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Many surveys in North America and Europe have indicated 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 automatically be equated with a need for care (6). It has been recommended that need should be defined by dimensions 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 frequent reason given by affected individuals for not consulting (72%) or for treatment dropout (58%) is the belief that the disorder 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 status (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 studies 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 prevalence rates of use for GPs (7%), psychologists (5%), and psychiatrists (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 service use for MH concerns from data that were collected consistently 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. MethodsData 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 province. We also collected information on the type of professional service used. Health service use in the past 12 months for MH reasons was grouped according to the following classifications, as previously 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) voluntary support network (internet support group or chat room, self-help group, or telephone help-line). 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, perceived 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 disorder, panic attack, agoraphobia, and social phobia, or an eating 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 interference 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 province.We did not observe multicollinearity among the variables. We chose final predictive logistic regression models, using a stepwise selection approach with a 0.10 level of significance 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 program developed by Statistics Canada (42). ResultsLifetime and Past-Year Prevalence of Mental Disorders The prevalence rates of ever having a specified mental disorder 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 agoraphobia, respectively. 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 conditions, and physical disability: female sex (OR 1.65; 95%CI, 1.46 to 1.87), self-rated MH (5 levels rated from poor to excellent, 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 agoraphobia. Of the people with suicidal ideation and drug dependency within the past year, only 44.1% and 37.3% consulted a 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. DiscussionIn 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, Quebec, 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 significant 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 ethnic 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 services will help, or who have language problems). Our findings suggest that a more specific issue, such as the level of awareness 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 paying 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 services for MH reasons by individuals is relatively equitable across provinces. Funding and SupportThis 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. 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Can J Psychiatry 1990;35:397–400. 38. Direction de la santé publique de Montréal. Rapport annuel 2001 sur la santé de la population. Garder notre monde en santé, un nouvel éclairage sur la santé mentale des adultes montréalais. Montreal (QC): Direction de la santé publique; 2002. 39. Gravel R, Béland Y. The Canadian Community Health Survey: Mental Health and Well-Being. Can J Psychiatry 2005;50:573–9. 40. Lesage A, Patten S. Overview, design and methods of the CCHS 1.2. Can J Psychiatry 2005. Available: www.statcan.ca/english/concepts/health/ cycle1_2/content.htm. Accessed 2004 Sept. 41. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behavior 1995;36:1–10. 42. Brisebois F, Bédard M. Formation pratique à l’utilisation de la méthode du bootstrap. Centre interuniversitaire québécois de statistiques sociales (CIQSS), 21 mars, 2003. 43. Leaf PJ, Livingston BM, Tischler GL, Weissman MM, Holzer CE, Myers JK. Contact with health professionals for the treatment of psychiatric and emotional problems. Med Care 1985;23:1322–37. 44. Dewa CS, Rochefort DA, Rogers J, Goering P. Left behind by reform: the case for improving primary care and mental health system services for people with moderate mental illness. Appl Health Econ Health Policy 2003;2(1):43–54. Author(s)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
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