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CAPE Special Issue
Service Use for Mental Health Reasons:
Cross-Provincial Differences in Rates, Determinants,
and Equity of Access
Helen-Maria Vasiliadis, PhD
1
, Alain Lesage, MD
2
, Carol Adair, PhD
3
, Richard Boyer, PhD
4
614
W Can J Psychiatry, Vol 50, No 10, September 2005
Objectives: In 2002, Canada undertook its first national survey on mental health and well-being, including
detailed questioning on service use. Mental disorders may affect more than 1 person in 5, according to past
regional and less comprehensive mental health surveys in Canada, and most do not seek help. Individual
determinants play a role in health resource use for mental health (MH) reasons. This study aimed to provide
prevalence rates of health care service use for MH reasons by province and according to service type and to
examine determinants of MH service use in Canada and across provinces.
Methods: We assessed the prevalence rate (95% confidence interval [CI]) of past-year health service use for
MH reasons, and we assessed potential determinants cross-sectionally, using data collected from the Statistics
Canada Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). We estimated models
of resource use with logistic regression (using odds ratios and 95%CIs).
Results: The prevalence of health service use for MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%).
The highest rates, on average, were observed in Nova Scotia (11.3%; 95%CI, 9.6% to 13.0%) and British
Columbia (11.3%; 95%CI, 10.1% to 12.6%). The lowest rates were observed in Newfoundland and Labrador
(6.7%; 95%CI, 5.3% to 8.0%) and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%). In Canada, the general
medical system was the most used for MH reasons (5.4%; 95%CI, 5.1% to 5.8%) and the voluntary network
sector was the least used (1.9%; 95%CI, 1.7% to 2.1%). No difference was observed in the rate of service use
between specialty MH (3.5%; 95%CI, 3.2% to 3.8%) and other professional providers (4.0%; 95%CI, 3.7% to
4.3%). In multivariate analyses, after adjusting for age and sex, the presence of a mental disorder was a
consistent predictor of health service use for MH across the provinces.
Conclusions: There is up to a twofold difference in the type of service used for MH reasons across provinces.
The primary care general medical system is the most widely used service for MH. Need remains the strongest
predictor of use, especially when a mental disorder is present. Barriers to access, such as income, were not
identified in all provinces. Different sociodemographic variables played a role in service seeking within each
province. This suggests different attitudes toward common mental disorders and toward care seeking among the
provinces.
(Can J Psychiatry 2005;50:614–619)
Information on funding and support and author affililations appears at the end of the article.
Clinical Implications
·
Need is the strongest predictor of help seeking for MH reasons.
·
Different sociodemographic determinants seem to play a role in health service use among the provinces.
Limitations
·
The cross-sectional study design precludes examination of whether needs were met.
·
The lifetime trajectory of service use and the sequence of shared mental health care cannot be established.
·
We did not assess the perceived need for individual care in terms of preferred types of interventions or expert
assessment of need for care and services in this large community survey.
Key Words: mental health, service use
M
any surveys in North America and Europe have indi
-
cated that mental disorders affect nearly 1 person in 5
each year (1–3) and that most (60% to 75%) do not seek
help (1–5). In the absence of an expert assessment of the
patient’s evaluated need for care, the presence of a disorder
cannot automaticallybe equated with a need for care (6). It has
been recommended that need should be defined by dimen
-
sions of distress and dysfunction, as well as by the perception
of need (3). Service use however is not determined only by
need. In addition to acceptability issues (for example, attitude
toward illness or toward the health care system), the most fre
-
quent reason given by affected individuals for not consulting
(72%) or for treatment dropout (58%) is the belief that the dis
-
order will go away by itself or that they can manage on their
own (2). Of those not seeking help, 45% reported that they
thought consulting would not help (2). Predisposing variables
such as age (7–12), sex (1,4,10,11,13–15), marital sta
-
tus (10,11,16–21), and education (22,23) but also enabling or
barrier factors such as income (24), rural vs urban location
(2,25,26), and social support (27–30) have also been shown to
play a role in help-seeking in many studies. In one Canadian
regional study, need was the strongest predictor (18), with sex
and perceived MH as significant, although less strong,
predictors.
One-year rates of service use for MH reasons have been
reported worldwide (1,5,10,31–36). The only Canadian stud
-
ies available to date have reported rates in the order of 12.7%
in the 1980s in Edmonton (37), 8.6% in 1990 in Ontario (1),
and up to 14.5% in the east end of Montreal (14). In the US, the
5-site ECA Study reported a 14.7% rate of service use (4). A
more recent Montreal survey reported various 1-year preva
-
lence rates of use for GPs (7%), psychologists (5%), and psy
-
chiatrists (2.7%) (38). Service use estimates are not entirely
comparable across these previous Canadian studies because
of differences in populations, time frames, questionnaire
items, and data collection methods. The CCHS 1.2 provided,
for the first time, an opportunity to examine variation in ser
-
vice use for MH concerns from data that were collected con
-
sistently across all provinces.
The objectives of this brief report are, first, to provide the
national and provincial prevalence rates of service use for MH
reasons by type of service and, second, to examine individual-
level determinants of MH service use in Canada and across the
provinces.
Methods
Data
We analyzed cross-sectional data on health care resource use
for MH reasons and potential determinants of MH service use,
as collected by Statistics Canada in the CCHS 1.2. The study
population comprised people aged 15 years and over living in
private occupied dwellings in the 10 provinces (n = 36 984
respondents). More details on content and survey methods are
presented in the methods paper of this issue (39) and
elsewhere (40).
Dependent Outcome: Past-Year Health Care Service Use
For MH Reasons
The dependent variable of interest in our study was service use
for MH reasons in the past 12 months in Canada and by prov
-
ince. We also collected information on the type of profes
-
sional service used.
Health service use in the past 12 months for MH reasons was
grouped according to the following classifications, as previ
-
ously reported (4,14): 1) specialty MH services (a psychiatrist
or psychologist); 2) general medical system (GP or family
doctor) or other medical specialist; 3) other professional
(nurse, social worker, religious advisor, or other); and 4) vol
-
untary support network (internet support group or chat room,
self-help group, or telephone help-line).
Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access
Can J Psychiatry, Vol 50, No 10, September 2005 W 615
Abbreviations used in this article
AD anxiety disorder
ADD addictions
BAR barriers to service use
CC chronic condition
CIHR Canadian Institutes of Health Research
CCHS 1.2 Canadian Community Health Survey: Mental
Health and Well-Being
CI confidence interval
COB country of birth
DIS distress
DSB disability
ECA Epidemiologic Catchment Area
EDU education
GP general practitioner
INT interference
LNG language spoken
MD mood disorder
MH mental health
MS marital status
OR odds ratio
REV household income
SRH self-rated health
SUI suicidal ideation
SUPP support
U unmet mental health need
Independent Variables
We examined individual determinants of resource use for MH
reasons from all the variables collected in the CCHS 1.2 in
Canada and in each province, using Andersen’s classic model
of predisposing, enabling, and need factors (41). Predisposing
variables included age, sex, marital status, education,
language, country of birth, and cultural or ethnic origin.
Enabling or impeding factors studied included urban or rural
area of residence, tangible social support, affection, positive
social interaction, emotional or informational support, per
-
ceived unmet MH need, and accessibility, acceptability, and
availability barriers (summarized as barriers) to resource use.
Need factors included standardized interview questions
designed to detect, with high probability, the presence of a
mental disorder (40), including depression, mania, panic dis
-
order, panic attack, agoraphobia, and social phobia, or an eat
-
ing disorder and included questions about the extent to which
the mental disorder caused interference with life, as well as
suicidal thoughts and chronic medical conditions. Other need
factors studied were distress, self-perceived stress, ability to
handle unexpected problems, and ability to handle day-to-day
demands (summarized as distress). We studied psychological
well-being, self-rated health, life satisfaction, and self-rated
physical and mental health (summarized as self-rated health).
We also examined the presence of a problem with gambling,
alcohol, or illicit drug dependency (summarized as addiction)
and whether addictions (alcohol or illicit drugs) caused inter
-
ference with life. We considered variables reporting on the
impact of health problems on participation and activity
limitation and whether the respondent needed help for a series
of tasks or had difficulty with social situations (summarized as
disability).
Statistical Modelling
We used logistic regression to model overall service use as a
function of individual determinants in Canada and by prov-
ince.We did not observe multicollinearity among the vari
-
ables. We chose final predictive logistic regression models,
using a stepwise selection approach with a 0.10 level of signif
-
icance to enter the model and a 0.05 significance level to stay
in the model. We also included age and sex in the final models.
We obtained estimates (95%CI) from the BOOTVAR pro
-
gram developed by Statistics Canada (42).
Results
Lifetime and Past-Year Prevalence of Mental Disorders
The prevalence rates of ever having a specified mental dis
-
order and of having the disorder in the past year were 7.3%
(95%CI, 6.9% to 7.7%) and 4.8% (95%CI, 4.4% to 5.1%) for
depression, 1.4% (95%CI, 1.2% to 1.6%) and 1.0% (95%CI,
0.8% to 1.1%) for mania, 2.1% (95%CI, 1.9% to 2.3%) and
1.5% (95%CI, 1.3% to 1.7%) for panic disorder, 12.0%
(95%CI, 11.5% to 12.5%) and 7.8% (95%CI, 7.4% to 8.2%)
for panic attacks, 4.7% (95%CI, 4.4% to 5.0%) and 3.0%
(95%CI, 2.7% to 3.2%) for social phobia, and 0.7% (95%CI,
0.6% to 0.8%) and 0.7% (95%CI, 0.6% to 0.9%) for agora
-
phobia, respectively.
616
W Can J Psychiatry, Vol 50, No 10, September 2005
The Canadian Journal of Psychiatry—CAPE Special Issue
Table 1 Past-year prevalence by type of service used for MH reasons
Region Any type of service use Specialty MH General medical Other professional Voluntary network
% (95%CI) % (95%CI) % (95%CI) % (95%CI) % (95%CI)
Canada 9.5 (9.1–10.0) 3.5 (3.2–3.8) 5.4 (5.1–5.8) 4.0 (3.7–4.3) 1.9 (1.7–2.1)
NL 6.7 (5.3–8.0) 1.8 (1.0–2.5) 4.8 (3.5–6.0) 2.8 (1.7–3.8) 0.8 (0.3–1.3)
PEl 7.5 (5.8–9.3) 1.7 (0.9–2.6) 3.1 (2.1–4.1) 3.3 (2.2–4.5) 3.2 (1.9–4.4)
NS 11.3 (9.6–13.0) 3.8 (2.8–4.9) 7.6 (6.4–8.9) 3.4 (2.7–4.2) 1.7 (1.1–2.4)
NB 9.5 (7.9–11.0) 3.9 (3.0–4.8) 5.2 (4.0–6.5) 2.8 (2.0–3.6) 1.3 (0.7–1.8)
Que 9.6 (8.4–10.7) 4.6 (3.9–5.3) 4.9 (4.2–5.7) 3.7 (2.8–4.5) 1.6 (1.2 –2.1)
Ont 8.7 (8.1–9.4) 3.1 (2.7–3.5) 5.4 (4.9–5.9) 3.7 (3.3–4.1) 1.6 (1.4 –1.9)
Man 10.5 (8.8–12.2) 3.4 (2.3–4.5) 5.3 (4.0–6.6) 4.7 (3.6–5.9) 2.3 (1.4–3.1)
Sask 9.8 (8.3–11.3) 2.5 (1.7–3.4) 4.5 (3.5–5.5) 5.0 (3.8–6.1) 2.9 (1.9 –3.9)
Alta 9.7 (8.4–11.1) 3.4 (2.6–4.3) 5.1 (4.1–6.1) 3.8 (3.1–4.5) 2.9 (2.1–3.6)
BC 11.3 (10.1–12.6) 3.3 (2.6–4.0) 6.6 (5.6–7.6) 5.7 (4.8–6.6) 2.5 (1.9–3.0
Prevalence rates (95%CI) are weighted and bootstrapped
Past-Year Prevalence of Service Use for MH Reasons
The past-year prevalence rate of any type of resource use for
MH reasons in Canada was 9.5% (95%CI, 9.1% to 10.0%),
and our data suggest differences among some of the provinces
(Table 1). Differences were observed wherein Nova Scotia
(11.3%; 95%CI, 9.6% to 13.0%) and British Columbia
(11.3%; 95%CI, 10.1% to 12.6%) had the higher rates and
Newfoundland and Labrador (6.7%; 95%CI, 5.3% to 8.0%)
and Prince Edward Island (7.5%; 95%CI, 5.8% to 9.3%) had
the lower rates. In Canada, the general medical system was the
most used for MH reasons, and the voluntary network sector
was the least used (Table 1). No difference in use was
observed between the specialty MH and other professional
services (Table 1). Shared care in Canada, indicated by use of
an MH specialist or other professional in addition to a general
medical provider, represented 31% of those reporting the use
of the general medical system. In turn, use of only the general
medical system for MH reasons accounted for 27%, and any
type of provider except the general medical system accounted
for 42%.
Determinants of Service Use for MH Reasons (Table 2)
Among the variables examined in the multivariate analysis,
the following were consistent predictors of health service use
in Canada after controlling for age, marital status, education,
country of birth, language spoken, social support, barriers in
accessing health services, distress, medical chronic condi
-
tions, and physical disability: female sex (OR 1.65; 95%CI,
1.46 to 1.87), self-rated MH (5 levels rated from poor to excel
-
lent, OR 0.63; 95%CI, 0.57 to 0.68), and the presence of a
mental disorder such as depression (past OR 1.80; 95%CI,
1.50 to 2.16; present OR 4.23; 95%CI, 3.39 to 5.27), mania
(past OR 1.81; 95%CI, 1.22 to 2.68; present OR 1.29; 95%CI,
0.82 to 2.032), panic attack (past OR 1.14; 95%CI, 0.96 to
1.35; present OR 2.02; 95%CI, 1.64 to 2.48), and panic dis-
order (past OR 2.21; 95%CI, 1.60 to 3.03; present OR 1.78;
95%CI, 1.22 to 2.60) compared with mental disorder never
diagnosed as well as past-year suicidal ideation (OR 1.52;
95%CI, 1.14 to 2.02). Most people in Canada with a mental
disorder or illicit drug dependence did not consult health
resources for MH reasons in the past year. In our study, only
33.7% of respondents with presence of lifetime depression
reported past-year use. The corresponding percentages were
42.3% for mania, 21.9% for panic attacks, 38.0% for panic
disorder, 28.6% for social phobia, and 28.8% for agorapho
-
bia. Of the people with suicidal ideation and drug dependency
within the past year, only 44.1% and 37.3% consulted a
Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access
Can J Psychiatry, Vol 50, No 10, September 2005 W 617
Table 2 Summary determinants of type of health care services used for MH reasons across Canada
Region Important determinants of any type of services used
Predisposing factors Enabling factors Need factors
Age Sex MS EDU COB Race LNG SUPP BAR U SRH DIS CC MD AD SUI ADD INT DSB
Canada
Ö
Ö Ö Ö Ö
Ö ÖÖÖÖÖÖÖ
*
ÖÖ Ö
NL Ö* Ö*
ÖÖÖ Ö
PEI Ö* Ö*
NS Ö* Ö
ÖÖÖ Ö
*
NB Ö Ö
ÖÖ Ö
*
Que Ö* ÖÖÖ Ö
ÖÖ ÖÖÖ Ö
Ont Ö ÖÖÖÖ
ÖÖÖÖ Ö
Man Ö Ö*
ÖÖÖ
*
Sask Ö Ö*
ÖÖÖ Ö
*
Alta Ö* Ö
ÖÖÖ Ö
BC Ö* Ö ÖÖ
ÖÖÖÖÖÖ
Ö*: Not significant after adjusting for all other variables in the model. MD includes depression and mania; AD includes agoraphobia, social phobia, panic
attack, panic disorder, and eating disorder.
Household income and urban or rural variables are not presented, since they were not significant.
service, respectively. Further, of those for whom alcohol or
illicit drug dependency caused interference with daily life,
only 26.4% and 26.7%, respectively consulted a service.
Discussion
In this study, the general medical system was the most widely
consulted service for MH reasons in Canada, as reported in
previous Canadian studies and in other countries
(4,10,18,36,37). In Canada, 5.4% of respondents used the
general medical system, and this did not differ significantly
among the provinces, with the exception of Prince Edward
Island having a lower rate, compared with Nova Scotia, Que
-
bec, Ontario, and British Columbia. The next most frequently
sought service in Canada was, on average, other professionals
(4.0%), except for Nova Scotia, New Brunswick, and Quebec,
where the specialty MH services (3.5%) were sought next.
Finally, in Canada, the voluntary support network was the
least used system, with 1.9% of respondents.
Our multivariate models of service use showed that, among
the variables studied, need was an important driver of
resource use, as expected (41). Apart from the presence of a
mental disorder, self-rated and perceived health was a signifi
-
cant predictor of service use in all provinces (41).
Among the predisposing factors, sex, marital status,
education, country of birth, and ethnicity (only for Quebec)
were significant factors. Similar to previous reports, girls and
women and single and divorced people were more likely to
use a health service for MH reasons (18,43). People with
lower educational levels (less than high school) were less
likely to use a service, as were people born outside Canada. It
has been reported elsewhere that differences in perceived
acceptability of using health services for MH reasons by eth-
nic group may explain service use differences (18). In our
study, however, ethnic status remained a significant predictor
even after adjusting for acceptability (for example, people
who prefer to manage on their own, who do not think MH ser
-
vices will help, or who have language problems). Our findings
suggest that a more specific issue, such as the level of aware
-
ness of MH issues and available resources, may play a role in
these groups. With respect to enabling factors, in Canada and
among the provinces, household income did not appear to
influence health service use.
Our results underlie the need for further study of individual
determinants that may explain differences in the type of
resource preferred and used for MH reasons across provinces.
Overall, however, at a time when Canadian planners are pay
-
ing greater attention to moderate mental disorders and to
increasing consultations for MH reasons (44), consistent with
other countries, most people with an MH condition do not
consult. Further, if they do consult, need is the most important
predictor of use. This suggests that access to health care ser
-
vices for MH reasons by individuals is relatively equitable
across provinces.
Funding and Support
This paper was supported by a CIHR grant to the authors and the
following investigators: Rebecca Fuhrer, Paula Goering, Elliot
Goldner, Nick Kates, Elisabeth Lin, Anne Rhodes, Renee
Robinson, and Raymond Tempier.
Acknowledgements
The research and analysis are based on data from Statistics
Canada, and the opinions expressed do not represent the views of
Statistics Canada. Dr Vasiliadis is a CIHR Strategic Training
Fellow.
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Manuscript received and accepted May 2005.
1
Postdoctoral Fellow, Department of Psychiatry, Université de Montréal,
Montreal, Quebec; Postdoctoral Fellow, Centre de Recherche
Fernand-Seguin, Hôpital Louis-H Lafontaine, Montreal, Quebec.
2
Professor, Department of Psychiatry, Université de Montréal, Montreal,
Quebec; Researcher, Centre de Recherche Fernand-Seguin, Hôpital
Louis-H Lafontaine, Montreal, Quebec.
3
Associate Professor, Departments of Psychiatry and Community Health
Sciences, University of Calgary, Calgary, Alberta.
4
Associate Professor, Department of Psychiatry, Université de Montréal,
Montreal, Quebec; Head of Social Psychiatry Unit, Centre de Recherche
Fernand-Seguin, Hôpital Louis-H Lafontaine, Montreal, Quebec.
Address for correspondence: DR H-M Vasiliadis, Unité 218, Pav Bédard,
Hôpital Louis-H Lafontaine, 7401 rue Hochelaga, Montreal QC H1N 3V2
e-mail: helen.vasiliadis@mail.mcgill.ca or
hvasiliadis.hlhl@ssss.gouv.qc.ca
Service Use for Mental Health Reasons: Cross-Provincial Differences in Rates, Determinants, and Equity of Access
Can J Psychiatry, Vol 50, No 10, September 2005 W 619
Résumé : L’utilisation des services pour des raisons de santé mentale :
les différences interprovinciales de taux, de déterminants et d’équité d’accès
Objectifs : En 2002, le Canada a entrepris sa première enquête nationale sur la santé mentale et le bien-être, qui comprenait des
questions détaillées sur l’utilisation des services. Les troubles mentaux peuvent affecter plus d’une personne sur 5, selon de précédentes
enquêtes régionales moins complètes sur la santé mentale au Canada, et la plupart ne recherchent pas d’aide. Les déterminants
individuels jouent un rôle dans l’utilisation des ressources de santé pour des raisons de santé mentale (SM). Trouver les taux de
prévalence de l’utilisation des services de santé pour des raisons de SM par province et selon le type de service, et examiner les
déterminants de l’utilisation des services de SM au Canada et dans les provinces.
Méthodes : Nous avons évalué le taux de prévalence (intervalle de confiance [IC] de 95 %) de l’utilisation des services pour des
raisons de SM dans l’année écoulée, et nous avons évalué les déterminants potentiels de façon transversale, à l ’aide des données
recueillies dans le volet Santé mentale et bien-être de l’Enquête sur la santé dans les collectivités canadiennes (ESCC, Cycle 1.2). Nous
avons estimé les modèles d’utilisation des ressources au moyen de la régression logistique (à l’aide de risques relatifs et d’IC de 95 %).
Résultats : La prévalence de l’utilisation des services pour des raisons de SM au Canada était de 9,5 % (IC 95 %, de 9,1 % à 10,0%).
Les taux les plus élevés, en moyenne, ont été observés en Nouvelle-Écosse à 11,3 %, (IC 95 %, de 9,6 % à 13,0%) et en
Colombie-Britannique, à 11,3 % (IC 95 %, de 10,1 % à 12,6 %), et les taux les plus faibles, à Terre-Neuve et au Labrador, à 6,7 %
(IC 95 %, de 5,3 % à 8,0 %) et à l’Île-du-Prince-Édouard, à 7,5 % (IC 95 %, de 5,8 % à 9,3 %). Au Canada, le système médical général
était le plus utilisé pour des raisons de SM, à 5,4 % (IC 95 %, de 5,1 % à 5,8 %), et le secteur des réseaux bénévoles était le moins
utilisé, à 1,9 % (IC 95 %, de 1,7 % à 2,1 %). Aucune différence n’a été observée dans le taux d’utilisation des services entre les
spécialistes de la SM (3,5 %, IC 95 %, de 3,2 % à 3,8 %) et d’autres fournisseurs professionnels (4,0 %, IC 95 %, de 3,7 % à 4,3 %).
Dans les analyses multivariées, après rajustement selon l’âge et le sexe, la présence d’un trouble mental était un prédicteur constant
d’utilisation des services de santé pour des raisons de SM dans toutes les provinces.
Conclusion : Il y a presque une double différence dans le type de service utilisé pour des raisons de SM dans les provinces. Le système
médical général des soins primaires est le service le plus largement utilisé pour la SM. Le besoin demeure le prédicteur le plus fort de
l’utilisation, en particulier la présence d’un trouble mental. Les obstacles à l’accès, comme le revenu, n’ont pas été identifiés dans
toutes les provinces. Différentes variables sociodémographiques ont joué un rôle dans le recours aux services, dans chaque province, ce
qui suggère différentes attitudes à l’endroit des troubles mentaux fréquents et du recours aux soins parmi les provinces.
