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.

Ovarian cancer incidence and death in average-risk women undergoing bilateral salpingo-oophorectomy at benign hysterectomy.

BACKGROUND: Opportunistic bilateral salpingo-oophorectomy is often offered to patients undergoing benign hysterectomy to prevent ovarian cancer, but the magnitude of risk reduction obtained with bilateral salpingo-oophorectomy in this population remains unclear and must be weighed against potential risks of ovarian hormone deficiency. OBJECTIVE: This study aimed to quantify the relative and absolute risk reduction in ovarian cancer incidence and death associated with bilateral salpingo-oophorectomy at the time of benign hysterectomy. STUDY DESIGN: We performed a population-based cohort study of all adult women (≥20 years) undergoing benign hysterectomy from 1996 to 2010 in Ontario, Canada. Patients with ovarian pathology, previous breast or gynecologic cancer, or evidence of genetic susceptibility to malignancy were excluded. Inverse probability of treatment-weighted Fine-Gray subdistribution hazard models were used to quantify the effect of bilateral salpingo-oophorectomy on ovarian cancer incidence and death while accounting for competing risks and adjusting for demographic characteristics, gynecologic conditions, and comorbidities. Analyses were performed in all women and specifically in women of postmenopausal age (≥50 years) at the time of hysterectomy. RESULTS: We identified 195,282 patients (bilateral salpingo-oophorectomy, 24%; ovarian conservation, 76%) with a median age of 45 years (interquartile range, 40-51 years). Over a median follow-up of 16 years (interquartile range, 12-20 years), 548 patients developed ovarian cancer (0.3%), and 16,170 patients (8.3%) died from any cause. Bilateral salpingo-oophorectomy was associated with decreased ovarian cancer incidence (hazard ratio, 0.23; 95% confidence interval, 0.14-0.38; P<.001) and decreased ovarian cancer death (hazard ratio, 0.30; 95% confidence interval, 0.16-0.57; P<.001). At 20 years follow-up, the weighted cumulative incidences of ovarian cancer were 0.08% and 0.46% with bilateral salpingo-oophorectomy and ovarian conservation, respectively, yielding an absolute risk reduction of 0.38% (95% confidence interval, 0.32-0.45; number needed to treat, 260). After restricting to women aged ≥50 years at hysterectomy, the absolute risk reduction was 0.62% (95% confidence interval, 0.47-0.77; number needed to treat, 161). CONCLUSION: Bilateral salpingo-oophorectomy resulted in a significant absolute reduction in ovarian cancer among women undergoing benign hysterectomy. Population-average risk estimates derived in this study should be balanced against other potential implications of bilateral salpingo-oophorectomy to inform practice guidelines, patient decision-making, and surgical management.

Examining Variations in the Prevalence of Diagnosed Mood or Anxiety Disorders Among Migrant Groups in Ontario, 1995-2015: A Population-Based, Repeated Cross-Sectional Study.

BACKGROUND: International evidence on the frequency of mood or anxiety disorders among migrant groups is highly variable, as it is dependent on the time since migration and the socio-political context of the host country. Our objective was to estimate trends in the prevalence of diagnosed mood or anxiety disorders among recent (<5 years in Canada) and settled (5-10 years in Canada) migrant groups, relative to the general population of Ontario, Canada. METHODS: We used a repeated cross-sectional design consisting of four cross-sections spanning 5 years each, constructed using health administrative databases from 1995 to 2015. We included all Ontario residents between the ages of 16 and 64 years. We assessed differences in the prevalence of mood or anxiety disorders adjusting for age, sex, and neighbourhood-level income. We further evaluated the impact of migrant class and region of birth. RESULTS: The prevalence of mood or anxiety disorders was lower among recent (weighted mean = 4.10%; 95% confidence interval [CI], 3.59% to 4.60%) and settled (weighted mean = 4.77%; 95% CI, 3.94% to 5.61%) migrant groups, relative to the general population (weighted mean = 7.39%; 95% CI, 6.83% to 7.94%). Prevalence estimates varied greatly by region of birth and migrant class. We found variation in prevalence estimates over time, with refugee groups having the largest increases between 1995 and 2015. CONCLUSIONS: Our findings highlight the complexity of mood and anxiety disorders among migrant groups, and that not all groups share the same risk profile. These results can be used to help inform health service allocation and the development of supportive programs for specific migrant groups.

Health System-Level Evaluation of Tele-Mental Health Services Among Children and Adolescents in Ontario, Canada.

OBJECTIVE: To describe the characteristics of children and adolescents receiving tele-mental health services in Ontario, Canada and examine access to a psychiatrist, in-person or via tele-mental health services, following a mental health and addictions (MHA)-related emergency department (ED) visit or hospitalization. METHOD: Using linked health and administrative data, we described two cohorts: (1) children and adolescents (1-18 years) who used a provincial tele-mental health programme from January 1, 2013 to March 31, 2017, comparing their MHA-related service use (outpatient, ED, hospitalization) in the 1 year prior to and the 1 year following initial consultation; (2) children and adolescents with high mental health service needs, defined as those with an incident MHA-related ED visit or hospitalization between January 1, 2013 and December 31, 2016, examining their 1-year follow-up with telemedicine and other health care utilization. RESULTS: In the first cohort, 7,216 children and adolescents (mean age 11.8 [±3.8] years) received tele-mental health services. The proportion of MHA-related ED visits [15.1% pre vs. 12.6% post (test statistic 23.57, P < 0.001)] or hospitalizations [10.2% pre vs. 8.7% post (test statistic 11.96, P < 0.001)] declined in the year following tele-mental health consultation, while local psychiatry visits increased [8.4% pre vs. 17.0% post (test statistic 298.69, P < 0.001)]. In the second cohort (n = 84,033), only 1.5% received tele-mental health services, 40.7% saw a psychiatrist in-person, and 32.5% received no MHA-related outpatient care in follow-up. CONCLUSIONS: Tele-mental health services were rarely used in Ontario, even among high-needs children and adolescents, despite their association with increased access to care and less need for acute mental health care.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study.

BACKGROUND: There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission. METHODS: This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors. RESULTS: Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED. CONCLUSIONS: We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Practice variation in bilateral salpingo-oophorectomy at benign abdominal hysterectomy: a population-based study.

BACKGROUND: Bilateral salpingo-oophorectomy at benign hysterectomy is not recommended in premenopausal women who are in the premenopausal stage because of its potential associations with increased all-cause mortality and cardiovascular disease; however, contemporary practice patterns are unknown. OBJECTIVE: This study aimed to quantify between-surgeon variation in bilateral salpingo-oophorectomy and identify surgeon and patient characteristics associated with bilateral salpingo-oophorectomy to evaluate current quality of care and identify targets for knowledge translation and future research. STUDY DESIGN: We conducted a population-based retrospective cross-sectional study of adult women (≥20 years) undergoing benign abdominal hysterectomy from 2014 to 2018 in Ontario, Canada. Hierarchical multivariable logistic regression models, stratified by age group (<45, 45-54, ≥55 years), were used to model between-surgeon variation after multivariable adjustment for patient and surgeon characteristics. Cases of bilateral salpingo-oophorectomy were classified as potentially appropriate or potentially avoidable based on the presence or absence of diagnostic indications. RESULTS: Of 44,549 eligible women, 17,797 (39.9%) underwent concurrent bilateral salpingo-oophorectomy, and 26,752 (60.1%) did not. In all three age strata, the individual surgeon providing care was one of the strongest factors influencing whether patients received bilateral salpingo-oophorectomy (median odds ratio, 2.00-2.53). Surgeons accounted for more than 22% of the residual observed variation in bilateral salpingo-oophorectomy in women aged 45-54 years compared with 16% and 14% of the residual observed variation in bilateral salpingo-oophorectomy in women aged <45 and ≥55 years, respectively. Non-gynecologic patient factors, such as obesity (odds ratio, 1.33; 95% confidence interval, 1.17-1.52; P<.001) and residing in low-income regions (odds ratio, 1.34; 95% confidence interval, 1.16-1.55; P<.001), were also associated with bilateral salpingo-oophorectomy. Approximately 40% of patients who underwent bilateral salpingo-oophorectomy had no indication for the procedure in their discharge records. CONCLUSION: Marked between-surgeon variation in bilateral salpingo-oophorectomy rates, even after adjusting for patient case mix, suggests ongoing uncertainty in practice. Stronger evidence-based guidelines on the risks and benefits of salpingo-oophorectomy as women age are needed, particularly focusing on perimenopausal women.

Trends in objectively measured and perceived mental health and use of mental health services: a population-based study in Ontario, 2002-2014.

BACKGROUND: Mental illness is widely perceived to be more of a public health concern now than in the past; however, it is unclear whether this perception is due to an increase in the prevalence of mental illness, an increase in help-seeking behaviours or both. We examined temporal trends in use of mental health services as well as objectively measured and perceived mental health. METHODS: We conducted a repeat cross-sectional study of Ontario residents who participated in Statistics Canada's Canadian Community Health Survey (2002-2014). We assessed temporal trends in objectively measured past-year major depressive episode (based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and International Classification of Diseases, 10th Revision) and past-month psychological distress (Kessler Psychological Distress Scale-6 score ≥ 8) and perceived, self-rated mental health. We also examined use of mental health services, including service use among those with a need for mental health care. RESULTS: A total of 260 090 survey participants were included. The age- and sex-standardized prevalence of a major depressive episode (4.8%, 95% confidence interval [CI] 4.2%-5.3% in 2002 v. 4.9%, 95% CI 4.2%-5.7% in 2012; p = 0.9) and psychological distress (7.0%, 95% CI 6.3%-7.6% in 2002 v. 6.5%, 95% CI 5.7%-7.5% in 2012; p = 0.4) did not change significantly over time. However, self-rated fair or poor mental health status increased from 4.9% in 2003-2005 to 6.5% in 2011-2014 (p trend < 0.001), as did the use of mental health services (7.2% to 12.8%, p trend < 0.001). The percentage of individuals who had subjective or objectively measured mental health problems and did not access mental health services decreased significantly over time. INTERPRETATION: Given the stable prevalence of objectively measured psychiatric symptoms, the increase in use of mental health services appears to be, at least partly, explained by an increase in perceived poor mental health and help-seeking behaviours.

Health Service Use among Individuals with Depression and Psychological Distress: A Population-Based Cohort Study in Ontario, Canada: Utilisation des services de santé par les personnes souffrant de dépression et de détresse psychologique : une étude de cohorte dans la population de l'Ontario, Canada.

OBJECTIVES: Relatively little is known about how health-care utilization differs among individuals with psychological distress compared to those with major depressive disorder (MDD). METHODS: Ontario participants of the Canadian Community Health Survey Cycle 1.2 (2002) were linked to health administrative data to follow their health-care utilization patterns for up to 15 years. Based on their survey responses, we classified individuals hierarchically into Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria MDD, psychological distress (Kessler-6: 8 to 24), or an unexposed group with neither condition. We compared the rates of outpatient and acute care mental and nonmental health-related visits across the 3 groups over time using Poisson regression. RESULTS: Among the 430 individuals with MDD, 668 with psychological distress, and 9,089 in the unexposed group, individuals with MDD and psychological distress had higher rates of health-care utilization than the unexposed overall and across time. The rates of psychiatrist visits for the MDD group were significantly higher than the other groups initially but declined over the follow-up. Conversely, the rates of psychiatrist visits among the psychological distress group increased over time and converged with that of the MDD group by the end of follow-up (rate ratioMDD vs. psychological distress at 1 year: 4.20 [1.97 to 11.40]; at 15 years: 1.53 [0.54 to 4.08]). Acute care visits were similar between the MDD and psychological distress groups at all time points. CONCLUSIONS: Individuals with psychological distress required mental health care rivalling that of individuals with MDD over time, suggesting that even a cross-sectional assessment of significant psychological distress is a serious clinical concern.

Epidemiology of Interpersonal Trauma among Women and Men Psychiatric Inpatients: A Population-Based Study.

OBJECTIVE: Small clinical samples suggest that psychiatric inpatients report a lifetime history of interpersonal trauma. Since past experiences of trauma may complicate prognosis and treatment trajectories, population-level knowledge is needed about its prevalence and correlates among inpatients. METHODS: Using health-administrative databases comprising all adult psychiatric inpatients in Ontario, Canada (2009 to 2016, n = 160,436, 49% women), we identified those who reported experiencing physical, sexual, and/or emotional trauma in their lifetime, 1 year, and 30 days preceding admission. We described the prevalence of each type of trauma, comparing women and men using modified Poisson regression, and identified individual-level characteristics associated with lifetime trauma history using multivariable logistic regression. RESULTS: 31.7% of inpatients reported experiencing trauma prior to admission. Lifetime prevalence was higher in women (39.6% vs. 24.1%; age-adjusted prevalence ratio [aPR] = 1.68; 95% CI, 1.65 to 1.71), including sexual (22.7% vs. 8.4%; aPR = 2.81; 95% CI, 2.73 to 2.89), emotional (33.3% vs. 19.4%; aPR = 1.76; 95% CI, 1.72 to 1.79), and physical trauma (24.2% vs. 14.8%; aPR = 1.68; 95% CI, 1.65 to 1.72). Factors most prominently associated with lifetime trauma were witnessing parental substance use (adjusted odds ratio [aOR] = 8.68; 95% CI, 8.39 to 8.99), female sex (aOR = 2.29; 95% CI, 2.23 to 2.35), and number of recent stressful life events (aOR = 1.62; 95% CI, 1.59 to 1.65). CONCLUSIONS: These results suggest that trauma-informed approaches are essential to consider in the design and delivery of inpatient psychiatric services for both women and men.

Maternal schizophrenia and adverse birth outcomes: what mediates the risk?

PURPOSE: Maternal schizophrenia is associated with adverse birth outcomes, but the reasons for this remain unclear. In a population-based cohort of infants born to women with schizophrenia, we determined the occurrence of key perinatal outcomes and explored whether factors identifiable in our datasets explained any elevated risk. METHODS: Using population-level health administrative data linked to clinical birth-registry data in Ontario, Canada (2006-2011), we examined the relative risk (RR) of preterm birth (< 37 weeks), small for gestational age (SGA), and Apgar scores < 8 in infants of women with schizophrenia (n = 4279) versus infants of unaffected women (n = 286,147). Generalized estimating equations determined whether reproductive history, maternal health conditions, pregnancy exposures, and complications explained elevated RRs. RESULTS: Among infants of women with schizophrenia, risk was higher for prematurity (11.4% vs. 6.9%, aRR 1.64, 95% CI 1.51-1.79), SGA (3.5% vs. 2.5%, aRR 1.40, 95% CI 1.20-1.64), and Apgar score < 8 at 1 (19.0% vs. 12.8%, aRR 1.49, 95% CI 1.40-1.59) and 5 min (5.6% vs. 3.0%, aRR 1.90, 95% CI 1.68-2.16). Smoking, fourfold more common among women with schizophrenia, was the variable that explained the greatest proportion of the elevated aRR for prematurity (9.9%), SGA (28.7%), and Apgar < 8 at 1 and 5 min (9.8%, 5.6%). Illicit substance use, certain reproductive history variables, and pregnancy complications also contributed to the elevated aRR for preterm birth. CONCLUSIONS: Elevated risks of preterm birth, SGA, and low Apgar scores in infants of women with schizophrenia are partly explained by potentially modifiable factors such as smoking and illicit drug use, suggesting opportunities for targeted intervention.

Mental Health and Addictions System Performance in Ontario: An Updated Scorecard, 2009-2017.

Scorecards, particularly those that report on health system performance over time, can shed light on issues related to access and quality. In this updated 2020 Mental Health and Addictions Scorecard, we report on a number of indicators between 2009 and 2017. In general, we found that the performance of the mental health and addictions health system did not improve substantially over time. Among the many findings, over the past decade, suicide rates have not declined and rates of emergency department visits for deliberate self-harm have continued to rise. The highest rates of deliberate self-harm and the greatest rise over time in overall mental health and addictions-related outpatient visits, emergency department visits and hospitalizations were experienced by individuals aged 14-24 years. There continues to be a growing use of mental health services in outpatient settings, with the majority of care provided by primary care physicians. We also observed a slight decrease over time in the proportion of individuals who had no physician-delivered mental health care prior to presenting to the emergency department, which suggests an improvement in access over time.

Long-term mortality in mothers of infants with neonatal abstinence syndrome: A population-based parallel-cohort study in England and Ontario, Canada.

BACKGROUND: Opioid addiction is a major public health threat to healthy life expectancy; however, little is known of long-term mortality for mothers with opioid use in pregnancy. Pregnancy and delivery care are opportunities to improve access to addiction and supportive services. Treating neonatal abstinence syndrome (NAS) as a marker of opioid use during pregnancy, this study reports long-term maternal mortality among mothers with a birth affected by NAS in relation to that of mothers without a NAS-affected birth in 2 high-prevalence jurisdictions, England and Ontario, Canada. METHODS AND FINDINGS: We conducted a population-based study using linked administrative health data to develop parallel cohorts of mother-infant dyads in England and Ontario between 2002 and 2012. The study population comprised 13,577 and 4,966 mothers of infants with NAS and 4,205,675 and 929,985 control mothers in England and Ontario, respectively. Death records captured all-cause maternal mortality after delivery through March 31, 2016, and cause-specific maternal mortality to December 31, 2014. The primary exposure was a live birth of an infant with NAS, and the main outcome was all deaths among mothers following their date of delivery. We modelled the association between NAS and all-cause maternal mortality using Cox regression, and the cumulative incidence of cause-specific mortality within a competing risks framework. All-cause mortality rates, 10-year cumulative incidence risk of death, and crude and age-adjusted hazard ratios were calculated. Estimated crude 10-year mortality based on Kaplan-Meier curves in mothers of infants with NAS was 5.1% (95% CI 4.7%-5.6%) in England and 4.6% (95% CI 3.8%-5.5%) in Ontario versus 0.4% (95% CI 0.41%-0.42%) in England and 0.4% (95% CI 0.38%-0.41%) in Ontario for controls (p < 0.001 for all comparisons). Survival curves showed no clear inflection point or period of heightened risk. The crude hazard ratio for all-cause mortality was 12.1 (95% 11.1-13.2; p < 0.001) in England and 11.4 (9.7-13.4; p < 0.001) in Ontario; age adjustment did not reduce the hazard ratios. The cumulative incidence of death was higher among NAS mothers than controls for almost all causes of death. The majority of deaths were by avoidable causes, defined as those that are preventable, amenable to care, or both. Limitations included lack of direct measures of maternal opioid use, other substance misuse, and treatments or supports received. CONCLUSIONS: In this study, we found that approximately 1 in 20 mothers of infants with NAS died within 10 years of delivery in both England and Canada-a mortality risk 11-12 times higher than for control mothers. Risk of death was not limited to the early postpartum period targeted by most public health programs. Policy responses to the current opioid epidemic require effective strategies for long-term support to improve the health and welfare of opioid-using mothers and their children.

Gaps in Understanding of the Epidemiology of Mood and Anxiety Disorders among Migrant Groups in Canada: A Systematic Review.

OBJECTIVE: Estimates of mood and anxiety disorders are highly variable among migrant groups, as they are influenced by the socio-political context. Our objective was to conduct a systematic review and meta-analysis to synthesize available Canadian evidence on the prevalence and incidence of mood and anxiety disorders among migrant groups. METHODS: Studies were identified from MEDLINE, EMBASE, and PsycINFO. They were included if they used population-based samples, presented data on the incidence or prevalence of diagnosed or self-reported mood or anxiety disorders for first-generation migrant groups in Canada, and used a Canadian-born or long-term resident reference group. RESULTS: Nineteen studies met our inclusion criteria. Prevalence ratios ranged from 0.48 to 0.87, and nearly all estimates were obtained from population health surveys. Prevalence estimates among migrant groups were lower than the reference group, with the 90th percentile of estimates ranging from 1.5% to 8.2%. Risk factors for mood and anxiety disorders among migrants included being female, younger, unemployed, having lower income, and living in neighborhoods with a lower proportion of migrants. CONCLUSIONS: There remain many gaps in our current understanding of mood and anxiety disorders among migrant groups in Canada. Although evidence suggests the prevalence of mood and anxiety disorders are consistently lower among migrant groups, a lack of incidence estimates limits the strength of this conclusion. Future research should focus on comparisons of self-reported and diagnosed estimates, the use of a range of different primary or secondary data sources, and consideration of important risk factors. PROSPERO CITATION: Jordan Edwards, Malini Hu, Amardeep Thind, Saverio Stranges, Maria Chiu, Kelly Anderson. The burden of mood and anxiety disorders among immigrant and refugee populations in Canada: a systematic review. PROSPERO 2018 CRD42018087869 Available from: http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018087869 .

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.

Ethnic Differences in Mental Health Status and Service Utilization: A Population-Based Study in Ontario, Canada.

BACKGROUND: The purpose of this study was to compare the prevalence of self-reported mental health factors, mental health service use, and unmet needs across the 4 largest ethnic groups in Ontario, Canada: white, South Asian, Chinese, and black groups. METHODS: The study population was derived from the Canadian Community Health Survey, using a cross-sectional sample of 254,951 white, South Asian, Chinese, and black residents living in Ontario, Canada, between 2001 and 2014. Age- and sex-standardized prevalence estimates for mental health factors, mental health service use, and unmet needs were calculated for each of the 4 ethnic groups overall and by sociodemographic characteristics. RESULTS: We found that self-reported physician-diagnosed mood and anxiety disorders and mental health service use were generally lower among South Asian, Chinese, and black respondents compared to white respondents. Chinese individuals reported the weakest sense of belonging to their local community and the poorest self-rated mental health and were nearly as likely to report suicidal thoughts in the past year as white respondents. Among those self-reporting fair or poor mental health, less than half sought help from a mental health professional, ranging from only 19.8% in the Chinese group to 50.8% in the white group. CONCLUSIONS: The prevalence of mental health factors and mental health service use varied widely across ethnic groups. Efforts are needed to better understand and address cultural and system-level barriers surrounding high unmet needs and to identify ethnically tailored and culturally appropriate clinical supports and practices to ensure equitable and timely mental health care.

Temporal Trends in Mental Health Service Utilization across Outpatient and Acute Care Sectors: A Population-Based Study from 2006 to 2014.

OBJECTIVE: Although evidence suggests that treatment seeking for mental illness has increased over time, little is known about how the health system is meeting the increasing demand for services. We examined trends in physician-based mental health service use across multiple sectors. METHOD: In this population-based study, we used linked health-administrative databases to measure annual rates of mental health-related outpatient physician visits to family physicians and psychiatrists, emergency department visits, and hospitalizations in adults aged 16+ from 2006 to 2014. We examined absolute and relative changes in visit rates, number of patients, and frequency of visits per patient, and assessed temporal trends using linear regressions. RESULTS: Among approximately 11 million Ontario adults, age- and sex-standardized rates of mental health-related outpatient physician visits declined from 604.8 to 565.5 per 1000 population over the study period ( Ptrend = 0.04). Over time, the rate of visits to family physicians/general practitioners remained stable ( Ptrend = 0.12); the number of individuals served decreased, but the number of visits per patient increased. The rate of visits to psychiatrists declined ( Ptrend < 0.001); the number of individuals served increased, but the number of visits per patient decreased. Concurrently, visit rates to emergency departments and hospitals increased (16.1 to 19.7, Ptrend < 0.001 and 5.6 to 6.0, Ptrend = 0.01, per 1000 population, respectively). Increases in acute care service use were greatest for anxiety and addictions. CONCLUSIONS: The increasing acute care service use coupled with the reduction in outpatient visits suggest, overall, an increase in demand for mental health care that is not being met in ambulatory care settings.

Trends in standardized mortality among individuals with schizophrenia, 1993-2012: a population-based, repeated cross-sectional study.

BACKGROUND: We examined mortality time trends and premature mortality among individuals with and without schizophrenia over a 20-year period. METHODS: In this population-based, repeated cross-sectional study, we identified all individual deaths that occurred in Ontario between 1993 and 2012 in persons aged 15 and over. We plotted overall and cause-specific age- and sex-standardized mortality rates (ASMRs), stratified all-cause ASMR trends by sociodemographic characteristics, and analyzed premature mortality using years of potential life lost. Additionally, we calculated mortality rate ratios (MRRs) using negative binomial regression with adjustment for age, sex, income, rurality and year of death. RESULTS: We identified 31 349 deaths among persons with schizophrenia, and 1 589 902 deaths among those without schizophrenia. Mortality rates among people with schizophrenia were 3 times higher than among those without schizophrenia (adjusted MRR 3.12, 95% confidence interval 3.06-3.17). All-cause ASMRs in both groups declined in parallel over the study period, by about 35%, and were higher for men, for those with low income and for rural dwellers. The absolute ASMR difference also declined throughout the study period (from 16.15 to 10.49 deaths per 1000 persons). Cause-specific ASMRs were greater among those with schizophrenia, with circulatory conditions accounting for most deaths between 1993 and 2012, whereas neoplasms became the leading cause of death for those without schizophrenia after 2005. Individuals with schizophrenia also died, on average, 8 years younger than those without schizophrenia, losing more potential years of life. INTERPRETATION: Although mortality rates among people with schizophrenia have declined over the past 2 decades, specialized approaches may be required to close the persistent 3-fold relative mortality gap with the general population.

Ethnic Differences in Mental Health and Race-Based Data Collection.

There is strong evidence of ethnic disparities in chronic medical conditions, such as diabetes and cardiovascular diseases; however, less is known about ethnic differences in mental illness and health service utilization. Previous studies have shown that Asians are more likely to avoid or delay seeking help for their mental illness. We conducted a population-based study using Ontario health administrative data to examine ethnic differences in mental illness severity at hospital presentation. We found that Chinese and South Asian psychiatric patients were significantly more likely to be involuntarily admitted and exhibited more aggressive behaviours and psychotic symptoms compared to the general population. Our study highlights the need to better understand how individual, family and health-system factors contribute to the observed ethnic disparities. This paper also describes the current status of ethnicity and race-based data collection in Ontario and the benefits of routinely collecting more ethnicity data in our healthcare system to ensure equitable healthcare access and outcomes for all Ontarians.

The Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada: The CANHEART Immigrant Study.

BACKGROUND: Immigrants from ethnic minority groups represent an increasing proportion of the population in many high-income countries but little is known about the causes and amount of variation between various immigrant groups in the incidence of major cardiovascular events. METHODS AND RESULTS: We conducted the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Immigrant study, a big data initiative, linking information from Citizenship and Immigration Canada's Permanent Resident database to nine population-based health databases. A cohort of 824 662 first-generation immigrants aged 30 to 74 as of January 2002 from eight major ethnic groups and 201 countries of birth who immigrated to Ontario, Canada between 1985 and 2000 were compared to a reference group of 5.2 million long-term residents. The overall 10-year age-standardized incidence of major cardiovascular events was 30% lower among immigrants compared with long-term residents. East Asian immigrants (predominantly ethnic Chinese) had the lowest incidence overall (2.4 in males, 1.1 in females per 1000 person-years) but this increased with greater duration of stay in Canada. South Asian immigrants, including those born in Guyana had the highest event rates (8.9 in males, 3.6 in females per 1000 person-years), along with immigrants born in Iraq and Afghanistan. Adjustment for traditional risk factors reduced but did not eliminate differences in cardiovascular risk between various ethnic groups and long-term residents. CONCLUSIONS: Striking differences in the incidence of cardiovascular events exist among immigrants to Canada from different ethnic backgrounds. Traditional risk factors explain part but not all of these differences.

Mental Health Service Use Among Children and Youth in Ontario: Population-Based Trends Over Time.

OBJECTIVE: Little is known about mental health service use among Canadian children and youth. Our objective was to examine temporal trends in mental health service use across different sectors of the health care system among children and youth living in Ontario. METHODS: We conducted a population-based, repeated annual cross-sectional study of mental health service use, including mental health- and addictions-related emergency department (ED) visits, psychiatric hospitalizations, and mental health-related outpatient physician visits using linked health administrative databases. Subjects included Ontario residents between 10 and 24 years of age. We tested temporal trends between 2006 and 2011 using linear regression models. RESULTS: Between 2006 and 2011, the relative increase in rates of mental health-related ED visits and hospitalizations were 32.5% and 53.7%, respectively. The absolute increase in anxiety disorders, the most common reason for ED visits, was 2.2 per 1000 population (P < 0.001) while mood and affective disorders, the most common reason for hospitalizations, showed an increase of 0.6 per 1000 population (P < 0.01). The overall relative increase in rates of outpatient visits was 15.8%, with the largest absolute increase found among family physician visits (28.7 per 1000 population, P = 0.01). CONCLUSIONS: Mental health care use for children and youth is increasing over time in all sectors, but appears to be increasing at a greater rate in the acute care sector. Further research is required to understand whether the observed differences reflect difficulty with access to outpatient care.