Rosina Mete^1* and Yonghong Tong²

¹Independent Researcher and Consultant, Canada

²Department of Computer & Information Sciences, College of Art and Sciences, Niagara University, USA

Keywords: Emergency Department; Mental Illness; Ontario; Psychiatrist

Background: Health Care in Canada

The concept of universal health care is synonymous with Canada in that certain procedures and treatments are covered for legal residents. The Canada Health Act is a federal piece of legislation which allocates funding to provinces and territories for health care. The provinces and territories must pay for all medically necessary treatments provided within a hospital and/or by physicians. Each province and territory determine the definition of medically necessary treatment since there is no set definition [3].

According to the Mental Health Commission of Canada, “one in five Canadians are affected, either directly or indirectly, by mental illness” [2]. Ontario, the most populated province of Canada with roughly 13.6 million residents, will be examined within the following study [5].

Ontario, Health Care and Access to Psychiatric Services

In 2006, Ontario established the Local Health System Integration Act which created organizations to organize, plan, and provide strategic directions for health care providers in Ontario. The non-profit organizations, or Local Health Integration Networks (LHINs) are associated with a specific geographic area within the province. There are 14 LHINs in Ontario [5,6].

The LHIN within each geographic area provides funding to health care facilities such as hospitals, many psychiatric facilities, long-term care homes, Community Care Access Centres, community health centres, and community mental health and addiction agencies. Each LHIN determines an Integrated Health Service Plan (IHSP) which outlines its priorities within a three-year period. The priorities include ideas which often correlate with patient-centered care [6]. A study by Martin & Hirdes [5] examined seven LHINs which identified mental health as a priority within 2007-2010. Their research found that individuals within the geographic LHIN area that prioritized mental health were more likely to have accessed a psychiatrist, occupational therapist, or dietitian than those in non-priority LHIN areas. Additionally, individuals within the highlighted LHINs also had exposure to different types of therapy [5]. Therefore, the strategic direction of the LHIN may impact the availability of mental health services.

To explain the publicly funded health care model in Ontario, family physicians are often an individual’s first encounter regarding their mental health. Research identified family physicians spending “a substantial portion of their time (26-50%) addressing mental health issues” [7]. However, “in Ontario, psychiatrists are the only mental health professionals whose services are eligible for reimbursement by the publicly funded health insurance program” [8]. Access to a psychiatrist in Ontario normally requires a doctor’s referral or a hospital visit [9]. A federal survey of family physicians regarding access to psychiatrists yielded negative results, with a rating of poor as the most frequent response [8]. The Canadian Psychiatric Association “recommends a supply of 15 psychiatrists per 100,000 residents…however, rural Ontario has identified a psychiatrist shortage for the past two decades” [8].

Unfortunately, it appears that, in Ontario, there is a discrepancy in availability to psychiatrist among specific populations. Kurdyak et al. [8] found that individuals within a higher socio-economic status (SES) and without prior psychiatric admissions were more likely to see a psychiatrist more than twice or on a semi-regular basis. Similarly, Steele et al. [9] found that individuals within a higher SES were more likely to see a psychiatrist for nonpsychotic disorders and social disorders. Individuals within a lower SES reported higher rates of addictions and psychotic disorders. Some of the barriers to care identified by Steele et al. [9] include communication issues between patient and provider as well as stigma surrounding mental illness. Therefore, one may deduce that universal psychiatric care is not equally distributed within Ontario.

In Canada, many mental health agencies and crisis intervention departments are normally available during the day or early evening. Consequently, the Emergency Department may be the only resource open for mental health services. In a five-year study of Ontario individuals with mental health or substance use issues, Graham et al. [10] determined these people were more likely to visit the emergency department more than once when compared to others without those issues.  A report by Health Quality Ontario found that “one-third of emergency department visits for a mental illness or addiction are by people who have never been assessed and treated for these issues before by a physician” [11].

Mood and Anxiety Disorders

The most common mental health diagnoses in Canada are mood and anxiety disorders [12]. This trend is also evident within the province of Ontario which is represented within the geographic analysis found in results [12,13]. The 11th edition of the International Classification of Diseases (ICD) defines anxiety disorders as “excessive fear and anxiety and related behavioral disturbances” with symptom intensity that impacts functioning in different areas such as personal life, family, social, or work [14]. The ICD-11 notes that “fear and anxiety are closely related phenomena; fear represents a reaction to perceived imminent threat in the present, whereas anxiety is more future-oriented, referring to perceived anticipated threat” [14]. Examples of anxiety disorders include generalized anxiety disorder (GAD), panic disorder, and social anxiety disorder.

Alternatively, mood disorders are “defined according to particular types of mood episodes and their pattern over time. The primary types of mood episodes are Depressive episode, Manic episode, Mixed episode, and Hypomanic episode” [14]. Examples of mood disorders include bipolar disorder, dysthymic disorder, and single episode depression. Depressive disorders are within mood disorders and are categorized by “depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioral, or neurovegetative symptoms that significantly affect the individual’s ability to function” [14].

GIS and Mental Health

At present, many studies investigating mental health and utilizing geographic information systems (GIS) provide information on “sense of community” and emotional wellbeing within specific regions [15,16]. There are studies examining access to care within identified LHINs, including access to rehabilitative services and cardiac care [17,18]. One study specifically identified transportation routes within the Champlain LHIN in relation to hospital and acute care facilities. In regards to mental health, the Ontario Ministry of Health and Long-Term Care examined the variety of funded services within each LHIN and utilized GIS to clarify each region. While each LHIN collects data within its geographic region, there has not been a comparative study of access to psychiatry services, emergency department rates, and police interactions utilizing GIS software at present time.

The research will attempt to determine the following questions: What is the state of access to publicly funded mental health care in Ontario? What are the utilization rates of emergency room departments for mental illness? What are some of the barriers to care? [Figure 1].

Figure 1: Visualization of service availability of psychiatrists correlated with emergency room visits due to mental health issues within the province of Ontario.

The abovementioned maps will provide a visualization of service availability of psychiatrists correlated with emergency room visits due to mental health issues within the province of Ontario. The mental health issues are focused on the two most common mental health disorders: mood and anxiety. The results will assist in developing strategies within each LHIN for access to publicly funded mental health care.

Data Collection

The majority of data used was obtained from Statistics Canada research and related databases in the fall of 2016. The data related to LHIN regions was provided by the Ministry of Health and Long-Term Care. The population data for Ontario was from the most recent census held in Canada in 2011. Statistics Canada [19,20] collected the data and made it available to the public via their website. The 2011 public health region shapefiles for Ontario were downloaded from the Statistics Canada website. The provincial population was divided into public health regions as delineated by the data obtained from Statistics Canada. The population data provided the reader with an idea of Ontario’s overall population distribution. It was also useful to combine population density with mental health services availability since it explained access to care for residents.

Statistics Canada [21] conducted a nation-wide survey regarding access to health care and related topics in 2012. It was entitled the Canadian Community Health Survey (CCHS) and included a mental health component. The CCHS was administered to those 15 years of age and older within the population [21]. “Excluded from the survey's coverage were: persons living on reserves and other Aboriginal settlements; full-time members of the Canadian Forces and the institutionalized population. Altogether, these exclusions represented less than 3% of the target population” [21]. The CCHS used a mental health survey, the World Health Organization World Mental Health Composite International Diagnostic Interview 3.0 (WHO WMH-CIDI) developed by the World Health Organization (WHO) to assess the pervasiveness of mental health disorders [21]. Residents were asked specific criteria for mental health disorders, which may have occurred at some point within their lifetime until the administration of this survey. The WHO WMH-CIDI assesses for mood disorders, anxiety disorders, substance use disorders, and personality disorders [22]. The CCHS results were divided by province and outlined actual population numbers for mental health disorders, which are categorized by type [21]. Questions related to suicidal thoughts, stress level, and perceived level of mental health were also asked.

With a data agreement in place, Statistics Canada provided the full data of the CCHS from 2012 to the author. The data was divided into public health units within the province of Ontario. The author was able to determine number of individuals with an official diagnosis of anxiety or depression, along with the number of individuals who had accessed a psychiatrist or family doctor for a mental health concern.

One of the authors also works within a community health care organization (CHC) and obtained permission from the Haldimand Niagara Hamilton Brant LHIN authority to summarize aggregate Integrated Decision Support (IDS) data as a participant (CHC) to the data sharing agreement with IDS. The data was in aggregate form, with no personal health information and approved by the IDS Operations Committee. The IDS data was a pilot project featuring the following LHIN areas: Haldimand Niagara Hamilton Brant, South West, Waterloo Wellington, Erie St. Clair, Toronto Central, and Mississauga Halton. The data provided outlined the number of repeated emergency department visits for mental health or substance use concerns. The criteria for each concern was based on a mental health assessment administered within emergency departments across the province. A repeated visit was defined as more than one visit to the emergency room for the concern within the past 30 days. The data obtained included the fiscal years of 2013-2014 and 2014-2015. The data was utilized within the study to provide information on the number of emergency department visits for mental health concerns. It was presented in table and map form within the results section.

The Statistics Canada Mental Health survey of Canada has not been replicated since 2012 and provides comprehensive data reflective of Ontario residents. Recent studies of Canadian provinces regarding mental disorders and suicidality continue to use the CCHS [23]. Additionally, data within a similar timeframe was obtained from the provincial Ministry of Health and Long-Term Care in Ontario to enrich the study [24].

A map of the LHIN was obtained from the Ministry of Health and Long-Term Care’s [24] website. The author utilized the map to create a shapefile with the six LHIN regions highlighted. A map of the LHIN was obtained from the Ministry of Health and Long-Term Care’s [24] website. The author utilized the map to create a shapefile with the six LHIN regions highlighted.

The below map identifies the population of Ontario within each public health unit specified. The Figure 2 provides a framework for the reader to understand the population density of Ontario, which is Canada’s most populous province [4]. Furthermore, the different public health units are numbered and found in the following table, Table 1.

Figure 2: Ontario population by Public Health Region.

Table 1: Public health unit map number from Figure 1 with corresponding name and population.

Figure 3 utilizes the Statistics Canada data to show the number of individuals who were diagnosed with a mental health disorder of anxiety (such as generalized anxiety or panic disorder) or mood disorder (such as depression or bi-polar disorder). The numbers are plotted within the population data differentiated by health unit. The data identifies that an increase in population also yields an increase in anxiety and mood disorder rates.

Figure 3: Ontario population and mental health diagnosis by public health region.

Figure 4 utilizes the Statistics Canada data to show the number of individuals within Ontario who consulted with their family doctor or psychiatrist in regard to a mental health concern. The map data is outlined in Table 2. It is evident both in the map and data table that individuals in Ontario more frequently talk to their family doctor about mental health concerns, rather than a psychiatrist. Furthermore, the map graphically displays the psychiatry shortage within rural Ontario.

Figure 4: Ontario population access to psychiatrist or doctor for mental health concern.

Figure 5 displays the six LHIN regions which will be further discussed within the paper: Haldimand Niagara Hamilton Brant, South West, Erie St. Clair, Mississauga Halton, Waterloo Wellington, and Toronto Central. The population of each LHIN is provided in a gradient shade of purple. The reader is able to determine the most populated LHIN regions within the map.

Figure 5: Ontario LHIN regions with population dispersion.

Figure 6 graphically identifies the number of repeated emergency department (ED) visits for mental health or substance use concerns for the years 2013 to 2014 and 2014 to 2015. The data is plotted against the previous map of population data. Each dot represents 250 repeated visits or individuals who visited more than once within a 30-day period. This allows the reader to view the increasing rates of emergency room visits for mental health or substance use concerns. The categories are combined within the LHIN data obtained from IDS.

Figure 6: Ontario LHIN regions with repeated emergency department visits for mental health concerns, 2013 to 2015.

Table 3 provides the reader with the frequency of repeated emergency department visits within each of the six listed LHIN regions. One can determine that the number of individuals within Ontario who utilize emergency department services for a mental health or substance use issue is increasing with the currently available data. This number further supports the literature review in that 24-hour access to universal mental health care in Ontario is found within the emergency department of hospitals.

Table 3: Number of repeated emergency department (ED) visits within six LHIN regions for 2013 to 2015.

The results encapsulate a visual explanation of Ontario’s population dispersion prior to answering the study questions. Furthermore, the results, as shown in the literature, confirm that mental illness is becoming more prevalent within Ontario and therefore, Ontario health care policies should integrate more services for residents. The research article focused on the following questions: What is state of access to publicly funded mental health care in Ontario? What are the utilization rates of emergency room departments for mental illness? What are some of the barriers to care?

The Canadian Medical Association [25] possesses the number of registered physicians within the field of psychiatry in Ontario. In 2004, there were 1783 psychiatrists within the province and more recently, it was estimated that there were 1857 psychiatrists within Ontario in 2015 [25]. This number increased by less than 5% within 11 years. Meanwhile, the province of Ontario increased approximately 5.7% in population from 2006 to 2011 or in a five-year period [Table 1]. Consequently, it appears that the number of universally funded health care providers or psychiatrists are not increasing at the same rate as the population. These findings were confirmed within the visual display of psychiatry consultations within Ontario. Figure 3 shows the reduced availability of psychiatrists within rural areas of Ontario as well as overall including the increased consultation with family doctors for mental health issues.

The second question examines the utilization rates of emergency room departments for mental illness. Six LHIN regions are available for study: Haldimand Niagara Hamilton Brant, Southwest, Erie St. Clair, Mississauga Halton, Waterloo Wellington, and Toronto Central. Their geographical areas are some of the most populous within the province. Figure 5 identifies repeated emergency department visits for mental health concerns from fiscal years 2013 to 2014 and 2014 to 2015. Individuals who visited the emergency department more than once within a 30-day period are considered repeat visitors. Table 2 identifies the increases in repeated emergency department visits. It is apparent that while psychiatrist availability is scarce, individuals are attempting to access universal mental health care via the emergency department room. Further barriers to mental health care are communication issues as well as stigma regarding mental illness [9]. The lack of available mental health care is impacting other areas in Ontario, such as encounters with police [26].

More recent data from the Canadian Institute for Health Information (CIHI) [27] using the National Ambulatory Care Reporting System found that in 2017-2018 over 320,000 Canadians visited an emergency room for a mental health concern. Furthermore, 1 in 10 of these individuals had four or more emergency room visits in a year for a mental health or addictions issue. Within the dataset, the provinces of Ontario and Alberta along with the Yukon territory had comprehensive data from their emergency rooms regarding frequent visits for mental health or addictions concerns [27]. In 2017-2018, the Yukon territory had the highest rate of 16.3%, with Alberta at 10.3%, and Ontario at 9.5% of emergency room visits per 100 people. The data also identified that two-thirds of frequent emergency room users who required support with mental health or addictions issues were hospitalized [27]. Additionally, regional data analyses have identified that an increase in emergency room visits for mental were found among a pediatric Ontario population [28]. The researchers identified trends from 2007 to 2017 where visits for mental health issues increased by 66% among pediatric patients. It is apparent that accessing universal mental health care via the emergency room has become common for both adults and children within the province of Ontario.

Additionally, given the prevalence of Ontario residents with a diagnosis of a mood or anxiety disorder, it may also be beneficial for the Ontario government to consider funding evidence-based practices for mental health in the form of psychotherapy [12,13].  Cognitive-behavioral therapy, or CBT, is one form of psychotherapy that has been shown to be effective in reducing symptoms of depression and anxiety [29]. If the Ontario government provided publicly funded psychotherapy by registered mental health professionals, it may help to address some of the increased mental health emergency room visits as identified in the LHIN statistics. Scharf & Oinonen [30] identified that benefits of publicly funded psychological care would be improving access to mental health care, providing earlier and preventative treatment to address severity of symptoms and reduce the strain on physicians and emergency care. Ideally the graphical representation of the number of repeated emergency department visits within each LHIN area will assist in diverting funds to mental health care facilities and non-profit organizations. For example, many organizations that offer mental health care and crisis services are closed after business hours or after 9 pm. This may explain the increase in repeated emergency room visits for mental health concerns.

The raw data from IDS will not be available publicly – if other researchers are interested in using the data, they are welcome to contact the IDS Operations Committee for permission and research guidelines. The ArcMap files from Statistics Canada can be obtained from their website http://www.statcan.gc.ca.

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Corresponding author: Dr. Rosina Mete, Independent Researcher and Consultant, Canada, E-mail: rmete@mail.niagara.edu

Copyright: © 2021 All copyrights are reserved by Rosina Mete, published by Coalesce Research Group. This work is licensed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.