First Aid Training for Bhutanese Refugees: Results from a Multi-state Program Evaluation

Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare individuals to recognize and respond to mental health warning signs. This was a non-randomized program evaluation. Using pre- and post-training questionnaires developed for prior evaluations of MHFA, we examined the effectiveness of training offered with and without culturally-appropriate orientation to mental health terminology and concepts (N = 458). Pre- to post-training improvement in ability to recognize schizophrenia, ability to respond to schizophrenia and depression, and the overall mental health literacy was greater for Bhutanese refugees who attended orientation relative to other participants (P < 0.05). In scaling up MHFA training for other immigrant communities, we recommend developing and systematically evaluating culturally-appropriate orientation materials that introduce mental health vocabulary and contextualize mental health concepts.

Suicide and Self-Harm in Recent Immigrants in Ontario, Canada: A Population-Based Study

OBJECTIVE

To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes.

METHODS

Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario (N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants (n = 130 suicides, 3.3/100,000) than long-term residents (n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male-female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants (n = 2,256 events, 4.4/10,000) than long-term residents (n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000).

CONCLUSION

Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.