Online First

2021 : Volume 1, Issue 1

Impact of Access to Mental Health Care in Ontario: A GIS-based Study

J Addict Psychiatry Ment Health

Article Type : Review Article

Rosina Mete1* and Yonghong Tong2

1Independent Researcher and Consultant, Canada

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

Abstract

The following article examines the state of universal mental health care within Ontario. The article provides information regarding access to universally funded mental health care, specifically family physicians and psychiatrists while examining repeated emergency room visits for the most common mental health concerns in the province, anxiety, and depression. The study utilizes statistics and geographic information system (GIS) software to visually display the geographic trends of publicly funded mental health care in Canada’s most populated province. The Canadian Community Health Survey (CCHS) of 2012 provides data regarding Ontario's population, mental health diagnoses, and access to universal mental health care via family doctors and psychiatrists. Emergency room visits for repeated mental health concerns for six Local Health Integration Networks (LHIN)s are outlined within the province. The results yielded that mental health diagnoses and access to emergency care are increasing while the rates of psychiatry availability are decreasing per population. The article provides visual representations via maps to assist with the determination of funding and program development for mental health care in Ontario. Additionally, mental health care via provincially funded psychotherapy is recommended to alleviate the burden on emergency room care.

 

Keywords: Emergency Department; Mental Illness; Ontario; Psychiatrist

Description

 

Literature Review

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.

Methodology

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.

Results

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.

 

Map number

Public Health Unit Name

Population

1

                          York Region Public Health

1,032,525

2

                           Huron Perth Health Unit

134,210

3

                           Region of Waterloo, Public Health

507,095

4

                           Southwestern Public Health

193,180

5

                           Hamilton Public Health Services

519,950

6

                           Thunder Bay District Health Unit

147,350

7

                           Peel Public Health

1,296,810

8

                           Lambton Public Health

126,200

9

                           Wellington-Dufferin-Guelph Health Unit

265,240

10

                           Brant County Health Unit

137,100

11

                           Middlesex-London Health Unit

439,150

12

                           Sudbury and District Health Unit

194,620

13

                           Haliburton, Kawartha, Pine Ridge District Health Unit

172,370

14

                           Niagara Region Public Health Department

431,345

15

                           Chatham-Kent Health Unit

104,075

16

                           Kingston, Frontenac and Lennox and Addington Health Unit

191,560

17

                           Windsor-Essex County Health Unit

388,780

18

                           Peterborough Public Health

134,935

19

                           Grey Bruce Health Unit

158,670

20

                           Eastern Ontario Health Unit

196,545

21

                           North Bay Parry Sound District Health Unit

124,790

22

                           Ottawa Public Health

883,395

23

                           Leeds, Grenville and Lanark District Health Unit

164,970

24

                           Northwestern Health Unit

74,745

25

                           Haldimand-Norfolk Health Unit

108,050

26

                           Timiskaming Health Unit

33,365

27

                           Renfrew County and District Health Unit

102,620

28

                           Toronto Public Health

2,615,060

29

                           Halton Region Health Department

501670

30

                           Hastings and Prince Edward Counties Health Unit

160190

31

                           Simcoe Muskoka District Health Unit

504110

32

                           Durham Region Health Department

608125

33

                           Porcupine Health Unit

84245

34

                           Algoma Public Health Unit

114785


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.

 


   Population

   Mood

   Anxiety

   FamDoc  

       Psychiatrist

The District of Algoma

114,785

11479

8379

58081

25023

Brant County

137,100

14944

11516

69236

41267

Durham Regional

608,125

55948

46826

350280

101557

Elgin-St. Thomas

87,460

7522

5947

50639

16530

Grey Bruce

158,670

12852

10631

84412

18564

Haldimand-Norfolk

108,050

9292

7455

70124

18260

Haliburton, Kawartha, Pine Ridge

172,370

12583

10342

110317

18099

Halton Regional

501,670

38127

28094

344647

89799

City of Hamilton

519,950

44716

35357

301051

98271

Hastings and Prince Edward Counties

160,190

18582

12014

107968

23228

Huron County

59,100

4669

3723

31796

9397

Chatham-Kent

104,075

9679

8326

53807

19878

Kingston, Frontenac, and Lennox and Addington

191,560

20114

14367

117618

43676

Lambton

126,200

12115

8077

75972

19813

Leeds, Grenville and Lanark District

164,970

13693

12703

105581

29035

Middlesex-London

439,150

40402

30301

239337

89147

Niagara Regional Area

431,345

36664

34939

282531

58232

North Bay Parry Sound District

124,790

12229

9234

58277

15724

Northwestern

74,745

4186

4335

40661

3812

City of Ottawa

883,395

82156

68021

448765

189047

Oxford County

105,720

8986

6132

64912

12686

Peel Regional

1,296,810

73918

63544

826068

294376

Perth District

75,110

6459

5107

13970

43489

Peterborough County

134,935

15248

8771

84065

21050

Porcupine County

84,245

7414

5560

46840

16681

Renfrew County

102,620

9852

6876

60648

18677

Eastern Ontario

196,545

13955

13758

115962

48350

Simcoe Muskoka

504,110

49907

39825

307507

78641

Sudbury and District

194,620

16932

17516

115994

28025

Thunder Bay District

147,350

13262

10609

78685

22545

Timiskaming

33,365

2869

2269

19318

6306

Waterloo

507,095

45131

34482

314399

76064

Wellington-Dufferin-Guelph

265,240

22545

19097

161531

55966

Windsor-Essex County

388,780

33435

21772

217717

85532

York Regional

1,032,525

58854

51626

583377

204440

City of Toronto

2,615,060

211820

146443

1320605

787133


Table 2: Diagnosis statistics for anxiety or mood disorder and consultation with a family doctor or psychiatrist for mental health concern within Ontario.


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.