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Are Mental Health Services for Children Distributed According to Needs?
Discussion
The rates of mental disorders among children found in this study are similar to those found in other studies (13). An interesting finding is that, while the prevalence of problems is higher in the youngest group, the perception of need for help by parents is highest in the oldest group. Possibly, parents do not recognize some behaviours in their young children as problems that require help, whereas problems at a later age may be more obvious and therefore taken more seriously.
Although the rates of mental problems did not significantly differ across regions, the level of resources both within and outside the school system and the rates of services provided varied considerably. Similar results were obtained in Ontario (4). Within the school system, no single region appears to have more resources across all professions. In the community at large, however, the Montreal metropolitan area has more health professionals than do other regions. The lack of psychiatrists outside Montreal has long been noted and again recently emphasized (22). Similarly, the rates of physician services are higher for all age groups in the metropolitan region. The highest rates of hospitalization in other regions may reflect the fact that, in these regions, there are fewer physicians to follow patients in the community. A much higher availability of mental health resources for adolescents and adults in urban areas, compared with less populated areas, was also noticed in Ontario (9).The concentration of highly specialized resources in urban areas partly explains the variation.
In 1989, the Quebec Ministry of Health and Social Services had already acknowledged the inequitable distribution of resources across regions for mental health problems. When the Ministry proposed a new mental health policy, it intended to ensure that a broad range of services would become available in each region (23). In particular, formal links would be established with the Ministry of Education to meet the needs of school children. This study showed that, in 1992–1993, the situation remained unchanged, but 5 years later (1997–1998), the situation became worse. Although the mental health policy should have had time to take effect, the discrepancies among regions were just as large. In its assessment of the mental health policy implementation, the Quebec Ministry of Health and Social Services acknowledged that mental health services for youths remained deficient and fragmented (24). Its most recent action plan stressed that equitable access to mental health services for children aged 0 to 17 years should be given high priority (25).
That the level of resources varies across regions does not indicate whether some regions have too many resources or whether others have too few—either or both could be true. However, it is most likely that resources are not distributed according to needs. Future planning of mental health resources should be based more closely on thorough assessment of children’s needs. Along with using the kind of data presented here, it would be useful to assess unmet needs by measuring the extent to which people who needed help could not get it or had to wait a long time.
This study has several limitations. First, the various and multiple manifestations of mental health problems made it impossible to precisely measure the resources available to treat them. For example, within the school system, professionals and nonprofessionals—other than the ones usually identified as “mental resources”—could develop significant relationships with children and provide help (for example, religious counsellors and guidance counsellors). Second, for professionals in the community, it was impossible to assess the FTE resources that were specifically available for children; many professionals also work with youths and adults. The data, which came from different professional colleges, did not contain this level of detail during the study periods. Possibly, school and community resources somewhat compensate for the lack of professional resources and services that are observed in some regions. Yet, given the large variations across regions, it is unlikely that those other resources can by themselves fill the gap in services that children need. Third, to produce more reliable indicators, the original health regions were grouped into 4 large regions, thus hiding the specific level of needs in each health region. Using the original health regions as a unit of analysis could have revealed even more discrepancies in the level of resources. Fourth, the study findings cannot be generalized to the province’s 7 smallest health regions that were excluded, owing to small numbers or lack of data. Even so, the overall findings remain valid: they are based on more than 90% of the province’s population. Fifth, needs were assessed only for the first study period, thus hindering the generalizability of the findings to the second study period. It would be useful to repeat the initial survey to check the evolution of children’s needs. Overcoming these limitations in future studies would help provide a more precise answer to the question of whether mental health resources and services are distributed according to needs.
Conclusion
Using data from within the school system and from the community, this study showed that, despite the existence of universal health care in the province of Quebec and a government mental health policy stressing equity of access, mental health resources available for children aged 6 to 14 years varied greatly across regions, while needs did not vary significantly. Data on a second period indicated that the discrepancies in resources between regions had not decreased 5 years later. These results suggest that more evidence-based planning is required, specifically using epidemiologic survey data, to distribute professional resources and services according to children’s mental health needs. Most important, monitoring the situation over time ensures that policies are effectively implemented and that adjustments are made as needs evolve.
Funding and Support
This study was funded by the Quebec Ministry of Health and Social Services.
References
1. Paul-Shaheen P, Clark JD, Williams D. Small-area analysis: a review and analysis of the North American literature. J Health Polit Policy Law 1987;12:741–809.
2. Roos NP, Roos LL. Small area variations, practice style and quality of care. In: Evans RG, Barer ML, Marmor TR, editors. Why are some people healthy and others not? New York: Aldine De Gruyter; 1994.
3. Beitchman J. Social class type and the utilization of children’s psychiatric services. Some comparative Canadian data. Can J Psychiatry 1978;23:297–302.
4. Boyle MH, Offord DR. Prevalence of childhood disorder, perceived need for help, family dysfunction and resources allocation for child welfare and children’s mental health services in Ontario. Can J Behav Sci 1988;20:374–87.
5. Goering P, Lin E. Mental health: levels of need and variations in service use in Ontario. In: Goel V, Williams JI, Anderson GM, Fooks C, Blackstein-Hirsch P, Naylor CD, editors. Patterns of health care in Ontario. 2nd ed. Ottawa: Canadian Medical Association; 1996.
6. Lin E, Goering PN, Offord DR, Campbell D, Boyle MH. The use of mental health services in Ontario: epidemiologic findings. Can J Psychiatry 1996;41:572–7.
7. Badawi M, Kramer M, Eaton W. Use of mental health services by households in the United States. Psychiatr Serv 1996;47:376–80.
8. Burns BJ, Friedman RM. Examining the research base for child mental health services and policy. J Ment Health Adm 1990;17:87–98.
9. Lin E, Chan B, Goering PN. Variations in mental health needs and fee-for-service reimbursement for physicians in Ontario. Psychiatr Serv 1998;49:1445–51.
10. Norquist GS, Regier DA. The epidemiology of psychiatric disorder and the de facto mental health care system. Annu Rev Med 1996;47:473–9.
11. Leaf PJ, Livingston B, Tischler GT, Freeman DH, Weissman MM, Myers JK. Factors affecting the utilization of speciality and general medical mental health services. Med Care 1988;26:9–26.
12. Breton JJ, Valla JP, Bergeron L, Berthiaume C, Gaudet N, Toupin J, and others. Enquête québécoise sur la santé mentale des jeunes de 6 à 14 ans, 1992. Volume 2, partie 2. Utilisation des services. Hôpital Rivière-des-Prairies et Santé Québec; 1997.
13. Costello EJ, Burns BJ, Angold A, Leaf P. How can epidemiology improve mental health services for children and adolescents? J Am Acad Child Adolesc Psychiatry 1993;32:1106–14.
14. Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J, and others. Quebec Child Mental Health Survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatr 1999;40:375–84.
15. Offord DR, Boyle MH, Szatmari P, Rae-Grant NI, Links PS, Cadman DT, and others. Ontario Child Health Study II. Six month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987;44:832–6.
16. Target M, Fonagy P. The psychological treatment of child and adolescent psychiatric disorders. In: Roth A, Fonagy P, editors. What works for whom? A critical review of psychotherapy research. New York: Guilford Press; 1996.
17. Breton JJ, Bergeron L, Valla JP, Berthiaume C, St-Georges M. Diagnostic Interview Schedule for Children (DISC-2.25) in Quebec: reliability findings in light of the MECA study. J Am Acad Child Adolesc Psychiatry 1998;37:1167–74.
18. Valla JP, Bergeron L, Bérubé H, Gaudet N, St-Georges M. A structured pictorial questionnaire to assess DSM-III-R based diagnoses in children (6-11 years): development, validity and reliability. J Abnorm Child Psychol 1994;22:403–23.
19. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, and others. A children’s global assessment scale (CGAS). Arch Gen Psychiatry 1983;40:1228–31.
20. Child ECA Project. Service Utilization and Risk Factor Interview. New York: New York Psychiatric Institute, Columbia University; 1990.
21. World Health Organization (WHO). International classification of diseases, 9th revision. Geneva: WHO; 1977.
22. Conseil Médical du Québec. Vue d’ensemble des propositions du Conseil Médical du Québec pour l’édification d’un système efficient de soins de santé et de services sociaux. Québec: Conseil Médical du Québec; 1996.
23. Ministère de la Santé et des Services sociaux. Politique de santé mentale. Québec, ministère de la Santé et des Services sociaux; 1989.
24. Potvin N: Bilan d’implantation de la politique de santé mentale. Québec : ministère de la Santé et des Services sociaux; 1997.
25. Ministère de la Santé et des Services sociaux . Plan d’action pour la transformation des services de santé mentale. Québec : ministère de la Santé et des Services sociaux; 1998.
Author(s)
Manuscript received April 2002, revised, and accepted September 2002.
1Professor, Department of Health Administration and Groupe de recherche interdisciplinaire en santé, Université de Montreal, Montreal, Quebec.
2Associate Professor, Department of Psychiatry, Université de Montreal, Montreal, Quebec; Head, Research Unit at Hôpital Rivière des Prairies, Montreal, Quebec; Researcher, Fernand-Seguin Research Center, Hôpital Louis-Hippolyte Lafontaine, Université de Montreal, Montreal, Quebec.
3Research assistant, Groupe de recherche interdisciplinaire en santé, Université de Montreal, Montreal, Quebec.
4Project coordinator, Research Unit, Hôpital Rivière des Prairies, Montreal, Quebec.
5Statistician, Research Unit, Hôpital Rivière des Prairies, Montreal, Quebec.
Address for correspondence: Dr R Blais, Groupe de recherche interdisciplinaire en santé, Université de Montreal, CP 6128, succursale Centre-ville, Montreal, QC H3C 3J7
e-mail: regis.blais@umontreal.ca
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