Recherche en bref : Accès à des soins ambulatoires en santé mentale avant une visite au Service des urgences psychiatriques

What you need to know

Access to ambulatory mental health and addictions (MHA) services is challenging. There is a lack of evidence about the extent to which individuals use the Emergency Department (ED) as the first point of access to mental health care, particularly when access to ambulatory services is limited. The researchers found that almost half of the patients seeking care in the ED for mental health illnesses and addictions had not accessed outpatient services in the two years prior to their ED admission. The researchers suggest this could be avoidable if patients had access to outpatient services.

Research Snapshots are brief, clear language summaries of research articles, presented in a user-friendly format.

This Research Snapshot is based on the article “Incidence of Access to Ambulatory Mental Health Care Prior to a Psychiatric Emergency Department Visit Among Adults in Ontario, 2010-2018,” which was published in JAMA Network Open in 2021. https://doi.org/10.1001/jamanetworkopen.2021.5902

What is this research about?

There is a lack of evidence about the extent to which individuals use the ED as the first point of access. Although the ED is an important access point for individuals experiencing a MHA-related crisis, it is unknown if the majority of adults visit the ED as their first point of contact for mental health care. While the ED is a service site important for individuals in crisis, the poor access to ambulatory MHA-related services means that the ED might be a point of care that is being used instead of ambulatory settings.  

The main objective of this study was to describe the extent to which the ED is the first point of contact for mental health among adults and identify key sociodemographic and clinical characteristics/factors associated with the ED being the first point of contact. 

What did the researchers do?

The researchers obtained and analyzed the following data:

  1. population-based administrative health data from Ontario, Canada
  2. MHA-related outpatient visits from the Ontario Health Insurance Plan (OHIP) physician billings database
  3. hospitalization data from inpatient discharge records in the Discharge Abstract Database and from the Ontario Mental Health Reporting System.

The individuals included in this study were adults and youths (aged 16 and older) from Ontario presenting to the ED for the first time for MHA-related issues between April 1, 2010, and March 31, 2018. The researchers excluded individuals older than 105 years of age, non-Ontario residents, those with a missing or invalid health card number and those without OHIP eligibility for at least two years prior to their ED visit. The researchers also excluded planned or scheduled ED visits.

The main outcome the researchers focused on was a first-contact ED visit in the mental health care system without previous MHA care in an outpatient setting in the two years prior to that visit.

The researchers captured data on the following factors:

  1. predisposing factors, such as sociocultural factors, including age, sex, immigrant status and the number of conditions affecting the individual at the same time
  2. enabling factors, such as obtaining or accessing care, including income, locations (rural, urban) area and whether or not individuals had a usual primary care clinician at the time of their ED visit
  3. need factors, such as immediate reasons for seeking health services, including health and functional issues
  4. mental health conditions, including substance-related disorders, schizophrenia and other nonorganic psychotic disorders (psychotic disorders), mood disorders, anxiety and adjustment disorders, self-harm and others.

What did the researchers find?

The researchers analyzed data from 659,084 individuals who visited the ED. 52% of these individuals were female, with a mean age of 39 years.

The researchers found that:

  • 298,924 (45%) of patients analyzed had no prior outpatient contact
  • patients with first-contact ED visits were younger than those with prior MHA contact and more likely to be male, to live in a rural setting, to be immigrants and to have no usual primary care clinician
  • first-contact ED visits varied by diagnosis, with the lowest rates of first contact occurring among individuals presenting with mood disorders and the highest rate occurring among individuals with substance use disorders.

Overall, the researchers found that almost half of the psychiatric visits to the ED were first-contact visits by patients who had not accessed outpatient services in the two years before their ED visit. The researchers suggest this could be avoidable if patients had access to outpatient services. 

Limitations of the research

The researchers note that their study had several limitations. Data on non-physician contact, including publicly funded mental health professionals (e.g., social workers and psychologists) and privately funded mental health professionals, were not available. Furthermore, it was unclear whether access to privately funded mental health professionals prior to a first-contact ED visit had resulted in an overestimate of the rate at which patients were first accessing the ED. Finally, the diagnostic categories used to organize the sample had not been validated.

How can you use this research?

The researchers note that to improve outpatient access, more focus is needed on populations with risk factors for those presenting to the ED first, including men, older adults, rural residents, those with poor primary care connectivity and those with substance-related diagnoses. However, in order to avoid the ED as a first place to visit, outpatient services need to become more accessible.

About the researchers

Paul Kurdyak,1,2,3,4 Sima Gandhi,1 Laura Holder,1 Mohammed Rashid,1 Natasha Saunders,1,3,5,6  Maria Chiu,1,3 Astrid Guttmann,1,3,5,6 Simone Vigod,1,2,3,7

  1. ICES, Toronto, Ontario, Canada
  2. Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. Centre for Addiction and Mental Health, Toronto, Ontario, Canada
  5. Hospital for Sick Children, Toronto, Ontario, Canada
  6. Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  7. Women’s College Hospital, Toronto, Ontario, Canada