Paul Kurdyak MD PhD

1. Burden, Access, and Unmet Need: the mental health service landscape in OntarioAssociation of General Hospital Psychiatric Services Paul Kurdyak MD PhD

2. Disclosures • Salary Support from: • ICES • CIHR

3. Overview The burden of mental illness and addictions Medical Comorbidity Access to psychiatrists Increasing help-seeking behaviour – a CAMH natural experiment

4. Opening Eyes, Opening Minds: The Ontario Burden of Mental Illness and Addictions Report

5. Burden of Mental Illness and Addictions in Ontario • A collaboration between PHO and ICES • Involved CAMH scientists • Important because: • Sets a baseline for evaluating future public health or population-based interventions • Has fostered relationships between mental health and public health

6. Unit of Measurement: HALY HALY: Health-Adjusted Life Years HALY = YLL + YERF YLL: Years of life lost due to premature mortality YERF: Equivalent years of healthy life lost due to disease/disability

7. Disease Categories • Mental Health Conditions • Agoraphobia • Bipolar disorder • Major depression • Panic disorder • Schizophrenia • Social phobia • Addictions • Alcohol use disorders • Cocaine use disorders • Prescription opioid misuse

8. HALYs by Mental Health Condition/ Addiction

9. YLLs by Mental Health Condition/ Addiction YLL by Mental Health Condition/ Addiction

10. YERFs by Mental Health Condition/ Addiction YERF by Mental Health Condition/ Addiction

11. HALYs by Age Group

12. Comparison to Other BoD Studies MI&A Cancers Infectious Diseases

13. Overview The burden of mental illness and addictions Medical Comorbidity Access to psychiatrists Increasing help-seeking behaviour – a CAMH natural experiment

14. Mortality Burden Dramatically Under-estimated Cause of death is disease-specific. No one dies from schizophrenia Premature mortality in schizophrenia mostly due to cardiovascular disease and risk factors Access to medical care is very poor

15. All Cause Mortality: SCZ and BPD (2006-2010)

16. Schizophrenia Outcomes Following AMI 89,825 AMI Subjects 1087 Allocated to Schizophrenia 88,738 Allocated to No Schizophrenia Excluded: 8 – Missing Data 81 – Not Incident AMI 156 – Death before Discharge Excluded: 394 – Missing Data 7628 – Not Incident AMI 9890 – Death before Discharge 842 with Schizophrenia 70,826 without Schizophrenia Mortality Outcome Excluded: 33 – Death within 30 days of discharge Excluded: 1724 - Death within 30 days of discharge 809 with Schizophrenia Process of Care Outcome 69,102 without Schizophrenia

17. Mortality Adjusted Unadjusted AOR 1.56, 95% CI 1.08-2.23; p=0.02

18. Cardiac Procedures Unadjusted Adjusted AOR 0.48, 95% CI 0.40-0.56; p<0.001

19. Cardiologist Visits Unadjusted Adjusted AOR 0.53, 95% CI 0.43-0.65; p<0.001

20. Overview The burden of mental illness and addictions Medical Comorbidity Access to psychiatrists Increasing help-seeking behaviour – a CAMH natural experiment

21. Ability to Access Psychiatrists Primary care physician surveys from multiple jurisdictions - psychiatrists most difficult specialists to access NPS survey 2007 - from 2004 to 2007, ability to accept urgent referral (< 1 week) increased from 44% to 49% Other specialties increased from 60% (2004) to 80% (2007) 2010 survey – 35% primary care physicans rated access to psychiatrists as poor (vs. 4% of GIM and 2% for pediatricians)

22. 297 Psychiatrists 230 Contacted 160 Unavailable (70%)

23. 297 Psychiatrists 230 Contacted 160 Unavailable (70%) 64 (27%) Need to review referral information and no wait-time estimate

24. 297 Psychiatrists 230 Contacted 160 Unavailable (70%) 64 (27%) Need to review referral information and no wait-time estimate 6 (3%) offered immediate appointments (wait times 4-55 days)

25. Ontario Psychiatrist Supply Toronto and Ottawa have 2-4 times more psychiatrists per capita than other regions in Ontario.

26. What Are Psychiatrists Doing? There are large differences between psychiatrist supply across different regions Toronto and Ottawa have large supplies per capita The rest of the province hovers around 10 psychiatrists/100,000 If there are so many psychiatrists (and so many more in Toronto and Ottawa), why are they the most difficult to access?

27. Mean # Unique Patients and # New Patients per Year Low supply area psychiatrists see twice as many patients and twice as many new patients/year

28. Psychiatrists vs Patients in Toronto25% of psychiatrists see 6% of outpatients

29. Patient Income Across Visit Categories - Toronto Almost half of patients seen >16 times/year are in the top income quintile

30. Summary Psychiatrists in high supply areas see fewer patients, fewer new patients and see these fewer patients more frequently and for longer per visit In high supply areas, as visit frequency increases, patient SES increases The increased psychiatrist supply does not translate into better follow-up post-hospitalization Access to psychiatrists does not improve with increased per capita supply

31. Follow-up 30 days Post-Hospitalization

32. Readmission 31-60 days Post-Hospitalization

33. Summary The burden of mental illness and addictions Medical Comorbidity Access to psychiatrists Increasing help-seeking behaviour – a CAMH natural experiment

34. Mental Illness and Addiction Treatment Rates Two thirds of people with depression do not seek help Up to 90% of people with addictions do not seek treatment Very little evidence on increasing treatment-seeking behaviours to address burden of mental illness and addiction

35. The CAMH Campaign

36. A Natural Experiment The campaign is the only intervention that occurred in March 2010 (nothing else changed that could explain changes in visit volumes) Permits an evaluation of the campaign using quasi-experimental methods ED volumes AND Gen Psych. Assessment Clinic volumes – direct-to-consumer marketing vs. service provider marketing

37. Methods All patients who presented to the ED (N=29,069) and the Gen Psych. Assessment Clinic (N=8326) from April 1, 2006 to December 31, 2011. Grouped monthly Pre-campaign – April 1, 2006 to March 31, 2010 Post-campaign – April 1, 2010 to December 31, 2011 Also used regional-level data for system-level analyses (preliminary)

38. Statistical Analysis Time series analysis methods used to model the data series and test for an effect of the campaign. Geographic Information Systems (GIS) using patient postal code for mapping patient distance from ED.

39. ED Volumes

40. General Psychiatry Assessment Clinic Volumes

41. ED Volumes: % new to CAMH and Region

42. Pre-Campaign Map

43. Post-Campaign Map

44. Maps Side by Side

45. Limitations • Just starting system context • Don’t know if we are duplicating services • Preliminarily – campaign increased volume in all categories: previous CAMH ED visit, new to CAMH, and new to region

46. Main Findings Addressing stigma increases help-seeking and referral behaviour Can have a significant impact on volumes Low treatment rates can be addressed using marketing strategies addressing stigma AND highlighting service availability

47. Summary Huge burden of mental illness and addictions in Ontario High supply of psychiatrists in Toronto and incentivization are perpetuating poor access in the face of very high psychiatrist supply Access to care at high times of need (post-hospitalization) is poor CAMH campaign suggests there is a large unmet need “market” that is currently not being served